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Mental Health and Substance Abuse Treatment Utilization among Individuals Served by Multiple Public Agencies in Three States Jeremy W. Bray, PhD Keith L. Davis, MA RTI International* Linda Graver Don Schroeder, PhD Thomson Medstat Jeffrey A. Buck, PhD Joan Dilonardo, PhD Rita Vandivort, MSW SAMHSA July 14, 2004 *RTI International is a trade name of Research Triangle Institute. Key words: MH/SA service utilizat ion, Medicaid, state MH/SA agencies Address correspondence to: Jeremy W. Bray, PhD Behavioral Health Economics Program RTI International 3040 Cornwallis Road Research Triangle Park, NC 27709 Phone: (919) 541-7003 Fax: (919) 541-6683 E-mail: bray@rti.org Acknowledgments: Funding for this study was pr ovided by the Substance Abuse and Mental Health Services Administration (SAM HSA). Outstanding comments and suggestions on this research were pr ovided by members of the Integrated Database Technical Expert Panel, which comprises a wide variety of researchers and treatment providers from several states and federal agencies. Excellent research assistance on this study was provided by Janet Cummings of RTI. 1 Author Information Jeremy W. Bray, PhD Senior Research Economist Behavioral Health Economics Program RTI International 3040 Cornwallis Road Research Triangle Park, NC 27709 Phone: (919) 541-7003 Fax: (919) 541-6683 E-mail: bray@rti.org Keith L. Davis, MA Research Economist Behavioral Health Economics Program RTI International 3040 Cornwallis Road Research Triangle Park, NC 27709 Phone: (919) 541-1273 Fax: (919) 541-6683 E-mail: kldavis@rti.org Linda Graver Senior Research Leader The MEDSTAT Group 5425 Hollister Avenue, Suite 140 Santa Barbara, CA 93111-2348 Phone: (805) 681-5879 Fax: (805) 681-5888 E-mail: linda.graver@medstat.com Don Schroeder, PhD Senior Programmer The MEDSTAT Group 5425 Hollister Avenue, Suite 140 Santa Barbara, CA 93111-2348 Phone: (805) 681-5868 Fax: (805) 681-5888 E-mail: don.schroeder@medstat.com 2 Jeffrey A. Buck, PhD Director of Organi zation and Financing Center for Mental Health Services Substance Abuse and Mental He alth Services Administration 5600 Fishers Lane, Room 15-87 Rockville, MD 20857 Phone: (301) 443-0588 Fax: (301) 480-8296 E-mail: jbuck@samhsa.gov Joan Dilonardo, PhD Social Science Analyst Center for Substance Abuse Treatment Substance Abuse and Mental Health Services Administration 5515 Security Lane, Room 7-206 Rockville, MD 20852 Phone: (301) 443-0555 Fax: (301) 480-3045 E-mail: jdilonar@samhsa.gov Rita Vandivort, MSW Public Health Analyst Center for Substance Abuse Treatment Substance Abuse and Mental Health Services Administration 5515 Security Lane, Room 7-198 Rockville, MD 20852 Phone: (301) 443-0789 Fax: (301) 480-3045 E-mail: rvandivo@samhsa.gov 3 Mental Health and Substance Abuse Treatment Utilization among Individuals Served by Multiple Public Agencies in Three States 4 Abstract Patterns of mental health (MH) and substa nce abuse (SA) treatm ent utilization among populations receiving services through multiple public programs are not well known. This study examines the extent to which populations with MH and/or SA conditions utilize treatment services through Medicaid and St ate MH/SA Agencies. Data are from the SAMHSA Integrated Database, a multi-year file for three states combining Medicaid and State MH/SA Agency administrative data into a uniform database. Although populations with co-occurring conditions and those served by both Medicaid and State MH/SA Agencies have substantial contact with the public treatment system, a majority of the MH/SA populations examined here utilize few services over brief periods of tim e. Utilization is most limited among individuals with MH-only conditions and those served exclusively by Medicai d. While a lack of data on clinical outcomes prevents us from drawing conclusions about the e ffectiveness of MH/SA serv ices, results of this analysis do indicate that public pr ograms in the states examined here do not provide services that are primarily utilized on a frequent or chronic basis. 5 Introduction A common belief among many health care professionals is that individuals with mental health and/or substance abuse (MH/SA) conditions utilize treatme nt services frequently over long periods of time. Studies suggest, however, that the majority of privat ely insured individuals utilize relatively few behavioral health se rvices over brief, disc rete periods of time. 1 -8 Cohen and Cohen9 refer to the discrepancy between the percei ved and actual use of MH/SA services as the 223clinician222s illusion,224 whereby long-term patients dominate clinicians222 time, use the vast majority of services, and thus create an unr epresentative impression of the general MH/SA population with regard to treatm ent frequency and duration. More over, characterizations that MH/SA populations remain in pub lic treatment for long periods of time do not support the recovery-based approach in both the MH and SA fields227that persons seeking MH/SA services often receive effective treatment a nd do not need treatment chronically.10, 11 Although limited service utiliza tion has been shown for Medicaid beneficiaries with MH conditions,12 few studies have examined the use of MH/SA services among populations covered by multiple public agencies. The lack of resear ch on these populations is due primarily to limited data. Because state organizations ma naging the delivery of MH/SA services often operate in isolation of one another, informati on about MH/SA service ut ilization resides with each individual agency.13 Databases containing informati on on individuals receiving MH/SA services through multiple public agencies are th erefore rare and typically incomplete. Fragmented data have impeded the efforts of re searchers and policymakers to determine whether service utilization varies between public agenci es and between individuals with single and co- occurring MH/SA conditions. Such information may greatly benefit state policy makers in 6 making difficult decisions about the distribution of scarce resour ces for the provision of MH/SA services. The purpose of this study is to describe patterns of utilization of mental health and/or substance abuse (MH/SA) treatment services provided through Medi caid and State MH/SA Agencies. A unique data source, the Integrated Database (IDB), is used to examine the length of time MH/SA patients in three states remain in th e public treatment system, how often they utilize services, and through which agencies (Medicaid, St ate Agencies, or both) they receive services over a three-year study period. This study also examines the extent to which serv ice utilization varies between individuals with single or bot h MH and SA conditions. To the authors222 knowledge, this study is the first to present this information for populations receiving MH/SA services through multiple public ag encies over a multiyear period. Data and Methods Overview To address the lack of complete information on populations receiving public MH/SA services, the Substance Abuse and Mental Health Services Admi nistration (SAMHSA) initiated an effort in 1996 to integrate disparate sources of data on MH/SA services. The result of this effort, the IDB, assembles information from three types of state organiza tions: State Medicaid programs, State MH Agencies, and State SA Agencies. The IDB links service record information on MH/SA treatment utilization for e ach person into a uniform database. Because the IDB combines information for individuals who receive services under multiple public programs, the IDB thus provides a more complete picture of the MH/SA clients seen in more than one part of the state-supported MH/SA trea tment system. The IDB contains person- and 7 service-level data for all such cl ients within a state. For a fu ll description of the methodology used to link IDB service records across state organizations, see Whalen et al.14 The IDB contains administrati ve service records for indivi duals receiving public MH/SA services through Medicaid and/or State MH/SA Agencies and en compasses three full calendar years (19962261998) for three states: Delaware , Oklahoma, and Washington. The three participating states were chosen based on their availability of elec tronic data, the ability of their data systems to link clients across agencies, and state interest in the IDB project. The IDB also contains information on patient demographics, such as age, sex, race, and urban/rural location, as well as information on Medicaid eligibility st atus, MH/SA diagnosis codes, providers, and Medicaid drug prescriptions and othe r Medicaid medical records. Study Population The study population for this analysis consists of individuals who had a primary MH or SA diagnosis or who received any MH or SA service during the study period. MH/SA diagnoses are defined using codes based on the Internati onal Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-C M). MH/SA diagnoses are iden tified using ICD-9-CM codes listed in Coffey et al.13 Clients with missing diagnoses were selected for the study population based on evidence of having received an MH/SA service. MH/SA service categories were created using several criteria, including source of record and service description. 13 After identifying the study population based on diagnosis or use of service, persons older than 64 and persons who changed age category (youth to adult or adult to elderly) du ring the study period are excluded. Excluding persons older than 64 elim inates 7.9% of all clients in the IDB study population while exclusion of persons who changed age category eliminates an additional 1.2%. 8 After making these exclusions, roughly 70 percen t of the study population in each state is classified as adult (ages 18 to 64), with the remaining 30 percen t classified as youth (ages less than 18). Beginning in 1998, State MH Agency reco rds from Washington did not include information on specific outpatient service dates, but rather only the month of service and the number of service encounters within a month. As a result, encounter date s are evenly assigned to individuals within each month to approximate service use pa tterns similar to those seen in 1996 and 1997. Although this method does not reflec t the true date-speci fic service use of Washington service users in 1998, it is more r ealistic than the alternative of assigning all observed encounters within a month to a single date. Service encounter dates created in this manner account for roughly 35 percent of all MH /SA service dates from Washington across the three-year study period. Client Classification Individuals included in the an alysis are classified and examined on two major domains: (1) service agency and (2) MH/SA category. Servi ce agency refers to the data source (Medicaid or State MH/SA Agency) from which each IDB reco rd was obtained and allows us to generally identify individuals who receive MH/SA services through Medicai d only, through State Agencies only, or through both Medicaid and State Agencies. I ndividuals classified as having MH/SA service records in both Medicaid and State Agency databases, however, do not necessarily receive services th rough both auspices concurrently. A client with one Medicaid record at the beginning of the study period and one State Agency record at the end of the study period, for example, is classified as ha ving received services through both auspices. In some 9 cases, the same MH/SA service record appears on both the Medicaid and State Agency databases. Overlapping records may occur if Me dicaid reimburses a bill but the State Agency provides the service. To avoid ove rstating utilization rates, only one service date is counted for cases in which a service user, provider, servi ce, and service date ar e reported on both the Medicaid and State Agency databases. Additiona lly, individuals with these types of records are classified as receiving services through bot h Medicaid and State Agencies. For further information on the reconciliation of overlapping se rvice records in the IDB, see Coffey et al.13 The second domain on which individuals are cl assified and analyzed is MH/SA category, which is used to identify indi viduals who had services for onl y MH conditions (MH-only), only SA conditions (SA-only), or co-occurring (both MH and SA) conditions during the study period. Service users are assigned to MH-only and SA-only categories based on primary diagnosis, but secondary diagnostic information was considered for co-occurring conditions. Individuals are classified as having co-occurring conditions if th ey had any of the following within the three- year study period: (1) both a primary MH and SA diagnosis, (2) a primary MH and secondary SA diagnosis, or (3) a primary SA and secondary MH diagnosis. In th e absence of diagnosis information, MH-only and SA-only classifications were assigned based on the type of service received during the study period. For cases in which diagnosis information was not available, individuals were classified as having co-occurring conditions based on evidence of receiving both a MH and SA service. Individuals classified as having co-occurring conditions did not necessarily have MH and SA conditions concurre ntly. A client with a MH record at the beginning of the study period and a SA record at the end of the study period, for example, is classified as having co-occurring conditions. 10 Individuals served exclusively by Medicaid make up 20 to 40 percent of the study population across all three states, while 45 to 66 percent are served exclusively by State Agencies. The proportion of individuals serv ed by both Medicaid and St ate Agencies varies from 12 to 36 percent across the th ree states. Most service users (55 to 70 percent across all three states) in the study populati on are classified as MH-only, while a much smaller proportion of clients (16 to 28 percent) ar e classified as SA-only. Indivi duals classified as having co- occurring conditions make up 10 to 17 percent of the study population across all three states. Utilization Measures Medians and frequency distribut ions of individuals222 length of service window, number of total MH/SA encounter dates, and frequency of MH/SA service use are presented to examine the level of contact individuals in the study population have with th e public treatment system. A service window is defined as the number of days between an individual222s first and last observed MH/SA service record during the three-year study period. An individual222s total number of service encounter dates is defined as the count of unique date s over the entire study period on which they had an administrative record with at least one MH/SA diagnosis or service. Service encounter dates occurring within a single inpatient stay are considered to be distinct and separate encounter dates. To present a more comprehensive picture of public MH/SA service utilization, the concepts of service window lengt h and number of encounter date s are combined to create four mutually exclusive categories of service utilization: (1) single encounter date, (2) short-term, (3) occasional, and (4) frequent ut ilizers of the public MH/SA treatment system. Single encounter date utilizers are defined as persons with only one encounter date during the entire study period. 11 Short-term utilizers are defined as individuals wi th a service window of three months or less but more than one encounter date. Occasional utiliz ers are defined as thos e with a service window greater than three months but fewer than 10 encounter dates. Frequent ut ilizers are defined as persons with a service window gr eater than three months and 10 or more encounter dates. Results are presented for each state side-by-si de to aid readers222 comprehension of state- specific results and to identify within-state trends that appear similar across the three states. However, comparisons of MH/SA utilization betw een states should not be made because state programs managing the delivery of MH/SA services differ in many dimensions (e.g., MH/SA program financing, organization, benefits, provider payment arrangements, available settings for care, and provider networks). For further in formation on the organizational framework of MH/SA service delivery in each state, see Coffey et al.13 Results Because the IDB spans a three-year period, indivi duals appear in the database in different years and for varying lengths of time. A basic but important result of this analysis is that the majority of MH/SA service users (between 60 an d 73 percent across all three states) appear in the IDB during one and only one year of the study period, while a much smaller proportion of individuals (11 to 17 percent) a ppear in all three years. Betw een 14 and 20 percent of service users across all three states ha ve MH/SA service records in tw o consecutive years of the study period, while a very small proportion of individua ls (less than three pe rcent across all three states) have service record s in 1996 and 1998 but no records in 1997. These results are consistent with patient turnover rates estimated in other studies of Medicaid populations (e.g., [15]). 12 Length of service window Table 1 presents the distribution of service windows and suggests th at the majority of MH/SA service users in the states examined here have relatively brief contact with the public treatment system. Half of all MH/SA service users in each state, for example, are present in the treatment system for 139 days or less over a three year period while one quarte r of all individuals has service windows of 8 days or le ss. Contact with the treatment sy stem is particularly brief for those served exclusively by Medica id, as one quarter of these individuals have a service window of only one day. Persons receiving servic es through both Medicaid and State Agencies, however, appear to have a substa ntially longer period of contact with the treatment system than those receiving services through Medi caid or State Agencies alone. Among all service users, for example, 50 percent of those receiving services through both auspices ha ve a service window of at least 344 days compared to only 135 days for individuals served by Me dicaid alone or by State Agencies alone. Table 1 also indicate s that service window length varies by MH/SA category. Individuals with co-occurring conditions, for example, ge nerally have a lengthy service window (ranging from 302 to 465 days at the median across all thre e states) and remain in treatment more than four times longer (at the median) than individu als with single MH or SA conditions. For individuals with MH-only conditions , however, contact with the treat ment system is particularly brief as one quarter of these individuals in each state are present in the treatment system for only one day. Finally, individuals w ith MH-only conditions in two st ates have a shorter period of contact with the treatment system at the median than SA-only service users. 13 Total service encounter dates Table 2 presents the distribution of total serv ice encounter dates. Half of all service users in each state have 12 or fewer MH/SA serv ice dates over the thre e-year study period. While individuals served by bot h Medicaid and State Agencies have the greatest number of encounter dates over the study period, those served exclusively by Medicaid appear to have the fewest. Low intensity of utilization among Medicaid-only service users is further pronounced in that 75 percent of these individu als across the three states have fewer than 23 encounter dates over the three-year study period. Table 2 also shows that the number of se rvice dates varies by MH/SA category. As expected, individuals with co-occurring conditio ns have a higher median number of service encounter dates than those with a single MH or SA condition. Individuals with co-occurring conditions in each state, for example, have at least 20 more service dates at the median than those with MH-only conditions an d at least 11 more at the median than those with SA-only conditions. Moreover, three quarter s of individuals with co-occurr ing conditions have at least 8 encounter dates over the study period, and in two states three quarters of individuals with SA- only conditions have at least 6 encounter dates. Additionally, MH-only patients in two states have at least 20 fewer encounter dates at the median than th ose with SA-only conditions. Limited utilization among MH-only service user s relative to those with both co-occurring and SA-only conditions is further pronounced in that one quarter of all MH -only service users in each state have only one service encounter date over the study period. When MH-only patients are served by both Medicaid and State Agencies, however, service encounte r dates for this group rise substantially (to at least 11 enco unter dates) in 2 of the 3 states. 14 Levels of MH/SA service utiliz ation presented in Table 2 ar e somewhat lower than those found at the national level in previous studi es. Two recent studies by Olfson et al.,16, 17 for example, examined national trends in outpatien t treatment for depressi on and found that adults and adolescents had on average 8 to 9 annual encounters for depression over the 1996-1999 period. While still brief in duration, the number of annual behavioral he alth encounters found by Olfson et al. is somewhat higher than the 3-year levels found in the IDB. MH/SA service utilization categories Table 3 combines the concepts of service window length and number of encounter dates to classify MH/SA patients in the study populati on into four mutually exclusive categories. These categories consist of single encounter utilizers (i ndividuals with a single encounter date), short-term utilizers (individuals with a servi ce window of three months or less), occasional utilizers (individuals with a se rvice window greater th an three months, but less than 10 encounter dates), and frequent utilizers (i ndividuals with a service window greater than three months and more than 10 encounter dates). Table 3 presen ts the percentage of individuals in the study population that fall into each category. Additional evidence presented in Table 3 s uggests that the majority of MH/SA service users in the states examined here do not rece ive frequent care over l ong periods of time. Specifically, a substantial proportion of all MH/SA service users (at least 18 per cent across all three states) have only one service encounter date over the entire three-year study period. Additionally, after combining singl e encounter and short-term u tilizers, roughly half of all persons (44 to 54 percent across al l three states) are in the pub lic treatment system for three months or less. 15 Table 3 also provides additional evidence that individuals served by both Medicaid and State Agencies have the most contact with the public treatment system while those served by Medicaid only have the least contact. Across all three states, for example, roughly 65 to 81 percent of individuals served by both auspices are classified as frequent utilizers while only 5 percent or less are classified as single encounter utilizers. In c ontrast, only 35 percent or less of individuals served by Medicaid only across all three states are fre quent utilizers while as many as 52 percent of individuals served ex clusively by Medicaid have only a si ngle encounter date. Finally, Table 3 provides further evidence suppo rting the finding that individuals with co- occurring conditions have substantially more c ontact with the public treatment system than individuals with single MH or SA conditions. Specifically, individuals with co-occurring conditions are less likely to have a single enc ounter date and are more likely to be frequent utilizers of public MH/SA services than indi viduals with MH-only or SA-only conditions. Results presented in Table 3 also support the fi nding that SA-only service users generally have greater contact with the public tr eatment system than MH-only serv ice users. In two states, for example, those with SA-only conditions are su bstantially less likely to have only a single encounter date over the three-ye ar study period than those with MH-only conditions. Moreover, roughly half of all individuals with SA-only cond itions in two states are classified as frequent utilizers compared to only one third of MH-onl y service users classified as frequent utilizers during the three-y ear study period. Sensitivity analysis Service window and encounter date distributions presen ted in Tables 1 and 2 are potentially inflated as a result of individuals who are institutiona lized or receive services in an inpatient or other long-term setting. Tables 1 and 2 were reproduced (available upon request 16 from the authors) excluding those who received treatment in long-term settings and found only a minimal decrease in the median and upper perc entiles of service window length and total encounter dates. The potentially confounding effect of long-term service users is therefore quite small. Tables 1-3 were also reproduced separately for youths (ages 0-17) and adults (ages 18- 64) to detect differences in service utilization by age. Serv ice window length and number of total encounter dates were found to be lower among youths than among adults. In two states, youths were also found to be more likely to have a single encounter date and less likely to be frequent utilizers of public MH/SA services. Utilization among individu als served by Medicaid only, however, was found to be higher for youths th an for adults, a result that may reflect the youth-specific focus of many outreach initiatives implemented by state Medicaid programs. Limitations Results presented in this paper should be interpreted with cau tion, as this study has several limitations. First, comparisons of servic e utilization between stat es should not be made because the organizational framework and policie s under which services are delivered varies considerably across the states. Second, the li mited time frame of the IDB prevents us from observing data on individuals who utilized MH/SA services either before 1996 or after 1998. As a result, it is possible that some individuals w ho appear in the treatment system briefly at the beginning or end of the study period are in fact high utilizers of MH/SA services but are not captured as so in the three-year window. A th ird limitation of this study is that information on prescription drug utilization is not considered. It is thus possibl e that some individuals in the study population have few encounters because they are receiving treatment in the form of a medication-based maintenance program. Finally, because this analysis focuses on only discrete 17 events of service utilization without respect to clinical MH/SA outco mes or prevalence and severity of MH/SA conditions, conc lusions about the adequacy of treatment services provided in the states examined here cannot be drawn. Desp ite these limitations, results presented in this study have important implications that may aid states in the de livery and management of public MH/SA services. Implications for Behavioral Health Services Previous studies have shown that privately insured MH/SA patients generally receive few treatment services over brief periods of time. 1 -8 Results of this analysis indicate a similar pattern for individuals receiving MH/SA services through multiple public agencies. These results may support those from previous studies that prom ote a recovery model227that persons seeking MH/SA services often receive effective treatm ent and therefore do not need treatment on a continual basis. While a lack of data on clinical outcomes preven ts us from drawing conclusions about the effectiveness of MH/SA services, the results do indicate that public treatment programs in the states examined here do not primarily provi de services that are utilized on a frequent or chronic basis. The results presented in this study also indi cate that MH/SA service use varies across funding agencies, as individuals served by both Medicaid and State Agencies have substantial contact with the treatment system while thos e served only by Medica id have very limited contact. Specifically, in dividuals served by both Medicaid an d State Agencies are generally the most likely to be frequent utilizers and the least likely to have a single en counter date while those served by Medicaid alone are the most likely to have a single en counter date and the least likely to be frequent utilizers. 