Findings from the SAMHSA Managed Behavioral Health Care in the Public Sector Study Judith A. Cook, Ph.D. Professor and Director Center for Mental Health Services Research & Policy Department of Psychiatry, University of Illinois at Chicago Presented at Using Research to Move Forward: A Consensus Conference on Publicly Funded Managed Care for Children & Adolescents with Behavioral Health Disorders and Their Families September 29 & 30, 2003, Washington, DC

Study Locations, Site and Coordinating Center PIs, & Family Representative* Rural Counties in NW Oregon Portland State University Robert I. Paulson, Ph.D. Tennessee and Mississippi Vanderbilt University Craig Anne Heflinger, Ph.D. Westchester County, New York Columbia University Christina Hoven, Dr.P.H. Rural Counties in Central Pennsylvania University of Pittsburgh Kelly Kelleher, M.D. Hamilton & Summit Counties, Ohio Pacific Institute for Research & Evaluation, Al Stein-Seroussi, Ph.D. Coordinating Center University of Illinois at Chicago Judith A. Cook, Ph.D. Family Representative Federation for Families Valerie Burrell-Mohammed *Funded by CMHS & CSAP of SAMHSA

Focus of the Study: Children with Severe Emotional Disorders (SED) Inclusion Criteria DSM-IV Diagnosis Intensive Service Use (defined as use of any of the following: inpatient, residential, day treatment, partial hospitalization, in- home support, rehabilitation, therapeutic foster care, special school, crisis services, intensive case management, or use of outpatient services 3 or more days/week) Age: 4-17 years at time of sampling Medicaid-eligible In managed care or fee-for-service plan at baseline interview Exclusion Criteria DSM-IV Diagnosis of solely MR, SA, or adjustment disorder Children with severe/profound MR/DD or those served primarily through the MR/DD system(s)

Study Methodology Parents and children were recruited through mailings to households containing children with SED being served through MC and FFS plans; one site (OR) also used newspaper advertisements Response rates ranged from 10% to 98% Consenting caregivers and children (age 11+ years) were interviewed at study baseline (T1) and six month followup (T2) Followup rate was 88% (N=1517); there were no attrition differences re: child’s age, gender, functional impairment, health status, symptomatology, or caregiver strain; only significant difference was in race/ethnicity.

The Adult Respondent The most knowledgeable caretaker of the child, including relatives (if available) and professional caregivers (if not).

Managed Care Arrangements: Variations at Different Sites Who pays? For which services? For which children/adolescents? How is risk shifted?

Who Pays?

For Which Services?

For Whom?

How is Risk Shifted?

Research Questions Addressed Today Did psychiatric status, level of functional impairment, & likelihood of mental health service utilization differ significantly between children in managed care vs. fee- for-service arrangements? Did satisfaction with the child’s provider organization and behavioral health care plan differ significantly between caregivers of children in the two types of plans? Did caregivers’ ratings of provider service coordination differ for children in the two types of plans?

Description of the Sample

1 st Research Question – Children’s Statuses & Service Outcomes Does the psychiatric status, level of functional impairment, and likelihood of mental health service utilization differ significantly between children with SED served under managed care versus fee-for-service arrangements?

Dependent Variables Psychiatric Status (Child Behavior Checklist - CBCL) Functional Impairment (Columbia Impairment Scale - CIS) Service Utilization (Services Utilization Instrument - SUI) ›Inpatient/Residential ›Traditional Outpatient ›Psychotropic Medication ›Non-Traditional Services (i.e., day treatment, partial hospitalization, in-home treatment, school-based services, case management, or group home care)

Levels of Functional Impairment and Psychiatric Symptomatology CIS baseline: 79% scored at or higher than the clinical cutoff of 16. CBCL Total baseline: over 50% scored above the clinical mean, indicating the presence of psychiatric symptoms characteristics of children being treated for mental health disorders

Proportion of Children Using Each Type of Service between T1 & T2 *p<.05; **p<.01; ***p<.001

Model Tested - Symptoms and Functioning Block #1: T1 Score for Dependent Variable (CIS or CBCL) Block #2: Child Characteristics (age, gender, minority status, juvenile justice involvement, health) Block #3: Caregiver Characteristics (education, gender, age, caregiver strain, physical health, mental health, satisfaction with behavioral health plan) Block #4: Household/Neighborhood Characteristics (income, number of co-residents, urban neighborhood, rural neighborhood) Block #5: Study Condition (managed care versus fee-for- service) Block #6: Site (TN/MS, OR, PA)

Model Tested - Service Utilization Block #1: Child’s Need Variables (level of functional impairment, level of psychiatric symptomatology, substance use ever) Block #2: Child Characteristics (age, gender, minority status, juvenile justice involvement, health) Block #3: Caregiver Characteristics (education, gender, age, caregiver strain, physical health, mental health, satisfaction with behavioral health plan) Block #4: Household/Neighborhood Characteristics (income, number of co-residents, urban neighborhood, rural neighborhood) Block #5: Study Condition (managed care versus fee-for- service) Block #6: Site (TN/MS, OR, PA)

