Why do states privatize mental health services? Six state experiences. The MEDSTAT Group

State governments fund more than one-half of public mental health service system costs through mental health departments, other state agencies, and the Medicaid program. They use some of these resources to finance community-based mental health services through purchase-of-service contracts. I explored the reasons why states privatize mental health services and focused on political, economic, and organizational theories as possible frameworks for contracting. I gathered data during site visits to Massachusetts, Michigan, New York, Oregon, Tennessee, and Texas, where I interviewed more than one hundred individual stakeholders about mental health purchase-of-service contracting. I also examined relevant documents about contracting practices for mental health services in each state. My results suggest that state policy makers can use mental health contracting to effect multiple goals. Contracting helps states achieve political, economic, and organizational objectives, such as avoiding the influence of interest groups and leveraging state resources, while avoiding conflict. With contracting, state policy makers can also continue the ongoing mental health policy paradigm shift begun during deinstitutionalization, in which persons with serious and persistent mental illnesses receive services from community-based providers rather than in state hospitals. Finally, my results suggest that contracting will continue to be an important state policy tool in further development of state-supported mental health systems.     

Musings of a bureaucratic psychologist.

The value of having a background in both experimental and clinical psychology is evaluated from the perspective of an essentially administrative career. The opportunity to have a significant impact on major public policy issues is an important factor in choosing to become involved in a state bureaucracy. Some of the reasons why states have recently turned to managed care for mental health services are explored. The fact that psychologists have not taken an aggressive role in helping to define how public agencies should move into managed care is unfortunate, both from a public policy standpoint as well as for the future of the profession. The future role of psychologists in the changing mental health-managed care environment is also reviewed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Public and private responsibility for mental health services.

Relative to public services, private sector corporate mental health care has significantly increased since the late 1960s. The many tensions encountered in assigning public and private responsibility for mental health services give rise to significant value-laden questions for psychologists. These questions go to the heart of community mental health, deinstitutionalization, mental health policy development and evaluation, and many other areas in which psychologists are playing major roles. The public–private issue should be understood historically, from the twin vantage points of developments in general medicine and in mental health. Among the many public interest and public policy matters psychologists and others concerned with mental health should address are the emergence of corporate chains; the nature, cost, and quality of private sector services; the compatibility of profit motivation and the motivation to provide care; and patient selection issues (e.g., cream-skimming). Public and private cooperation and planning are certainly in order if the public interest is to be served in addressing the nation's mental health problems. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Evaluating risk and functioning in persons with serious and persistent mental illness.

The Current Evaluation of Risk and Functioning-Revised (CERF-R), an assessment instrument designed for use with adults with severe and persistent mental illness (SPMI) delineates 18 areas of risk and functioning along with judgments regarding level of care needs. Consensus treatment team ratings were obtained on 736 state hospital patients and 2,607 clients receiving public sector mental health services in the community. Results indicate that the CERF-R exhibits a high level of internal consistency, test-retest, and interrater reliability. Concurrent validity was evident for the functional subscale. The functional and risk items successfully discriminate level of service needs. Factor analysis of the CERF-R is consistent with the three primary reasons persons with SPMI need public mental health services. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Carving-out mental health benefits to Medicaid beneficiaries: a shift toward managed care

Several states have designed and implemented innovative programs for Medicaid beneficiaries that carve-out the provision of mental health from general health care. This paper describes several such programs and outlines the choices states face in designing these services. Major decisions include the selection of a public or private agency, how that agency is chosen, reimbursement schemes, eligibility criteria, and benefits to be covered. While carve-out programs have yielded initial savings, more research is needed on their effect on quality of care and general health care costs.     

Developing community capacity to treat post-deployment mental health problems: A public health initiative.