18 A major implication of the results presented here relates to the general finding that the majority of the MH/SA populations in the states examined here display limited use of public MH/SA services over brief periods of time. Given such transitory patterns of service use, it is likely that state organizations managing the delivery of MH/SA serv ices are not funding treatment of the same individuals from year to year. While most individuals do not remain engaged in public treatment from year to year, they appear much more likely to do so when they have co-occurring conditions. Service use among clients with MH-only conditions was shorter than for those with co-occurring conditions but still of significant duration. With little data on the severity of client conditions, it is difficult to determine whether the level of service use observed here is adequate for favorable client outcomes. Analysis results also indicate that treatment utilization for individuals with SA-only conditions was more intense for a brief initial period of time, but continuity of services after the initial time period was relatively absent. Greater intensity of in itial service use is encouraging, as it may indicate successful treatm ent engagement. The lack of s ubsequent treatment utilization after an initial period of intense service use among clients with SA-only conditions may be the result of several factors that ca nnot be detected in the IDB data , including patient follow-up with non-billing services such as Alcoholics Anonymous . Given the relapsing nature of addictions, however, the lack of con tinuing care observed in this study may raise the possibili ty that needed services are not being utilized a nd further study is thus warranted. The generally limited level of treatmen t utilization among the MH/SA populations examined here may be the result of several factors that have not been accounted for, such as state-specific managed care restrictions18 or participation in Aid to Families with Dependent Children (AFDC) or Temporary Assistance for Needy Families (TANF), criminal justice 19 programs, nonbilling programs such as Alcoholics Anonymous, or other Federal programs that provide resources for the use of me dical services. It is also unclear what effect evaluation and consultation visits have on utilization rates. Pr eliminary analyses suggest that evaluation visits may account for a substantial number of the singl e encounter date utilizers observed in this study. It may also be possible that some MH /SA patients require fe wer service encounters because of participation in medication-based ma intenance programs in addition to therapy. To the extent that a combination of medication and therapy is more efficacious than either treatment alone,19-21 short treatment durations and few encount er dates may be the preferred scenario among clinicians and policy makers. Investigating the impact of managed care penetration, participation in other Federal programs, the use of medications, and other factors on MH/SA service use is an important di rection for future studies. An additional implication relates to the in terpretation given to the lower levels of treatment utilization f ound among individuals served by Medica id only. Specifically, differences in utilization between Medicaid and State Agencies may in part be accounted for by differences in the populations covered. For instance, Medi caid populations have a large number of TANF- eligible families that access MH/SA services at a lower rate and may need only one or a few service encounter dates in the public specialty treatment system . Low utilization among those served by Medicaid only may also be the resu lt of Medicaid providers engaging State MH/SA Agencies for individuals with more intensive treatment needs. Low utilization among Medicaid- only users may also reflect differences in the types of services covered under Medicaid. Moreover, low utilization among Medicaid-only serv ice users may be even less of a concern considering the relatively high rate of utilization found among i ndividuals receiving services through both Medicaid and State Agencies. 20 Finally, results of this analys is also indicate that individu als with co-occurring conditions have a higher level of contact wi th the public MH/SA treatment system than those with only MH or only SA conditions, and those with SA-only cond itions have higher levels of service use than those with MH-only conditions. It is reassuring to find, howev er, that individuals who are potentially the most severely ill (e.g., those with co-occurring conditions), have more extensive contact with the public treatment system than i ndividuals with a single MH or SA condition. Although several important findings are presente d in this paper, further research is needed to gain a more complete understanding of the delivery, financing, and utilization of public sector MH/SA service utilization. In li ght of previous resear ch documenting the cost offsets associated with both MH and SA treat ment ([22] and [23] respectively), one area of future research would be to examine the subseque nt general health care utilization of clients in the IDB. The IDB is a unique and rich data source that may support such studies. 21 References 1. Taube CA, Goldman HH, Burns BJ, et al. High users of outpatient mental health services, I: Definition and characteristics. American Journal of Psychiatry . 1988;145(1):19-24. 2. 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Mental Health and Substance Abuse Treatment: Results from a Study Integrating Data from State MH, SA, and Medicaid Agencies. SAMHSA Publication No. SM A-01-3528. Rockville, MD: Center for Substance Abuse Treatment and Center for Me ntal Health Services, Substance Abuse and Mental Health Services Administration; 2001. 14. Whalen D, Pepitone A, Graver L, et al. Linking Client Records fr om Substance Abuse, Mental Health, and Medicaid State Agenci es. SAMHSA Publication No. SMA-01-3500. Rockville, MD: Center for Substance Abuse Treatment and Center for Mental Health Services, Substance Abuse and Mental H ealth Services Administration; 2001. 15. Hadley TR, Schinnar A, Rothbard A. Manage d mental health care in the public sector. In: Feldman S, ed. Managed Mental Health Services . Springfield, IL: Charles C. Thomas; 1992. 23 24 16. Olfson M, Marcus SC, Druss B, Elinson L, Tanielian T, Pincus HA. National trends in the outpatient treatment of depression. Journal of the American Medical Association. 2002;287(2):203-209. 17. Olfson M, Gameroff MJ, Marcus SC, Waslic k BD. Outpatient treatment of child and adolescent depression in the United States. Archives of General Psychiatry . 2003;60(12):1236-1242. 18. Stromberg C, Loeb L, Thomsen S, et al. State initiatives in health care reform. The Psychologist222s Legal Update. 1996;8:1-16. 19. O222Malley S, Jaffe A, Chang G, et al. Naltrexone and copi ng skills therapy for alcohol dependence: A controlled study. Archives of General Psychiatry . 1992;49:881-887. 20. Volpicelli J, Alterman A, Hayasguda M, et al. Naltrexone in the treatment of alcohol dependence. Archives of General Psychiatry . 1992;49(11):876-880. 21. National Health Policy Forum (NHPF). Depressi on: A Decade of Progress, More to Do. No. 786; 2002. 22. Anderson N, Estee S. Medical cost offsets a ssociated with mental health care: A brief review. Research and Data Analysis Division Report Number 3.28. Washington Department of Social and Health Services. 2002. 23. Holder HD, Lennox RD, Blose JO. The economic benefits of alcoholism treatment: A summary of twenty years of research. Journal of Employee Assistance Research . 1992;1(1):63-82. Table 1 Distribution of MH/SA service window lengtha, b (in days) by MH/SA category, service agency,c and state over the period 19962261998, ages 0 to 64 Delaware Oklahoma Washington Service Window Percentiles by MH/SA Category All Service Users Medicaid Only State MH/SA Agency Only Medicaid + Agency All Service Users Medicaid Only State MH/SA Agency Only Medicaid + Agency All Service Users Medicaid Only State MH/SA Agency Only Medicaid + Agency A l l s e r v i c e u s e r s N 35,009 14,011 15,618 5,380 195,513 47,305 124,887 23,321 325,608 62,059 146,258 117,291 25% 8 1 23 264 2 1 1 199 5 1 3 100 50% (median) 139 45 135 629 66 82 36 537 103 1 58 344 75% 507 325 394 1,021 361 394 207 975 352 126 215 765 M H - O n l y N 19,367 11,987 4,682 2,698 130,177 43,049 71,246 15,882 227,987 52,191 95,725 80,071 25% 1 1 23 193 1 1 1 174 1 1 1 77 50% (median) 98 41 141 562 59 78 24 493 72 1 33 297 75% 498 307 687 1,019 337 378 157 954 316 122 168 728 (continued) 25 Table 1 Distribution of MH/SA service window lengtha, b (in days) by MH/SA category, service agency,c and state over the period 19962261998, ages 0 to 64 (continued) Delaware Oklahoma Washington Service Window Percentiles by MH/SA Category All Service Users Medicaid Only State MH/SA Agency Only Medicaid + Agency All Service Users Medicaid Only State MH/SA Agency Only Medicaid + Agency All Service Users Medicaid Only State MH/SA Agency Only Medicaid + Agency S A - o n l y N 9,879 881 8,550 448 31,719 1,008 30,605 106 64,695 7,011 45,950 11,734 25% 11 1 18 248 1 1 1 39 22 1 25 101 50% (median) 113 8 117 502 14 3 15 204 107 1 102 271 75% 366 89 366 896 86 48 86 417 314 56 288 559 M H + S A N 5,763 1,143 2,386 2,234 33,617 3,248 23,036 7,333 32,926 2,857 4,583 25,486 25% 116 57 45 366 70 44 49 276 179 17 99 241 50% (median) 432 301 255 723 302 265 220 643 465 162 274 557 75% 856 623 687 1,039 743 702 615 1,009 836 444 540 903 aA service window is defined as the number of days between an individual222s first and last observed service encounter date over t he 3-year study period. bBecause the IDB spans a 3-year period (1996-1998), the maximum service window length MH/SA clients may have is 1,096 days. cService agency refers to the agency (Medicaid and/or State Agency) from which each IDB record is obtained. 26 Table 2 Distribution of MH/SA se rvice encounter datesa by MH/SA category, service agency,b and state over the period 19962261998, ages 0 to 64 Delaware Oklahoma Washington Service Date Percentiles by MH/SA Category All Service Users Medicaid Only State MH/SA Agency Only Medicaid + Agency All Service Users Medicaid Only State MH/SA Agency Only Medicaid + Agency All Service Users Medicaid Only State MH/SA Agency Only Medicaid + Agency A l l s e r v i c e u s e r s N 35,009 14,011 15,618 5,380 195,513 47,305 124,887 23,321 325,608 62,059 146,258 117,291 25% 2 1 6 17 2 1 1 15 2 1 2 7 50% (median) 12 3 22 62 7 5 6 40 8 1 7 24 75% 56 11 70 263 29 22 22 99 36 3 29 77 MH-Only N 19,367 11,987 4,682 2,698 130,177 43,049 71,246 15,882 227,987 52,191 95,725 80,071 25% 1 1 3 11 1 1 1 12 1 1 1 5 50% (median) 5 2 12 34 5 4 4 35 5 1 4 16 75% 27 10 40 155 23 21 14 88 18 3 13 53 (continued) 27 Table 2 Distribution of MH/SA se rvice encounter datesa by MH/SA category, service agency,b and state over the period 19962261998, ages 0 to 64 (continued) Delaware Oklahoma Washington Service Date Percentiles by MH/SA Category All Service Users Medicaid Only State MH/SA Agency Only Medicaid + Agency All Service Users Medicaid Only State MH/SA Agency Only Medicaid + Agency All Service Users Medicaid Only State MH/SA Agency Only Medicaid + Agency SA-only N 9,879 881 8,550 44 8 31,719 1,008 30,605 10 6 64,695 7,011 45,950 11,734 25% 6 1 8 31 1 1 1 7 6 1 7 17 50% (median) 26 2 29 119 5 2 5 15 26 1 28 45 75% 83 9 84 383 19 6 20 35 67 6 67 109 MH+SA N 5,763 1,143 2,386 2,234 33,617 3,248 23,036 7,333 32,926 2,857 4,583 25,486 25% 8 3 6 32 8 5 7 22 13 2 14 18 50% (median) 37 9 29 99 25 15 20 54 46 3 45 56 75% 143 28 94 344 65 52 51 124 123 8 106 140 aService encounter dates are the number of unique dates of service over the 3-year period. bService agency refers to the agency (Medicaid and/or State Agency) from which each IDB record is obtained. 28 Table 3 Distribution of service use by MH/SA diagnosis category, service agency,a and state over the period 19962261998, ages 0 to 64 Delaware Oklahoma Washington Service Use Category All Service Users Medicaid Only State MH/SA Agency Only Medicaid + Agency All Service Users Medicaid Only State MH/SA Agency Only Medicaid + Agency All Service Users Medicaid Only State MH/SA Agency Only Medicaid + Agency All service u sers N 35,009 14,011 15,618 5,380 195,513 47,305 124,887 23,321 325,608 62,059 146,258 117,291 Single encounter utilizers 17.6% 35.7% 7.2% 0.6% 24.5% 27.1% 27.9% 1.2% 21.9% 51.6% 22.8% 5.1% Clients with 3 months in the system (short-term utilizers) 26.0% 21.8% 34.9% 10.9% 29.8% 24.4% 35.1% 12.6% 26.3% 20.1% 35.0% 18.7% Clients with >3 months in the system but <10 encounter dates (occasional utilizers) 10.3% 18.7% 3.7% 7.4% 9.8% 16.3% 7.7% 7.9% 11.3% 20.2% 7.5% 11.3% Clients with > 3 months in the system and >10 encounter dates (frequent utilizers) 46.2% 23.8% 54.2% 81.2% 35.9% 32.2% 29.3% 78.3% 40.5% 8.1% 34.6% 64.9% (continued) 29 Table 3 Distribution of service use by MH/SA diagnosis category, service agency,a and state over the period 19962261998, ages 0 to 64 (continued) Delaware Oklahoma Washington Service Use Category All Service Users Medicaid Only State MH/SA Agency Only Medicaid + Agency All Service Users Medicaid Only State MH/SA Agency Only Medicaid + Agency All Service Users Medicaid Only State MH/SA Agency Only Medicaid + Agency MH- only N 19,367 11,987 4,682 2,698 130,177 43,049 71,246 15,882 227,987 52,191 95,725 80,071 Single encounter utilizers 26.7% 37.8% 13.0% 0.9% 27.5% 28.2% 32.9% 1.6% 28.5% 53.0% 32.9% 7.3% Clients with 3 months in the system (short-term utilizers) 22.3% 20.9% 29.7% 15.9% 28.2% 24.0% 33.9% 13.9% 24.9% 19.2% 31.6% 20.5% Clients with >3 months in the system but <10 encounter dates (occasional utilizers) 14.7% 18.7% 7.2% 9.8% 10.9% 16.5% 8.1% 8.6% 13.6% 21.1% 9.7% 13.4% Clients with > 3 months in the system and >10 encounter dates (frequent utilizers) 36.3% 22.6% 50.0% 73.4% 33.3% 31.4% 25.0% 75.9% 33.0% 6.7% 25.8% 58.8% (continued) 30 Table 3 Distribution of service use by MH/SA diagnosis category, service agency,a and state over the period 19962261998, ages 0 to 64 (continued) Delaware Oklahoma Washington Service Use Category All Service Users Medicaid Only State MH/SA Agency Only Medicaid + Agency All Service Users Medicaid Only State MH/SA Agency Only Medicaid + Agency All Service Users Medicaid Only State MH/SA Agency Only Medicaid + Agency SA- only N 9,879 881 8,550 448 31,719 1,008 30,605 106 64,695 7,011 45,950 11,734 Single encounter utilizers 6.8% 40.6% 3.7% 0.0% 34.5% 44.9% 34.2% 0.9% 9.0% 55.8% 3.9% 0.9% Clients with 3 months in the system (short-term utilizers) 38.3% 35.0% 40.4% 4.5% 41.5% 37.3% 41.6% 37.7% 37.5% 25.0% 43.5% 21.9% Clients with >3 months in the system but <10 encounter dates (occasional utilizers) 2.3% 9.9% 1.3% 7.6% 4.7% 7.1% 4.6% 12.3% 3.7% 5.9% 3.1% 4.6% Clients with > 3 months in the system and >10 encounter dates (frequent utilizers) 52.5% 14.5% 54.6% 87.9% 19.3% 10.6% 19.5% 49.1% 49.8% 13.3% 49.5% 72.7% (continued) 31 Table 3 Distribution of service use by MH/SA diagnosis category, service agency,a and state over the period 19962261998, ages 0 to 64 (continued) Delaware Oklahoma Washington Service Use Category All Service Users Medicaid Only State MH/SA Agency Only Medicaid + Agency All Service Users Medicaid Only State MH/SA Agency Only Medicaid + Agency All Service Users Medicaid Only State MH/SA Agency Only Medicaid + Agency MH +SA N 5,763 1,143 2,386 2,234 33,617 3,248 23,036 7,333 32,926 2,857 4,583 25,486 Single encounter utilizers 5.4% 9.7% 8.0% 0.3% 3.3% 6.7% 3.8% 0.4% 1.8% 15.1% 1.5% 0.3% Clients with 3 months in the system (short-term utilizers) 17.0% 20.7% 25.3% 6.1% 25.2% 26.4% 30.1% 9.2% 14.2% 25.2% 21.8% 11.6% Clients with >3 months in the system but <10 encounter dates (occasional utilizers) 9.0% 25.5% 5.3% 4.4% 10.1% 16.7% 10.3% 6.4% 10.3% 40.4% 6.6% 7.6% Clients with > 3 months in the system and >10 encounter dates (frequent utilizers) 68.7% 44.0% 61.3% 89.1% 61.4% 50.1% 55.7% 84.0% 73.7% 19.3% 70.0% 80.5% aService agency refers to the agency (Medicaid and/or State Agency) from which each IDB record is obtained. 32

Mental Health and Substance Abuse Treatment: Results from a Study Integrating Data from State Mental Health, Substance Abuse, and Medicaid Agencies Rosanna M. Coffey, Ph.D. Linda Graver Don Schroeder, Ph.D. Jon D. Busch, Ph.D. Joan Dilonardo, Ph.D. Mady Chalk, Ph.D. Jeffrey A. Buck, Ph.D. 2001 U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Substance Abuse and Mental He alth Services Administration Center for Substance Abuse Treatment Center for Mental Health Services 5600 Fishers Lane Rockville, MD 20857 Acknowledgements Numerous people contributed to and reviewed this report, which was based on a larger study. Linda Graver coordinate d the project and monitored th e results. Don Schroeder and Dian Zheng provided analytic expertis e and computer programming. Mylea Yost prepared the manuscript. Joan Dilonar do, Jeffrey Buck and Mady Chalk of SAMHSA guided the work and provided many helpfu l comments and suggestions throughout this project. Mary Jo Larson of the New England Research In stitute provided methodological guidance. Robert Anderson, National Associa tion of State Alcohol and Drug Abuse, and Ted Lutterman, National Association of State Mental Health Program Directors Research Institute, provided guidance throughout the project. The Advisory Panel (named in Appendix A) provided many insights on policy relevance of the results. Disclaimer This report was prepared by The MEDSTAT Group for the Substance Abuse and Mental Health Services Administration (SAMHSA) of the U.S. Department of Health and Human Services (HHS) under Contract No. 270-96-0007, Joan Dilonardo, Ph.D., Government Project Officer. The content of this publication does not necessarily reflect the views or policies of SAMH SA or HHS, nor does it necessarily reflect the views of any of the Advisory Panel members. Public Domain Notice All material appearing in this report is in the public domain and may be reproduced or copied without permission from the Substa nce Abuse and Mental Health Services Administration. Citation of the source is appreciated. However, this publication may not be reproduced or distributed for a fee without the specific, written authorization of the Office of Communications, SAMH SA, U.S. Department of H ealth and Human Services. Recommended Citation Coffey, R.M., Graver, L., Schroeder, D., Busch, J.D., Dilonardo, J., Chalk, M., & Buck, J.A. Mental Health and Substance Abuse Tr eatment: Results from a Study Integrating Data from State MH , SA, and Medicaid Agencies. SAMHSA Publication No. SMA-01-3528. Rockville, MD: Center for Subs tance Abuse Treatment and Center for Mental Health Services, Substance Abuse a nd Mental Health Serv ices Administration, 2001. Electronic Access and Copies of Publication This publication can be accessed electroni cally through the following Internet World Wide Web connections: http://www.samhsa.gov or http://www.ncadi.org or http://www.mentalhealth.org . For additional copies of the document without charge, please call the National Clearinghouse fo r Alcohol and Drug Information, 1-800-729- 6686 or the CMHS Knowledge Exchange Network, 1-800-789-2647. Originating Office Office of Quality Improvement and Financi ng, Center for Substance Abuse Treatment, 5600 Fishers Lane, Rockwall II Buildi ng, Suite 740, Rockville, MD 20857 i Foreword For years, the lack of detailed data on utilization of publicly funded mental health (MH) and substance abuse (SA) services has impeded res earchers and policymakers in their efforts to optimize the delivery and financing of such servi ces. To address this serious lack, the Center for Substance Abuse Treatment (CSAT) and the Ce nter for Mental Health Services (CMHS) of the Substance Abuse and Mental Health Servi ces Administration (SAM HSA) together funded and implemented the Integrated Data Base Project. This data base links client-level data from MH and SA abuse agencies and Medicaid, permitting us, for the first time, to track individuals across all three systems. In this report, we are pleased to present the ini tial analytical findings from the Integrated Data Base. The project greatly enhances our ability to examine many important questions related to treatment patterns in mental health and substance abuse. Clearly, such data integration has far- reaching implications for States as they strive to improve the delivery of substance abuse and mental health services. Joseph Autry, M.D. Acting Administrator, Substance Abuse and Mental Health Services Administration H. Westley Clark, M.D., J.D., M.P.H., CAS, FASAM Director, Center for Substance Abuse Treatment Bernard S. Arons, M.D. Director, Center for Mental Health Services ii Executive Summary State and local governments manage a substan tial portion of all substance abuse (SA) and mental health (MH) treatment dollars. Multiple agencies treat the same clients, and multiple data systems collect information on them. To understand the full spectrum of treatment for clients with MH and SA disorders, States ne ed information from many data systems. Few States have an integrated information system. The Center for Substance Abuse Treatment (CSAT) and the Center for Mental Health Services (CMHS) of the Substance Abuse and Mental Health Services Administration (SAMHSA) initiated an effort five years ago to integrate Medicaid, State me ntal health, and State substance abuse agency data. Now under confidentiality ag reements with the States, data from this CSAT/CMHS Integrated Data Base (IDB) Project has been analyzed and is the subject of this first report. The IDB, currently built for the year 1996, assemb les information from three types of State organizations – State MH, State SA, and Medicaid agencies. The IDB contains data from these types of organizations on mental health and substance abuse clie nts, their use of services, and level of expenditures. The IDB is assembled separately for three participating States – Delaware, Oklahoma, and Washington – and links person-level and service-level information across the multiple organizations in each State into one uniform data base. This report presents findings from analyses of a subset of IDB records - persons with a primary mental or substance abuse disorder who are unde r age 65. Information about three groups of clients is presented: clients with mental di sorders only (MH-only clients), clients with substance abuse disorders only (SA-only clients), and client s with dual MH+SA disorders (MH+SA clients). The study answers questions a bout the treatment services received by these populations under three different St ate auspices - the State MH a nd/or SA agency, Medicaid, or multiple auspices. Study questions include: Which State organizations (MH , SA agencies, Medicaid, or both) support which types of clients (MH-only, SA-only, or MH+SA clients)? What MH and/or SA conditions are most prevalent within and across States and State organizations? Where - in what settings - do cl ients receive services? Does it differ between State MH and SA agencies and Medicaid? How many clients receive services under these different State auspi ces? What types of services do they receive? States are analyzed separately because there are many dimensions that differ among the States that can greatly influence the results by Stat e. These include organization of the delivery system, administration of funding, range of serv ices covered, payment methods, State-specific epidemiology, and many other factors. iii Key Findings About 4 percent of the population of each St ate (Delaware, Oklahoma, and Washington) was treated for primary MH and/or SA diso rders in 1996 under the