Venue: The Fuqua School of Business, Duke University, 1 Towerview Drive, Durham, NC 27708-0120
Presentation
Changes in Service Use and Costs Under Managed Competition
Specific Aims: To analyze changes in service delivery and costs among seven Adult and Older Adult Mental Health Services (AOAMHS) outpatient and case management programs involved in Managed Competition (MC)
Background: During the fiscal year 2004-2005, the County of San Diego accepted bids for seven county owned-and-operated programs under the MC initative. Non-profit, organized mental health providers were allowed to bid on the programs. The County retained the option of continuing the programs under the reduced budget of the winning bid, or to contract the program to the organized provider. As a result of this process, two outpatient clinics were contracted to organized providers, while the remaining five programs remained operated by San Diego County. Medical directors and staff psychiatrists determine staffing levels and treatment protocols in county-owned clinics. Administrative staff with a greater consideration of cost determine service levels in county-contracted clinics.
Preliminary Studies: In preliminary work, we have compared the services use and costs of clients of county, county-contracted, and fee-for-service (FFS) providers in fiscal years 2002-2003 and 2003-2004. We assigned clients to a specific provider type (county, contracted, or FFS) based on a plurality of outpatient medication management visits. Utilization data was derived from the AOMHS database. Cost data were derived from detailed examination of cost reports and Medi-Cal fee schedules. Exploratory analyses suggest that that clients of county, county-contracted, and FFS providers received a similar number of outpatient visits. However, the costs of outpatient services varied substantially, as did the probability of hospitalization.
Research Design: Analyses will be performed at the program level and at the person level using a quasi-experimental difference-in-difference design (Goldman et. al. Behavioral Health Insurance Parity for Federal Employees. N Engl J Med 354;13). Comparison groups for MC programs will be created by matching to county-contracted programs not included in MC by program type, size, and location. Person-level comparison groups will be created by matching on demographic and clinical characteristics of individual in the matched programs. At the program level, we will compare numbers of clients receiving services, services provided, and cost in fiscal year 2004-2005 and the two previous fiscal years. At the person level, we will compare services received and costs, using multivariate models and comparing alternative strategies for person to program assignment. We hypothesize that costs will decrease for each program, and will examine whether this is achieved through a change in the mix of services, reduced services, or reduced costs per service. In the last case, we will examine the cost components (e.g. physician services vs. staffing) that were affected. Future work will begin to assign value to outputs (e.g. visits), in terms of alternative measures of patients' well being (for example, their functional status), by taking advantage of new assessment measures for programs initiated under the Mental Health Services Act. With this information on inputs and outputs, we can begin to examine the efficiency of service provision, with the goal of informing quality-based procurement strategies.