AHCPR's User Liaison Program (ULP) disseminates health services research findings in easily understandable and usable formats through interactive workshops. Workshops and other support are planned to meet the needs of State, local and Federal policymaker and other health services research users, such as purchasers and health plans.
This seminar offered State executive and legislative officials and senior-level State policymakers information to develop a better understanding of the individual insurance market and the impact that reforms implemented have had to date. It was held in Albuquerque, New Mexico, July 19-21, 1999.
All across the country, States are actively involved in a wide variety of innovative health and human service program activities, including such things as welfare reform, managed care contracting, health care coverage expansions, and child welfare initiatives. The desired outcomes of these activities vary according to the nature of the initiative and may include:
One thing these initiatives often have in common, however, is that in many cases a significant number of individuals within their target populations may suffer from mental health or substance abuse (MH/SA) problems. For example, the U.S. General Accounting Office (GAO) estimates that 78 percent of young children in foster care come from families in which substance abuse is a significant factor in placing the child out of home care. Additionally, two of the major health problems facing adolescents—an age group that contains many potential State Child Health Insurance Program (SCHIP) enrollees—are depression and substance abuse problems.
MH/SA problems can create significant barriers to the achievement of the goals and objectives of broader health and human service program and policy initiatives. Health care initiatives that do not adequately address the MH/SA problems of target populations they serve may result in fragmented care, significant unmet need, and ultimately, higher health care spending. All the training in the world may not be enough to help a former welfare recipient with a serious substance abuse problem hold a job. Unaddressed mental health or substance abuse problems may doom any efforts to reunite and strengthen families.
Although a compelling argument may be made for addressing these MH/SA problems as part of these broader initiatives, doing so is not necessarily a simple task. The challenges that often exist across States include:
The AHCPR User Liaison Program designed this workshop to help State officials address these challenges. The workshop objectives were developed to provide participants with:
It should be emphasized that the goal of the workshop was not designed to tell State officials what they should do, but rather to provide them with useful information that can help them make more informed decisions.
This workshop was not designed exclusively for officials from State mental health and substance abuse agencies. It was, however, designed to address the needs of a broad range of State officials responsible for the design, implementation, and evaluation of new health and human service programs. The 60 workshop participants were health officials from a broad range of organizations, including: State legislatures, State Medicaid agencies, and State health departments as well as State MH/SA agencies, human and social service agencies, State youth and families departments, and governors' offices.
Key Issues and Challenges in Addressing the Mental Health and Substance Abuse (MH/SA) Problems in the Populations Served by Public Programs
Key Issues in the Finance and Delivery of MH/SA Services
The MH/SA Cost Offset Issue: Unrealized Potential?
Managed Care Contracting for MH/SA
Matching Strategies and Populations: Innovative MH/SA Components in Other State Purchasing Programs
Welfare-to-Work Initiatives: Strategies for Overcoming MH/SA-related Problems
Designing for Success: Addressing the MH/SA Needs of Populations Served by Other State Health and Human Service Programs
And the Envelope, Please: Evaluating the Success of MH/SA Strategies in the Context of Broader Program Initiatives
Moderator:
Larry Bartlett, Ph.D., Health Systems Research, Inc., Washington, DC
In this session, participants discussed the issues and challenges that they face within their own States in attempting to address the mental health and substance abuse needs of persons who are a part of the target populations for Temporary Assistance for Needy Families (TANF), child welfare, juvenile justice, and other public programs. Among those issues raised by participants were the following:
These and other important issues were discussed further in subsequent sessions of the workshop.
Presenter:
Clarke Ross, D.P.A., Deputy Executive Director, National Alliance for the Mentally Ill, Arlington, Virginia
In this session, Clark Ross, Deputy Executive Director of the National Alliance for the Mentally Ill, and former Executive Director for the American Managed Behavioral Healthcare Association, provided an overview of current key issues in the financing and delivery of mental health and substance abuse services. Among those issues presented were:
Presenter:
Mark Olfson, M.D., M.P.H., Associate Professor of Clinical Psychiatry, New York State Psychiatric Institute and Columbia University, New York, New York
An issue often raised in discussions about making greater investments in MH/SA treatment is the potential that these investments can have the effect of reducing spending on other health care services that would otherwise be incurred (the "cost offset" issue). In this session, Dr. Mark Olfson of the New York State Psychiatric Institute and Columbia University, the author of a recent Health Affairs article on the subject, discussed the research examining the extent to which these offsets can be realized.
Dr. Olfson presented findings from a number of studies that did show reductions in other health care expenditures after the initiative of specific MH/SA interventions. In the subsequent discussions, the focus was broadened to include the impact of MH/SA treatment on a broader array of costs, including productivity/work days lost (from an employer perspective), other public program costs, and societal costs associated with substance abuse-related criminal activity.