auspices of State MH/SA agencies and/or Medicaid. For persons treated for primary MH and/or SA disorders under those auspices across the three States, 68 percent received mental health services only, 21 percent received substance abuse services only and 11 percent received se rvices related to both MH and SA. (Clients with dual disorders may be underestimated because some organizations did not collect enough information to determine dual diagnoses.) A significant proportion of clie nts with MH-only disorders received care only under the Medicaid program (26 to 52 percent across th e three States). Clients with SA-only disorders were treated predominately under St ate SA agencies – 65 to 97 percent of SA clients across the three States. Clients with dual MH+SA disorders were mo re likely to be tr eated under the MH/SA agencies than under Medicaid in the States. Of those under the MH/SA agencies, about half (averaged across the States) were treated under both the MH and SA agency, with the remainder being treated mostly under the MH agency only. Youth clients were predominantly males, whether they had MH, SA, or dual MH+SA disorders. Adult MH-only clients were more likely to be female. Minorities (from backgrounds other than non- Hispanic white) were found among the MH- only population at about the same rate as they were among the resident population of each State. However, minorities were a larger portion of clients w ith SA-only disorders compared to the populations of each State. Adult MH clients treated under Medicaid onl y (not under State MH agencies) were less likely to have schizophrenia, major depressi on, and psychoses – the most serious mental illnesses. Clients with single diagnoses (MH or SA) were very unlikely to be hospitalized, 87 stays per 1000 MH-only clients and 23 stays per 1000 SA -only clients in 1996. However, clients with dual MH+SA disorders were much more likely to be hospitali zed, at a rate of 457 hospitalizations per 1000 clients. Hospitalization rates of clients under different State auspices varied tremendously. For example, for MH-only youth clients, be tween about 5 per 1000 and 500 per 1000 were hospitalized in 1996, depending on the Stat e organization supporting the client. Residential care was rarely provided to persons with MH-only disorder s, but frequently was the setting for those with SA-only di sorders and with dual disorders. iv TABLE OF CONTENTS Foreword....................................................................................................................... ............................................i Executive Summary.............................................................................................................. ...................................ii Key Find ings................................................................................................................... .....................................iii Chapter 1. Overview of the Integrated Data Base............................................................................... ................1 Introduc tion................................................................................................................... ........................................1 Overview of the Integrat ed Data Base (IDB)..................................................................................... ...................2 The Population of the In tegrated Da ta Base..................................................................................... .....................3 Characteristics of the Participati ng States.................................................................................... .........................4 Delaware....................................................................................................................... ...................................6 Oklahoma....................................................................................................................... ................................10 Washin gton..................................................................................................................... ...............................11 A Note of Warning ab out State Co mparison....................................................................................... ...............12 Protecting Confidentia lity of th e Data......................................................................................... .......................13 Structure and Size of the Data Base............................................................................................ ........................14 Purpose of this Report......................................................................................................... ................................15 Organization of the Report..................................................................................................... .............................16 Chapter 2. Methods of Analysis for the Integrated Data Base (IDB)............................................................. ..17 Study Popu lation............................................................................................................... ..................................17 Classifying Type s of Clients................................................................................................... ............................18 Developing Serv ice Cate gories.................................................................................................. .........................19 Overlapping Client s and Services............................................................................................... ........................19 Other Statisti cal Ma tters...................................................................................................... ................................20 Limitations.................................................................................................................... ......................................20 Chapter 3. Clients with Mental Disorders Only................................................................................. ................23 Both State MH Agencies and Medicaid Provide MH Serv ices........................................................................ ...23 Medicaid Supports a Yo unger MH C lientele....................................................................................... ...............24 Young Males and Adult Females Comprise the Majority of St ate MH Clients..................................................25 Minorities in State MH Populations Generally Ar e in Proportion to th e State Populations...............................26 Youth and Adult Mental Health Clients Have Different Ment al Disorders........................................................27 MH Services: A Large Propor tion of MH Clients Receive Treatment in Outpatient Settings Only.................................................................................................................. .....................................29 The Number of Hospitalizations Va ries Markedly by Stat e Entity................................................................. ....31 Use of Residential Facilities by MH Clients is Even Less Likely th an Hospitalization.....................................33 Chapter 4. Clients with Sub stance Abuse Di sorders Only........................................................................ ........35 State Substance Abuse (SA) Agenci es Care for Most SA Clients................................................................... ...35 SA Clients are Older, On Av erage, than MH Clients.............................................................................. ...........36 Males Dominate the Stat e SA Youth Population................................................................................... .............36 Proportionately More Minorities Are Treated fo r SA than in the Tota l State Popu lations.................................37 More Youth Treated for Drug Disorders and Mo re Adults Treated for Alcohol Disorders................................39 SA Services: Treatment of SA Clients Is Pr ovided Mostly in Outpa tient Settings Only...................................41 Substance Abuse Youth Clients are Rarely Treated in Hospitals.................................................................. .....44 SA Clients Are More Likely to Receive Residential Care th an Hospital Care...................................................45 v Chapter 5. Clients with Dual Mental Health and Substance Abuse Disorders...............................................49 Medicaid Alone Supports Some Client s with Dual MH+SA Disorders.............................................................50 A Small Proportion of C lients with Dual MH+SA Disorders are Young...........................................................52 Males Dominate Youth and Females Domina te Adults with Du al Disorders.....................................................52 Minority Representation Among Clients with Dual Disorders Is Comparable to the State Population in Two States.................................................................................................................. ....................................53 Different Types of Dual Disord ers Affect Youth and Adults...................................................................... .......54 Type of Substance Use Differs by Age Grou p for Those with Dual MH+SA Disorders....................................56 The Prevalence of MH Diagnoses by SA Diagnoses and Vice Versa.................................................................5 7 MH/SA Services: Clients with Dual Disorders Are Frequently Treated in Multiple Settings...........................59 Clients with Dual MH+SA Disord ers Are Frequen tly Hosp italized.................................................................. .60 Residential Care is one of the Multiple Settings Used for Clients with Dual Disorders.....................................62 Chapter 6. Summary and Conclusions............................................................................................ ...................65 The Integrated Data Base (IDB) Project......................................................................................... ....................65 Results of the First An alysis of the IDB....................................................................................... ......................66 Which State Organizations Su pport Which MH /SA Clients?......................................................................... ....66 What are the Characteristics of Clients Receivi ng MH/SA Treatment under State Auspices?...........................67 What MH/SA Disorders Are Treated across State Or ganizations?................................................................... ..67 Do settings of Service for MH/SA C lients Differ by St ate Organization?......................................................... .68 How Many Services Are Provided to Client s under Different Stat e Organizations?..........................................68 Limitations.................................................................................................................... ......................................69 Future Di rections.............................................................................................................. ..................................70 References..................................................................................................................... ..........................................73 Appendix A. Advisory Panel.................................................................................................... ............................75 Appendix B. Detailed Methods of Da ta Development for this Study............................................................... 77 Selection of Clients for the In tegrated Data Base (IDB)........................................................................ .............77 Selection of Study Popu lation from the IDB..................................................................................... .................77 Diagnostic Ca tegoriza tion...................................................................................................... .............................78 Number in the Study Population................................................................................................. ........................79 Number in the Study Populatio n without Detaile d Diagnoses...................................................................... ......80 Service Cate goriza tion......................................................................................................... ...............................80 Identification and Flagging of Duplicat e Services.............................................................................. ................83 Medicaid Enrollment............................................................................................................ ..............................86 Other Statistical Issues Specific to Th is Study................................................................................ ....................87 Further Methods De tail Ava ilable............................................................................................... ........................87 vi TABLES Table 1.1: State Populatio n Receiving State-Administ ered MH/SA Services....................................................4 Table 1.2: Characteristics of Programs that Support MH/SA Services in Participating States , 1996.................................................................................................................. .....................7 Table 1.3: Number of Reco rds Received, by State................................................................................ ...........15 Table 2.1: Number of Clients in the IDB and Excluded from the Study, by Reason for Exclusion and by State...................................................................................................................... ......................17 Table 2.2: Number of People in the IDB and Select ed for Study (with Primary MH/SA Disorders of Any MH/SA Service and Age less than 65) by State and by Diagnosis.................................................18 Table 2.3: Number and Percent of Study Population Assigned to MH or SA Categories by Method of Classification – Diagno sis or Relate d Service............................................................................19 Table 4.1: Percent of Youth SA Clients Who R eceived Selected Services, by State and State Organization.................................................................................................................. ..................43 Table 4.2: Percent of Adult SA Clients Who Received Se lected Services, by State and State Organization...43 Table 5.1: Clients with Dual MH+SA Disorders by Source of Treatment, Excluding Medicaid in Each State and Youth Serv ices in Delaware*......................................................................................... .51 Table B.1: Diagnoses Used as Selection Criteri a for the IDB.................................................................... .......77 Table B.2: Diagnosis Categories Used as Inclusion Crite ria for th e St udy....................................................... 78 Table B.3: Number of Client Records for Analysis of MH/SA Services by Type of Client, State, and Organization Supporting Treatment.............................................................................................. ..81 Table B.4: Percent of MH/SA Client Records with Mi ssing Detailed Diagnosis-Related Data,* by Type of Client, State, and Organiza tion Supporting Treatment....................................................................82 Table B.5: Serv ice Cate gories.................................................................................................. .........................84 Table B.6: Enrollment in Medicaid for Clients R eceiving Medicaid MH/SA Se rvices, by State.....................86 vii FIGURES Figure 3.1: MH Clients Are Treat ed Mainly by the MH Agency or Medicaid, Not Usually Both.......................24 Figure 3.2: A High Proportion of MH Clients under Medicaid Only Are Young in Two States.........................25 Figure 3.3: Young MH Clients Are Predominantly Male Regardless of Th eir Source of Support.......................25 Figure 3.4 Adult MH Clients Are Predominantly Fe male Regardless of Their Source of Support.....................26 Figure 3.5: Minority Status of Yo uth MH Clients Is Similar to the Youth Population in Two States.................26 Figure 3.6: Adult MH Clients in Two Stat es Reflect the State Minority Popul ation............................................27 Figure 3.7: Childhood and “Other” Mental Diso rders Most Common among Youth MH Clients.......................28 Figure 3.8: Serious and “Other” Mental Diso rders Most Common among Adult MH Clients............................29 Figure 3.9: Youth MH Clients Recei ved Mostly Outpa tient Services............................................................... ...30 Figure 3.10: Adult MH Client s Received Outpatient Servi ces Almost Ex clusively...............................................31 Figure 3.11: Hospital Stays More Likely fo r Youth MH Clients und er Both Auspices.........................................32 Figure 3.12: Hospital Stays More Likely fo r Adult MH Clients und er Both Auspices..........................................33 Figure 3.13: Few Youth MH Clie nts Received Re sidential Care.................................................................... .......34 Figure 3.14: Few Adult MH Clie nts Received Resi dential Care.................................................................... ........34 Figure 4.1: Most SA Clients Are Treated in Programs under State SA Agencies Only.......................................36 Figure 4.2: A Small Percent of SA Clients Are Young, Yet It Varies by Source of Support...............................36 Figure 4.3: Most SA Youth Client s Are Male..................................................................................... .................37 Figure 4.4: Most SA Adult Clients Treat ed under SA Agencies Only Are Male.................................................37 Figure 4.5: SA Youth Clients Are More Likely to be Minority than is the State Yo uth Population....................38 Figure 4.6: SA Adult Clients Are More Likely to be Minority than is the State Adult Po pulation......................38 Figure 4.7: Most SA Youth Clients Have a Pr imary Drug Disorder................................................................. ...40 Figure 4.8: Most SA Adult Client s Have a Primary Alcohol Disorder.............................................................. ..40 Figure 4.9: Young SA Clients Are Treated Al most Exclusively in Outpatient Settings......................................41 Figure 4.10: Adult SA Clients Are Tr eated Mostly in Ou tpatient Settings........................................................ ....42 Figure 4.11: SA Youth Clients Ar e Rarely Treated in Hospitals.................................................................. ..........45 Figure 4.12: SA Adult Clients Supported by Medicaid (Alone or Jointly) Are More Likely to be Hospitalized...45 Figure 4.13: Residential Care for Youth Clients with SA Disorders Is Only Unde r the State SA Agency............46 viii Figure 4.14: A Substantial Number of Adu lt SA Clients Are in Residentia l Care.................................................4 6 Figure 5.1: Clients with Dual MH+SA Disorders Ar e Less Likely to be Treat ed Under Medicaid Alone..........51 Figure 5.2: A Small Portion of C lients with Dual MH+SA Are Youth............................................................... .52 Figure 5.3: Most Youth with Dual MH+SA Disorders Under Stat e MH/SA Agencies Are Male.......................53 Figure 5.4: Most Adults with Dual MH+SA Di sorders Under State MH/S A Agencies Are Male.......................53 Figure 5.5: Minorities Amon g MH+SA Youth Clients Gene rally Are Proportionate to State Populations.........54 Figure 5.6: Minorities Amon g MH+SA Adult Clients Generally Are Pr oportionate to State Populations..........54 Figure 5.7: Youth Clients with Dual MH+SA Have Ma inly Childhood, Mood/Anxiety, and Stress/Adjustment Disorders...................................................................................................................... ......................55 Figure 5.8: Adult Clients with Dual MH+SA Have Mainly Schizophrenia, Major Depression, and Psychoses..56 Figure 5.9: Youth Clients with Dual MH+SA Are More Li kely to Have Primary Drug than Alcohol Disorders57 Figure 5.10: Adult Clients with Dual MH+SA Are As Likely to Have Primary Alcohol as Drug Disorders in Two States......................................................................................................................... .........................57 Figure 5.11: MH+SA Clients Using Different Primary Substances Have Similar Distributions of Mental Disorders.................................................................................................................... .......................58 Figure 5.12: MH+SA Clients Are Split between Primary Alcohol and Drug Disorders for All Mental Disorders..................................................................................................................... .......................59 Figure 5.13: Youth Clients with Du al MH+SA Rarely Receive Only Inpa tient or Only Residential Care............60 Figure 5.14: Adult Clients with Dual MH+SA Are More Likely to Receive Care in Multiple Settings than Youth......................................................................................................................... .........................60 Figure 5.15: Youth with Dual MH+SA Treated under So me Auspices Have High Rates of Hospitalization........61 Figure 5.16: Adults with Dual MH+SA Treated under So me Auspices Have High Rates of Hospitalization.......61 Figure 5.17: MH+SA Youth Are More Likely Treated in Residential Settings than MH or SA Only Youth Clients....................................................................................................................... .........................62 Figure 5.18: MH+SA Adults Are More Likely Treated in Residential Settings than MH Only Adult Clients......63 1 Chapter 1. Overview of the Integrated Data Base Introduction Mental health and substance abuse treatment services in the United States are funded by various public and private en tities. State and local govern ments manage a substantial portion of all substance abus e (SA) and mental health (MH) treatment dollars.1 Of the $11.9 billion spent on SA treatment in 1997, State and local governments managed 48 percent of those dollars; of the $73.4 billion spent on MH serv ices in that year, they managed 41 percent. The relative role of States in managing MH/SA services is in contrast to their voice in all health care: th ey managed only 22 percen t of all health care dollars in 1997. Most States have multiple agencies suppor ting or managing MH/SA services. Mental health can be administered separately from substance abuse; services for youth can be administered separately from those for adults; and both Medicaid and State MH/SA agencies can be involved in supporting such services. As a result, information about public MH/SA services resides w ith individual agencies: who receives services from the agency, who delivers the services, what type s of service are being delivered, and how much the services cost. Understanding issues such as whether a person is being treated for substance abuse and mental disorders, the continuity of ca re across Medicaid and other State or local agencies, or the total cost of care per MH/SA client2 is not feasible with separate data systems. Furthermore, pooling these diverse data sources is not straightforward. The Center for Substance Abuse Treatment (C SAT) and the Center for Mental Health Services (CMHS) of the Substance Abuse a nd Mental Health Services Administration (SAMHSA) initiated an effort five years a go to integrate valuable sources of data on substance abuse and mental health servi ces: Medicaid data and State MH/SA agency data. This one-time Integrated Data Base (IDB) project demonstrates the feasibility and difficulty of linking data across agencies in three States (see Whalen et al., 2001). The first phase of the project is complete, a nd now, information from the CSAT/CMHS IDB, available for analyses by SAMHSA and the pa rticipating States, is the subject of this report. CSAT and CMHS undertook the IDB project to create a better understanding of how States support individuals in need of serv ices, given the States’ important and complex role in MH/SA care. The IDB assembles information on mental health and substance abuse clients, utilization, and expenditures at the State level. The st udy is able to address many important questions about the populations treated in State organizations and the services provided to them, such as: 1 Estimates from the CSAT/CMHS Spending Estimates Pr oject (Coffey et al., 2001). In addition to State and local tax dollars that support Medicaid and other MH/SA health services, State and local governments manage the Federal portion of Medicaid and Federal SA and MH block grants. 2 Throughout this report, “MH,” “SA, ” or “MH/SA” are used as shorthan d to refer, albeit imperfectly, to clients with mental illness, alcohol, or drug abuse disorders. 