Meeting the mental health needs of Veterans returning from recent deployment requires the coordinated effort of partnerships across Department of Defense (DoD), Department of Veterans Affairs (VA), and state and local communities. Although the proportion of Veterans of Iraq and Afghanistan who have accessed VA health care has grown, the majority of these new combat Veterans have yet to present for VA care. The stigma associated with reporting a deployment-related mental health problem may be one factor in this, but access to treatment may also be an important concern among the one third of American Veterans who live in rural or highly rural areas. As these Veterans are more likely to present to a primary care, faith-based or mental health provider in their own community, partnerships between community providers, DoD, and VA are of critical importance in ensuring appropriate care, regardless of treatment setting. In an effort to improve services and access to services, especially to rural Veterans, an educational public health initiative was created to educate community providers about military culture, deployment-related mental health issues, VA resources, and evidence-based treatments. We describe the development, dissemination and evaluation of this initiative, as well as lessons learned for future similar endeavors. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Health sector reform: lessons from China

As a result of China's transition to a socialist market economy, its rural health services have undergone many of the changes commonly associated with health sector reform. These have included a decreased reliance on state funding, decentralisation of public health services, increased autonomy of health facilities, increased freedom of movement of health workers, and decreased political control. These changes have been associated with growing inequality in access to health services, increases in the cost of medical care, and the deterioration of preventive programmes in some poor areas. This paper argues that the government's strategy for addressing these problems has overemphasised the identification of new sources of revenue and has paid inadequate attention to factors that influence provider behaviour. The strategy also does not address contextual issues such as public sector employment practices and systems of local government finance. Other countries can learn from China's experience by taking a systematic approach to the formulation and implementation of strategies for health sector reform.     

Restructuring public mental health and substance abuse service systems

The authors originally circulated the concepts in this proposal during May 1995. The purpose was to support an open, public dialogue regarding the restructuring of the mental health and substance abuse services in Illinois in anticipation of Medicaid funding changes. Restructuring mental health and substance abuse service systems should follow certain key principles. These principles are applicable to other states, particularly those large in territory and population. The authors propose the temporary use of multiple managed care companies serving as administrative services only (ASO) organizations, each of whom would have responsibility for a given geographic portion of a state. The role of the ASOs would be to organize providers into networks on a regional basis and transfer managed care expertise in financing and clinical management to the relevant state departments and provider groups. Changes in the service delivery system would be phased in over time with reorganization of key components of the system during each phase. Where the provision of mental health, substance abuse, and social services is split among multiple state agencies, these agencies would be merged to achieve unified funding and administrative efficiency. Patients and advocacy organizations would play a key role in overseeing and shaping system restructuring at all levels, including a governmental board reporting to the governor, overseeing ASO organizations' operations and assuring quality and access at the provider level. The authors propose funding of public behavioral health services through use of a tiered, integrated funding model.     

Local Medicare policies: A pathway for providing mental health services to older adults.

Inconsistent local Medicare service coverage policies constitute one of the most prominent barriers encountered by mental health professionals who provide services to older adults. In this study, the authors analyzed the scope and delineation of local Medicare policies for 19 types of psychiatric and psychological services in 2003 and again in 2006. Results indicated policies now exist for all Medicare services in all the states, and many of the local policies provide definitive statements to guide practice. However, some policies lacked delineation and variability persists from one region to the next. While researchers ascertain how local policies can impact service outcomes, providers should form issue networks and resolve current problems such as the inequities surrounding service documentation requirements and the lack of guidance in providing mental health care to older persons with dementia. Given that the Medicare administrative structure will undergo substantive changes in the next five years, there is an exceptional opportunity for providers to address these problems successfully and pave a pathway for providing specialty mental health services to older adults. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Mental health services to children and adolescents: A national view of public policies.

Summarizes and discusses the implications of a national study conducted by the present author (1982) on public policies affecting the delivery of mental health services to disturbed children and adolescents. Relevant state officials and advocacy organizations were surveyed, state reports and child and adolescent mental health statutes were analyzed, federal programs and policies were reviewed, and responsive program models were identified. Findings suggest that there is more knowledge about how to help children and adolescents in need of mental health services than is reflected in the organization, funding, and delivery of these services. Three encouraging developments, policy recommendations, and implications for psychologists are discussed. (28 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Psychologists working for unions: Developing the United Federation of Teachers' Victim Support Program.

This article describes the development of in-house mental health services in a large labor union local representing public school pedagogical employees. It focuses on the role of a psychologist in guiding program components for a targeted membership group through various stages of development: identifying needs, shaping intervention services, and creating a prevention module. It also describes the movement of services beyond the frame of the specific program to encompass a broader array of emergent mental health service needs, including consultation, technical advice, assistance in dealing with mental health managed care, and expansion of clinical–counseling services to a wider range of membership groups. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Discharge of psychiatric patients into the community: how many more must die?