References:
Olfson M, Schlesinger HJ. Mental Health/Medical Care Cost Offsets. Opportunities for Managed Care 1999 Mar/Apr;18(2):79-90.
Simon G, Katzelnick D. Depression, Use of Medical Services and Cost-Offset Effects. J Psychosom Res 1997;42(4):333-344.
Holder, H. Recent Developments in Alcoholism, Volume 14: The Consequences of Alcoholism. ed. Galanter. New York: Plenum Press; 1998. Chapter 14, The Cost Offsets of Alcoholism Treatment.
Presenters:
Sheila Baler, Ph.D., M.P.H., Chief Operating Officer, Menninger Care Systems, Plano, Texas
Gail Robinson, Ph.D., Vice President, Lewin Group, Falls Church, Virginia
In this session, Sheila Baler, the Chief Operating Officer of Menninger Care Systems, a managed behavioral healthcare organization, and Gail Robinson of the Lewin Group, discussed issues related to Medicaid and other public agencies' contracting with managed care organizations for the provision of MH/SA services. Dr. Robinson began by providing an overview of State activity in this area, identifying the range of different managed care models and at-risk arrangements involved in these contracting arrangements.
Ms. Baler then addressed some of the critical issues associated with contracting with public programs such as Medicaid from the perspective of a managed care organization. She highlighted a number of key points, including:
References:
Lewin Group. MCOs' Experience in Public Mental Health Contracting: Key Issues identified by Managed Care Organizations. Prepared for the Center for Mental Health Services and the Office of Managed Care. The Lewin Group, Jun 1999.
SAMHSA Managed Care Tracking Report. Managed Behavioral Health Care Updates 1999 Jun; 2(1). Rockville, MD.
Fox HB, Wicks LN, McManus M, Kelley RW. Medicaid Financing for Mental Health and Substance Abuse Services for Children and Adolescents. Technical Assistance Publication. U.S. Department of Health and Human Services. Public Health Service. Substance Abuse and Mental Health Services Administration. Center for Substance Abuse Treatment, 1999. Rockville, MD.
Presenters:
Gail Vail, M.P.A., Administrator, Acute Care Services, Medicaid Program Development, Florida Division of Medicaid, Florida Agency for Health Care Financing, Tallahassee, Florida
James Walkup, Ph.D., Assistant Professor, Rutgers University, New Brunswick, New Jersey
This session highlighted examples of ways in which MH/SA-related needs may be addressed through other types of health care coverage and insurance programs. Gail Vail of Florida's Agency for Health Care Financing, described how that State developed an innovative approach to address the mental health and substance abuse needs of certain children under its new Children's Health Insurance Program (CHIP). In an effort to better address the significant needs of children age 5 to 18 with serious emotional disturbances or serious mental illness (i.e., schizophrenia, bipolar disorder, major depression, or substance abuse) and who meet certain treatment criteria, Florida established a new behavioral health network that provides an array of speciality behavioral health services to the children.
James Walkup of Rutgers University then described a research effort sponsored by a major disability insurance company that seeks to examine the extent to which the detection and treatment of previously undetected depression among persons with medical disabilities can reduce the length and severity of depressive episodes, reduce disability, and expedite return to work. Positive results from this study are likely to increase employers' and disability insurers' interest in pursuing effective interventions that will reduce productivity losses and insurance costs due to depression. The implications of preventing persons with physical disabilities and co-occurring depression from leaving the workforce and onto State Medicaid programs as a result of their disabilities was also discussed.
References:
Wells K, Strum R, Sherbourne C, et. al. Caring for Depression. Cambridge, MA: Harvard University Press; 1996. Chapter 3, The Social Role of Depression and Health Care Policy.
Schulberg H, Katon W, Simon G, et al. Treating Major Depression in Primary Care Practice: An Update of the Agency for Health Care Policy and Research Practice Guidelines. Arch Gen Psychiatry 1998 Dec;55:1121-1127.
Marin JK, Blum TC, Beach S, et. al. Subclinical Depression and Performance at Work. Soc Psychiatry Psychiatr Epidemiol 1996;31:3-9.
Finklestein S, Berndt E, Greenberg SM, et. al. Improvement in Subjective Work Performance After Treatment of Chronic Depression: Some Preliminary Results. Psychopharmacol Bull 1996;32(1):33-40.
Presenters:
Colleen Keenan, M.B.A., Project Director, Work First New Jersey Substance Abuse Initiative, New Jersey Division of Addiction Services, Trenton, New Jersey
Sandra Naylor-Goodwin, Ph.D., M.S.W., Executive Director, California Institute of Mental Health, Sacramento, California
This session highlighted innovative strategies that two States are pursuing to increase the success of their welfare-to-work initiatives by building in strategies to address the MH/SA needs of the individual and families making this transition.
