An evaluation of the Connecticut General Assistance Managed Behavioral Health Care Pilot Program

286 Pages·1998·11.4 MB·English

by  Thakur, Neil M

AnEvaluationoftheConnecticutGeneralAssistanceManagedBehavioralHealthCare
PilotProgram
ADissertation
PresentedtotheFacultyoftheGraduateSchool
of
YaleUniversity
inCandidacyfortheDegreeof
DoctorofPhilosophy
by
NeilM.Thakur
DissertationDirector:MarkSchlesinger,Ph.D.
December1998
Abstract
AnEvaluationoftheConnecticutGeneralAssistance
ManagedBehavioralHealthCarePilotProgram
NeilM.Thakur
1998
ThisdissertationwillevaluatetheConnecticutDepartmentofMentalHealthand
AddictionServices(DMHAS)GeneralAssistancePilot(GAP)programthatprovided
managedmentalhealthandsubstanceabuseservicestoGeneralAssistance(GA)clients.
TheGAPwasdesignedtoincreaseaccesstocareandlowercostsbycollocating
cliniciansatwelfareoffices,creatingprovidernetworks,andmanagingutilization.
TheevaluationfocusesonthethreelargestandoldestGAPsites:Bridgeport;
Hartford;andNewHaven. Keyinformantinterviewsandarchivalanalysisareusedto
qualitativelyexploreorganizationalimpactsofthecollocationstrategy. Quantitative
analysisofelectronicGAandDMHASrecordsfrom1992-1996explorethecasefinding
andutilizationmanagementprocesses.
Thisdissertationexplorestwopolicyissues. Thefirstconcernsintegratingthe
deliveryofsocialservicesacrossagencieswithdifferenttraining,expertise,funding,and
missions. Resultsindicatethatcollocationfirstledtotensionbetweenclinicaland
welfarestaff,butlaterresultedinproductivecollaboration. GARecipientsfromHartford
andNewHavenweremorelikelytoaccessDMHAScareafterimplementationofthe
GAPiftheirGAbenefitswereactive. TheGAPaccessprocesswasmostefficientin
siteswiththemostintensecollocation.
Thesecondpolicyissueisthatofstateagenciesdirectlymanagingtheirown
services. Qualitativedataanalysissuggestspubliclyoperatedmanagedcareprograms
mayhaveweakeroversightandmanagenetworkproviderslessaggressivelythanother
publicmanagedcaremodels.
ThoughcostsofDMHASservicesforGAclientsdroppedafterimplementationof
theGAP,DMHAScostsalsofellforthesesameclientswhiletheircarewasnotmanaged
bytheGAP. Themainreasonforcostsdeclinesmaybeareductioninthenumberof
DMHASmentalhealthinpatientbeds,andtheimplementationofapriorauthorization
programforallinpatientadmissionspriortoimplementationoftheGAP.
Thoughsometheseoffindingsaremixed,theGAPdoessuggestaviablemodel
forpubliclyoperatedmanagedcare. WaystocorrectsomeoftheGAP'sshortcomings
willalsobeconsidered.
©1998byNeilM.Thakur
Allrightsreserved.
Acknowledgments
Thisworkwouldnothavebeenpossiblewithoutthewisdom,time,andresources
ofmanydifferentpeople. Iespeciallyappreciatethesupportfrommydissertation
advisors:MarkSchlesinger;JoeMorrissey;andWilliamSledge. Ialsogratefully
acknowledgefinancialsupportfromtheNIMHservicestraininggrant,theHealthCare
FinanceAdministration,theDepartmentofMentalHealthandAddictionServices,and
theYaleUrbanHealthInitiative.
SpecialthankstoJoeGouletandDebSullivanforprogrammingassistance;
MarilynStolarandDanZeltermanforstatisticalconsultation;RaniHoffforgrantwriting
adviceandeditorialcomments; TomHelminiak,NancyWolff,andJackTebesforcost
estimates;andPamDaltonandJimCatalanottoforadviceandprotection.
Myinterviewees'honesty,insight,andfeedbackwereinvaluable,andIam
gratefulfortheirpatiencewithmymanyfollow-upquestions. Outofrespectfortheir
privacy,Iwillnotnamethem.
Thefollowingpeoples'professionalassistancewereinstrumentalincompleting
thisproject:
FromYaleUniversity:DaveBruce,AnnGreen,RayLoomis,MartinMador.
FromtheCityofNewHaven: TomNguyen,ArtSickle.
FromtheCityofBridgeport: KathyHunter.
From theCityofHartford: NeeruOhri,BarbaraZebrowski,VernonJohnson.
FromEDS: DianeValegorski,HelenWu,RichBatza.
FromDSS: DavidParella,BillRufleth,MarshaMains,ClaudetteCarveth,Alice
Franculli.