Since the advent of community care, mental health services are increasingly coming under scrutiny, particularly the management of people with mental health problems in the community. Several murders committed by psychiatric patients in the community have fuelled public debate. This article reports on a study examining the recommendations of the Department of Health regarding the discharge of psychiatric patients from hospital to community care. It describes the background to events such as the Clunis report and guidance from the Department of Health on the management of mental health services. Semi-structured interviews, questionnaires and document analysis were used to ascertain the views of community psychiatric nurses and managers regarding the discharge of patients into the community. The findings identify areas of good practice and the need for nurses to improve their knowledge of the care-programming approach, risk assessment and inter-agency collaboration.     

Critical issues in mental health service delivery: what are the priorities?

The director, one other professional, and one para-professional in 515 community mental health centers and 193 state hospitals throughout the United States were asked to rate 57 critical issues in mental health services as to their importance now and five years from now. Issues judged most important now are services for children and for adolescents; five years from now children's services still top the list. Answers to two other questions revealed that respondents placed research on prevention at the top of a list of needed research areas, and that the most useful NIMH service to agencies was person-to-person assistance such as consultation and workshops.     

Children's mental health problems and services: Current federal efforts and policy implications.

This article discusses the current federal role in the collection of information about the mental health problems of children and the provision of mental health services to children. It also describes the federal programs that help finance mental health services, support their coordination, and provide funding for research and training of mental health researchers and clinicians. Recent changes in federal policy are also described. This article, and the Office of Technology Assessment report on which it is based, conclude that although it is in some ways considerable, the federal role in providing mental health services to children is fragmented. This lack of cohesive policies toward children and across service programs may create difficulties for those who would move public policy toward the continuum of care that many observers conclude is needed to address children's mental health needs. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Role of the public health (and environmental) office in urban development--current status and perspectives

Our central question is how the local public health services can influence urban development and urban renewal policies. The need for a three-way cooperation between departments of urban planning and development, environmental affairs and health is now being widely acknowledged. In practice, however, it has to face manifold and serious problems. We suggest that there are basically three essential "instruments" which could lead to a new and defined role of health departments in urban development: environmental and health audits, local health profiles and "health promotion committees" or similar bodies for closer cooperation at the local level. These three "instruments" are described in terms of the present state of development and dissemination by analysing empirical studies from public health research. The results indicate that the "new role" of local health services in urban planning and development is presently fulfilled only in a few pilot cases. The lack of basic requirements particularly in terms of resources, motivation and qualifications is the main cause for the inability to implement the three "instruments" on a broader level in local health services.     

Providing mental health care services to Americans.

Summarizes legislation introduced or cosponsored by the author, a US Senator from Minnesota, to respond to Americans' need for mental health services. This legislation included the Medicare Ambulatory Mental Health Services Access Amendments of 1987; S.123, a bill that would amend Part B of the Medicare program to recognize and reimburse psychologists as independent mental health providers; S.763, the Services for Homeless Mentally Ill Individuals Act of 1987; S.809, the Urgent Relief for the Homeless Act; and S.1663, the Child Abuse Prevention Act of 1987. The author encourages mental health professionals to promote public policies that expand Americans' access to public health services through research, effective communication of this research, and preventive mental health efforts (such as programs aimed at preventing teen suicide). (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Psychologist by training, bureaucrat by practice.

Communication with Congress; state and local officials; and numerous professional, advocacy, scientific, and public interest groups is essential to working on mental health and substance abuse issues at the federal policy level. The public administrator's work is diverse and fast-paced, involving issue analysis, proposal development and justification, public speaking, and dialogue with advocacy and policy analysis groups. Making decisions that will serve the public good in the long run is the core of the job. As the competition for resources escalates, the perspectives' of consumers of services and their families are important to guide decisions. In a career that is based on interactions, relationships, judgments, and evaluation of multifaceted issues, success is measured by a reputation for fairness and by accomplishments that are based on numerous individual decisions. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Utilization of psychologists in positions of responsibility in public mental health programs: A national survey.

Describes a 1969 survey of mental health programs in all 50 states. To document current status and provide precedence data, the survey sought information concerning positions including these at a divisional level within state programs and as program director of community mental health centers. 1/2 the states had psychologists as divisional chiefs, while in 75% of the states, the principle of competence in the appointment of local community mental health program directors was formally recognized. (PsycINFO Database Record (c) 2010 APA, all rights reserved)