2 How many people receive treatment services under various State entities that provide MH or SA services? How many receive services from multiple State entities? What are the characteristics of clients w ho receive such services, including those diagnosed with both mental a nd substance abuse disorders? How many and what types of services do they receive? Overview of the Integrated Data Base (IDB) The IDB, currently encompassing one year of data (1996) for three States (Delaware, Oklahoma, and Washington) incorporates Medi caid data and State MH/SA agency data. The latter may be organized under one agency (as in Oklahoma) or two (as in Washington) or may be organized by adult and child services (as in Delaware). Medicaid programs typically collect information for adjudicating fee-for-service claims or monitoring prepaid care. Stat e MH and SA agencies typica lly collect data to track treatment and outcomes of their clients. Each State has a different organizational arrangement and structure of benefits for public MH and SA services; an overview is presented in the sections that follow. The unique feature of the IDB is that it comb ines into one data base for each State information for individuals who receive se rvices under multiple public programs that provide MH and SA care in that State. T hus, the IDB provides a more complete picture of the MH/SA clients seen in more than one part of the State-supported MH/SA care system. (Individuals who receive services under only one organiza tion during the year are also included.) The IDB contains person- level and service-level data for all such clients within a State. Thus, for example, the IDB can reveal the combined expenditures on treatment for individuals who use services under multiple State organizations that support MH/SA care. Strict data confiden tiality protections, described below, were applied to these sensitive health data. The three participating States were chosen af ter a search for States with electronic data, the ability of their data systems to link clie nts across agencies, and State interest in the project. At the beginning of this project, Washington State had made significant progress in creating such linkages and the IDB pr oject drew on their methodology. Throughout the IDB project, each of the States provided strong support of the concept and valuable staff time to provide data, documentation, cons ultation, and advice. Without this support the IDB would not have been possible. Th e data base provides a ready and uniform source of information for the three States and for CSAT and CMHS researchers. The data base currently contains informati on on MH and/or SA clie nts, including all of the physical or MH/SA services delivered to those clients through Medicaid or the State MH and/or SA agencies. Service and co st information are included, as well as demographics, client history, Medicaid eligib ility status throughout the year, diagnoses, providers, and prescription drug information. MH/SA agencies and Medicaid are part of the project in each State. (Some other Stat e programs, such as MH/SA programs within the justice or education systems, are not incl uded.) The IDB is complete for calendar year 3 1996. Years 1997 and 1998 are in process. The analyses presented in this report are based on 1996 data. This project also provides a data base fr amework for States that want to build and maintain integrated MH/SA data. A linking methodology, adaptable to other States that are interested in combining client data, is av ailable as part of the project (Whalen et al., 2001). The development of an integrated State data system is essential for States that plan to coordinate two or more funding str eams and to monitor continuity of care and analyze cost-effectiveness. The IDB is a secondary data source. “Seconda ry data” means the data were collected for some purpose other than to answer the specific research questions of this study. Purposes may include program administration, insuranc e reimbursement, health care management, or any others. The special purposes and requi rements of the original data collection will affect the completeness of the data bases, reliability of specific data elements, and the appropriateness of the data for a new purpose. This issue must be considered in analyzing any seconda ry data source. The Population of the Integrated Data Base The IDB is a census of people with mental a nd substance abuse disorders who are treated under State agencies – the MH agency, the SA agency, or the Medicaid program. For the data base, mental and substa nce abuse disorders are intent ionally defined broadly and include those persons who have clinical conditions that may or may not be indicative of a current mental or substance di sorder, such as a diagnosis of alcoholic cirrhosis, which may indicate sequelae from an earlier alc ohol dependence. For State MH or SA authorities, all persons who r eceived clinical treatment serv ices under their auspices are included in the IDB. For Medicaid data, severa l criteria are used to define the relevant population: persons with a primary or secondary mental illness or substance abuse diagnosis or with a related medical diagnosis, based on the International Classification of Diseases, 9th Revision, Clinic al Modification (ICD-9-CM); persons with procedures related to specific MH/SA services (for example, psychotherapy, rehabilitation, methadone, or counseling), based on codes that are either State-specific or from the manu al of Common Procedural Terminology, 4th Edition (CPT-4) ; those who receive specific type s of Medicaid services that may indicate mental or substance disorders, such as community me ntal health center services or inpatient psychiatric facility services; or those with records with appropriate revenue billing codes (for example, claims with psychiatric room charges, codes for in tensive psychiatric therapy, or alcohol rehabilitation charges). 4 As a result of applying such broad criteria, the IDB includes not only persons with an explicit mental or substance disorder but also those with an implied mental or substance disorder. Unlike the IDB, the population for the analyses in Chapter 2 and following includes only persons with an explicit MH a nd/or SA disorder. The inclus ion and exclusion criteria for those analyses are described more fully in Chapter 2 of this report. For all people in the IDB, all medical serv ices provided by Medicaid to the defined MH/SA population are included; this will enable future investigations of health care utilization and cost for the physical care of these MH/SA clients. People with dementia are excluded from the IDB except when they had another included MH or SA condition. (Patients with dementia without MH or SA conditions were omitted because their patterns and loci of care differ signi ficantly from the MH/SA group.) Using the full IDB (that is, the broader integrated State MH/SA agency and Medicaid data), Table 1.1 shows that the MH/SA populatio n treated under State auspices was about 4 percent of the 1995 populati on in each of the three St ates. The number of MH/SA clients unduplicated in the data base of th ese three States is just over 380,000, which is about 0.6 percent of the U.S. population that received MH and/or SA services in 1996 (U.S. Department of Health and Huma n Services, 1999; NIAAA, 1997; Epstein and Gfoerer, 1998). Table 1.1: State Population Receiving State-Administered MH/SA Services State State Population in 1995 Number of MH/SA Clients in the IDB Percent of State Population Receiving MH/SA Services Delaware 717,000 27,594 3.8 Oklahoma 3,278,000 137,704 4.2 Washington 5,431,000 215,111 4.0 Total IDB 9,426,000 380,409 4.0 Source: CSAT/CMHS IDB Project, 1996 data; Bureau of Census, 1995 projections of the 1990 Census. Characteristics of the Participating States The three IDB States (Delaware, Oklahoma and Washington) admi nister MH, SA, and Medicaid services through different or ganizational, financing, and payment arrangements. In Delaware, child and adult services are managed by different agencies; in the other two States, they are integrated within each agency. In Washington State, mental health and substance abuse services ar e separately administered; in Delaware and Oklahoma, they are integrated. All three Medicaid programs have managed care and fee- for-service reimbursement arrangements. Th e percent of the 1996 Medicaid population enrolled in managed care (that is, both capit ated and other arrangeme nts with and without primary care case management) varied across the States – 78 percent in Delaware, 19 percent in Oklahoma, and 100 percent in Wa shington (HCFA, 2001a). In Delaware, the 5 MH/SA authorities operate and oversee the ma naged behavioral hea lth care carve-out arrangement for Medicaid. In Washington, SA services are carved-out from Medicaid managed care and administered by the State SA agency. For MH services, a network of behavioral health professionals function as a prepaid plan for Medicaid MH services, which oversees those contracts. None of the States had passed legislation for MH parity by 1996 or 1997 (Lamphere et al., 1999). State Medicaid programs must provide Federally mandated health serv ices, regardless of physical or mental illness, and may provide a ny of the Federally defined optional services (HCFA, 2001b). The services are: Mandated Optional physicians services clinic services early and periodic screening, diagnosis, and treatment (EPSDT) services for children licensed practitioners’ services (e.g., podiatrists, psychologists, nurse anesthetists) inpatient hospital services other than in Institutions for Mental Diseases (IMD) inpatient hospital services to individuals age 65 or older in an IMD outpatient hospital, rura l health clinic, and Federally Qualified Health Center services nursing facility services to individuals age 65 or old in an IMD other laboratory and x-ray services prescription drugs (covered in all States) skilled nursing facilities services for individuals age 21 or older intermediate care facility for the mentally retarded (ICF/MR) services family planning services and supplies occupational therapy home health services for persons eligible for nursing facility services inpatient psychiatric services for individuals under age 21 nurse-midwife services to the extent allowed by State law nursing facility services for individuals age under 21 pediatric and family nurse practitioner services eyeglasses medical and surgical dental services diagnostic services screening services preventive services rehabilitative services case management services respiratory care services TB-related services private duty nursing dental services physical therapy speech, hearing and language therapy prosthetic devices hospice care services other medical services as approved by the Secretary All three States provide all mandated Medicaid benefits to Medicaid-eligible MH/SA clients. This includes EPDST, which require s that all medically necessary services be provided to children under the Medicaid progr am. However, the U.S. Congress and the 6 Federal Medicaid program have imposed limits on how services can be delivered to MH/SA clients. For example, Medicaid matc hing payments cannot currently be used for treatment of some MH/SA patients in Inst itutions for Mental Diseases, which are “inpatient facilities of more than 16 beds w hose patient roster is more than 51 percent severe brain disorders by primary admitting diagnosis” (NAMI, 2001). Medicaid cannot cover treatment in IMDs for patients between the ages of 22 and 64. Persons under age 22 or over age 64 can be treated in IMDs at State option, but not all States offer that option under Medicaid. Medicaid will pay for inpatient services to those aged 22 to 64 in general or community hospitals. The optional services under State Medicaid pr ograms vary, as do the services provided by State mental health and substance abuse agen cies. Below, services are identified that differ across the three States. The reader s hould realize that compar ison of Medicaid or other MH/SA services across States is compli cated because nomenclature of services and programs differ, making it difficult to know whether or not the same services are provided. Beyond Medicaid, State MH/SA services stand as fairly comprehensive safety nets for people who have mental and substance abuse disorders but who have limited or no Medicaid, private insurance benefits, or pers onal resources. The services provided by State MH/SA, as well as Medicaid, agenci es are listed in Table 1.2. Next, the organizations that administer or provide MH/SA care in each State are described along with MH/SA services and IDB developmen t issues specific to the three States. Delaware MH/SA data in Delaware reside in three distinct organizations: Division of Alcoholism, Drug Abuse and Ment al Health of the De laware Department of Health and Social Services (DADAMH/ DHSS) provides adult behavioral health services. Division of Social Services, Medicaid Progr am of DHSS provides behavioral health services to adults and children with relatively low needs for such services. The Department of Services for Children, Youth and Their Fam ilies (DSCYF) of the Division of Child Mental Health Services (DCMHS) provides child behavioral health services. The Diamond State Health Plan, a capitated managed care plan, was established January 1996 under a Medicaid waiver. Th e behavioral health portio n of the plan is a basic benefit administered by Medicaid, and ad ministered by the DADAMH for seriously mentally ill (SMI) adults and by DCMHS for children. Fee-for-service MH services are also provided under Medicaid for adu lts. DADAMH and DCMHS also provide medically necessary extended services beyond the basic Medicaid benefit to eligible 7 Table 1.2: Characteristics of Programs that Suppo rt MH/SA Services in Participating States, 1996 Characteristic Delaware Oklahoma Washington Organization, Domains, and Populations Served Adult MH/SA agency priority populations: Low-income adults with little or no insurance including people with acute needs or those who are seriously and persistently ill. Adults with severe and persistent mental illness and/or substance abuse who exceed their basic Medicaid benefit (carve-out clients). Medicaid-enrolled adults, not enrolled in managed care, with services that are reimbursed by Medicaid Child MH/SA agency covers: Medicaid-eligible, SCHIP1-eligible children for extended services Uninsured children. Medicaid program covers: Eligible adults and children with low to moderate long term needs Disabled adults (SPI3) with high needs are funded by Medicaid and care managed by DADAMH. MH/SA agency covers: Low-income children, adults, elderly Persons with chronic MI Persons with emergencies, regardless of income Persons eligible for Medicaid in rural, non-HMO areas jointly with Medicaid Medicaid covers: All adults and youth enrolled in Medicaid MH agency covers: Low-income adults and children, except for MRDD2 Low-income severely mentally or emotionally ill Emergencies for higher incomes Medicaid eligible adults and children for monitoring of services SA agency: Covers indigent and low-income youth, adults and families. Covers priority populations of pregnant women, parents with small children, and youth Manages programs funded by Medicaid in addition to Federal Block Grant and State dollars Medicaid covers: Eligible adults and children Medicaid Income Eligibility Rules for Selected Groups Pregnant women 133% of poverty Children 6-18 100% of poverty Delaware does not include Medically needy Pregnant women 133% of poverty Children 6-17 100% of poverty Medically needy 39% of poverty Pregnant women 133% of poverty Children 6-17 100% of poverty Medically needy 76% of poverty Population under 65 in poverty under Medicaid 47 percent 40 percent 46 percent Federal Medicaid Match 50 percent 70 percent 50 percent 8 Characteristic Delaware Oklahoma Washington Types of MH/SA Services Covered beyond Mandated Medicaid Services Adult MH/SA agency covers: Outpatient counseling Community centers Program of Assertive Community Treatment/Assertive Community Treatment (PACT/ACT) Intensive case management Short-term and long-term residential rehabilitation Methadone maintenance Detoxification Child MH/SA agency covers: Basic benefits for non-Medicaid youth Extended Services for all youth that exceed basic benefits Medically necessary MH/SA services without limit to eligible children Case management Medicaid covers: Psychiatric inpatient care for those under 22 and over 64 Hospital outpatient services Residential treatment Case Management Community MH services Acute inpatient services Rehabilitation services Emergency services Day treatment Detoxification Transportation MH/SA agency covers all services without limits: Detoxification Inpatient treatment Outpatient mental health centers Residential treatment Halfway houses Long term care inpatient Case management Medicaid covers: Psychiatric inpatient care for those under 22 and over 64 Outpatient services including physician services. Also includes psychologists for youth. Residential treatment for youth and pregnant women and their children, provided in inpatient facilities Case management for severely mentally ill MH/SA outpatient services for those in nursing facilities Rehabilitation services Emergency services Day treatment for youth Detoxification including up to five inpatient days. Up to twelve inpatient days in a general hospital for all needs including MH/SA MH agency covers: Community MH Services Elderly mental health services Inpatient psychiatric services Case management SA agency (DASA) covers: Inpatient detoxification Intensive inpatient treatment Intensive outpatient treatment Recovery house/extended care recovery house Long term residential care Residential treatment for youth Youth outpatient Medicaid covers: Psychiatric inpatient care for those under 22 and over 64 Hospital outpatient Residential treatment by inpatient providers Case management Community mental health centers Psychosocial rehabilitation Emergency services (DASA manages the alcohol/drug portion of the Medicaid funded program such as various levels of outpatient services, limited hospital based detoxification, medical stabilization for pregnant women, and assessment of clients.) Provider Arrangements Adult MH/SA agency has a network of providers across State: State-run providers Contract providers And operates and/or funds: MH/SA agency operates and/or funds: 3 State mental hospitals (two adult, one youth facility). 2 private psychiatric hospitals Residential care facilities MH agency contracts with: 14 county-based prepaid health programs that provide community mental health services – Regional Support Network (RSN) 9 Characteristic Delaware Oklahoma Washington 1 State psychiatric hospital including a psychiatric nursing facility 2 non-State psychiatric hospitals 7 multi-service MH organizations with or without residential care Outpatient mental health centers SA treatment programs, including counseling, case management, residential rehabilitation, methadone maintenance and detoxification Community mental health centers, some with internal or contracted inpatient beds and day programs. 2 State SA treatment centers Contracts with SA service providers 2 State mental hospitals SA agency funds: Prevention, treatment, and support services (transitional housing, child care, limited transportation) Counties which contract with private SA treatment agencies Community SA treatment centers Medicaid Payment Arrangements Medicaid uses: Capitated, managed MH/SA care for adults Fee-for service MH care for adults Capitated, managed MH/SA for children Adult MH/SA agency: Manages the MH/SA managed carve- out program for Medicaid adults Child MH/SA agency: Manages managed MH/SA carve-out for Medicaid children Contracts w/ managed behavioral health carve-out plans Medicaid uses and oversees: Capitated managed MH/SA care in urban areas (for TANF only). Fee-for-service (FFS) for all other Medicaid clients in urban areas and all clients in rural areas. Medicaid uses and oversees: Capitated payment to a pool for RSN (see above) FFS option and managed care option (latter chosen by 60% of Medicaid enrollees) DASA oversees and manages SA resources for Medicaid; billing occurs through the Medicaid MMIS system and services are funded on a fee-for- service basis. IDB Issues Children: Children = 18 years and under Dual Records: Exist (e.g., DADAMH and Medicaid) for identical persons, services, and dates, and must be identified and unduplicated Children: Children = 17 years and under Dual Records: Exist occasionally for DMHSAS and OHCA for identical persons, services, and dates; and must be unduplicated. Dual records within DMHSAS are not a problem due to their unique ID system. Other Issues: DMHSAS classifies: a) program clients and, b) contacts who received too few services to be admitted to the program Children: Children = 17 years and under Dual Records: Shared services between SMHA and Medicaid managed care are found less often in the data because Medicaid managed care reimbursement is sent directly to the RSNs. As a result, fewer diagnoses and shared expenditures are in the data base. 1SCHIP = State Child Health Insurance Program. 2MRDD = mental retardation and developmental delay. 3SPI = severely and persistently mentally ill. 10 adults and children, respectiv ely. DADAMH and DCMHS cont ract with a network of independent providers. DSCY F also is an accredited managed care organization. In 1996, Delaware provided an extensive se t of benefits for persons with MH/SA disorders, not only as Medicaid optional serv ices but also as services specific to DADAMH and DSCYF. Delaware covered ex tensive MH/SA benefits beyond Medicaid for all eligible youth and Assertive Community Treatment programs. Delaware has integrated adult MH agency a nd adult SA agency information, but has not integrated child behavioral health data with these integrated adult data. There is only limited integration of Medicaid a nd adult agency data for Medicai d-eligible clients. This complicated organizational structure for behavi or health information has implications for assembling an integrated data base for State services. Records for the same people are tracked at two agencies – Medicaid and either DADAMH or DCMHS. This occurs when, for example, DADAMH is responsible fo r providing the behavior al health benefits and Medicaid pays part of the bill. To reconcile duplicate records and assemble total spending, the data systems of separate organizations must be linked. An IDB issue that was resolved differently fo r Delaware than the other two participating States was the definition of the youth population. Delaware cla ssifies 18 year olds (as of December 31, 1996 for the 1996 file) in the youth population for their programs; the other States count 18 year olds in the adult population. As a convenience to the States, who wanted to use these files for progra m evaluation and planning, the IDB counts 18 year olds as youth in Delawa re and as adults in Oklahoma and Washington State. Oklahoma MH/SA data in Oklahoma reside in two di stinct and independent organizations: Department of Mental Health and S ubstance Abuse Services (DMHSAS) is responsible for the State’s mental he alth and substance abuse services. Oklahoma Health Care Authority (OHCA) is responsible for all medical and MH/SA services for persons e ligible for Medicaid. Under a 1995 Medicaid 1115 waiver, OHCA bega n a transition in urban areas from completely fee-for-service (FFS) reimbursement to FFS and managed care (called SoonerCare). In 1996, only those persons meeting requirements for Temporary Assistance to Needy Families (TANF) were en rolled in managed care; all other Medicaid persons received services under FFS. Rega rdless of the paymen t system, identical MH/SA services are provided to all Medicaid recipients. Any MH/SA service not covered under Medicaid is available from DMHSAS, which also provides all MH/SA treatment services to non-Medicaid low-income persons. In 1996, Oklahoma had limits on services under Medicaid. For example, Oklahoma Medicaid limited: all care in inpatient facilities to 12 days (for fee-for-service benefits); psychologist services to youth cl ients; residential treatment to youth; case management to children with severe emotional disturbances and adults with severe mental illness; day treatment to youth; and inpatient detoxification to 5 days during the year. Some of these 11 services were unlimited under the State MH/S A agency: inpatient treatment, residential treatment, case management and detoxifi cation. Oklahoma does not offer Assertive Community Treatment programs. Although data for MH and SA services at DM HSAS are integrated through their unique client identifiers, neither is integrated with Medicaid data . DMHSAS distinguishes their recipient population as 1) clients admitted to a program for treatment and 2) contacts who received services without being admitted to a treatment program. The latter may receive preventive screening, educational serv ices, and one-time services. Both clients and contacts are included in the IDB. Only clients are included in the analyses in this report because this study is focusing on those treated for mental or substance abuse disorders. Washington MH/SA data for Washington State reside w ith three separate ag encies, each under the Department of Social and Health Services (DSHS): State Mental Health Agency (SMHA) unde r the Mental Health Division (MHD) Division of Alcohol and Substance Abuse (DASA) Medical Assistance Administration (MAA), which is responsible for Medicaid. MAA offers its Medicaid enrollees MH treatment under managed care, through the Integrated Community Mental Health Plan. In 1996, virtually 100 percent of Medicaid enrollees participated in the manage d care program, which operates under a 1915b waiver. SMHA funds community mental he alth services thro ugh contracts with 14 Regional Support Networks (RSNs), which ar e county or multi-county prepaid health networks. The RSNs are directly acc ountable to the Mental Health Division. Washington offers a second program, the Basic Health Plan, which is primarily a medical managed care plan that offers limited MH/SA services for the uninsured and underinsured. Although funded by Medicaid, all SA services for Medicaid enrollees are managed by DASA using managed care principles but still provided on a fee-for–service reimbursement basis. DASA contracts with county organizations to arrange outpatient treatment services and contracts directly with inpatient providers for residential services. DASA provides SA prevention and treatment needs for the entire State population. Washington Medicaid limits some MH/SA se rvices. For example, for MH clients Washington Medicaid covers re sidential care only through ge neral inpatient facilities. (Thus, residential services c ould not be identified in th e Washington Medicaid data. Furthermore, Washington State could not provide to this proj ect the residential services data provided through the State MH agency.) In addition, detoxification for SA clients is limited to inpatient settings only. Als o, Washington does not provide Assertive Community Treatment programs. 