Annotated Bibliography - Special Populations

This special supplementary section of the bibliography provides an independently produced annotated bibliography on managed behavioural healthcare prepared for the US Substance Abuse and Mental Health Services Administration; please see the first page of the supplement for recommended citation information.

Table of Contents

  1. Introduction
  2. Benefit and System Design
  3. Capitation
  4. Community Mental Health Services
  5. Diagnosis-Related Groups (DRGs)
  6. Economics, Forecasting, and Pricing
  7. Employee Assistance Programs (EAPs)
  8. Health Maintenance Organizations (HMOs)
  9. Law and Ethics
  10. Provider Issues
  11. Public Sector
  12. Quality Assurance and Outcomes
  13. Special Populations
    1. Children
    2. Elderly
    3. Ethnic Groups
    4. Women
  14. Substance Abuse
  15. Training and Education
  16. Utilization Management
  17. Author Index
  18. Keyword Index

Special Populations


334. Eisen, S., Griffin, M., Sederer, L., Dickey, B., & Mirin, S. M. (1995). The impact of preadmission approval and continued stay review on hospital stay and outcome among children and adolescents. The Journal of Mental Health Administration 22(3), 270-277.

This article reports on results of a study that used a multiple regression model to predict the impact of utilization review on length of inpatient stay and clinical outcomes for children and adolescents under 18 years of age. The independent variables used in the model included demographic and clinical characteristics, hospital ownership type, and pre-admission approval or continued stay review. Results of the study indicated that only two of the 10 predictor vari-ables included in the model were statistically significant in predicting length of stay: previous psychiatric hospitalization and for-profit hospital status. The model was unsuccessful in accounting for a significant amount of the variance in hospital outcome. The authors conclude with a discussion of limitations of the study, and the implications of the findings for health care reform.
Keywords: children, outcomes, utilization management

335. Gresenz, C. R., Liu, X., & Sturm, R. (1998). Managed behavioral health services for children under carve-out contracts. Psychiatric Services, 49(8), 1054-1058.

Amidst the recent growth in managed care organizations that specialize in administering behavioral health care benefits apart from general health services, few studies have focused on the effects of these new carve-out plans on children. In this study, researchers investigated children’s cost and utilization patterns in carve-out plans and compared them with the pat-terns of adults in these plans. From the results, adolescents in this plan were twice as likely as adults and about seven times as likely as children ages 6 to 12 to use inpatient services. Adolescents were also more likely than adults or other children to have higher inpatient costs, while adults were the most likely to have higher outpatient costs. The authors conclude that adolescents may benefit most from the elimination of caps on mental health care costs covered by insurance.
Keywords: carve-outs, children, costs, utilization

336. Kaplan, D. W., Calonge, B. N., Guernsey, B. P., & Hanrahan, M. B. (1998). Managed care and school-based health centers. Archives of Pediatric and Adolescent Medicine 145, 25-33.

This article examines the use of physical and mental health services for adolescents who par-ticipate in managed care organizations, comparing those who have access to school-based health centers (SBHCs) to those who do not. The study specifically looked at the use of pri-mary and specialty medical, mental health, substance abuse, preventative health, and urgent care services. Results showed that adolescents with access to SBHCs were 10 times more likely to make a mental health or substance abuse visit than non-SBHC students. Students with access to SBHCs made one more medical visit per year, had decreased rates of use of emergency or urgent care, were more likely to have one comprehensive health supervision visit, and were more likely to be screened for high-risk behaviors than students without access to SBHCs. SBHCs were shown to be very successful in improving access to treatment for mental health and substance abuse problems and to comprehensive health supervision.
Keywords: children, school-based health, substance abuse, utilization

337. Jellinek, M., & Little, M. (1998). Supporting child psychiatric services using current managed care approaches. Archives of Pediatric and Adolescent Medicine, 152(4), 321-326.

This report details specific business approaches used by for-profit behavioral health care companies that have carved out mental health services for children. First, the authors discuss the evolution of managed mental health services and the negative implications of managing the care of children by limiting access and shifting costs to the public sector and pediatricians. These factors are not sufficiently counterbalanced by some of the positive changes, such as lower costs from the decreased utilization of inpatient services within managed care, and political pressure by legislative means. Ultimately, the commentary recommends that child and adolescent psychiatric services should be reintegrated into the overall medical care of children and families, and that market-driven managed care allocations are not the optimal path to achieve high-quality mental health services for the Nation’s most vulnerable children.
Keywords: carve-outs, children

338. Lourie, I. S., Howe, S. W., & Roebuck, L. L. (1996). Systematic approaches to mental health care in the private sector for children, adolescents, and their families: Managed care organizations and service providers. Washington, DC: Georgetown University Child Development Center, National Technical Assistance Center for Child Mental Health.

