Title: Assessing MHICM: Program Effects on Mental Health Care Utilization and Costs*,** *Funding from HSR
1Assessing 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
2The 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)
3MHICM
4The 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
5Objectives
- 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
6Net Impact ()
7Declining 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
8Expected Cost Consequences of MHICM
VA Trend in Inpatient Psych Days Per Patient
Net Savings
0
Net Costs
Net Savings from MHICM ()
Time
9Study 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
10Study Timeline
Enrolled
MHICM Enrollees
Months
-12
0
12
High Hospital Use
Eligible
MHICM Eligible Non-Enrollees
Months
-12
12
0
High Hospital Use
11Sample
- 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
12Sample
- 2,102 new MHICM clients
- 25,630 MHICM-eligible non-enrollees
13Estimation
- Potential selection bias
- Enrollment into MHICM could be related to
severity of illness or need for MHICM -
14Estimation
- 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.
15Estimation
- 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(No Transcript)
17Estimation
- IV methods with non-linear outcomes required
modification of the model - Terza, Basu, Rathouz, J. Health Econ, 2008
- Estimate
- Obtain
- Estimate
18Estimation
- 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
19Estimation
- 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)
20One-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
21Descriptive characteristics pre-/post- matching Descriptive characteristics pre-/post- matching Descriptive characteristics pre-/post- matching Descriptive characteristics pre-/post- matching Descriptive characteristics pre-/post- matching Descriptive characteristics pre-/post- matching Descriptive characteristics pre-/post- matching
Unmatched Sample (N28,032) Unmatched Sample (N28,032) Unmatched Sample (N28,032) Matched Sample (N4,204) Matched Sample (N4,204) Matched Sample (N4,204)
No MHICM MHICM No MHICM MHICM
Male 92.7 90.6 90.2 90.6
Age in years 51.9 51.3 51.2 51.3
Any inpatient psych care past 30 days 45.3 67.3 66.0 67.3
Inpatient psych days past 12 months 51.5 68.5 68.1 68.5
Inpatient psych stays past 12 months 2.7 2.7 2.7 2.7
Partial hospital days past 12 months 3.3 9.8 10.6 9.8
Schizophrenia dx 62.2 80.3 81.4 80.3
Homeless past 12 months 36.2 26.5 27.6 26.5
with a service connected disability rating gt50 48.3 54.3 54.8 54.3
Substance use dx 57.5 47.3 48.2 47.3
Charlson comorbidity index 0.75 0.70 0.70 0.70
Died during 12 month follow-up period 10.7 4.4 4.4 4.4
Differs from No MHICM at Plt.05 Differs from No MHICM at Plt.05 Differs from No MHICM at Plt.05 Differs from No MHICM at Plt.05 Differs from No MHICM at Plt.05 Differs from No MHICM at Plt.05 Differs from No MHICM at Plt.05
22Mean use of mental health services during the first 12-months post-enrollment matched sample, N4,204 Mean use of mental health services during the first 12-months post-enrollment matched sample, N4,204 Mean use of mental health services during the first 12-months post-enrollment matched sample, N4,204
No MHICM(N2,102) MHICM(N2,102)
Any Service Use ()
Inpatient Psychiatric 57.9 61.2a
Partial Hospital 18.4 29.9a
Other Mental Health Outpatientb 85.3 80.5a
Nursing Home 10.4 4.3a
Days of Service Usec
Inpatient Psychiatric
Per year 50.1 36.3a
Per stay 26.3 15.1a
Partial Hospital 59.9 52.3a
Other Mental Health Outpatientb 19.2 17.5a
Nursing Home 184.4 98.8a
a Different from No MHICM at Plt.05 b All non-MHICM outpatient mental health services c Among persons with some use of services in category a Different from No MHICM at Plt.05 b All non-MHICM outpatient mental health services c Among persons with some use of services in category a Different from No MHICM at Plt.05 b All non-MHICM outpatient mental health services c Among persons with some use of services in category
23Estimated marginal effects of MHICM services on use of other mental health services in the first 12 months post enrollment, by service category matched sample, N4,204 Estimated marginal effects of MHICM services on use of other mental health services in the first 12 months post enrollment, by service category matched sample, N4,204 Estimated marginal effects of MHICM services on use of other mental health services in the first 12 months post enrollment, by service category matched sample, N4,204 Estimated marginal effects of MHICM services on use of other mental health services in the first 12 months post enrollment, by service category matched sample, N4,204 Estimated marginal effects of MHICM services on use of other mental health services in the first 12 months post enrollment, by service category matched sample, N4,204 Estimated marginal effects of MHICM services on use of other mental health services in the first 12 months post enrollment, by service category matched sample, N4,204 Estimated marginal effects of MHICM services on use of other mental health services in the first 12 months post enrollment, by service category matched sample, N4,204 Estimated marginal effects of MHICM services on use of other mental health services in the first 12 months post enrollment, by service category matched sample, N4,204 Estimated marginal effects of MHICM services on use of other mental health services in the first 12 months post enrollment, by service category matched sample, N4,204 Estimated marginal effects of MHICM services on use of other mental health services in the first 12 months post enrollment, by service category matched sample, N4,204 Estimated marginal effects of MHICM services on use of other mental health services in the first 12 months post enrollment, by service category matched sample, N4,204