12 Some services obtained from other States were not obtained from Washington. In addition to residential services, which could not be identified in Washington State data, data from the Medicaid agency for admissi ons to State mental institutions were not provided to this project. Medicaid covers services for such institutional care only for those under age 22 and over 64. The Office of Research and Data Analysis (ORDA) operates a management information system that integrates information from SMHA, DASA, Medicaid, and other agencies. ORDA provided methods for eliminating duplic ate person records and service records, which were useful for the IDB project. In order to apply consistent methods and create uniform files across the three States, the ID B project did not use the ORDA-integrated data for the IDB, but worked w ith the original agency files. A data integration issue of overlapping serv ices results from Washington contracting arrangements. Because Medicaid reimburse s the RSNs directly, SMHA and Medicaid rarely record utilization and spending for the same people a nd services. As a result, MH diagnoses from the Mental Health Agency are not collected and shar ed services between SMHA and Medicaid are available less frequen tly in Washington than in Delaware and Oklahoma. A Note of Warning about State Comparison Because of the many differences among the St ates, this report could have presented the results for each State separately. However, mo st statistics in this report for each State are shown side-by-side to aid read ers’ comprehension of State-sp ecific results and to identify where general statements are possible because of general, underlying trends in MH/SA treatment that appear as similar results across the three States. Comparisons of MH/SA utilization and expendi tures between States should not be made because State programs for delivering MH/SA services differ in so many dimensions. Their history in such programs can differ, as can their program resources and financing, organization, benefits, arrangements for pa ying providers, incentives for treatment, available settings for care, extent of manage d behavioral health care, and networks of providers. Some of these differe nces were highlighted in the previous sections. Also, the epidemiology of mental disorders being treated across regions or States can differ, as can the demographics of the populations. Furthe rmore, characteristics of Medicaid programs (their benefits, eligibility criteria, payment a rrangements, levels of payment, and extent of managed care) also vary considerably from State to State. In addition, the amount of joint administration and fundi ng for MH/SA services differs across the States. These multi-dimensional differences make it impossibl e to ascribe any particular finding across the States to one underlying factor or another. Furthermore, although a nation-wide view of State and local services would be an obvious goal for this type of investigati on, this project cannot approximate national estimates with data from only three States. Th e reader should keep in mind that the range of estimates across these three States may not reflect the full range of differences that might be observed if all 50 States were available in the IDB and these analyses. 13 Protecting Confidentiality of the Data Both Federal and State requirements for prot ection of client information were followed for the IDB Project. States differed somewhat in their requirements, but each required: 1) submission of detailed descriptions of th e project (purpose, pla nned studies, and time frame), 2) files and data elements needed, a nd 3) safeguards to be used for protecting the data. The United States Department of Health and Human Services (HHS) has strict rules for protecting alcohol and drug trea tment records (42 CFR Part II) . Those provisions specify that records with identifying information can be disclosed only in limited, specified, and controlled circumstances. One of the allowed disclosures is for re search purposes, under which data were obtaine d for the IDB project. The HHS 42 CFR regulations ar e subject to reasonable interpretation by the States – so requirements for documentation and review can differ across the States. To comply with HHS 42 CFR and State requirements, agreemen ts on data sharing and non-disclosure were signed with each State. Those agreements describe the procedures to be followed throughout the project to protec t the confidentiality of the data. The most stringent requirements of any State were applied to the data for all States. Personal identifiers and personally identifying information3 had to be obtained to link clients across organizations within a State and to construct the ID B. However, after linkage and verification, all personal iden tifiers were removed from the IDB and anonymous unique client identification numbers were assigned throughout the files of the data base to permit internal linkage of data f iles for analyses. No formula was retained in the data base to convert anonymous client iden tifiers back to origin al identifiers. With the Final Rule on Personally Identifying Information released by HHS December 2000 (under the Health Insurance Portability and Accountability Act of 1996), the IDB will be reviewed for consistency with that final rule, which requires compliance by April 2003. In addition, the IDB is stored on a dedicated computer in a locked room at one of the contractor’s facilitie s. Specified custodians of the data base are responsible for identifying authorized users, restricting acce ss to the data and the locked room, managing password protection of the data, and destro ying confidential results from data base processing or analyses. Any portable results of processing (printouts or electronic media containing confidential informa tion) are kept in locked st orage and are destroyed when no longer needed. All data f iles received under the project are tracked with respect to date of receipt, type of data, year of the f ile, supplier of the data, contact person, and final disposition. 3 Personal identifiers are data that identify individuals directly – such as name, address, telephone number, Social Security Number or another identification numbe r. Personally identifying information can also be indirect pieces of information about a person – such as birth date, postal co de, county of residence, diagnosis – which combined together allow the observer to identify the individual involved either through linkage with an outside data base or by personal knowledge of the circumstances of an individual. For instance, one person over the age of 100 may live in a county. With both pieces of information, age and county, it may be possible to identify the individual and learn confidential information about the person. In this circumstance, age and county would be considered personally identifying data. 14 Finally, in reporting results, analysts remove any statistics that are based on so few observations that indirect identi fication of a client might be po ssible. For example, in this study, only results based on 30 cas es or more are reported. Structure and Size of the Data Base In each of the States, the data items collected by the State substance abuse, mental health, and Medicaid agencies differed substantially. Although a separate IDB was built for each State, the structure of each IDB is the same and records of the same type were made uniform. The IDB for each State consists of 12 files – three client-level files, eight service-level files, and one person-summary file. Files are separated by type of organization that supplied the data (MH/SA agency, Medica id) and by type of service (inpatient, outpatient, etc.). The files can be linked at the service-level and person-level with service-based and client-based indices, respectively. The file structure is: Client Files: Core MH/SA Client File: one record per user of any mental health, alcohol, or drug abuse service from a State MH/SA agency or Medicaid agency, containing basic demographics. Detailed MH/SA Agency Client File: one or more records per client of State MH/SA agency, containing c lient attributes and conditions at points during treatment. Detailed Medicaid Enrollment File: one record per time period that an individual is enrolled in Medicaid during the year (with multiple records possible per person), cont aining demographic and eligibility information. Service Files: All Services File: one record per service for all services received from the State MH/SA authorities or Medicaid; each record links to a service detail record in one of the files below. SA Service File: one record per service fr om State substance abuse agencies, containing details on the service provided. Outpatient MH Service File: one record per outp atient service from State MH agencies, containing de tails on the service provided. Institutional MH Service File: one record per stay or per month in an institution (hospital, residential, or other institutional facility) covered by a State MH agency, c ontaining details on the service provided. 15 Medicaid Inpatient File: one record per stay in an inpatient hospital facility covered by Medicaid, cont aining diagnoses, and details of service provided. Medicaid Long-Term-Care File: one record per month in a long- term-care facility covered by Medi caid, containing diagnoses, and details of service provided. Medicaid Prescription Drug File: one record per prescription filled and covered by Medicaid. Medicaid Outpatient and Other Service File: one record per event for any other service covered by Medicaid not mentioned above, containing diagnoses, types of service, dates of service. In addition to outpatient services, this file in cludes durable medical equipment, transportation, laboratory services, physician charges for inpatient treatment, etc. Summary File: Person Summary File: one record per person in the IDB summarizing basic demographi cs, service utilization, and expenditures across a ll types of files. Over 62 million observations were processed to develop the IDB. Each State submitted all records for users of State-sponsored MH /SA care, whether through a mental health agency or a substance abuse treatment agenc y. In addition, each State submitted records of users of Medicaid-sponsored services (medical and behavi oral health) as well as the enrollment records for the total population of persons covered by Me dicaid (whether or not they used any type of service during the year). The table below lists the counts of records by State for major types of file contributed to the IDB Project. Table 1.3: Number of Records Received, by State Number of Records Received from: Incoming Files Delaware Oklahoma Washington Three States State MH/SA agency records 954,554 2,500,721 3,357,092 6,812,367 Medicaid claim/encounter records 3,625,018 13,734,015 26,718,568 44,077,601 Medicaid enrollment records 1,088,473 3,947,390 6,586,762 11,622,625 Total records 5,668,045 20,182,126 36,662,422 62,512,593 Source: CSAT/CMHS ID B Project, 1996 data Purpose of this Report This report introduces the three-State integrated data base and describes the first analyses performed. The analyses focus on persons w ith a primary MH and/or SA disorder. 16 Although health care utilization and costs for comorbid conditions (such as trauma or HIV/AIDS) are contained on the data base fr om Medicaid data, these analyses examine only the direct costs of the di agnosis and treatment of MH/SA disorders, rather than any relationship between MH/SA and physical health disorders. The analyses are conducted separately for clie nts with mental disorders only, for clients with SA disorders only, and for clients with bo th types of disorders. The analyses answer basic questions, illustrated here for MH-only clients: 1. How many people receive MH services from the State? Within a State, how many people receive these services from the State mental health agency only, from the State Medicaid program only, and from both? 2. Who receives MH services from the State MH agency and who from Medicaid? How do the youth and adult populations diffe r between the two organizations – demographically and clinically? 3. What types of services do MH clients receive from the State MH agency, from Medicaid, and from both? Ar e different types of services provided to youth and adults? Organization of the Report Following this overview of the integrated da ta base and the major differences among the States, Chapter 2 describes the methods used in this initial study of the integrated information on clients of State MH/SA agencies and Medicaid agencies. Chapters 3, 4, and 5 in this repo rt look separately at three ty pes of client populations that receive MH/SA treatment thr ough some State organization: Chapter 3 examines clients w ith mental disorders only, Chapter 4 studies those with subs tance abuse disorders only, and Chapter 5 reports on persons with both mental illness and alcohol and/or drug disorders. Chapter 6 summarizes and discusses the findings. 17 Chapter 2. Methods of Analysis fo r the Integrated Data Base (IDB) Study Population This analysis is based on a subset of persons in the Integrated Data Base (IDB) of State mental health or substance abuse (MH/SA) ag ency and Medicaid agency records. Both clinical conditions and age of the client define the subset. Four types of client records were excluded from the study. They are listed in the next Table in the order in which they were excluded. Table 2.1: Number of Clients in the IDB and Excluded from the Study, by Reason for Exclusion and by State Clients Delaware Oklahoma Washington Total Number in IDB 27,594 137,704 215,111 380,409 Number excluded for: No primary MH/SA diagnosis or service* 8,881 12,217 57,118 78,216 Missing age 33 21 1,285 1,339 Age over 64 1,051 8,537 13,276 22,864 All reasons 9,965 20,775 71,679 102,419 Total in study 17,629 116,929 143,432 277,990 *In Appendix B, Table B.2 shows diagnoses included in the study. While the IDB contains persons with a primar y or secondary MH or SA disorder, this analysis includes only those who had a primary MH or SA diagnosis or who received any MH or SA service at some point during cale ndar year 1996. The percent of people in the IDB excluded from the study due to lack of pr imary diagnosis or evidence of clinical treatment was 21 percent (78,216 out of 380,409), which represented 32 percent in Delaware, 9 percent in Oklahoma, and 27 per cent in Washington (calculated from Table 2.1). The mental disorders are schizophrenia, major depression, psychoses, stress and adjustment disorders, childhood disorders, mood/anxiety disorders, and other mental disorders. The “other” group includes persona lity disorders, phys iological malfunction arising from mental factors, and mental disorders due to organic brain damage. The SA conditions include alcohol psychoses, al cohol dependence, alcohol abuse, drug psychoses, drug dependence, and drug abuse. A detailed list of MH and SA disorders included in the study is in Table B.2 in Appe ndix B. These conditions clearly reflect MH or SA disorders; they exclude conditions that may or may not indicate a MH or SA disorder (for example, cirrhosis of the liv er). When a State agency provided records without diagnoses, a service re lated to MH or SA treatmen t was used to identify MH/SA clients, and their specific “detaile d” diagnosis was labeled “unknown.” While the IDB contains all age groups trea ted by the State agencies, this analysis excludes clients over 64 years of age and those of unknown age. Persons aged 65 and over were excluded from the study because in formation about their Medicare coverage 18 was not included in the data base, resulting in a partial view of th eir publicly supported MH/SA service utilization and expenses. Less than 7 percent of each State’s IDB client population was excluded due to age over 64 (c alculated from Table 2.1). Records for clients with missing age were excluded because they could not be used for an important classification in this analysis – youth and adult subgroups. Less th an 1 percent of each State’s client population in the IDB was excluded due to an unknown age (calculated from Table 2.1). For the analysis, the study population was sp lit into two age groups: youth (aged 0-18 for Delaware and 0-17 for Oklahoma and Washingt on) and adults (aged 19-64 for Delaware and 18-64 for Oklahoma and Washington), followi ng the definitions used in each State. Table 2.2 shows the total number of people in the IDB, the number excluded from this analysis, and the resulting size of the study population, by type of MH/SA condition. The data base for this study includes 277,990 MH/SA clients. About 6 pe rcent of the study population is from Delaware, 42 percent is from Oklahoma and 52 percent from Washington. For all of these clients, information was available on over six million service records for MH and/or SA treatment. Table 2.2: Number of People in the IDB and Selected for Study (with Primary MH/SA Disorders or Any MH/SA Service and Age l ess than 65) by State and by Diagnosis Study Population by Disorder* Mental Illness Substance Abuse State Number in IDB Number Excluded from Study Number in Study Population Percent Number Percent Number Delaware 27,594 9,965 17,629 68% 12,020 38% 6,749 Oklahoma 137,704 20,775 116,929 83% 96,497 27% 31,306 Washington 215,111 71,679 143,432 77% 110,264 30% 43,130 Total 380,409 102,419 277,990 79% 218,781 29% 81,185 Source: CSAT/CMHS IDB Project, 1996 data. *Persons with MH and SA disorders are counted in each diagnosis cell so the total of these two columns is greater than the total study population; the percent is relative to the States’ study population. Classifying Types of Clients Based on diagnoses and services, clients were classified into those with a mental disorder only (“MH only” clients), those with a substance a buse disorder only (“SA only” clients), or those with both mental disorders and subs tance abuse (“MH+SA” clients). A client was given a dual MH+SA classification, if the client had one or more of three combinations of diagnoses or services: 1) both a primary MH and a primary SA disorder, 2) a primary MH and a secondary SA disorder , or 3) a primary SA and a secondary MH disorder. Otherwise, the client was assigned to either “MH only” or “SA only” based on the client’s single assignment to a MH cat egory or a SA category. Table 2.3 shows the number of clients assigned to a MH-o nly, SA-only, or MH+SA category based on 19 diagnoses. Clients missing diagnoses we re assigned to these categories by a classification of the services received. A desc ription of the classifi cation process follows. For the 277,990 clients treated under various ag encies across the three States, 68 percent received mental health services only, 21 pe rcent received substance abuse services only and 11 percent received services for both MH and SA (calculated from Tables 2.3 and 2.2). These are the client categories that are analyzed in Chapters 3, 4 and 5 respectively. Table 2.3: Number and Percent of Study Population Assigned to MH or SA Categories by Method of Classification – Diagnosis or Related Service MH Only SA Only MH+SA Percent based on: Percent Based on: Percent Based on: Number Dx Service Number Dx* Service Number Dx** Service Delaware 10,254 96% 4% 5,426 19% 81% 1,949 96% 4% Oklahoma 79,620 64% 36% 20,037 12% 88% 17,272 88% 12% Washington 98,325 49% 51% 32,887 58% 43% 12,220 90% 10% Total 188,199 58,350 31,441 Source: CSAT/CMHS IDB Project, 1996 data. *Does not include diagnoses determined by use of an indicator for agency admitting category of alcohol or drug of choice, which was used after the study population was drawn. **Counted as “diagnosis-based” if either the MH or SA classification was based on diagnosis. Developing Service Categories In building the IDB, each service record was assigned to one of about 50 detailed service categories (for example, inpatient, outp atient, medication monitoring, MH therapy, durable medical equipment, or transportation). This assign ment was based on: source of record, type of service provi ded, provider type, revenue code and a few other data elements. See Appendix B for de tail on service categories used. For this analysis, detailed service categories were aggregated by sett ing of care: inpatient general hospital, inpatient psychiatric hosp ital, residential care , long-term care, and outpatient and other services. These were stil l further designated as MH, SA, or medical service (i.e., not a MH or SA service). C lients with no diagnoses were assigned to the MH-only, SA-only, or MH+SA group based on categorization of services. Finally, type-of-agency indicators were assi gned to each client based on whether State MH/SA agencies or Medicaid agencies or both provided MH or SA services to the client. The agency indicator was based on whether MH or SA services came from a particular division within a State. This study focuse s primarily on type-of-agency and general- categories-of-care aggregations and comparisons. Overlapping Clients and Services One of the unique features of the IDB is th e ability to make observations about clients and services in more than one State MH, SA or Medicaid agency. This feature requires that duplicate entries be detected for certain analyses. One client service may be reported by more than one source - State MH agency, SA agency, or Medicaid. For example, the same client, service, provider, and date could ap pear in the data base of each source; this 20 can occur, when Medicaid pays the bill and the State MH/SA agency manages the care. If utilization was simply added together from the two sources, the total number of inpatient or residential stays for a client would be overstated. Thus, for this study, when inpatient utilization rates acro ss Medicaid and State Agency records were calculated, the reported days of service were counted fr om one source only. (Note: duplicate records from different administrative sources are reta ined in the data base for other purposes.) The reconciliation of duplicate inpatient records was based on matching services provided to the same patient on the same or ove rlapping dates. When the client, the type of provider, the service, and dates of service were the same in the MH/SA agency and Medicaid data bases, then only one source of the inpatient service was counted. As noted in Chapter 1, because the MH/SA agency r ecords and the Medicaid records are organized separately in the data base and because multiple records were identified for the same service, the number of servic es can be counted in an unduplicated fashion across multiple sources. The analyses that follow are based on linked data bases and unduplicated counts of clients and inpatient services. The analyses of residential and outpa tient services were designed to avoid the need for unduplicated serv ices. For example, residential services are counted in terms of the number of clients (unduplicated ) who have any residential stay(s) during the year. Other Statistical Matters The following decision rules were us ed in conducting these analyses: Minimum cell sizes of 30 cases in deno minators were set for reporting rates. In addition, at least 30 percent of records must have diagnos is to be reported in the analyses of types of mental or substance abuse disorders. Regardless of cell size, at least 10 percent of other values must be present for estimates to be reported. Statistical tests were not us ed because the study is based on a census of information in each State and, thus, sampling does not affect the results. Additional details regarding these issues can be found in Appendix B. Limitations Limitations of this work relate primarily to the differences in the underlying data structure and content across State MH agen cies, SA agencies, and Medicaid. The limitations include: Missing Diagnoses. While diagnoses from Medicaid claims were generally available for analysis, diagnoses on State MH or SA agency data were often not available for a portion of clients and sometimes not available for an en tire organization. When that 22 enrollment in Medicaid will affect counts of services fo r Medicaid compared to State MH/SA agencies, although receipt of services from the latter agencies also varies in the length of time for MH/SA clients. De spite these issues, the pattern of Medicaid enrollment was similar across the three Stat es, which means that Medicaid enrollment patterns should have little effect on the di fferences in service utilization across the States. Initially, this study included an alyses of expenditures for MH/SA services. However, in the process of analysis, it became clear that complex patterns of missing data, varying definitions of services, and differences in the underlying MH/SA infrastructures in the States could not be resolved within the tim eframe of this report. Additional study of underlying data issues and differences in the st ructure, financing, and delivery of MH and SA services among the three Stat es are planned in the future. Additional detail about methods used in analyses in this report is available in Appendix B and on the SAMHSA/CSAT Web site at http://www.samhsa.gov/cen ters/csat/csat.html . 