In this study of private sector models for delivering mental health services to children, adoles-cents, and their families, researchers examined five provider sitesÑtwo managed care organiza-tions and three service provider agenciesÑall of which offer their own managed care products. Among the findings are the lack of a true system of care in the private sector including mecha-nisms for access to services, case management/coordination at the client level, coordination across agencies, and mechanisms for financing services; the positive potential for managed care; and the growing private sector continuum of care. The book provides in-depth analysis of managed care organizations, service providers, and public/private integration issues. Appendices include site visit reports, values and principles for the System of Care outlined by the Federal Child and Adolescent Service System Program, a list of advisers, a list of qualified nominated organizations, and the private system of care questionnaire.
Keywords: children, evaluation, integration, models

339. Mason, M. J. (1998). School-based health clinics and the role of mental health services: A review of the literature. Journal of Health and Social Policy, 10(2), 1-13.

This article begins by establishing the heightening national concern about targeting mental health and substance abuse problems in children, and points to goals cited in the Healthy People 2000 initiative. It describes the origins and growth of the school-based health center (SBHC) as a model of service delivery that effectively broadens access to health services in general for children and adolescents. According to the author, SBHCs play an important role in delivering counseling, assessment, and referral services for mental health and substance abuse problems. A variety of issues affecting the proliferation of SBHCs are discussed, includ-ing the need to build in systematic research protocols that would aid in accounting for the cost-effectiveness of services delivered in these facilities. Some other issues addressed are current and potential future sources of funding for SBHCs, the need for attention to public relations concerns, and the impact of managed care on SBHCs. Managed care organizations (MCOs) have traditionally been reluctant to contract with SBHCs because of the difficulty they have in meeting practice guidelines of the MCOs. The article calls for research initiatives to prove the importance and effectiveness of SBHCs in delivering mental health services to youth.
Keywords: children, overviews, school-based health, substance abuse

340. Nicholson, J., Young, S. D., Simon, L., Bateman, A., & Fisher, W. H. (1996). Impact of Medicaid managed care on child and adolescent emergency mental health screening in Massachusetts. Psychiatric Services, 47(12), 1344-1350.

This article reports on an initial evaluation of the impact of the Massachusetts Medicaid managed mental health reform on service use and dispositions for children and youth through an examination of the emergency mental health screening process. The study com-pared client attributes and system characteristics (payer, referral source, and disposition) for emergency mental health screenings for the year before and the first year after implementa-tion of Medicaid managed care. The study found that after the implementation of managed Medicaid mental health and substance abuse benefits, the volume of emergency mental health screening for children and adolescence significantly increased, while the percentage of inpatient admissions decreased. The authors further discuss these findings and the necessity to address issues of quality of care and longer term savings.
Keywords: carve-outs, children, evaluation, Massachusetts, Medicaid, public sector

341. Nicholson, J., Young, S. D., Simon, L. J., Fisher, W. H., & Bateman, A. (1998). Privatized Medicaid managed care in Massachusetts: Disposition in child and adolescent mental health emergencies. The Journal of Behavioral Health Services and Research, 25(3), 279-292.

Against the backdrop of Massachusetts’s transition to Medicaid managed care, this study investigates two questions: the impact of privatized Medicaid managed care on the level of care provided to children and adolescents with the greatest clinical need, and the relationship between payer source and disposition. To answer these questions, the researchers examined data from child and adolescent emergency mental health screening episodes before and after privatized Medicaid managed care. They found that the transition to Medicaid managed care decreases the likelihood of hospitalization by more than 60 percent for individuals covered by Medicaid compared with those covered by HMOs. Additionally, privatized Medicaid managed care does not seem to compromise quality of care, as measured by matching clinical need with level of care. The authors describe the multiple forces shaping professional standards, decision making, and quality of care as well as implications for behavioral health policymakers.
Keywords: carve-outs, children, evaluation, Massachusetts, Medicaid, utilization

342. Pumariega, A. J., Nace, D., England, M. J., Diamond, J., Fallong, T., Hanson, G., Lourie, I., Marx, L., Solnit, A., Grimes, C., Thurber, D., & Graham, M. (1997). Community-based systems approach to children’s managed mental health services. Journal of Child and Family Studies, 6(2), 149-164.

