Mental health programs need outcomes measures
Mental health programs need outcomes measures
A report by the Department of Health and Human Services Office of the Inspector General (OIG) said efforts to answer questions about the value of Medicaid managed mental health services are hampered by the lack of clinical outcomes data and other statistical information.
The report recommended the Health Care Financing Administration (HCFA) work with the Substance Abuse and Mental Health Services Administration "to develop outcome measurement systems that can be used as a condition of waiver approval."
HCFA said it disagrees with the recommendation because no reliable and cost-effective outcome measurement system currently exists and requiring states to develop such a system will stall the waiver process.
But the National Alliance for the Mentally Ill in Arlington, VA, says the recommendation mirrors its view that outcome measurement is a necessity.
The OIG studied Medicaid managed health care programs in seven states — Arizona, Colorado, Iowa, Massachusetts, North Carolina, Utah, and Washington — to take an early look at the changes that mandatory managed care has had on state Medicaid mental health services for people with serious mental illness. Five of the states had been under a mandatory mental health managed care program for at least three years as of April 1997. Iowa and Colorado were chosen by HCFA because of their innovative programs.
Managed care has allowed state officials to offer more specialized and creative outpatient services, and overall use of mental health services has increased, the OIG found. Costs have been reduced by setting limits for mental health costs in managed care contracts and by shifting care from inpatient to outpatient settings. Cost savings often are returned to a state’s general fund or used to expand services to those ineligible for Medicaid and help fund managed care administration.
Among new services documented by the OIG in the states studied were group home residential services, vocational services, respite care services, in-home programs, club house/day services, personal services, and evaluation and treatment centers.
"State officials cited the flexibility to provide [such] services . . . as one key advantage of managed care over their previous fee-for-service system," the report stated. "They said that such services generally would not have been offered by states under fee-for-service [programs]."
The report also cited innovative steps that could be taken when more flexibility is available, including providing residential telephone service for a beneficiary in an isolated rural area, making it possible for the person to call managed care providers and support networks, reducing costly hospital emergency department visits. In another instance, a plan called for a fence to be built around the home of a beneficiary with serious mental illness, reducing paranoiac episodes to the point that the individual could remain employed in the community and remain out of the hospital.
Four of the seven states documented increased overall use of mental health services due to the conversion to managed care and its shift of focus to community-based outpatient programs.
"While states reported decreased use of inpatient care, they reported larger increases of outpatient care. Importantly, several states noted that the time beneficiaries had to wait to receive services was less under managed care than it was under their prior fee-for-service plan," the report stated.
Plans reported that costs remained stable or were reduced as a result of contracting with managed care organizations for mental health services under capitated arrangements. Some states set the contracted capitation rate lower than the anticipated fee-for-service rate, while others allowed the contracted rate to match the expected fee-for-service rate. All seven claimed dramatic declines in inpatient costs by shifting the emphasis to outpatient programs and by reducing length of stay for those still hospitalized.
However, the report noted that psychiatric hospital readmission rates were generally higher under managed care, and stakeholders expressed concern that too many hospital beds are being eliminated from the system too quickly. Stakeholders also are concerned about the reduction in length of stay, fearing that the higher readmission rates mean that people are being discharged too soon.
The ultimate question is whether managed care is improving the health of persons with serious mental illness, and the OIG found that question can’t be answered because "none of the states included in our study had working outcome measures in place before or after they converted to managed care. Even basic utilization data, such as lengths of hospital stays, and number of visits, were inconsistently reported by states. Therefore, HCFA and states have no systematic way to determine the impact of managed care on the health of persons with serious mental illness."
The OIG reported that state officials, providers, and stakeholders in all seven states said they believe that overall mental health care has improved, but there is little quantifiable proof. While beneficiary satisfaction surveys and grievance reports exist, they may not be reliable indicators of a program’s success, the OIG added.
In addition to calling for development of outcome measures, the OIG report said HCFA should encourage states to establish independent, third-party mental health systems for conducting beneficiary satisfaction surveys, and should ensure that states obtain an 1115 waiver before using savings from managed care operations to expand services to non-Medicaid populations. HCFA disagreed with both of these recommendations, as well.
Clarke Ross, deputy executive director for public policy of the National Alliance for the Mentally Ill, says, "[The group] is extremely pleased with the report. It reflected our advocacy points, especially in calling for independent, third-party systems."
Mr. Ross tells State Health Watch that HCFA’s disagreement with the OIG recommendations demonstrates that the agency "just wants to get along with the states and not significantly improve state performance in the federal-state partnership in an election year."
Jerome Vaccaro, MD, vice president and corporate medical director for PacifiCare Behavioral Health in Laguna Hills, CA, looks at the OIG report from a provider perspective. "[The recommendations] push the quality envelope by establishing accountability for the outcomes of care; support the transition from uncontrolled fee-for-service systems to managed care, facilitating the development of systems of care and making our fragmented nonsystems a thing of the past; and recognize the importance of behavioral health care."
Both Mr. Ross and Mr. Vaccaro say the call for outcomes measurement is the most important recommendation in the report. PacifiCare has developed a system that not only measures outcomes but improves them, Mr. Vaccaro says. "This is the future of our industry."
[Contact Mr. Ross at (703) 524-7600 and Mr. Vaccaro at (818) 782-1100.]
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