Standard Standard Standard Standard Instrumental Variables Instrumental Variables Instrumental Variables Instrumental Variables
Service Category µ0a ME t P ME z P
Any Service Use
Inpatient Psychiatric 0.648 0.033 2.11 0.035 -0.084 -1.57 0.117
Partial Hospital 0.169 0.128 10.16 lt0.001 0.486 24.08 lt0.001
Other Mental Health Outpatientb 0.927 -0.050 -4.41 lt0.001 -0.256 -6.89 lt0.001
Nursing Home 0.061 -0.047 -6.72 lt0.001 -0.011 -0.51 0.607
Days of Service Usec
Inpatient Psychiatric
Per Year 56.0 -7.5 -3.22 0.001 -29.5 -2.73 0.006
Per Stay 30.4 -9.1 -7.18 lt0.001 -21.7 -3.76 lt0.001
Partial Hospital 38.5 -5.8 -1.67 0.095 -1.1 -0.10 0.924
Other Mental Health Outpatientb 14.7 -0.1 -0.14 0.890 7.9 3.54 lt0.001
Nursing Home 159.1 -28.1 1.61 0.107 -94.3 -1.37 0.171
Plt.05 Plt.01 Plt.001 Plt.05 Plt.01 Plt.001 Plt.05 Plt.01 Plt.001 Plt.05 Plt.01 Plt.001 Plt.05 Plt.01 Plt.001 Plt.05 Plt.01 Plt.001 Plt.05 Plt.01 Plt.001 Plt.05 Plt.01 Plt.001 Plt.05 Plt.01 Plt.001 Plt.05 Plt.01 Plt.001 Plt.05 Plt.01 Plt.001
a Estimated average among MHICM-eligible non-enrollees a Estimated average among MHICM-eligible non-enrollees a Estimated average among MHICM-eligible non-enrollees a Estimated average among MHICM-eligible non-enrollees a Estimated average among MHICM-eligible non-enrollees a Estimated average among MHICM-eligible non-enrollees a Estimated average among MHICM-eligible non-enrollees a Estimated average among MHICM-eligible non-enrollees a Estimated average among MHICM-eligible non-enrollees a Estimated average among MHICM-eligible non-enrollees a Estimated average among MHICM-eligible non-enrollees
b All non-MHICM mental health outpatient services b All non-MHICM mental health outpatient services b All non-MHICM mental health outpatient services b All non-MHICM mental health outpatient services b All non-MHICM mental health outpatient services b All non-MHICM mental health outpatient services b All non-MHICM mental health outpatient services b All non-MHICM mental health outpatient services b All non-MHICM mental health outpatient services b All non-MHICM mental health outpatient services b All non-MHICM mental health outpatient services
c Estimates for persons with any service use in each category c Estimates for persons with any service use in each category c Estimates for persons with any service use in each category c Estimates for persons with any service use in each category c Estimates for persons with any service use in each category c Estimates for persons with any service use in each category c Estimates for persons with any service use in each category c Estimates for persons with any service use in each category c Estimates for persons with any service use in each category c Estimates for persons with any service use in each category c Estimates for persons with any service use in each category
24Adjusted effects of MHICM on average service days, first 12 months post-enrollment (matched sample) Adjusted effects of MHICM on average service days, first 12 months post-enrollment (matched sample) Adjusted effects of MHICM on average service days, first 12 months post-enrollment (matched sample) Adjusted effects of MHICM on average service days, first 12 months post-enrollment (matched sample) Adjusted effects of MHICM on average service days, first 12 months post-enrollment (matched sample)
Without MHICM With MHICM ? ?
Standard
Inpatient psychiatric 28.0 24.2 -3.8 -14
Partial hospital 7.0 10.6 3.6 52
Other mental health outpatient 16.1 14.7 -1.4 -9
Instrumental Variables
Inpatient psychiatric 28.0 14.8 -13.2 -47
Partial hospital 7.0 28.0 21.0 300
Other mental health outpatient 16.1 10.3 -5.8 -36
N4,204 N4,204 N4,204 N4,204 N4,204
25Adjusted effects of MHICM on VA costs, first 12 months post-enrollment (matched sample) Adjusted effects of MHICM on VA costs, first 12 months post-enrollment (matched sample) Adjusted effects of MHICM on VA costs, first 12 months post-enrollment (matched sample) Adjusted effects of MHICM on VA costs, first 12 months post-enrollment (matched sample) Adjusted effects of MHICM on VA costs, first 12 months post-enrollment (matched sample)
Without MHICM With MHICM ? ?
Standard
Total cost 31300 32541 1241 4
Inpatient psychiatric 25913 19976 -5937 -23
Partial hospital 1007 1585 577 57
Other mental health outpatient 1365 1254 -111 -8
Instrumental variables
Total cost 31300 33666 2366 7
Inpatient psychiatric 25913 16985 -8927 -34
Partial hospital 1007 5468 4460 443
Other mental health outpatient 1365 1447 83 6
N4,204 Average MHICM cost is 7669 N4,204 Average MHICM cost is 7669 N4,204 Average MHICM cost is 7669 N4,204 Average MHICM cost is 7669 N4,204 Average MHICM cost is 7669
26Net 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
27Implications
- 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
28Future Work
- What happens to utilization/costs in the second
year of MHICM? - What predicts disengagement from MHICM?
- Does fidelity to the ACT model matter?
29Thank you!
- Contact Information
- Eric Slade
- VISN5 Capitol Network MIRECC
- Baltimore, Maryland
- Eric.Slade_at_va.gov
- 410-706-2490