FromDMHAS: MelodiePeet,DavidHunter,JillBenson,LeslieLemert,SandySalus,
KenMarcus,MichaelLevine,SueGraham,SteveLynch,DebBurr,CherylCroll,
DickTurzo,KarenSnyder,WillieRamierez,SheilaAmdur,PaulPotamianos.
Mostofall,Iwishtothankmyfamilyandfriendsfortheirsupport.
TableofContents
CHAPTER1:INTRODUCTION n
231...PIImnrptoergtorudasumcftodireosrncertfiopotpriumobnlicsectorbehavioralhealthsystem ""111314
4.PolicyIssues 16
CHAPTER2:REVIEWOFTHELITERATURE 19
1.BehavioralHealthSystemOverview 20
A.Clientneed. -)q
B.Difficultyinintegratingsubstanceabuseandmentalhealthcaremodels 22
2.Administrativeshortcomingsinsocialservicedelivery 25
A.Federallevelincomeassistance 25
B.Stateandlocallevel. 27
3.TA.heCaGnAPintaengrdatSiyosntiemmpsroIvnetseegrrvaicteiso?n *2789
B.Whatisneededforintegration 34
C.ImplicationsfortheGAP j£
4.ManagingCare 37
A.ManagedcareprinciplesintheGAP 37
B.AnalyticFramework 45
C.Implicationsoftheframework. jj
D.Managedcareeffectsonminorityenrollees 54
5.Conclusions 56
CHAPTER3:PROGRAMDESCRIPTIONANDHYPOTHESES 57
1.GeneralDescriptionoftheGAPmodel ..57
A.AccessingservicesandmanagingutilizationpriortotheGAP 57
B.GenericGAPModel 50
2.SCi.teMaDnesacgreidptCiaornesHypotheses ; 6585
A.Bridgeport 59
B.Hartford. 75-
C.NewHaven 77
3.CA.roOsrsgasniitzeactoiomnpaalrriessoenarschquestions _§842
B.Inter-sitevariationandmanagedcareoutcomes 85
4.Conclusion 86
CHAPTER4:METHODS 87
1.ParticipantObservation 87
2.Qualitativedatacollectionandhypotheses 88
A.Datasourcesandmethods #9
B.OrganizationalAnalyses qq
C.KeyInformantInterviews 97
D.Limitations 97
3.Quantitativedatacollectionandhypotheses 99
A.Obtainingthedata 99
B.Linkingthedata JQ2
C.AccesstoCareAnalysis /05
D.TargetEfficiencyanalyses 722
E.Modelingtotaldirectcosts 725
4.Analysisofoutcomesbyracialsubgroups 136
5.Conclusions 136
1
CHAPTER5:QUALITATIVEANALYSISANDFINDINGS 139
1.Introduction 139
2.Integrationmethods 141
A.ProcessofIntegration ]4j
BC.IInntterra--oorrggaanniizzaattiioonnaallcroenlfaltiicto.ns J1S4O4
3.Publiclyoperatedmanagedcare 16
4.Conclusion 165
CHAPTER6:QUANTITATIVERESULTS 167
1.Accesstocare 167
A.Onewaymodelsandfrequencies 168
B.Accessmodelselection /74
C.FinalAccessmodels 184
D.Cross-Sitecomparisons 190
2.TargetEfficiencyAnalysis 192
A.Onewayfrequenciesandmodels 193
B.TargetEfficiencymodelselection. 196
C.FinalTargetEfficiencymodels 201
3.Modelingcostsofcare 204
A.Onewayfrequenciesandcostmodels 204
B.Costsmodelselection 208
C.Finalcostmodels 214
4.RaceandManagedcare 229
A.Noconclusivedifferencesincostmodels 229
B.RaceandaccesstocareinHartford 229
CHAPTER7:DISCUSSION 234
1.TheGAPasaServiceIntegrationmechanism 234
A.InteragencyaspectsoftheGAP 234
B.Intra-agencyeffects 238
2.Managedcarepractices 240
A.Findings 240
B.Minoritydifferencesandmanagedcare 241
C.DMHAScostsversusprivatecosts 242
3.Theutilityofstatesdirectlyadministeringmanagedcareprograms 243
A.Problemswithstatesmanagingcare 243
B.Planningprocess 245
C.Operationalprocess 249
4.Waystominimizeproblemsendemictopubliclyoperatedmanagedcare 250
A.Increasingexpertise 253
B.Increasingexpertiseandaccountability 254
5.Conclusions 255
APPENDIX—DataHandlingAndRecordLinkageProcedures 259
21..TThheeNHaerwtHfaovrdenGGAARoRsotsetrer 226509
3.DMHASUtilizationRecords 261
4.MergingDMHASandGArecords 264
BIBLIOGRAPHY 268
ListofTables
Table3-1: SummaryofGAPsitedifferences 83
Table4-1:ListingofIntervieweesJobTitlesbyGAPSite 92
