Coordinating Center for the Managed
Behavioral Health Care in the Public Sector:
Children and Adolescents with
Severe Emotional Disorders Study

Background and Purpose

The past ten years have seen dramatic growth in the prevalence and variety of managed care arrangements for overseeing the provision of mental health and substance abuse treatment services, and more can be expected. Once largely a feature of the private sector, managed care has more recently been expanding in public sector programs, particularly Medicaid. Government officials have increasingly turned to managed care in an effort to control rising publicly-funded health care costs. States have differed greatly in their strategies to switch from the traditional fee-for-service delivery system to managed systems of care, using contractual cost-saving strategies such as capitation, selective provider networks, and utilization management controls. The rapid and decentralized development of managed care creates significant differences in the form that managed care plans take and the philosophies and structures under which they operate. This, in turn, may have an effect on the outcomes of the populations that these organizations serve.

Reform in the delivery system has progressed much faster than has the understanding of the effects of managed care practices on persons with mental health and substance abuse problems. Little research has been conducted on the impact of managed care on costs, service utilization, and outcomes. The Substance Abuse and Mental Health Services Administration (SAMHSA) is sponsoring the Managed Behavioral Health Care in the Public Sector Study to enhance knowledge about the effects of public sector managed behavioral health care on patterns of service use, service costs, outcomes, and satisfaction with care. This multi-site study is jointly funded and administered by the three SAMHSA Centers: The Center for Substance Abuse Treatment (CSAT), the Center for Substance Abuse Prevention (CSAP), and the Center for Mental Health Services (CMHS).

The Centers have funded 21 sites in ten states to evaluate managed behavioral health services for four populations:

Adults with substance abuse disorders,

Adults with severe mental illness,

Children and adolescents with severe emotional disorders, and

Adolescents with substance abuse disorders.

The UIC Coordinating Center is working with the five Children and Adolescents sites, with funding support from CSAP and CMHS.

The study comprises four major components:

A prospective study focusing on service use and outcomes of individuals enrolled in managed care and fee-for-service comparison groups;

An administrative data study focusing on patterns of service use and service expenditures;

Development of a taxonomy of managed care arrangements; and

A study of prevention services in managed care.

The Prospective Study

The prospective study utilizes a structured in-person interview to compare service use, client outcomes, and client satisfaction in samples of individuals enrolled in managed care and fee-for-service behavioral health care plans. Data were collected at baseline and six months later. Some projects collected data at additional time points. The major domains include:

Demographics
Service history
Mental health symptomatology
Level of functioning
Substance use
Patterns of service use
Client satisfaction

The Children and Adolescents Study sites conducted interviews with the primary adult caregiver for children ages 4-17 who were selected to participate in the project. If the child was between 11 and 17 years of age, s/he also was asked to complete a separate interview protocol. Children were selected for participation in the study based on their age, Medicaid eligibility status, and prior recent use of intensive mental health and substance abuse services, such as residential treatment, psychiatric hospitalization, frequent outpatient or day treatment visits, crisis services, and/or in-home support.

The adults and children were asked to provide answers to questions in a variety of domains, such as those described above. As long as the primary adult caregiver did not have a professional relationship with the child (i.e., was not the child's case manager, psychologist, etc.), a brief series of questions also was asked of the adult her or himself.

Copies of the Children and Adolescent Prospective Interview Protocols can be downloaded from the HSRI Web site.

The Administrative Data Study

The Administrative Data Study involves the analysis of service use and expenditure data for systems of care at each site. The analysis compares expenditures prior to and following the implementation of managed care for both managed care and fee-for-service systems. Analyses are being conducted with data from agencies which track Medicaid funded mental health and substance abuse services and, to the extent possible in each site, mental health and substance abuse services that are funded with state agency or other public funds.