23 Chapter 3. Clients with Mental Disorders Only The Integrated Data Base (IDB) enables analys es of three distinct groups of clients who receive State-administered MH and SA treatme nt services. The three distinct groups are clients with – mental illnesses, substance abuse disorders, and both MH+SA disorders. Because the treatment systems – the networks of provider, sources of financial support, and settings of care – often differ by disease (Coffey et al., 2000), it is instructive to examine the care of these populat ions separately. In this chapter, State clients with mental disorders only are explored. Like other disorders, some people with ment al disorders who do not have the personal resources to receive treatment privately (t hrough private health insurance or personal financing) usually can rely on the State for evaluation and treatment of mental illness. States have had important roles in treatment of mental illness si nce the days of poor houses and the growth of State mental hospi tals, which flourished until the 1970s. The treatment of mental disorders since th at time has moved to the community. State support for mental health (MH) servic es is usually provid ed through two major organizations – Medicaid and State MH agenci es. Changing circumstances of clients can alter their eligibility for Medicaid and its benefits. Individual s can exhaust Medicaid benefits or require services not covered by Me dicaid in their State. When these things happen, MH agencies usually provide a safety net for those who need treatments for mental disorders. These State MH agencies also care for people who have limited financial means but are not eligible for Medicaid. To understand how States organize care for peop le with mental disorders, this chapter examines the characteristics of clients w ho receive mental health services from: State mental health agencies only (MH Agency Only), Medicaid agencies only (Medicaid Only), and Both types of organization (Both Auspices). The IDB permits examination of MH servic es under all of these State auspices. A Note of Warning about State Comparison: Chapter 1 discussed the multiple dimensions along which States differ in th eir organization, financing, and delivery of MH/SA services and the difficulty that poses for identifying the causes for different estimates across States. Therefore, interpreta tions focus on differences within the States and on general patterns that appear for all States. Both State MH Agencies and Me dicaid Provide MH Services The proportion of MH clients served by different State agencies varies across the States. Of the three States in th is study – Delaware, Oklahoma , and Washington – State MH agencies were the dominant support of MH clients in two – Oklahoma and Washington 24 (Figure 3.1). However, Delaware Medicaid a pparently played a larg er role in providing MH services than the MH/SA agencies. In Oklahoma and Washington, State MH agencies alone provided MH services to 51 and 59 percent of MH clie nts, respectively. In Delaware, Medicaid alone provided treatm ent to 52 percent of MH clients. Persons with mental illness served by both Medicaid and the State MH agency represented under one-quarter of State MH clients across th e three States, ranging from 13 percent in Oklahoma to 22 percent in Washington State. The availability of diagnoses across sources most likely influences these estimates. While fee-for-service Medicai d claim submissions must have diagnoses, Medicaid managed care claims submitted for monthly payments for clients generally do not. Delaware does ask providers submitting monthl y bills for youth clients to include their diagnoses, and virtually all Delaware MH yout h records had diagnoses. This difference in availability of diagnosis on client reco rds may explain, at least partly, the higher proportion of MH clients treated under Medicaid in Delaware. Conversely in Washington, the majority of Medicaid MH clients received outpatient care through Regional Support Networks, which are county-le vel health authoritie s that purchase and manage MH services and function as prepaid health plans. Those clients could not be identified in the Medicaid data base but could be identified in the State MH agency data base. However, the State MH agency does not collect diagnoses on outpatient records for those clients. This difference in availability of diagnosis on client records may be related to the lower rate of MH clients treated under Medicaid in Washington. Fi g ure 3.1: MH Clients Are Treated Mainl y b y the MH Agency or Medicaid, Not Usually Both 17 13 22 52 29 26 31 59 51 0% 20% 40% 60% 80% 100%DelawareOklahomaWashingtonPercent of MH Clients by State Organization MH Agency Only Medicaid Only Both Auspices Source: CSAT/CMHS IDB Project, 1996 data. Medicaid Supports a Younger MH Clientele While the proportions of youth in the three States’ populations are almost identical (25 to 28 percent among the States are under 18 year s of age, based on 1995 projections of the 1990 Census, not shown), the proportions of youth served under diffe rent organizations within the States are not. In Delaware, almost 70 percent of the Medicaid population receiving MH benefits through Medicaid only is under age 19 (the Delaware cut-off for the youth population) (Figure 3.2). In Oklahom a over half (52 percen t) is under age 18. In Washington, those over 18 years of age – th e adults – dominate the MH clients served 25 by Medicaid only. The percent of Medicaid- only MH-only clients who are adults in Washington is 65 percent ( 100 minus 35 percent youth). Fi g ure 3.2: A Hi g h Proportion of MH Clients under Medicaid Only Are Young in Two States17 31 40 69 52 35 42 41 26 0 20 40 60 80 100 DelawareOklahomaWashingtonPercent of MH Clients Who Are Young MH Agency Only Medicaid Only Both Auspices Source: CST/CMHS IDB Project, 1996 data. In contrast, patients treated only under State MH agency bud gets in two States are less likely to be young – only 17 percent in Delawa re and 31 percent in Oklahoma (Figure 3.2). In Washington, 40 percent of client s under the State MH agency are young. Thus, 60 to 80 percent of the State MH only populations across the States are adults. The larger adult populations exist across all types of organizations in Oklahoma and Washington, but not in Delaware, where Medicaid recipien ts of MH services are predominately young. Young Males and Adult Females Comprise the Majority of State MH Clients Across all ages, State MH clients are slightly more likely to be female – between 47 and 65 percent, depending on the State and State organization (not show n). However, the gender distributions differ markedly betw een youth and adult populations. While youth receiving MH services are more likely to be male (51 to 68 percent in Figure 3.3), adults receiving MH services across all agencies ar e predominantly female (55 to 79 percent in Figure 3.4). Fi g ure 3.3: Youn g MH Clients Are Predominantl y Male Regardless of Their Source of Support57 51 54 67 64 68 63 59 65 0 20 40 60 80 100DelawareOklahomaWashingtonPercent of MH Youth Clients Who Are Male MH Agency Only Medicaid Only Both Auspices Source: CSAT/CMHS IDB Project, 1996 data. 26 Fi g ure 3.4: Adult MH C lients Are Predominantl y Female Regardless of Their Source of Support55 66 57 79 75 72 65 70 59 0 10 20 30 40 50 60 70 80 90DelawareOklahomaWashingtonPercent of MH Adult Clients Who Are Female MH Agency Only Medicaid Only Both Auspices Source: CSAT/CMHS IDB Project, 1996 data. Minorities in State MH Populations Generally Are in Proportion to the State Populations Generally, the State MH populations include proportions of minority racial and ethnic clients (that is, other than non-Hispanic white s) that are similar to the proportion of minorities in the resident populations of the States (based on 1995 projections of the 1990 Census). One exception is Delaware. Wh ile 30 percent of Dela ware’s youth population is from minority groups, 51 percent of youth treated under Medicaid and 42 percent treated under both Medicaid and the State MH agency are minority. For Oklahoma, a 26- percent minority youth population is more comparable to a 30-to-40-percent minority youth MH population, depending on the State or ganization. In Washington, the minority youth and the MH minority youth proportions ar e more similar – 21 percent Statewide versus 16 to 22 percent among the St ate organizations (Figure 3.5). Fi g ure 3.5: Minorit y Status of Youth MH Clients Is Similar to the Youth Population in Two States29 40 22 51 30 20 42 30 16 30 26 21 0 20 40 60 80 100DelawareOklahomaWashingtonPercent of MH Youth Clients and State Youth Population Who Are Minorities MH Agency Only Medicaid Only Both Auspices State Youth Pop. Source: CSAT/CMHS IDB Project, 1996 data. Bureau of Census, 1995 projections based on 1990 27 Fi g ure 3.6: Adult MH Clients in Two States Reflect the State Minority Population29 24 17 38 23 25 43 21 13 23 19 15 0 20 40 60 80 100DelawareOklahomaWashingtonPercent of MH Adult Clients and State Adult Population Who Are Minorities MH Agency Only Medicaid Only Both Auspices State Adult Pop. Source: CSAT/CMHS IDB Project, 1996 data. Bureau of Census, 1995 projections based on 1990 Likewise for adults, the percent of mi norities among the MH clients of State organizations is comparable generally to th e percent of minorities among the State adult population. Again, Delaware has a higher propo rtion of minorities among the State adult MH clients than among State ad ult residents (Figure 3.6). Youth and Adult Mental Health Clie nts Have Different Mental Disorders A Note About Diagnostic Detail: The availability of dia gnosis-related information varies across organizations’ data systems and across the States (see Table B.3 in Appendix B). A high proportion of records without diagnoses in the Washington MH agency excludes that organization from compar isons on diagnosis. The criterion for this descriptive study is that diagnos tic statistics are repor ted only when 30 percent or more of records contain the item of interest (that is, no more than 70 pe rcent of records are missing the item of interest). In addition in Oklahoma, 66 percent of youth MH records and 59 percent of adult MH records from the State MH agency had no diagnoses, and this weakens conclusions about the diagnostic makeup of their clie nts. Nevertheless, most State subgroups (that is, 14 of 18 State-organization-age subg roups for MH-only clients, as shown in Appendix B, Table B.4) had a low rate of missing diagnosis-related information: 12 of the 14 had 2 percent or fewer clients with missi ng diagnoses and 2 of the 14 had 12 percent or fewer with missing di agnoses. This means that, other than for Washington and Oklahoma MH agencies, the diagnostic comparisons are based on solid evidence. For the following youth and adult analyses, the seven diagnosis groups in the study (Table B.2) were collapsed to three groups. Serious mental disorders included schizophrenia, major depression, and psychoses. Childhood disorders included attention deficit/hyperactivity disorder a nd other childhood disorders. Other mental disorders included stress/adjustment, mood/ anxiety, personality, and sexua l disorders, as well as physiologic malfunctioning related to ment al factors and organic brain damage. As expected, young MH patients are more likely to be diagnosed with childhood disorders than are adult patients who receiv e State-supported servic es. Between 38 and 28 77 percent of youth clients treated under a ny type of State organization had childhood diagnoses, and between 17 and 55 percent of youth MH clients had “other mental disorders” (stress/adjustment disorders, mood/ anxiety disorders, or other mental disorders listed above) (Figure 3.7). Only 5 to 13 per cent of youth had serious mental disorders: schizophrenia, major depression, or psychoses . The distribution of youth with these serious mental disorders was less for Medica id only clients than for clients supported under other auspices in each St ate. Otherwise, the magnit ude and variance of serious mental illness across the three States was similar. The underlying epidemiology of age at onset of serious mental illness may be influencing those distributions, along with referral of clients with serious disord ers to the State MH agency (e ither as the sole source of treatment or jointly with Medicaid support). However, the other two categories (childhood and other disorders) vary without a consistent pa ttern across State entities, which may reflect variability in diagnosis a nd coding of mental di sease or organization- specific referrals. Adult MH clients are more likely than youth to have serious mental disorders such as schizophrenia, major depression, and psychos es. Between 25 and 78 percent of adult clients were diagnosed with these conditions (Figure 3.8). A small proportion of adults is treated for childhood disorders, such as attent ion deficit/hyperactivity disorders. Other mental disorders such as mood/ anxiety disorders, stress/adjus tment disorders, and others are common as primary diagnoses for adul ts; between 22 and 61 pe rcent of adult MH clients have these disorders. Fi g ure 3.7: Childhood and "Other" Menta l Disorders Most Common among Youth MH Clients 55 41 34 48 33 44 17 27 38 54 53 45 62 47 77 61 8 13 9 13 5 6 5 7 0% 20% 40% 60% 80% 100%MH Agency Only Medicaid Only Both Auspices MH Agency Only Medicaid Only Both Auspices MH Agency Only Medicaid Only Both AuspicesPercent of MH Youth Clients by Disorder Serious Mental Dis. Childhood Dis. Other Mental Dis. Washington Oklahoma Delaware*Source: CSAT/CMHS IDB Project, 1996 data. *Less than 30 percent had diagnoses. 29 Fi g ure 3.8: Serious and "Other " Mental Disorders Most Common among Adult MH Clients 34 61 22 38 57 28 60 33 1 11 1 13 15 65 28 78 58 30 68 25 64 * 3 4 3 0% 20% 40% 60% 80% 100%MH Agency Only Medicaid Only Both Auspices MH Agency Only Medicaid Only Both Auspices MH Agency Only Medicaid Only Both AuspicesPercent of MH Adult Clients by Disorder Serious Mental Dis. Childhood Dis. Other Mental Dis. Washington Delaware Oklahoma Consistent diagnostic patterns occur by organization across th e States. Adult MH clients treated under Medicaid alone (outside of St ate MH agencies) are less likely to be diagnosed with the serious mental illnesse s of schizophrenia, major depression, and psychoses. That proportion for Medicaid-only clients (between 25 and 30 percent) is about half of the portion of State-MH-agency- only clients with serious mental illness (58 and 65 percent in the two States reported). At the same time, the percent of clients treated under both Medicaid and State MH agen cies with serious mental illness is the highest – 78 percent in Delaware, 68 percent in Oklahoma, and 64 percent in Washington. MH Services: A Large Proportion of MH Cl ients Receive Treatment in Outpatient Settings Only To simplify the combinations of types of se rvice examined for MH clients, this study classifies clients into those who receive only one type of serv ice (outpatient-only, inpatient-only, or residential-only care) a nd those who receive multiple services (any combination of those services). While outpatient care only may be a reasonable treatment setting for many clients, inpatient onl y or residential only is less fitting for MH treatment today. Clients who are not severely ill can usually be treated effectively in outpatient settings without inpatient or re sidential admissions, while clients who are severely ill usually require a sp ectrum of services that may include inpatient, residential, and outpatient care. Clients with outpatient , inpatient, or residential treatment in combination with other services are reflected in the “multiple settings” group. Hospital and residential care in total during the year (t hat is alone or with any combination of other services) are examined in the next two sections. Source: CSAT/CMHS IDB Project, 1996 data. *Less than 30 percent had diagnoses. 30 In 1996, a high proportion of youth and adult MH clients received outpatient services only. This was especially apparent for thos e provided care under one organization only (the MH agency only or Medicaid only) in a ll three States (Figures 3.9 and 3.10). For all six State organizations (excl uding the both-auspices category) , 84 percent or more of the youth or adult MH clients receiv ed outpatient services only. Multiple services (for example, at least tw o types of service such as outpatient and inpatient care) during the year were mostly provided to MH c lients who were eligible for and received services under bot h Medicaid and the State MH ag ency. This indicates that clients cared for jointly by two State agencies were probably more seriously ill and more complicated to treat. Perhaps those who e xhausted Medicaid benefits (which tend to cover acute care services) required more ex tended care from State MH agencies. Or, perhaps those clients treated under both au spices needed services not covered by Medicaid. The proportion of clients who r eceived services from both agencies and who received multiple types of se rvice ranged from 13 to 46 pe rcent of youth MH clients and from 19 to 26 percent of adult MH client s across the States (Figures 3.9 and 3.10). Fi g ure 3.9: Youth MH Clients Received Mostl y Outpatient Services0% 20% 40% 60% 80% 100%Percent of MH Youth Clients by Type of Service Outpatient Only 89925484928010010087 Inpatient Only 100010000 Residential Only 060200000 Multiple Services 10146138200013 MH Agency Only Medicaid Only Both Auspices MH Agency Only Medicaid Only Both Auspices MH Agency Only Medicaid Only Both Auspices Source: CSAT/CMHS IDB Project, 1996 data. Delaware Oklahoma Washington 31 Fi g ure 3.10: Adult MH Clients Received Outpatient Services Almost Exclusively0% 20% 40% 60% 80% 100%Percent of MH Adult Clients by Type of Service Outpatient Only 888981879474979976 Inpatient Only 720110201 Residential Only 020100000 Multiple Services 5719116262024 MH Agency Only Medicaid Only Both Auspices MH Agency Only Medicaid Only Both Auspices MH Agency Only Medicaid Only Both Auspices Source: CSAT/CMHS IDB Project, 1996 data.DelawareOklahomaWashington Consistent with the changing philosophy of treating mental il lness in outpatient rather than inpatient settings, inpa tient only treatment was rare in this population in 1996. For youth across all organizations and States, 1 percent or less of them received only inpatient care. For adults, only as much as 7 pe rcent of them in a sing le State MH agency received only inpatient services ; the other State organizations used inpatient only services for 2 percent or less of adult MH clients. Few youth received care only in residential setti ngs. In Delaware, 6 percent of clients treated under the Medicaid program received re sidential services only. In Oklahoma, 2 percent of State MH agency youth clients received such services. In Washington, no clients are shown receiving residential services only, because the State MH agency does not include residential treatment in their data base and because Medicaid includes all residential treatment as inpatient care. In Oklahoma, residential car e under Medicaid also is counted as inpatient treatment. Under al l other auspices, fewer than 0.5 percent of youth clients received solely re sidential care. For adult MH clients, 2 percent or fewer received treatment for a mental illness in a residential facility only. The Number of Hospitalizations Varies Markedly by State Entity This section examines the rates of hospitaliz ation – the number of hospital stays per 1000 MH clients – whether or not they received onl y hospital services or hospital services in combination with other MH services. Hospitals are the most expensive setting for tr eatment of mental illness. For that reason and to promote the ability of clients to function in the community, many organizations 32 aim to minimize the number of hos pital stays for MH clients. In addition, Medicaid does not permit the States to cover inpatient treatme nt for clients aged 22 to 64 in Institutions for Mental Diseases (IMDs) (explained in Chapter 1). This exclusion applies to psychiatric hospitals and to resi dential facilities of 16 beds or larger. This exclusion does not apply to youth under age 22 treated in IMDs. The data displayed in Figures 3.11 and 3.12 s how that clients who are treated under both the State MH agency and Medicaid are much mo re likely to have had a hospital stay than are clients receiving services from a single organization – Medicaid only or a State MH agency only. For youth, Delaware had 503 hos pitalizations per 1000 MH clients treated under joint auspices, Oklahoma had 300, and Washington 153. (Recall that Oklahoma Medicaid and all Washington hos pitalization rates include residential stays.) Averaged across the three States, State organizations, and age groups, the hospitalization rate for MH-only clients was 87 per 1000 clients (not shown). The low rate of hospitalization for Medicaid -only MH youth clients in Delaware (5 per 1000) and Washington (3 per 1000) occurred in an environment where Federal Medicaid does not prohibit any State from covering such treatment and the EPDST program requires that treatment services be provided to children when medically necessary. All three States indicated that they cover psychiatric inpati ent care for those under 22 years of age as an optional Medicaid service. These low hospitalization rates in Delaware and Washington might be related to their mature Medicaid managed care programs compared to Oklahoma, which started their Medicaid managed care program in 1996 in a few areas. The higher Oklahoma rate of hospitalization fo r Medicaid youth also may be related to the coverage of residential treatment as i npatient services, alt hough this was true of Washington as well. Furthermore, in Wash ington, a few inpatient stays for MH youth clients may be missing – less than 100 childre n under the Children Long Term Inpatient Program (CLIP) – because Washington St ate did not collect those data in 1996. Fi g ure 3.11: Hospital Sta y s More Likel y for Youth MH Clients under Both Auspices141 10 5 5 122 3 503 300 153 0 200 400 600 800 1000 DelawareOklahomaWashingtonHospitalizations Per 1000 MH Youth Clients MH Agency Only Medicaid Only Both Auspices Source: CSAT/CMHS IDB Pro j ect , 1996 data. 33 Fi g ure 3.12: Hospital Sta y s More Likel y for Adult MH Clients under Both Auspices114 74 5 137 74 38 298 289 3170 200 400 600 800 1000 DelawareOklahomaWashingtonHospitalizations Per 1000 MH Adult Clients MH Agency Only Medicaid Only Both Auspices Source: CSAT/CMHS IDB Project, 1996 Use of Residential Facilities by MH Client s is Even Less Likely than Hospitalization Because residential services we re either accounted for as inpatient services or excluded under all three Washington organizations and co unted as inpatient care under Oklahoma Medicaid in 1996, Figure 3.13 shows no resident ial services under those auspices. Otherwise in Oklahoma, 151 per 1000 youth, who were treated under the State MH agency only, received resi dential care, and only 19 per 1000 youth who were treated under both the MH agency and Medicaid received residential services. In Delaware, 213 per 1000 youth under both Medicaid and the State MH agency were admitted to residential care for treatment, while 74 pe r 1000 youth MH clients und er Medicaid only received residential care. Only in Delaware does Medicaid report residential services for youth. The other two States ma y provide residential services under Medicaid in inpatient facilities. Residential treatment for adults has a some what different patter n. Again, Washington reported no residential treatment for adult MH clients outside of hosp ital settings in 1996 (Figure 3.14). Delaware almost never admitted adult MH clients to a residential facility. Such adults in Oklahoma were more likely to receive residentia l care. In 1996, 82 per 1000 Oklahoma adults treated under the State MH agency alone received residential care; 112 per 1000 treated under both th e State MH agency and Medicaid received residential treatment. Almost no adult MH Medicaid-only c lients were treated in residential settings. These results most likely reflect the IMD ex clusion under Medicaid fo r adults 22 to 64 years of age (explained in Chapter 1). 34 Fi g ure 3.13: Few Youth MH Clients Received Residential Care 11 151 0 74 00 213 19 0 0 200 400 600 800 1000 DelawareOklahomaWashingtonNumber of MH Youth Clients in Residential Facilities Per 1000 MH Agency Only Medicaid Only Both Auspices Source: CSAT/CMHS IDB Project, 1996 data. Fi g ure 3.14: Few Adult MH Clients Received Residential Care0 82 0 21 10 13 112 0 0 200 400 600 800 1000 DelawareOklahomaWashingtonNumber of MH Adult Clients in Residential Facilities Per 1000 MH Agency Only Medicaid Only Both Auspices Source: CSAT/CMHS IDB Project, 1996 data. 35 Chapter 4. Clients with Substance Abuse Disorders Only States play a crucial role in substance abuse treatment. State and local tax dollars and Federal block grants to the States for substance abuse prevention, diagnosis, and treatment form the financial backbone of subs tance abuse services in the United States (Coffey et al., 2001). In addition for people mee ting specific eligibility criteria, Medicaid programs provide some acute care and emergenc y services for substance abuse. State SA agencies sometimes cover care for anyone w ith an emergency substance abuse disorder, regardless of their income. To understand how States organize care for peop le with substance abuse disorders, this chapter examines characteristics of clients who receive services th at are provided under the auspices of: State substance abuse agencies only (SA Agency Only), Medicaid agencies only (Medicaid Only), and Both (Both Auspices). The Integrated Data Base (IDB) permits exam ination of SA services under all of these State auspices. A Note of Warning about State Comparisons: Chapter 1 discussed the multiple dimensions along which States differ in th eir organization, financing, and delivery of MH/SA services and the difficulty that poses fo r identifying the reasons for differences in the estimates across States. Therefore, inte rpretations focus on differences within the States and on general patterns that appear for all States. State Substance Abuse (SA) Agencies Care for Most SA Clients State SA agencies were virt ually the exclusive source of support for treatment of State SA clients in all three States. In Oklahoma, 97 percent of clients were treated only under the State SA agency, with 3 percent under Medi caid and no shared clients (Figure 4.1). In Delaware, 87 percent were treated only under the State SA agency, with 5 percent covered by multiple agencies (the State SA ag encies and Medicaid). Only 8 percent of Delaware clients were treate d for SA only under the Medicaid program. Medicaid played a more significant role in Wa shington, providing services for 11 percent of SA-only clients without assistance from the State SA agency and for 24 percent of clients jointly with the State SA agency. In Washington, the SA agency manages all Medicaid funds for SA treatment in addition to Federal block grant and other State funds for SA treatment. 