Results: Symptoms, Functioning, & Serice Use There were no significant differences in the functional status of children served in MC versus FFS arrangements There were no significant differences in the psychiatric status of children served in MC versus FFS arrangements, although a trend toward significance indicated somewhat poorer mental health status among children in the MC condition There were significant differences in the likelihood of some types of mental health service utilization but not others:  Children in MC arrangements were significantly less likely to receive inpatient/residential treatment  Children in MC were significantly less likely to receive non- traditional mental health services  There was a trend toward significance in which children in MC were somewhat less likely to receive psychopharmacologic treatment  There was no significant difference in the likelihood of receiving traditional outpatient mental health services

2 nd Research Question - Satisfaction Does caregiver satisfaction with the child’s provider organization, and the child’s behavioral health care plan differ significantly between children served under managed care versus fee- for-service arrangements?

Caregiver Satisfaction with Behavioral Health Care Provider Agency “Using any number on a scale from 0 to 10, where 0 is the worst possible care and 10 is the best possible care, what is your overall rating of the care [child’s name] has received from [the agency providing the most hours of service in the past six months].” MCFFSTotal Group Average Score = (difference non-significant)

Caregiver Satisfaction with Behavioral Health Care Plan “Overall, what is your rating of [health care plan name] now? Use any number on a scale from 0 to 10, where 0 is as bad as a health insurance plan can be, 5 is okay or average, and 10 is as good as a health insurance plan can be.” MCFFSTotal Group* Average Score = * p <.001, difference remains significant controlling for site

Proportion Reporting Different Types of Provider Agency Satisfaction and Relationship to 0-10 Rating Usually/Always Got appointment promptly80* Would recommend agency83* Agency explained things well86* Agency listed carefully85* Agency aware of services87* Involved caregiver in decisions79* Caregiver treated with respect91* Significant relationship with 0-10 Provider Agency rating p <.05

Proportion Reporting Different Types of Health Care Plan Satisfaction/Dissatisfaction & Relationship to 0-10 Satisfaction Rating * Significant relationship with 0-10 Provider Agency Rating, p<.05

Model Tested - Provider/Plan Satisfaction Block #1: Child Characteristics (age, gender, minority status, juvenile justice involvement, health) Block #2: Caregiver Characteristics (education, gender, age, caregiver strain, physical health, mental health) Block #3: Household/Neighborhood Characteristics (income, number of co-residents, urban neighborhood, rural neighborhood) Block #4: Child’s Behavioral Health Need Variables (level of psychiatric symptomatology, level of functional impairment) Block #5: Child’s Service Utilization (inpatient/residential treatment, outpatient treatment, psychotropic medication, nontraditional services) Block #6: Study Condition (managed care versus fee-for-service) Block #7: Site (TN/MS, OR, PA, OH)

Results: Provider & Plan Satisfaction There were no significant differences in level of satisfaction with the child’s provider agency (as rated by adult caregivers) between children served in managed care versus fee-for-service arrangements. Satisfaction with the child’s behavioral health care plan was significantly lower among caregivers whose children were enrolled in managed care versus fee- for-service plans. This was rue even controlling for characteristics of the child, caregiver, household/ neighborhood, child’s level of need, recent service utilization, and study site.

3 RD Research Question: Service Coordination Does the caregiver’s rating of degree of service coordination vary by whether the child was enrolled in a managed care plan versus a fee-for-service plan?

Service Coordination Scale (SCC) A set of 9 Likert-scaled responses to items asking caregivers about the degree to which the child’s service providers communicate & coordinate their service delivery efforts Administered to 266 caregivers of children & adolescents with SED, the scale had good psychometrics (high internal consistency, good construct validity with measures of satisfaction and family participation) (Koren, Paulson, Kinney et al., 1997)

Degree of Service Coordination Among Providers as Assessed by Caregivers

Model Tested - Service Coordination Block #1:Child Characteristics (age, gender, minority status) Block #2:Caregiver Characteristics (caregiver education, caregiver gender) Block #3:Caregiver Stressors (level of caregiver strain, caregiver health, caregiver depression) Block #4:Child Need (child’s mental health symptoms) Block #5: Site (TN/MS, OR, PA) Block #6:Study Condition (MC vs. FFS)

Results: Service Coordination Most caregivers are fairly satisfied with the degree of service coordination occurring on behalf of children and youth with SED. As perceived by their caregivers, children in MC behavioral health plans experience lower levels of service coordination than do children in FFS plans. This difference remained significant in multivariate models, even controlling for study site, caregiver strain, and caregiver physical health. Other significant predictors of service coordination include caregiver’s education, caregiver’s level of depression, and severity of child’s psychiatric symptoms.

Conclusions While there were no differences between the functional status & psychiatric symptom severity of children enrolled in MC vs. FFS plans, there was significantly lower utilization of some mental health services. There was lower satisfaction with the child’s behavioral health care plan among caregivers of children in MC arrangements compared to FFS. There was significantly lower service coordination among providers of children served in MC vs. FFS plans.

For further information Visit the website… study description downloadable protocols research presentations link to larger study