Table4-2: Listingofinterviewerpromptsandgoalsforsemi-structuredKeyInformant
interviews 94
TTTTaaaabbbblllleeee4444----5643::::NSHSaueurmbwtmpfaeoHrrraiidvzoGedinAndgPaGtDAePsPSolaMiPncodyCliolPcdeeynergsiPtoehdrsifoordsaccessanalysis "ZZZZZ"! 1P111y1492i
Table4-7:1994directcostestimates pg
Table4-8: Subperioddatesandlengthsforcostanalysis 130
TTTTaaaabbbblllleeee6666----4231::::NNHHaaeerrwwttffoHoHrraaddvveeuacnnncaeduascjnscuaesdbsjtasuessdebtaaemscdoecdeamescoscldemseosldmeoldsels 111177755709
TTTTaaaabbbblllleeee6666----8765::::NFHHiaeanrrawttlffoHaoracrdcvdeeaascnsncdeamscoNscdeeecswolsnsHcffoaoonvurfneobdnuointnahdcgicscenishgtseesccrhkaetcekjointmodel,Periods2-6 111198881420
Table6-9:Hartfordunadjustedefficiencyestimates 194
Table6-10:NewHavenunadjustedefficiencyestimates 195
Table6-11:HartfordandNewHavenbaseefficiencymodels 197
Table6-12:Changeindeviancetestsforefficiencymodelbuilding 198
Table6-13:HartfordEfficiencymodelconfoundingcheck 199
Table6-14:NewHavenEfficiencymodelconfoundingcheck 200
Table6-15:FinalRRregressiontargetefficiencymodelsforbothcities 201
Table6-16:Hartfordunadjusteddailyaveragecosts 206
Table6-17:NewHavenunadjusteddailyaveragecosts 207
Table6-18:Hartfordbasecostmodels 209
Table6-19:NewHavenbasecostmodels ..210
Table6-20:Hartfordcostsmodelbuilding 211
Table6-21: NewHavencostsmodelbuilding .211
Table6-22:HartfordCostsmodelsconfoundingcheck 212
Table6-23:NewHavenCostsmodelconfoundingcheck _ 213
Table6-24:FtestsforfinalHartfordcostmodels 214
Table6-25: FtestsforfinalNewHavencostmodels 214
Table6-26:Hartfordfinalcostmodels 215
Table6-27:NewHavenfinalcostmodels 217
Table6-28:Hartfordadjusteddailyaveragecostsbydiagnosticgroup 219
Table6-29:NewHavenadjusteddailyaveragecostsbydiagnosticgroup 219
Table6-30:HartfordGAandnon-GAcostcontrasts 226
Table6-31:NewHavenGAandnon-GAcostcontrasts 227
Table7-1:PercentagesofsubjectswithmissingdiagnosesatinitialDMHAScontact,by
intakeunitandperiod 236
TTaabblleeAA--2l::DGAMPHAAsSseDsesmmoegnrtarpehciocrdrsecloirndksedlwiniktehdGwAithRosGtAersRosters 226667
ListofFigures
Figure2-1:AFlowchartforManagedCareEvaluation 47
Figure3-1:Pre-GAPmodel 58
Figure3-2:GenericGAPmodel 61
Figure3-3: BridgeportGAPclientflow 72
Figure3-4: HartfordGAPclientflowchart 76
Figure3-5: NewHavenGAPclientflowchart 81
Figure4-1:HartfordCrudeIncidenceRatesandKeyPolicyEvents 109
Figure4-2:NewHavenCrudeIncidenceRatesandKeyPolicyEvents 11
Figure4-3:Hartfordaccesscollapsibilitytest 120
Figure4-4:NewHavenaccesscollapsibilitytest 121
Figure4-5:Hartfordcostscollapsibilitytest 135
Figure4-6:NewHavencostscollapsibilitytest 135
Figure5-1:TheorizedInteragencyCollocationEffectsOverTime 149
Figure6-1:Hartfordunadjustedaccessrates 173
Figure6-2:NewHavenunadjustedaccessrates 173
Figure6-3:Hartfordaccessfinalmodel, Period*GAstatusataccess 187
Figure6-4:NewHavenaccessfinalmodel,Period*GAStatusataccess 188
Figure6-5:HartfordadjustedOtherdiagnosiscostsbyGAstatus 223
Figure6-6:HartfordadjustedMISAcostsbyGAstatus 223
Figure6-7:HartfordadjustedAxis1costsbyGAstatus 224
Figure6-8:NewHavenadjustedMISAcostsbyGAstatus 224
Figure6-9:NewHavenadjustedAxis1costsbyGAstatus 225
Figure6-10:NewHavenadjustedsubstanceabusecostsbyGAstatus 225
Figure6-11:Hartfordraceperiodinteraction,whenGAbenefitsareinactive 231
Figure6-12:Hartfordraceperiodinteraction,whenGAbenefitsareactive 232