Assessing MHICM: Program Effects on Mental Health Care Utilization and Costs*,** *Funding from HSR - PowerPoint PPT Presentation

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Assessing MHICM: Program Effects on Mental Health Care Utilization and Costs*,** *Funding from HSR

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Assessing MHICM: Program Effects on Mental Health Care Utilization and Costs ... What happens to utilization/costs in the second year of MHICM? ... – PowerPoint PPT presentation

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Title: Assessing MHICM: Program Effects on Mental Health Care Utilization and Costs*,** *Funding from HSR


1
Assessing MHICM Program Effects on Mental Health
Care Utilization and Costs,Funding from
HSRD grant IIR 06-115 and the VISN5
MIRECCData provided by the following VA
research centers SMITREC, NEPEC, and HERC
  • Investigators Eric Slade1,2
  • Lisa Dixon1,2
  • Marcia Valenstein3,4
  • John McCarthy3,4
  • Analysts Stephanie Visnic3, Rose Ignacio3,
    Deborah Welsh3, Lan Li1,2
  • 1VISN 5 Mental Illness Research and Education
    Clinical Center, Baltimore
  • 2University of Maryland School of Medicine
  • 3VA Serious Mental Illness Treatment Research and
    Evaluation Center, Ann Arbor
  • 4University of Michigan School of Medicine

2
The MHICM Program
  • A psychiatric hospital without walls
  • Uses the Assertive Community Treatment (ACT)
    model.
  • Similar in staffing intensity to inpatient
    psychiatric care
  • Team-based mobile care
  • Small caseloads per team member
  • Team available 24/7
  • Care is comprehensive
  • Improves patients quality of life and
    satisfaction with care, and reduces their
    inpatient utilization
  • 1980s VA randomized trials of Intensive
    Psychiatric Community Care (IPCC) (Rosenheck et
    al., 1995 1998)

3
MHICM
4
The MHICM Program
  • Formally implemented as MHICM in FY2000
  • Implemented high hospital use entry criterion
  • Rapid growth
  • FY00 FY07
  • Teams 46 100
  • Clients 2,655 7,609
  • Cost 14.5 mil. 46 mil.
  • lt10 of eligible veterans have enrolled
  • MHICM programs require a max. client-staff ratio
    of 12 to 1

5
Objectives
  • Estimate the effects of MHICM on mental health
    services utilization during the first 12 months
    following clients first enrollment in MHICM
  • psychiatric inpatient days of stay
  • partial hospital program days
  • other outpatient mental health days
  • Assess the VA cost consequences of the MHICM
    program

6
Net Impact ()
7
Declining VA psychiatric inpatient use may reduce
savings achieved with MHICM
Trend in VA Psychiatric Inpatient Use
  • FY00 FY07 ?
  • LOS (Days) 15.0 11.4 -24
  • Bed Census 4,106 2,958 -28
  • Bed Days/Veteran 22.0 16.8 -24

8
Expected Cost Consequences of MHICM

VA Trend in Inpatient Psych Days Per Patient

Net Savings
0
Net Costs
Net Savings from MHICM ()
Time
9
Study Design
  • Retrospective observational design
  • Sample MHICM-eligible VA patients in FY01 to
    FY04
  • Intervention Enrollment in MHICM
  • Comparison Usual care
  • Follow-up period The 12-month period following
    either MHICM initiation or becoming MHICM-eligible

10
Study Timeline
Enrolled
MHICM Enrollees
Months
-12
0
12
High Hospital Use
Eligible
MHICM Eligible Non-Enrollees
Months
-12
12
0
High Hospital Use
11
Sample
  • Data sources
  • VA National Psychosis Registry (SMITREC)
  • VA MHICM enrollment data archive (NEPEC)
  • VA HERC Average Costs data archive
  • Inclusion criteria
  • Schizophrenia or bipolar disorder diagnosis
  • Residence within 60 miles of a VA hospital
  • Recent history of high hospital use
  • Inpatient psychiatric utilization of gt30 days or
    3 stays in the past 12 months

12
Sample
  • 2,102 new MHICM clients
  • 25,630 MHICM-eligible non-enrollees

13
Estimation
  • Potential selection bias
  • Enrollment into MHICM could be related to
    severity of illness or need for MHICM

14
Estimation
  • Want to estimate E(yx,M), where
  • yi a0 a1xi dMi ui.
  • d is the average effect of MHICM on study outcome
    y.
  • E(u)0, Cov(M,u)0 are key assumptions of model.
  • Initiation into MHICM services
  • Pr(Mi 1) F(ß0 ß1zi vi)
  • If Cov(v,u) ? 0 Cov(M,u) ? 0, and regression
    estimates of d will be biased and inconsistent.

15
Estimation
  • Propensity score one-to-one matching was used to
    balance the sample on observable
    characteristics z
  • If selection into MHICM is correlated with
    unmeasured confounders,
  • i.e., E(yz,M,v) ? E(yz,M)
  • propensity score matching will not alleviate
    bias
  • ? Method of instrumental variables was used to
    further minimize selection bias
  • But, there is another complication

16
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17
Estimation
  • IV methods with non-linear outcomes required
    modification of the model
  • Terza, Basu, Rathouz, J. Health Econ, 2008
  • Estimate
  • Obtain
  • Estimate

18
Estimation
  • IV model requires that z include at least one
    variable that is not in x
  • These instruments must be correlated with M but
    not with y conditional on M
  • For tests of these assumptions, see Baum et. al.,
    Stata Journal, 7(4), 2007.
  • Instruments
  • distance to the nearest MHICM team and
  • whether a MHICM team was onsite at the VA
    hospital where client had last psych inpatient
    stay

19
Estimation
  • Used two-part generalized linear model (GLM)
  • P(y) gt 0 (vs. 0) modeled as a normally
    distributed binary random variable
  • E(y y gt 0) modeled as a gamma distributed
    random variable with a log link
  • ln E(y) a0 a1xi dMi
  • where y is gamma distributed.
  • To calculate averages, used
  • E(y) P(ygt0)E(yygt0)

20
One-to-One Matching
  • Pre-matching
  • 2,102 new MHICM clients
  • 25,630 MHICM-eligible non-enrollees
  • Post-matching
  • 2,102 new MHICM clients
  • 2,102 MHICM-eligible non-enrollees

21
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22

23
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24
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25
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26
Net savings from MHICM during the 1st year of
enrollment
HIGHER
LOWER
Inpatient Use in the Year Prior to MHICM
Average effect
Clients' Inpatient Psych Days of Stay 1 Yr Prior
to MHICM
27
Implications
  • MHICM is a cost-effective program
  • However, financial savings from MHICM have
    decreased
  • Future expansions should continue to focus on the
    disabled
  • Enrollment in MHICM increases subsequent use of
    partial hospitalization program services
  • Unclear whether this effect is desirable
  • Thousands of MHICM-eligible VA patients are not
    enrolled in MHICM
  • Persons who are homeless, have concurrent
    substance use conditions, and reside further away
    from MHICM teams may have less access than others

28
Future Work
  • What happens to utilization/costs in the second
    year of MHICM?
  • What predicts disengagement from MHICM?
  • Does fidelity to the ACT model matter?

29
Thank you!
  • Contact Information
  • Eric Slade
  • VISN5 Capitol Network MIRECC
  • Baltimore, Maryland
  • Eric.Slade_at_va.gov
  • 410-706-2490
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