36 Fi g ure 4.1: Most SA Clients Are Treated under State SA Agencies Only 5% 24% 11% 3% 8% 87% 97% 65% 0% 20% 40% 60% 80% 100% DelawareOklahomaWashingtonPercent of SA Clients under State Auspices SA Agency Only Medicaid Only Both Auspices Source: CSAT/CMHS IDB Pro j ect, 1996 data SA Clients are Older, On Average, than MH Clients Only 6 to 13 percent of SA clients of State SA agencies, the major source of support for SA treatment in the three States, are youth (F igure 4.2). There is no consistent pattern of age differences across clients under different auspices – St ate SA agency only, Medicaid only, and both sources of support. The portion who are young among clients with SA- only disorders (5 to 31 percent, depending on the State organization) is lower than in Chapter 3 for clients with MH only disord ers (17 to 69 percent (Figure 3.2)). Fi g ure 4.2: A Small Percent of SA Clients Are Youn g , Yet It Varies by Source of Support23% 15% 31% 13% 11% 6% 13% 5% 30%0% 20% 40% 60% 80% 100% DelawareOklahomaWashingtonPercent of SA Clients Who Are Young SA Agency Only Medicaid Only Both Auspices Source: CSAT/CMHS IDB Project, 1996 data Males Dominate the State SA Youth Population Nearly 60 percent or more of the young SA population treated under State auspices across all types of support is male (Fi gure 4.3). The proportion of males among youth treated under the State SA agency in Delaware is much higher, almost 80 percent. (Note: This statistic and others below for Oklahom a youth who received services under both the 37 State SA Agency and Medicaid are not reported because there are fewer than 30 such youth.) Figure 4.3: Most SA Youth Clients Are Male67% 57% 58% 79% 59% 66% 63% 64% 0% 20% 40% 60% 80% 100% DelawareOklahomaWashingtonPercent of SA Youth Clients Who Are Male SA Agency Only Medicaid Only Both Auspices Source: CSAT/CMHS IDB Project, 1996 data. *Based on fewer than 30 cases.* Fi g ure 4.4: Most SA Adult Clients Treated under SA Agencies Only Are Male39% 54% 45% 75% 71% 76% 47% 52% 46% 0% 20% 40% 60% 80% 100%DelawareOklahomaWashingtonPercent of SA Adult Clients Who Are Male SA Agency Only Medicaid Only Both Auspices Source: CSAT/CMHS IDB Project, 1996 data. For the adult SA population, only the State SA agency has a hi gh proportion of male clients – 71 to 76 percent (F igure 4.4). Among adults treated under the Medicaid program or under both the State SA agency a nd Medicaid, females frequently dominate – only 39 to 47 percent of the clientele in f our of the six remaining groups are male. Medicaid typically serves a higher proportion of females, especially low-income pregnant and postpartum women. Proportionately More Minorities Are Trea ted for SA than in the Total State Populations Against the benchmark of the 1990 Census w ith projected 1995 St ate youth populations, a large proportion of youth tr eated for SA under State auspic es is from minority groups (that is, from groups of othe r than non-Hispanic white ra ce/ethnicity) (Figure 4.5). In Delaware, 30 percent of youth Statewide is minority, while 32 to 60 percent of the youth in State-supported SA treatment is minorit y, depending on the source of support. In 38 Oklahoma, 26 percent of the Statewide youth po pulation is minority, compared to 32 to 40 percent of the youth being treated for SA under State auspices. In Washington, 21 percent of the State’s youth is minority compar ed to 29 to 35 percent of State’s SA youth clients. In addition to the fact that each of the SA mi nority proportions (ranging from 29 to 60 percent) exceeds the minority repres entation among the gene ral population, they also exceed the minority representation am ong the population treated for mental illness (ranging from 16 to 51 percent, shown in Figure 3.5). Fi g ure 4.5: SA Youth Clients Are More Likel y to be Minority than Is the State Youth Population60% 40% 35% 34% 32% 34% 32% 29% 30% 26% 21% 0% 20% 40% 60% 80% 100% DelawareOklahomaWashingtonPercent of SA Youth Clients and State Youth Population Who Are Minority SA Agency Only Medicaid Only Both Auspices State Youth Pop. Source: CSAT/CMHS IDB Project, 1996 data. Bureau of Census, 1995 p rojections based on 1990 census. *Based on fewer than 30 cases.* Fi g ure 4.6: SA Adult Clients Are More Likel y to be Minority than Is the State Adult Population62% 34% 25% 30% 30% 41% 26% 45% 57% 15% 19% 23%0% 20% 40% 60% 80% 100%DelawareOklahomaWashingtonPercent of SA Adult Clients and State Adult Population Who Are Minority SA Agency Only Medicaid Only Both Auspices State Adult Pop. Source: CSAT/CMHS IDB Project, 1996 data. Bureau of Census, 1995 projections based on 1990 census. The percent of minorities among adult SA clients is also substantially greater than among the resident adult population of each State. In Delaware, the proportion of minorities among adults treated under the Medicaid program only (62 percent) is nearly three times the proportion of minorities among a ll adults in the State (23 pe rcent). In the other two States, this relative proporti on is less than two times (34 versus 19 percent for Oklahoma and 25 versus 15 percent for Washington) (Fig ure 4.6). These results are affected by the racial/ethnic differences between the Medicaid and resident populations of the States. The State SA agencies also had high repres entations of minorities among their clientele. 39 More Youth Treated for Drug Disorders and More Adults Treated for Alcohol Disorders Statistics in this section on drug and alcohol disorders ar e based on primary diagnosis (when available) or primary drug use reporte d by the client (for those persons with no diagnosis but with a SA serv ice). Statistics are not base d on co-occurring alcohol and drug disorders. Thus, this chapter does not identify, as other studies do (OAS, 1999a and 1999b), people with SA disorders who have dua l SA disorders of both alcohol and drugs, based on secondary diagnoses. The study can identify clients that are treated in separate encounters for one disorder (say, alcohol) a nd then in another encounter for the other disorder (say, drug). However, fewer than 0.5 percent of the clients in the analytic data base were in that situation - too few to an alyze separately. Each of these clients was assigned to a single main condition of either alcohol or drug (based on an algorithm described in Appendix B). Thus, the empha sis here is on primary SA disorders. Young SA clients treated under State auspices are more likely to be treated for primary disorders with drugs than with alcohol (F igure 4.7). In Delaware, between 77 and 93 percent of youth in treatment under State auspic es had primary drug abuse disorders. In the other two States likewise, drug abuse or dependence was usually the dominant primary disorder, although primary alcohol diso rders were more preval ent in those States than in Delaware. In Oklahoma, about 60 percent of youth in SA treatment under State auspices had primary drug abuse disorders, whether treated under Medicaid or the State SA Agency. (Oklahoma youth treated under bot h Medicaid and the SA Agency were too few to analyze.) In Washington, youth suppor ted by Medicaid were more evenly divided between primary drug and primary alcohol diso rders (48 and 52 percent, respectively). For Washington youth under the SA agency only or under both auspices, primary drug disorders were dominant (69 and 58 percent, re spectively). Recall that here only primary drug or primary alcohol disorders are exam ined, although many SA clients use both drugs and alcohol (OAS, 1999a and 1999b). 40 Fi g ure 4.7: Most SA Youth Clients Have A Primar y Dru g Disorder 93% 86% 77% 61% 62% 69% 48% 58% 23% 39% 38% 31% 52% 42% 7% 14%0% 20% 40% 60% 80% 100%SA Agency Only Medicaid Only Both Auspices SA Agency Only Medicaid Only Both Auspices SA Agency Only Medicaid Only Both AuspicesPercent of SA Youth Clients by Type of Disorder Alcohol Abuse Drug Abuse *Source: CSAT/CMHS IDB Project, 1996 data. *Based on fewer than 30 cases. DelawareOklahomaWashin g ton Fi g ure 4.8: Most SA Adult Clients Have A Primar y Alcohol Disorder 58% 57% 74% 43% 31% 33% 38% 38% 46% 42% 43% 26% 57% 69% 67% 62% 62% 54%0% 20% 40% 60% 80% 100%SA Agency Only Medicaid Only Both Auspices SA Agency Only Medicaid Only Both Auspices SA Agency Only Medicaid Only Both AuspicesPercent of MH Adult Clients by Type of Disorder Alcohol Abuse Drug Abuse Source: CSAT/CMHS IDB Project, 1996 data. DelawareOklahomaWashington Adults with SA disorders are more likely to have a primary alc ohol disorder than a primary drug disorder in two States – 54 percen t or more of clients across the sources of support in Oklahoma and Washington (Figure 4.8) had primary alcohol disorders. However, in Delaware a larger proportion ( 57 to 74 percent) of the adult SA population had primary drug disorders. 41 SA Services: Treatment of SA Clients Is Pr ovided Mostly in Outpatient Settings Only This section looks at SA clie nts who received services in only one setting (outpatient only, inpatient only, or residential only4) during the year, compared to those who received services in two or more settings, called “m ultiple settings” (for example, outpatient and inpatient treatment) during the year. This is a different view than the number of clients who received any service of a pa rticular type (for example, outpatient treatment, whether or not they received inpatient treatment), wh ich is examined in the next two sections. In 1996, outpatient services only were the most li kely locus of treatment for SA clients in Delaware, Oklahoma, and Washington, for bot h youth and adult clients (Figures 4.9 and 4.10). Under some auspices, 70 percent or more of clients received outpatient services only, and thus, received no services in inpatient or residential settings. Fi g ure 4.9: Youn g SA Clients Are Treated Almost Exclusively in Outpatient Settings92% 79% 54% 82% 84% 98% 76% 96%0% 20% 40% 60% 80% 100%SA Agency Only Medicaid Only Both Auspices SA Agency Only Medicaid Only Both Auspices SA Agency Only Medicaid Only Both AuspicesPercent of Youth SA Clients Who Received Outpatient Services Only Source: CSAT/CMHS IDB Project, 1996 data. *Based on fewer than 30 cases.*DelawareOklahomaWashington 4 In Oklahoma, Medicaid covers residential treatment for youth SA clients and for pregnant women with children in inpatient facilities, but admission generally re quires more than a SA diagnosis. For this reason, no residential treatment is found for Oklahoma Medicaid among the clients identified as SA only, from diagnosis-related information. Washington includ es residential care in their inpatient services. 42 Fi g ure 4.10: Adult SA Clients Are Treated Mostl y in Outpatient Settings57% 75% 48% 70% 79% 27% 56% 97% 68%0 0.2 0.4 0.6 0.8 1SA Agency Only Medicaid Only Both Auspices SA Agency Only Medicaid Only Both Auspices SA Agency Only Medicaid Only Both AuspicesPercent of Adult SA Clients Who Received Outpatient Services Only Source: CSAT/CMHS IDB Pro j ect , 1996 data.Delaware OklahomaWashington Multiple types of services (at least two duri ng the year) were primarily provided to SA clients who were eligible for and received both Medicaid and State SA agency services (Tables 4.1 and 4.2 that follow). These client s may reflect people with more serious and complicated disorders who need a continuum of care across settings , such as acute care services under Medicaid and longer-term care unde r State agencies. Also in some States, clients with more serious disorders may e xhaust Medicaid benefits, requiring care delivered by State SA agencies. The proporti on of clients who received multiple services under these two auspices across the States ranged from 21 to 46 percent for youth and from 30 to 73 percent for adults. Consistent with the changing ph ilosophy of treating SA disorders in outpatient rather than inpatient settings, these data show that SA treatment is al most exclusively provided in outpatient settings. “Inpatient only” treatment was received by one percent or less of persons treated under the State SA agency or Medicaid, except for two situations -- “Medicaid only” adult clients in Delaware and Oklahoma, where 10 and 4 percent, respectively, received only inpatient treatment (Tables 4.1 and 4.2). The very low proportions of clients receiving inpatient only services may be a positive result; 1 or 2 percent of clients can receive inpatient only se rvices simply because they become eligible for State support late in the year with an emergency admission to the hospital. Government program restrictions undoubtedly a ffect the locus of care. Substance Abuse Prevention and Treatment (SAPT) block grants, which are managed by State SA agencies, cannot be used for i npatient treatment. At the sa me time, Medicaid prohibits SA treatment in Institutions for Mental Diseases (which incl udes psychiatric and chemical dependency hospitals and residential treatment cen ters of 16 beds more) for adults who are 22 through 64 years of age. 43 Table 4.1: Percent of Youth SA Clients Who Received Selected Services, by State and State Organization Outpatient OnlyInpatient Only Residential Only Multiple Services Delaware SA Agency Only 92% 0% 5% 4% Medicaid Only 79% 1% 11% 8% Both Auspices 54% 0% 0% 46% Oklahoma SA Agency Only 82% 0% 13% 4% Medicaid Only 96% 1% 0% 3% Both Auspices * * * * Washington SA Agency Only 84% 0% 12% 4% Medicaid Only 98% 0% 1% 1% Both Auspices 76% 0% 2% 21% Source: CSAT/CMHS IDB Project, 1996. *Based on fewer than 30 cases. Table 4.2: Percent of Adult SA Clients Who Received Selected Services, by State and State Organization Outpatient OnlyInpatient Only Residential Only Multiple Services Delaware SA Agency Only 57% 1% 32% 10% Medicaid Only 75% 10% 1% 14% Both Auspices 48% 0% 0% 52% Oklahoma SA Agency Only 70% 0% 15% 15% Medicaid Only 79% 4% 0% 17% Both Auspices 27% 0% 0% 73% Washington SA Agency Only 56% 1% 29% 15% Medicaid Only 97% 0% 0% 3% Both Auspices 68% 1% 0% 30% Source: CSAT/CMHS IDB Project, 1996 Tables 4.1 and 4.2 also show the percent of cl ients receiving SA serv ices in residential settings only, without an inpa tient stay and without separate outpatient services during the year. Youth received care in “residenti al settings only” almost exclusively under the SA agency, except in Delaware (Table 4.1). In Oklahoma, 13 percent of SA youth clients received residential ca re only under the State SA agency only and none received it under Medicaid only. In Washington, 12 percent of SA youth clients rece ived residential care only under the State SA agency only and 1 pe rcent received it under Medicaid only. In Delaware, 5 percent of SA youth clients receiv ed residential care onl y under the State SA agency, while 11 percent received “resid ential care only” under Medicaid only. Generally, none of the youth SA clients under both Medicaid and the State SA agencies 44 received only residential services during th e year, except in Washington where 2 percent did. The absence of Medicaid reimbursement for residential only services for youth is somewhat surprising because the Federal pr ohibition of Medicaid c overage for care in Institutions for Mental Diseas e (which includes a residential facility with more than 16 beds) does not apply to clients under 22 years of age. This does not imply that Medicaid paid for no care of youth in residential set tings, because clients who receive residential and other types of services during the year ar e included in the “multiple services” group. (A later section explores coverage of residential care under any circumstance.) The same pattern of treatment emerges for a dult SA clients (Table 4.2). Generally, only those covered under the State SA agency, and not under Medi caid, received residential treatment only without care in other settings during the year. However, the rate of residential care among adults under State SA agencies was higher than for youth – in Delaware, it was 32 percent for adults versus 5 percent for youth; Oklahoma, 15 versus 13 percent; and Washington, 29 versus 12 percent. Substance Abuse Youth Clients are Rarely Treated in Hospitals The hospital is the most expensive locus of treatment for substance abuse disorders and some suggest that hospitalization is not neces sary for a significant portion of SA clients (IOM, 1990a and 1990b). For that reason, ma ny organizations aim to minimize the number of hospital stays for SA clients. Fu rthermore, Federal rule s that apply to State SA agencies use of Substance Abuse Prev ention and Treatment (SAPT) block grants prohibit use of SAPT funds for inpa tient treatment of SA clients. From Figure 4.11, fewer than 63 per 1000 youth SA clients, regardless of type of State support, are hospitalized for substance abuse, including detoxification and/or treatment. Clients admitted to the ho spital under the State SA ag ency after a Medicaid hospitalization, or vice versa, are counted in the “both” category. There are no hospitalizations for youth clients treated under the State SA agency only, likely reflecting SAPT block grant restrictions that prohibit us e of SAPT funds for inpatient treatment. The infrequent hospitalization of youth also may reflect their lower need for detoxification because they are more likely to be involved with drugs rather than alcohol, are less likely to be alcohol dependent and in need of detoxificati on, and may be involved with drugs for which detoxification is not us ually recommended (for example, marijuana or cocaine). A greater proportion of adult SA clients ar e hospitalized compared with youth, up to 355 per 1000 SA adult clients (Figure 4.12). This may relate to higher rates of inpatient detoxification of adults or to the clinical complications that result from longer-term substance abuse. In additi on, the effects of different pr ogram rules on use of hospital services are more apparent in the adult population. Those SA adult clients treated only under Medicaid in Delaware and Oklahoma ar e at least 11 times or more likely to be hospitalized than are those treated only under the Stat e SA agency. Washington Medicaid limits SA-related hospitalizations to pregnant women or to clients who need 45 detoxification in counties that do not have freestanding detoxi fication facilities. Under both auspices (Medicaid and State SA agencies), hospitalizations of a dult SA clients also are relatively frequent, likely reflecting more serious SA di sorders and complications for those clients. Averaged across the three States, State orga nizations, and age groups , the hospitalization rate for all SA-only clients in this study was 23 per 1000 in 1996 (not shown). This is much lower than the comparable rate for MH-only client – 87 per 1000 – noted in Chapter 3. Fi g ure 4.11: SA Youth Clients Are Rarel y Treated in Hospitals52 43 2 0 0 0 62 6 0 200 400 600 800 1000 DelawareOklahomaWashingtonHospital Stays Per 1000 Youth SA Clients SA Agency Only Medicaid Only Both Auspices * Source: CSAT/CMHS IDB Project, 1996 data. *Based on fewer than 30 cases. Fi g ure 4.12: SA Adult Clients Supported b y Medicaid (Alone or Jointly) Are More Likely to be Hospitalized295 241 31 25 1 7 249 355 101 0 200 400 600 800 1000DelawareOklahomaWashingtonHospital Stays Per 1000 Adult SA Clients SA Agency Only Medicaid Only Both Auspices Source: CSAT/CMHS IDB Project, 1996 data. SA Clients Are More Likely to Receive Residential Care than Hospital Care Under the State SA agency only, from 83 to 177 per 1000 youth clients and from 303 to 434 per 1000 adult clients were treated in resi dential facilities at some time during the 12- month period (Figures 4.13 and 4.14). SA treat ment in residential se ttings can be funded under SAPT block grants to the States. In 1996, SA treatment in residential facilities larger than 16 beds could not be funded under Medicaid for those aged 22 to 64. Virtua lly no (less than 10 pe r 1000) adults with SA disorders were treated in residential setti ngs under Medicaid in the three States. If 24-hour care was provided under Medicaid, it had to be in a small residential facility. 46 For youth, very few Medicaid-onl y recipients with SA di sorders were treated in residential settings, except for Delaware. In Washington, there were 17 per 1000 youth; in Oklahoma none. In Delaware, 167 per 1000 Medicaid-only youth recipients were in residential treatment for SA. It is somewhat surprising that Medica id covered so little residential care for youth with SA disord ers since there was no prohibition on such coverage for clients younger than 22. This re sult may reflect the di fficulty of identifying residential treatment in Medicaid data; there is no uniform data element that specifies residential treatment. This result also may reflect increased community alternatives to residential care for youth or bil ling restrictions (see below). Fi g ure 4.13: Residential Care fo r Youth Clients with SA Disorders Is Only under the State SA Agency167 0 17 83 177 164 432 236 0 200 400 600 800 1000 DelawareOklahomaWashingtonNumber in Residential Facilities per 1000 Youth SA Clients SA Agency Only Medicaid Only Both Auspices Source: CSAT/CMHS IDB Project, 1996 data. *Based on fewer than 30 cases.* Fi g ure 4.14: A Substantial Numb er of Adult SA Clients Are in Residential Care9 0 2 420 303 434 444 613 262 0 200 400 600 800 1000 DelawareOklahomaWashingtonNumber in Residential Facilities per 1000 Adult SA Clients SA Agency Only Medicaid Only Both Auspices Source: CSAT/CMHS IDB Project, 1996 data. The near absence of Medicaid-only clients in residential settings is in contrast to the high rates of hospitalization of these clients. Some of this result may be due to State Medicaid coverage rules. For example, in Oklahoma all treatment in 24-hour service facilities occurs in a hospital setting and in Washington, if residential treatment occurs, it is usually covered through the State SA agency. The Me dicaid coverage exclusion of Institutions for Mental Diseases (which in cludes residential facilities of 16 or more beds) for persons aged 22 through 64 clearly limits the use of reside ntial facilities for SA treatment. This clearly influences the very low rate of reside ntial treatment for Medicaid adults. (A few clients under age 22 are classified as adults in the analyses here, likely accounting for the few adults in residential treatment under Medicaid.) 47 In the future, the SAMHSA IDB project may investigate whether the high hospitalization rate under Medicaid is related to det oxification services and whether providing detoxification in non-inpatient settings might save Medicaid dollars. States also may want to analyze the potential for moving bot h detoxification and treatment for SA from inpatient to outpatient or resi dential settings for more clie nts. This is an increasing practice in SA treatment, nonetheless tempered in some States by the severity of the client’s clinical condition (McKay et al, forthcoming). 