As managed care principles infiltrate into the children’s mental health service delivery system, there is concern that they could deprive children of necessary intervention and prevention serv-ices. In this paper, the authors review guidelines developed by the American Academy of Child and Adolescent Psychiatry for the implementation of managed Medicaid contracts through community-based systems of care principles. The authors describe the development and princi-ples of the community-based systems approach as a means to ensure that the needs of seriously emotionally disturbed children are met within the health system. The key principles of the sys-tem of care approach include access to a comprehensive array of services, individualized treat-ment, treatment in the least restrictive environment possible, full participation of families, interagency coordination, early identification and intervention, care management, advocacy efforts, effective transition into the adult system, and culturally sensitive services. The authors also examine the community-based systems approach to managed care, including guidelines on governance, benefit design, access to care, assessment, care plan development, treatment services, care management, quality, provider supports, and information management.
Keywords: children, contracting, Medicaid, overviews

343. Scholle, S. H., Kelleher, K. J., Childs, G., Mendeloff, J., & Gardner, W. P. (1997). Changes in Medicaid managed care enrollment among children. Health Affairs, 16(2), 164-170.

This study looks at voluntary enrollment and disenrollment data for Medicaid managed care in Allegheny County, PA, paying particular attention to patterns among children with mental illness. Self-selection patterns for managed care versus fee-for-service are significant because patients who voluntarily choose managed care are generally in better health and have lower utilization of health care services. This phenomenon can distort data about managed care per-formance, consumer satisfaction, cost savings, and other factors, and may benefit plans finan-cially if capitation payments are not risk-adjusted. These authors are particularly concerned with patients with mental illness, because managed care plans have traditionally provided a low level of mental health services. Results of this study indicate that markers for more severe mental illness were associated with lower levels of enrollment in managed care. In addition, disabled children and those receiving cash assistance were less likely to enroll. Disenrollments were higher for children with psychiatric conditions than for children with other conditions. The authors discuss causes of these trends and make policy recommendations.
Keywords: children, Medicaid, Pennsylvania, public sector

344. Semlitz, L. (1996). Adolescent substance abuse treatment and managed care. Child and Adolescent Psychiatric Clinics of North America, 5(1), 221-241.

This paper examines the impact of managed care on adolescent substance abuse treatment planning and care delivery. The author describes the emergence of the managed care era from the traditional fee-for-service system, including the types of managed care plans; the impact on the doctor-patient relationship; responses of insurance companies/HMOs, hospitals, and physicians to managed care; the idea of managed competition; and the trend toward capita-tion. Other components of managed care reviewed include patient placement criteria, patient treatment matching, outcome as a factor in treatment planning, treatment plan documenta-tion, successful treatment plans, and utilization review. The author examines the impact of managed care on substance abuse services and discusses ethical issues of managed care on the doctor-patient relationship, such as the importance of patient confidentiality, standards of review, and the prohibition of incentives to withhold care.
Keywords: children, substance abuse

345. Stroul, B. A., Pires, S. A., & Armstrong, M. I. (1998). Health care reform tracking project: Tracking state managed care reforms as they affect children and adolescents with behavioral health disorders and their families. Tampa, FL: University of South Florida Research and Training Center for Children’s Mental Health.

This is a report on calendar year 1997 of a 5-year project designed to track and analyze public sector managed care reform targeting children and adolescents with emotional and substance abuse problems and their families. The authors outline the specific goals of this report as describing the managed care reforms that affect behavioral health care for children and adolescents, analyzing the effects of these changes, and identifying both problem areas and effective strategies to help refine managed care systems for this vulnerable population. This report surveys all of the States on a broad range of managed care topics, and then analyzes the impact through examples from in-depth site visits to a select sample of States. The track-ing project finds that there is a wide variation in the extent to which States assume an active role in designing and overseeing managed care systems for this population.
Keywords: children, overviews, public sector, substance abuse


346. Colenda, C. C., Banazak, D., & Mickus, M. (1998). Mental health services in managed care: Quality questions remain. Geriatrics, 53(8), 49-63.

This article is intended to be useful to primary care health professionals who may be called upon to counsel their patients about decisions on whether to enroll in a Medicare managed care plan. The authors are particularly concerned that patients be well informed about the nature of mental health services delivered by these plans. In this article the authors profile Medicare risk contract plans, identify pros and cons, define and explain the difference between "carve-outs" and "carve-ins," and explain what patients should expect from a plan’s staffing model with regard to adequate numbers of mental health providers. Finally, the article discuss-es potential advantages and disadvantages of managed care plans specific to the prevention and treatment of Alzheimer’s disease.
Keywords: elderly, HMOs, overviews

347. Robinson, G. K., Crow, S. E., & Scallet, L. J. (1998). Managed care policy: Meeting the mental health needs of the aged? Generations, 22(2), 58-62.