Taxonomy of Managed Care Organizations

This study focuses on the managed care strategies and organizational arrangements employed in each of the study sites. The information gathered is being used to place the results from the prospective and administrative studies into the appropriate contexts. Data were collected via interviews with representatives of managed care and fee-for-service programs and by reviews of managed care contract documents. Major domains include:

Organizational arrangements
Covered services
Enrolled populations
Benefit design and medical necessity criteria
Benefit coverage determination procedures
Network composition
Risk sharing arrangements
Capitation arrangements
Accountability mechanisms

Presentations

In March, 2000, the Children and Adolescents Study Investigators presented a Symposium at the 13th Annual Research Conference held by the Research and Training Center for Children's Mental Health. The citations for these presentations appear below. If you would like a copy of the handouts from this symposium, please e-mail Genevieve Fitzgibbon, or phone her at (312) 355.1696 x16. A symposium for the 14th Annual Conference will be presented in February, 2001.

Additionally, you can view a list of past presentations given by the UIC Coordinating Center and the Children and Adolescents Study Sites.

SYMPOSIUM:

March 7, 2000 (Judith A. Cook - symposium chair, Genevieve Fitzgibbon, Terri Combs-Orme, Christina W. Hoven, Craig Anne Heflinger, Laura Flinchbaugh - discussant), The 13th Annual Research Conference - A System of Care for Children's Mental Health: Expanding the Research Base, Clearwater Beach, FL: The SAMHSA Multi-Site Study of Publicly Funded Children's Managed Behavioral Health Care.

PRESENTATIONS WHICH COMPRISED THE SYMPOSIUM:

Genevieve Fitzgibbon & Judith Cook, Ph.D.: The SAMHSA Multi-Site Study of Publicly Funded Children's Managed Behavioral Health Care: An Overview.

Terri Combs-Orme, Ph.D., Craig Anne Heflinger, Ph.D. & Celeste G. Simpkins: Comorbidity of Mental Health Problems and Chronic Illness or Handicaps in Children.

Christina W. Hoven, Robert R. Moore, George J. Musa, Fan Bin & Ping Wu: Stability of Functioning among Children and Adolescents with SED in Managed Care and Fee-for-Service: The Columbia Impairment Scale.

Judith A. Cook, Ph.D., Genevieve Fitzgibbon, Dennis Grey, Melissa Williams & Enrique Alonso: Prevention Efforts to Reduce the Use of Alcohol, Drugs and Tobacco among Children with SED.

Craig Anne Heflinger, Ph.D., Celeste G. Simpkins & Sarah H. Scholle, Dr.P.H.: Caregiver Satisfaction with Medicaid Managed Mental Health Care: Providers & Plans.

For more information about this project, please e-mail Judith A. Cook, Ph.D.

Children and Adolescents with SED Study Participants:

University of Illinois at Chicago Coordinating Center

Judith A. Cook, Ph.D., Study Leader

Genevieve Fitzgibbon, Project Manager

Study Site Principal Investigators:

Craig Anne Heflinger, Ph.D.
Vanderbilt University, TN

Christina W. Hoven, Ph.D.
Research Foundation for Mental Hygiene at NYS Psychiatric Institute, NY

Kelly Kelleher, Ph.D.
University of Pittsburgh, PA

Al Stein-Seroussi, Ph.D.
Pacific Institute for Research and Evaluation, NC

Robert Paulson, Ph.D.
Portland State University, OR

Government Project Officers
Center for Substance Abuse Prevention

Laura Flinchbaugh, M.P.H.

Shakeh Kaftarian, Ph.D.

Consumer Representative:

Valerie Burrell-Mohammed
Department of Youth and Family Services, VA

LINKS:

Human Services Research Institute

Here you will find a detailed description of the development of the two Children and Adolescents Prospective Interview Protocols; one is for the child as respondent and the other for the adult as respondent. Also, downloadable copies of the interviews, citations for the measures used in the interviews, and a link back to the Coordinating Center for the entire 21 site study can be found here.

Substance Abuse and Mental Health Services Administration

This link takes you to the main Web site for the Substance Abuse and Mental Health Services Administration. From there it is easy to access each of the three Centers of SAMHSA. You can link directly to CSAP by clicking here.

The Center for Health Care Strategies

One of the things you will find at the Center for Health Care Strategies' site is information on their previous studies of Medicaid Managed Care contracts, entitled Negotiating the New Health Care System: A Nationwide Study of Medicaid Managed Care Contracts. There are limited capabilities to search a database of topics covered in Managed Care contracts for examples of language, covered services, and information from specific states which participated in the studies.