Colleen Keenan, the Director of Work First New Jersey Substance Abuse Initiative, described this statewide program, which is a joint initiative between the State's Departments of Health and Senior Services, Human Services, and Labor. Among the program's key features are: an assessment and treatment placement process completed within the welfare offices; a "managed care look-alike" agency providing clinical gatekeeper services and provider networks meeting special program requirements; services covering a unified continuum of care; and treatment recognized as a work activity.
Sandra Naylor Goodwin of the California Institute of Mental Health then discussed the State of California's CalWORKS project that is involved with testing a number of different approaches to addressing the mental health, substance abuse, and domestic violence problems of persons who transition from welfare to work at the county level. Both Dr. Naylor and Ms. Keenan shared with participants the early lessons learned from the programs in their States, including features that problems encountered (e.g., those associated with having caseworkers do assessments in the welfare office), the need for flexibility in the design and delivery of services, and the importance of and challenges associated with interagency cooperation in addressing problems.
References:
Making Welfare Reform Work: Tools for Confronting Alcohol and Drug Problems Among Welfare Recipients. Legal Action Center Report. Funded by Annie E. Casey Foundation. Sep, 1997.
Presenters:
Hernando Posada, Assistant Director, Ohio Department of Alcohol and Addiction Services, Columbus, Ohio
Judge John T. Parnham, Circuit Judge, First District Court of Florida, Pensacola, Florida
This session completed the workshop's focus on specific innovative State and local programs by examining initiatives related to child welfare and the judicial system. Hernando Posada, Assistant Director of the Ohio Department of Alcohol and Addiction Services, opened the session by describing Ohio's initiative to undertake a thorough assessment of programmatic and fiscal strategies for addressing the substance abuse problems of the TANF population and the 70 percent of parents of children in foster care who have substance abuse issues. An important feature of this initiative is the development of a data system that will link client information across State systems while protecting confidentiality and allow the tracking and analysis of client demographics, services, and payment sources.
Judge John Parnham from the First District Court of Florida then described the "Family-Focused" Parent Drug Court he established in Pensacola, Florida. The approach is designed to promote collaboration and coordination across different government agencies, treatment providers, and the judicial system. He described a structure and process through which the judge and the court serves as an advocate for change and seeks to coordinate legal and therapeutic interventions in a support, non-adversarial manner to achieve positive outcomes.
References:
U.S. Department of Health and Human Services Administration for Children and Families. Substance Abuse and Mental Health Services Administration. Building Perspectives and Building Common Ground, A Report to Congress on Substance Abuse and Child Protection, April 1999. Internet address: http://aspe.hhs.gov/hsp/subabuse/99/subabuse.htm
Lutz L. Rethinking Child Welfare. Behavioral Health Tomorrow 1999 Apr;17-20.
Presenter:
Thomas Wickizer, Ph.D., M.P.H., Rohm and Haas Distinguished Professor of Public Health Services, School of Public Health and Community Medicine, University of Washington, Seattle, Washington
In this session, Thomas Wickizer of the University of Washington discussed the importance as well as the issues and challenges associated with designing and implementing approaches to evaluate the success of MH/SA strategies in the context of broader public problem initiatives. A major emphasis of his presentation was upon the potential value of using the information found in State administrative databases for evaluation purposes. Dr. Wickizer illustrated these points by sharing with participants information about the design and results of a number of different evaluations he has conducted focusing on the impact of MH/SA interventions on such outcomes as employment, disability, and treatment costs.
References:
Wickizer T, Wagner E, Cheadle A, et al. Implementation of the Henry J. Kaiser Family Foundation's Community Health Promotion Grant Program: A Process Evaluation. Milbank Q 1998;76(1):121-147.
Wickizer T. The Economic Costs of Drug and Alcohol Abuse in Washington State, 1996. Prepared for the Division of Alcohol and Substance Abuse, Department of Social and Health Services; University of Washington. 1999.
Wickizer T, Joesch J, Longhi D, et al. Employment Outcomes of Indigent Clients receiving Alcohol and Drug Treatment in Washington State. U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration Office of Applied Science 1997.
Wickizer T, Maynard C, Atherly A, et al. Completion Rates of Clients Discharges for Drug and Alcohol Treatment Programs in Washington State. Am J Public Health 1994 Feb;84(2):215-221.
Internet Citation:
Improving the Outcomes of State Health and Human Service Initiatives: Integrating Mental Health and Substance Abuse Strategies. Workshop Summary, July 19-21, 1999, User Liaison Program. Agency for Health Care Policy and Research, Rockville, MD. http://www.ahrq.gov/news/ulp/ulpmentl.htm
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