With many States moving to managed care in an effort to control public health care costs, the question arises of how managed care will affect mental health care for the elderly. This paper explores the approaches States are taking to manage public mental health services. In particular, the researchers focus on the advantages and disadvantages of integrated and carved-out mental health services as well as the different types of reimbursement. They describe one example of a program enrolling people eligible for both Medicaid and Medicare as a potential model for other programs for mental health care for the elderly. Finally, the authors present some policy questions concerning the methods and feasibility of managed mental health plans for the elderly.
Keywords: elderly, overviews, public sector


348. Dana, R. H. (1998). Problems with managed mental health care for multicultural populations, Psychological Reports, 83, 283-294.

This article suggests that current psychological treatment is inadequate in its consideration and treatment of multicultural populations. It explains that historically, interventions in the United States were designed primarily for Americans of European descent, and thus were oriented toward Caucasian patients. The author argues that managed care has reduced the availability and quality of these interventions for all patients and further limited the evolution and diversi-fication of treatment toward nonwhite patients. Culturally competent mental health services are described and related to the quality of care. An agenda for the implementation of culturally sensitive services is suggested.
Keywords: ethnic groups

349. Snowden, L. R. (1998). Managed care and ethnic minority populations. Administration and Policy in Mental Health, 25(6), 581-592.

This article addresses the impact on minority populations of changes in mental health practice patterns and utilization resulting from managed care. Differences in utilization of the mental health system across racial/ethnic groups and problems with the cultural appropriateness or accessibility of mental health services preceded the advent of managed care growth. Nonethe-less, these problems take a new form within the context of managed care. While oversight, coordination, and accountability may be beneficial aspects of managed care for minorities, other aspects can be detrimental. The inflexibility of when and where services can be accessed and the potentially intimidating and confusing nature of the bureaucracy are potential prob-lem areas. Additionally, the average cost of care per patient differs across ethnic groups, meaning that a reimbursement strategy based on capitation may create incentives to under-treat these clients or avoid covering them altogether. Further areas of concern are addressed, and some policy solutions are proposed.
Keywords: capitation, ethnic groups, overviews


350. Glied, S. (1997). The treatment of women with mental health disorders under HMO and fee-for-service insurance. Women & Health, 26(2), 1-16.

This report analyzes data on office visits by women with mental health problems from 1990 to 1994 to examine characteristics of office visits by payment type. The study finds that the expansion of managed care practices may harm the treatment of women with mental health problems. Specifically, women enrolled in HMOs are more likely to see a primary care physi-cian rather than a specialist, and of the women in specialty care, those in HMOs are more Special Report 136 likely to have medications substituted for psychotherapy than are those with fee-for-service payments. The author suggests that a possible solution might be to allow self-referral for women to lower cost specialty care.
Keywords: HMOs, women

351. Huskamp, H. A., Azzone, V., & Frank, R. G. (1998). Carve-outs, women, and the treatment of depression. Women’s Health Issues, 8(5), 267-282.

This article examines the impact of "carving out" mental health services on the treatment of depression in women. The first part of the article provides background information on behavioral health care carve-outs, describing the market functions of the two general forms of carve-outs, the health plan subcontract, and the payer carve-out. The authors provide an overview of women and depression and suggest some possible effects of carve-outs on the treatment of depression in women. The authors then report on their analyses of three separate employer-based data sets, which allowed them to examine the impact of behavioral health carve-outs on service utilization and spending for women with a diagnosis of depression. The first data set was used to examine a cross section of health plans. The other data sets were used to look at pre-post-comparison of a health plan subcontract model and an employer carve-out model.
Keywords: carve-outs, costs, depression, utilization, women

352. Newell, A. R., & Saltzman, G. M. (1997). The impact of managed mental health care on women. Journal of the American Medical Women’s Association, 52(2), 69-74.

Based upon differences in epidemiological patterns of mental illness in men and women, aspects of psychodynamic theory, and evidence from outcome and cost studies, these authors suggest that managed behavioral health care will have a differential impact on the receipt of mental health care by women. Women are more likely to seek mental health services, to be diagnosed with conditions that require care exclusively through the health care system, and to have conditions such as eating disorders or trauma from abuse that require long-term treat-ment. Various restrictions and cost-saving strategies involved in managed care strategies will therefore disproportionately affect women. This article argues that certain managed care cost-saving strategies do not make sense in light of evidence from cost-benefit studies of mental health services. Instead, the authors argue for more focused and appropriate managed care interventions, innovation in treatment methods, and legislation for minimum standards.
Keywords: overviews, women

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This page was last reviewed by Dr Greg Mulhauser, Thursday, 14 October 2021.