Capitation of public mental health services in Colorado: a five-year follow-up of system-level effects.

OBJECTIVE: Capitated Medicaid mental health programs have reduced costs over the short term by lowering the utilization of high-cost inpatient services. This study examined the five-year effects of capitated financing in community mental health centers (CMHCs) by comparing not-for-profit with for-profit programs. METHODS: Data were from the Medicaid billing system in Colorado for the precapitation year (1994) and a shadow billing system for the postcapitation years (1995-1999). In a panel design, a random-effect approach estimated the impact of two financing systems on service utilization and cost while adjusting for all the covariates. RESULTS: Consistent with predictions, in both the for-profit and the not-for-profit CMHCs, relative to the precapitation year, there were significant reductions in each postcapitation year in high-cost treatments (inpatient treatment) for all but one comparison (not-for-profit CMHCs in 1999). Also consistent with predictions, the for-profit programs realized significant reductions in cost per user for both outpatient services and total services. In the not-for-profit programs, there were no significant changes in cost per user for total services; a significant reduction in cost per user for outpatient services was found only in the first two years, 1995 and 1996). CONCLUSIONS: The evidence suggests that different strategies were used by the not-for-profit and for-profit programs to control expenditures and utilization and that the for-profit programs were more successful in reducing cost per user.

Capitation and racial and ethnic differences in use and cost of public mental health services.

This study investigated racial and ethnic differences in the probability of mental health service use and costs of treatment before and after the implementation of capitated financing. Models were created to test effects on utilization and costs of African American, Latinos, and white mental health consumers. As service use and costs declined under capitation, Latino, and white levels of use and cost tended to converge. African American utilization patterns in the capitated areas tended to parallel their white counterparts. Differential rejection by, or exclusion of, African American and Latino consumers did not appear to occur in response to capitation.

Social networks and their relationship to mental health service use and expenditures among Medicaid beneficiaries.

OBJECTIVE: This study examined the relationship between social networks and mental health services utilization and expenditures. METHODS: A sample of 522 Medicaid mental health consumers was randomly selected from the administrative records of Colorado's Department of Health Care Policy and Financing. The administrative records contain information on utilization of services and expenditures of Medicaid beneficiaries within Colorado's Mental Health Services. In addition to the administrative records, social network and psychosocial data were gathered through longitudinal survey interviews. The interviews were conducted at six-month intervals between 1994 and 1997. Measures used in the regression analysis included demographic characteristics, clinical diagnoses, the social network index, expenditures, and utilization variables. RESULTS: The social network index was positively associated with utilization of and expenditures for inpatient services in local hospitals but negatively associated with expenditures for inpatient services in state hospitals or outpatient services. Relationships with family were negatively related to expenditures for outpatient services. Relationships with friends were positively associated with utilization of and expenditures for psychiatric inpatient services in local hospitals. CONCLUSIONS: Consumers who had higher social network index scores utilized more inpatient psychiatric services in local hospitals and had higher expenditures than those who had lower scores. Consumers who had higher social network index scores also had lower expenditures for inpatient services in state hospitals and outpatient services than those who have lower scores. Findings suggest that social network is associated with mental health utilization and expenditures in various ways, associations that need to be researched further.

Use of antipsychotic medications in treating schizophrenia among different financing and delivery systems.

BACKGROUND: In 1995 in an effort to control costs, the State of Colorado implemented a pilot capitated payment system for individuals eligible for public financing of their mental health services. Contracts were with both Not-For-Profit (NFP) firms and For-Profit (FP) firms; the remainder were in the fee-for-service system (FFS). Pharmaceuticals were not included in the capitation rate. However, antipsychotic medications were included in the formularies for consumers who received their medical care through a Health Maintenance Organization (HMO). AIMS: This paper examines the use of antipsychotic medication compared to the use of atypical antipsychotics among consumers who are (i) enrolled in a medical HMO or not enrolled in a medical HMO and (ii) whose mental health services are reimbursed on a fee-for-service basis (FFS) or through a capitated system. METHODS: Data for this study were collected between 1995 and 1997 as part of the Colorado's Medicaid Mental Health Capitation Pilot Program. Atypical antipsychotics included in the study are: clozapine, risperidone, and olanzapine. The sample of this study consisted of 282 individuals diagnosed with schizophrenia. RESULTS: The utilization of antipsychotics was lower among consumers in HMOs. Compared to consumers in FFS areas of the state, the utilization of atypical antipsychotics was higher in capitated areas of the state. DISCUSSION: There was a strong incentive for the utilization of atypical antipsychotics to increase in capitated systems, unless consumers received their medication prescriptions through an HMO. Limitations include differences in observable and unobservable characteristics among the FFS, DC and MBHO areas, unavoidable selection bias and the small number of HMO enrollees. CONCLUSIONS: Capitation of mental health services provides incentives for more cost-effective treatments. HMO enrollment was not a crucial factor to determine access to atypical antipsychotic prescriptions. IMPLICATIONS FOR POLICY: These data suggest that capitation can affect the use of substitute services not in the capitation rate. Before recommending policy changes, we need to better understand whether the increased utilization leads to better outcomes. IMPLICATION FOR FURTHER RESEARCH: The next step is to determine whether the increased use of atypical antipsychotics leads to better outcomes for consumers.

Public Mental Health Services to Asian American Ethnic Groups in Two California Counties.

PURPOSE OF THE STUDY: The purpose of this article is to examine the use of public mental health services among Chinese, Filipino, Southeast Asians, Japanese, and other Asian Americans. SEARCH METHODS USED: This article used two data sources from San Francisco City and County and Santa Clara County. By combining data from these two counties, the study had access to information on 3,095 adult Asian users of services. SUMMARY OF IMPORTANT FINDINGS: The study found differences among various Asian ethnic groups in their likelihood of using individual service modalities, but fewer statistically significant differences in the amount of use once services started. MAJOR CONCLUSIONS: Differences in the use of public mental health services were related to differences in the two counties' implementing services. KEY WORDS: Asian Americans, Public Mental Health Services, Utilization, Ethnic Differences