48 49 Chapter 5. Clients with Dual Mental Health and Substance Abuse Disorders The Integrated Data Base (IDB) enables analyses of people who have co-occurring disorders related to mental illness and to substance abuse and are treated under State agencies. This is generally not possible in studies of administrativ e data because clients of State agencies may receive their mental health (MH) care from one agency and their substance abuse (SA) treatment from anothe r, with Medicaid sometimes covering some MH/SA services separately from the State MH/SA agencies. This chapter explores State clients with dual mental health and substance abuse disorders and looks at their care across State organizations. Fo r shorthand, clients with dual disorders are referred to as “MH+SA c lients” in order to di stinguish them from clients with single disorders of any type tr eated in MH and/or SA agencies (usually referred to, in shorthand, as “MH/SA agencies”). State governments have a long history of cari ng for severely mentally and emotionally ill clients with complicated substance abuse disord ers, such as mental illness in combination with drug and/or alcohol disorders. This project looks at State support of these MH+SA clients through three main organizations – a State mental health agency, a State substance abuse agency, and the Medicaid ag ency. However, States differ in their organization of such services a nd in their information systems re lated to such services. In some States such as Oklahoma, MH and SA agencies share one integrated information system. In others such as Washington, the two systems are separate, both the delivery system and the reporting of such services. In Delaware, the adult MH and SA services are co-located in a single agency, but their information system in 1996 was comprised of multiple data sources. In addition, Delaware ad ministers child services separately with a separate data system. Medica id services and information systems are always separate from the State MH/SA agencies and may or may not be under the same department as those agencies. Because of the complex nature of the pr oblems experienced by persons with MH+SA disorders, analysts often assume that these patients are trea ted under State MH/SA agencies, where a longer-term continuum of se rvices may be offered in comparison to Medicaid’s more acute care benefit. This assumption is examined here. Also, the characteristics of MH+SA clients, their clinic al conditions, and their use of services is studied. The same stratified analysis is used in this as in Chapters 3 and 4, to reveal how services are provided to clients who use: State mental health and/or substance abus e agencies only (MH/SA Agencies Only), Medicaid agencies only (Medicaid Only), and Both sources of support (Both Auspices). Because persons with dual MH+SA disorders may use MH, SA, or both types of services, the defined category of State agency now enco mpasses the MH and SA agencies (labeled 50 “MH/SA Agencies Only”). Also, the Medica id-only category is included as in earlier chapters. Thus, many sections discuss clie nts with dual disorder s who are receiving services under two or th ree State entities. In this chapter, we are able to explore where the dual clients receive their MH and SA treat ment – whether from a MH agency or from a SA agency. A Note of Warning about State Comparisons: Chapter 1 discussed the multiple dimensions along which States differ in th eir organization, financing, and delivery of MH/SA services and the difficulty that poses for identifying the causes for different estimates across States. Therefore, interpre tations here focus on differences within the States and on general patterns that appear for all States. A Note of Warning about Diagnostic Detail: Because clients’ MH/SA clinical designations are identif ied from services received when detailed diagnostic information was not available, all clients could not be distributed by types of mental illness or substance abuse. For the 31,441 clients with dual MH+SA disorders (however determined), information was available to a ssign 41 percent of them to more detailed diagnostic categories. The percent missing vari es by the breakdowns used in the analysis (age group, State, and organi zation supporting treatment). Appendix B shows the percent of clients with missing diagnostic detail. Whenever the proportion with missing diagnostic detail is greater than 70 percent of the total clients in a category, results for that category are not reported. Across the cate gories of the analyses for which statistics for the MH+SA group are reported, the percen t of clients with missing MH diagnostic detail is between 1 and 53 percent, depe nding on the State, organization supporting treatment, and age group; the percent missi ng SA diagnostic detail is between 2 and 70 percent (Table B.4 in Appendix B). Medicaid Alone Supports Some Clie nts with Dual MH+SA Disorders Medicaid alone supports the care of some dua l MH+SA clients in each State (Figure 5.1). In Delaware, the proportion of these clie nts supported by Medicaid is highest – 25 percent receive MH/SA services under Medicaid only. In th e other two States, 8 to 9 percent of clients with dual disorders are treated under Medi caid only. Furthermore, the patterns of care differ among the three States . In Delaware, all three arrangements – State MH/SA agencies only (both youth and adult), Medicaid only, and both auspices – treat a similar proportion of c lients with dual MH+SA disorders. In Oklahoma, most of these clients are treated solely by the MH/S A agencies. In Washington, both types of organization (MH/SA agencies and Medicaid ) jointly support three quarters of these clients. In Washington, the State SA agency and Medicaid coordina te services closely: the State SA agency manages Medicaid dollars for SA treatment of Medicaid eligibles and the same providers that treat Medicaid clients treat State SA agency non-Medicaid clients. Also the proportion of clients under different treatment syst ems – MH agency versus SA agency – can be explored cautiously for MH +SA clients. This was possible because these clients either had diagnos es reported in the various da ta bases or were linked across the MH and SA agencies databases, implying their type of disorder and revealing their 51 source of service. Thus, for clients identifie d with dual disorders, system of treatment can be studied. In making these comparis ons, we set aside the Medicaid only cases counted in Figure 5.1 and all Delaware youth serv ices because in the Delaware children’s program they provide MH and SA services under one agency. Fi g ure 5.1: Clients with Dual MH+SA Disorders Are Less Likely To Be Treated under Medicaid Alone25% 38% 22% 75% 8% 9% 38% 70% 16% 0% 20% 40% 60% 80% 100%DelawareOklahomaWashingtonPercent of Dual MH+SA Clients by State Organization MH/SA Agencies Only Medicaid Only Both Auspices Source: CSAT/CMHS IDB Project, 1996 data. Remaining clients with dual disorders were le ast likely to be treated under the SA agency alone, than under the MH agency alone. In Delaware, Oklahoma, and Washington, only 11, 6, and 17 percent, respectively, of the client s with dual disorders r eceived care only in the SA agency; conversely, 48, 48, and 31 percen t, respectively, received care in the MH agency only (Table 5.1). Nevertheless, these results also are likely to be affected by the availability of diagnostic information. For example, in Washington where the MH agency does not collect diagnos is, fewer clients with dual diagnoses were found to be treated in the MH agency alone relative to the other States. A substantial proportion of clients with dual disorders received serv ices under both the MH and the SA agency. In Delaware, 41 per cent of adults receiv ed services under both agencies. In Oklahoma, 47 percent of all yout h and adult clients re ceived care under both auspices. And, in Washington, 52 percent of all clients with dual disorders received treatment under both the MH and SA agency. Table 5.1: Clients with Dual MH+SA Diso rders by Source of Treatment, Excluding Medicaid in Each State and Youth Services in Delaware* Source of Treatment* Delaware Adults Oklahoma All Ages Washington All Ages MH Agency Only 48% 48% 31% SA Agency Only 11% 6% 17% Both MH and SA Agency 41% 47% 52% Source: CSAT/CMHS IDB Project, 19 96 data. *Denominators exclude cl ients receiving services from Medicaid only in each State and Delaware’s childre n services program, which combines MH and SA services under one agency. 52 A Small Proportion of Clients with Dual MH+SA Disorders are Young Only 6 to 33 percent of clients with dual MH+SA disorders across all States and sources of support are youth (Figure 5.2). Even for Me dicaid, which generally targets services to women and children, youth ar e a relatively small proporti on (12 to 33 percent) of MH+SA clients, compared to Medicaid recipien ts with a single mental disorder (35 to 69 percent, shown in Chapter 3). Youth were a small proportion of Medicaid clients with a single SA disorder (15 to 31 percent) in Chapter 4. Fi g ure 5.2: A Small Portion of Clients with Dual MH+SA Are Youth27% 33% 12% 15% 9% 6% 13% 16% 22% 0% 20% 40% 60% 80% 100%DelawareOklahomaWashingtonPercent of Dual MH+SA Clients Who Are Young MH/SA Agencies Only Medicaid Only Both Auspices Source: CSAT/CMHS IDB Project, 1996 data. Males Dominate Youth and Females Do minate Adults with Dual Disorders Although the distinctions are not as great in the populati on with dual MH+SA disorders as in that with single disorders, male s still dominate the youth MH+SA population supported by the State MH/SA agencies (Fi gure 5.3). For MH+SA youth under Medicaid and both types of State support, males and fe males are close to equally represented. In the adult population with MH+SA disorders, males dominate only in the MH/SA agencies where they comprise 60 to 65 percent of th e clientele (Figures 5.4). Male adult MH+SA clients makeup a low proportion of the Medicaid program (34 to 46 percent), as expected. Those who receive services under both auspices are more evenly divided by gender; 43 to 50 percent are male. 53 Fi g ure 5.3: Most Youth with Dual MH+S A Disorders under State MH/SA Agencies Are Male44% 49% 48% 63% 60% 63% 47% 48% 50% 0% 20% 40% 60% 80% 100% DelawareOklahomaWashingtonPercent of Dual MH+SA Youth Clients Who Are Male MH/SA Agencies Only Medicaid Only Both Auspices Source: CSAT/CMHS IDB Project, 1996 data. Fi g ure 5.4: Most Adults wi th Dual MH+S A Disorders under State MH/SA Agencies Are Male34% 44% 46% 65% 60% 63% 50% 46% 43% 0% 20% 40% 60% 80% 100% DelawareOklahomaWashingtonPercent of Dual MH+SA Adult Clients Who Are Male MH/SA Agencies Only Medicaid Only Both Auspices Source: CSAT/CMHS IDB Project, 1996 data. Minority Representation Among Clients w ith Dual Disorders Is Comparable to the State Population in Two States Against the benchmark of the State popul ation, in Oklahoma and Washington, the proportion of minorities among clients with dual MH+SA disorders is comparable, regardless of type of organi zation that supports them. In Delaware the proportions are different: the proportion of minorities am ong young Medicaid clients with MH+SA disorders (53 percent) is si gnificantly greater than among the Delaware youth population (30 percent) (Figure 5.5). The proportion of minorities among adult Medicaid clients with MH+SA disorders (49 percent) is more than twice as high as the proportion of minorities among the Delaware adult population (23 percent) (Figure 5.6). For other States and organizations, relative numb ers of minorities among the dual MH+SA population are comparable to or slightly gr eater than the respective State populations. 54 Fi g ure 5.5: Minorities amon g MH+SA Youth Clients Generally Are Proportion ate to State Populations53% 33% 20% 28% 32% 31% 20% 33% 26% 26% 30% 21%0% 20% 40% 60% 80% 100% DelawareOklahomaWashingtonPercent of Dual MH+SA Youth Clients and State Youth Population Who Are Minority MH/SA Agencies Only Medicaid Only Both Auspices State Youth Population Source: CSAT/CMHS IDB Project, 1996 data. Bureau of Census, 1995 projections of 1990 data. Fi g ure 5.6: Minorities amon g MH+SA Adult Clients Generally Are Proportionate to State Populations49% 26% 24% 24% 22% 17% 42% 27% 17% 15% 23% 19%0% 20% 40% 60% 80% 100% DelawareOklahomaWashingtonPercent of Dual MH+SA Adult Clients and State Adult Population Who Are Minority MH/SA Agencies Only Medicaid Only Both Auspices State Adult Population Source: CSAT/CMHS IDB Project, 1996 data. Bureau of Census , 1995 p ro j ections of 1990 data. Different Types of Dual Disord ers Affect Youth and Adults Young MH+SA clients treated unde r State auspices are more likely to have stress and adjustment disorders and, of course, childhood disorders than are adult patients treated under State auspices (Figure 5.7). Between 53 and 82 percent of youth, but only between 7 and 23 percent of adult, clients under State auspices have such diagnoses. In contrast, the adult MH+SA population is much more likely to be diagnosed with schizophrenia, major depression, and psychoses (Figure 5.8). Mood/a nxiety disorders are as common in the adult as youth MH+SA popul ation. Adult clients with single MH diagnoses (shown in Chapters 3) who were tr eated under Medicaid only (outside of State MH agencies) are less likely to have schi zophrenia, major depression, or psychoses. However, these serious mental illnesses are still significant among th e adult clients with dual MH+SA treated only unde r the Medicaid program. 55 Figure 5.7: Youth Clients with Dual MH+SA Have Mainly Childhood, Mood/Anxiety, and Stress/Adjustment Disorders0% 20% 40% 60% 80% 100%Percent of Dual MH+SA Youth Clients by Type of MH Disorder Schizo 0.0%0.0%1.3%1.0% 1.4%0.8%0.8%0.9% Maj. Depres. 8.1%0.8%7.6%9.6% 22.6%16.2%9.0%13.9% Psychoses 2.7%2.4%5.1%2.5% 4.0%2.0%3.3%7.9% Mood/Anx.Dis. 13.5%15.0%16.5%20.5% 17.7%15.0%26.2%22.4% Childhood Dis. 40.5%54.3%53.2%47.5% 45.8%53.4%50.0%40.6% Stress/Adj.Dis. 35.1%27.6%16.5%18.0% 8.3%11.6%9.8%12.5% Other 0.0%0.0%0.0%0.8% 0.2%1.0%0.8%1.9% MH/SA Agencies Only Medicaid Only Both Auspices MH/SA Agencies Only Medicaid Only Both Auspices MH/SA Agencies Only Medicaid Only Both Auspices *DelawareOklahomaWashingtonSource: CSAT/CMHS IDB Project, 1996 data. *Less than 10% had diagnoses 56 Fi g ure 5.8: Adult Clients with Dual MH+SA Have Mainl y Schizophrenia, Major Dep ression, and Psychoses0% 20% 40% 60% 80% 100%Percent of Dual MH+SA Adult Clients by Type of MH Disorder Schizo 21%8%28%17%14%34%3%10% Maj. Depres. 24%21%21%24%22%19%11%23% Psychoses 20%10%16%22%12%17%12%22% Mood/Anx.Dis. 18%35%23%24%33%19%49%32% Childhood Dis. 1%11%1%3%8%2%10%4% Stress/Adj.Dis. 10%12%6%9%7%6%8%7% Other 6%3%4%3%3%3%6%2% MH/SA Agencies Only Medicaid Only Both Auspices MH/SA Agencies Only Medicaid Only Both Auspices MH/SA Agencies Only Medicaid Only Both Auspices Source: CSAT/CMHS IDB Project, 1996 data. *Less than 10% have diagnoses coded.DelawareOklahomaWashington* Type of Substance Use Differs by Age Grou p for Those with Dual MH+SA Disorders Among young clients with dual MH+SA disorders, most of their substance use was with drugs rather than alcohol (Fi gure 5.9). In Washington State, however, alcohol disorders are a larger problem among such youth tr eated under Medicaid only and under both auspices. Among MH+SA adults compared to MH+SA yout h, alcohol disorders appear to be more prevalent (Figure 5.10). While between 12 a nd 36 percent of such youth have alcohol disorders in Delaware and Oklahoma depe nding on the source of support, 38 to 60 percent of such adults have alcohol diso rders in those States. In Washington, the proportion with alcohol disorder s is more similar between adults and youth with dual MH+SA disorders. 57 Fi g ure 5.9: Youth Clients with Dual MH+SA Are More Likely to Have Primary Dr ug than Alcohol Disorders 80% 88% 82% 66% 73% 64% 63% 48% 53% 20% 18% 34% 27% 36% 37% 52% 47% 12%0% 20% 40% 60% 80% 100%MH/SA Agencies Only Medicaid Only Both Auspices MH/SA Agencies Only Medicaid Only Both Auspices MH/SA Agencies Only Medicaid Only Both AuspicesPercent of Dual MH+SA Youth Clients by SA Disorder Alcohol Drug Source: CSAT/CMHS IDB Project, 1996 data.DelawareOklahomaWashington Figure 5.10: Adult Clients wi th Dual MH+SA Are as Likel y to Have Primar y Alcohol as Dru g Disorders in Two States 56% 60% 62% 40% 48% 46% 42% 52% 49% 44% 40% 38% 60% 52% 54% 58% 48% 51% 0% 20% 40% 60% 80% 100%MH/SA Agencies Only Medicaid Only Both Auspices MH/SA Agencies Only Medicaid Only Both Auspices MH/SA Agencies Only Medicaid Only Both AuspicesPercent of Dual MH+SA Adult Clients by SA Disorder Alcohol Drug Source: CSAT/CMHS IDB Project, 1996 data. DelawareOklahomaWashington The Prevalence of MH Diagnoses by SA Diagnoses and Vice Versa This data base provides a glimpse of the t ypes of dual diagnoses th at clients with one particular disorder might have. Caution is needed since a large pr oportion of clients are categorized in the MH+SA group because of pa rticular services they receive under the State MH/SA agencies rather than because of explicit diagnoses. However, because of this unusual capability of the IDB, these dia gnoses are presented whenever 30 percent or more of the clients have diagnoses, provided 30 or more cases are available. Appendix B shows the percent of clients with missing diagno stic detail by various analytic categories. Figure 5.11 shows the proportion of the dual MH+SA clients with primary alcohol disorders or with primary drug disorders by the types of primary mental illness that they have or the diagnosis most frequently asso ciated with their care in 1996. (Secondary 58 diagnoses were not allocated by type of diagnosis in this initial anal ysis of the IDB, and thus, the distribution for those with joint alc ohol and drug disorders is not presented.) As noted in Chapter 4, the primary drug use reporte d by the client was used to differentiate between drug and alcohol when diagnosis was unavailable. For youth and adults combined across three States and all sources of support, MH+SA clients with alcohol disorders and clients with drug abuse diso rders have almost identical patterns of mental disorders (Figure 5.11). Most have mood/anxiety disorders, major depression, or psychoses. Similarly for the converse view of individua ls with specific mental disorders, the distribution of clients by pr imary alcohol or drug disord ers is uniform (Figure 5.12). Between 42 and 56 percent had alcohol disord ers, regardless of the primary mental illness, compared across seven mental disease categories. Fi g ure 5.11: MH+SA Clients Usin g Different Primar y Substances Have Similar Distributions of Mental Disorders 9% 8% 7% 10% 32% 31% 17% 18% 21% 20% 11% 11% 3% 3%0% 20% 40% 60% 80% 100%Alcohol Abuse Drug AbusePercent of Dual MH+SA Clients in Three States by SA and MH Diagnosis Schizo Maj. Depres. Psychoses Mood/Anx.Dis. Childhood Dis. Stress/Adj.Dis. Other Source: CSAT/CMHS IDB Project, 1996 data. Distributions based on 41% of dual SA client records with diagnoses. 59 Fi g ure 5.12: MH+SA Clients Are Split between Primar y Alcohol and Drug Disorders for All Mental Disorders 47% 46% 50% 47% 58% 45% 44% 53% 54% 50% 53% 42% 55% 56% 0% 20% 40% 60% 80% 100%Schizo Maj. Depres. Psychoses Mood/Anx.Dis. Childhood Dis. Stress/Adj.Dis. OtherPercent of Dual MH+SA Adult Clients by SA Diagnosis Alcohol Abuse Drug Abuse Source: CSAT/CMHS IDB Project, 1996 data. Based on 41% of dual MH records with diagnoses. MH/SA Services: Clients with Dual Diso rders Are Frequently Treated in Multiple Settings This section examines the types of servi ce that clients with dual MH+SA disorders receive. Youth and adult clients with dua l MH+SA disorders are more likely to be treated in multiple settings (Figures 5.13 and 5.14) than are clients with single diagnoses (shown in Chapters 3 and 4). This is es pecially true for MH +SA clients receiving services under both auspices of MH/SA ag encies and Medicaid. These MH+SA clients likely have more complicated disorders that require a complex array of services across multiple settings. Nevertheless, many of these clients (often 65 percent or more of them) receive care in outpatient settings only. Very rarely do these clients rece ive care in inpatient or residential facilities only – less than 4 percen t of either youth or adult clients – which is consistent with the currently accepted vi ew that complex MH/SA clients require a continuum of care. 60 Fi g ure 5.13: Youth Clients with Dual MH+SA Rarel y Receive Only Inpatient or Only Residential Care0% 20% 40% 60% 80% 100%Percent of Dual MH+SA Youth Clients by Services Received Outpatient Only 79%79%21%69%40%45%75%91%65% Inpatient Only 0%0%0%0%4%0%0%1%0% Residential Only 0%3%1%1%0%0%0%0%0% Multiple Services 21%18%78%30%56%55%25%8%35% MH/SA Agencies Medicaid Only Both Auspices MH/SA Agencies Medicaid Only Both Auspices MH/SA Agencies Medicaid Only Both Auspices Source: CSAT/CMHS IDB Project, 1996 data.DelawareOklahomaWashington Fi g ure 5.14: Adult Clients with Dual MH+SA Are More Likel y to Receive Care in Multiple Settings than Youth0% 20% 40% 60% 80% 100%Percent of Dual MH+SA Adult Clients by Type of Service Received Outpatient Only 65%60%47%52%62%43%43%93%40% Inpatient Only 1%2%0%2%3%0%1%0%1% Residential Only 1%0%0%2%0%0%2%0%0% Multiple Services 34%37%53%44%35%57%54%7%59% MH/SA Agencies Medicaid Only Both Auspices MH/SA Agencies Medicaid Only Both Auspices MH/SA Agencies Medicaid Only Both Auspices Source: CSAT/CMHS IDB Project, 1996 data.Delaware Oklahoma Washington Clients with Dual MH+SA Disorders Are Frequently Hospitalized Generally in 1996, clients with dual MH+SA disorders who were supported under both Medicaid and State MH/SA agencies had highe r rates of hospitalizat ion relative to those treated only under separate agencies (Figur es 5.15 and 5.16) or to those with single disorders (as shown in earlier chapters). Those under auspices of both types of organization had almost 800 hospitalizations per 1000 clients with MH +SA disorders. Only for clients under one State program – the Medicaid only program in Oklahoma – was the rate higher and as high as 876 per 1000 MH+SH youth clients. However, 61 methodologically the Oklahoma rate is not co mparable to the other two States. In Oklahoma, the hospitalization rate for Me dicaid-covered youth includes residential treatment, which is billed as an inpatient service; thus, the two services could not be separated for Oklahoma in this analysis. Ignoring Oklahoma Medicaid, the rates of hosp italization still varied considerably by State and organization. Washi ngton had the lowest rates for youth and adults, regardless of type of organization provi ding the services. And client s under State MH/SA agencies only most often had the lowest rates of admi ssion to a hospital. Across all three States, the high rates of hospital stays reflect a high percent of MH+SA clients hospitalized once during the year (71 percent) and some MH+SA clients (29 percent) who had multiple hospitalizations during the year (not shown in figures). Averaged across the three States, State or ganizations, and age groups, the rate of hospitalizations for all clients with dual MH+SA disorders in this study was 456 per 1000 (not shown). This was over five times the ra te for MH-only clients and 20 times the rate for SA-only clients. Fi g ure 5.15: Youth with Dual MH+SA Treated under Some Auspices Have High Rates of Hospitalization23 30 3 37 119 876 198 782 7440 200 400 600 800 1000DelawareOklahomaWashingtonHospitalizations per 1000 Dual MH+SA Youth Clients MH/SA Agencies Only Medicaid Only Both Auspices Source: CSAT/CMHS IDB Project, 1996 data. Fi g ure 5.16: Adults with Dual MH+SA Treated under Some Auspices Have High Rates of Hospitalization504 472 85 172 418 80 729 793 5630 200 400 600 800 1000DelawareOklahomaWashingtonHospitalizations per 1000 Dual MH+SA Adult Clients MH/SA Agencies Only Medicaid Only Both Auspices Source: CSAT/CMHS IDB Project, 1996 data. 62 Residential Care is one of the Multiple Set tings Used for Clients with Dual Disorders Even though 2 percent or less of clients with dual MH+SA diso rders received care exclusively in residential facilities, these facilities are used frequently in conjunction with other settings of care for a much higher proportion of MH+SA clie nts. Except for one program, youth with MH+SA disorders had resi dential-stay rates from 68 per 1000 up to 556 per 1000 (Figure 5.17) – in rounded percentage terms 7 to 56 percent. The exception was Oklahoma Medicaid, which showed no admissions of MH+SA youth clients to residential care; recall that residential care under Medicaid in Oklahoma is billed as inpatient treatment. For adults, except for Medicaid admitting virt ually no MH+SA clients to residential care, the rate was comparable to youth, from 264 to 520 per 1000 adults (Figure 5.18) – 26 to 52 percent. The differences in use of resident ial services for youth and adults clearly is influenced by the Federal prohibition on use of Medicaid funds for treatment of those aged 22 to 64 in Institutions for Mental Dis eases (IMDs) with 16 or more beds. Medicaid dollars may be used for treatment of youth (under age 22) in IMDs. Compared to youth with a single disorder of mental illness especially, youth with dual MH+SA disorders were more likely to receiv e care in residentia l settings. Ignoring organizations that never admitted clients to residential care , youth with MH only disorders were in residential facilities at a rate of between 4 and 156 per 1000 (Figure 3.13), much lower than the 68 to 556 rate per 1000 for dual disorder clients (Figure 5.17). Youth with SA only disorders were in reside ntial care at a rate of between 17 and 432 per 1000 (Figure 4.13), closer to, but still lower than, the MH+SA c lient rate. Likewise for adults, those with dual MH+SA disorders were more likely to be admitted to residential care than those with mental disorders only (Figure 3.14). Those with SA only disorders were admitted at comparable rates to those with dual disorders (Figure 4.14). Fi g ure 5.17: MH+SA Youth Are More Likel y Treated in Residential Settings than MH or SA Only Youth Clients198 0 68 250 291 119 234 124 556 0 200 400 600 800 1000DelawareOklahomaWashingtonNumber in Residential Care per 1000 Dual MH+SA Youth Clients MH/SA Agencies Only Medicaid Only Both Auspices Source: CSAT/CMHS IDB Project, 1996 data. 63 Fi g ure 5.18: MH+SA Adults Are More Likel y Treated in Residential Settings Than MH Only Adult Clients3 0 1 520 286 264 298 286 278 0 200 400 600 800 1000DelawareOklahomaWashingtonNumber in Residential Care per 1000 Dual MH+SA Adult Clients MH/SA Agencies Only Medicaid Only Both Auspices Source: CSAT/CMHS IDB Project, 1996 data. 64 65 Chapter 6. Summary and Conclusions The Integrated Data Base (IDB) Project The CSAT/CMHS Integrated Data Base (IDB) was designed to provide State and Federal policymakers access to comprehensive inform ation on utilization and expenditures of mental health and substance abuse services for all clients treated under the major public organizations within three States. Unif orm definitions and methods ensure that comparisons of mental health (MH) and s ubstance abuse (SA) services across State agencies were the result of service differen ces rather than data processing methods. Constructing quality data bases for three part icipating States was an intensive process, requiring close collaboration of CSAT/CMHS and State staff. The IDB project and this report demonstrate the feasibility an d usefulness of linking data from multiple agencies within States that are involved in the delivery of MH and SA services. Although the current data base in cludes data for one calendar year, by the end of the project in September 2001, it will cont ain data for three consecutive years (1996, 1997, and 1998) for each of the three participating States. This three-year integrated data base will be used by the St ates, CSAT, and CMHS in the future to address important questions about the delivery of publicly financed mental health and substance abuse treatment services. In addition to the value of the data for polic y research, States may find the technical data base architecture a model for integrati ng other data systems. Although the three participating States had many and very differe nt data structures, th e IDB project showed that it was possible to design an architect ure that articulates among many data base structures, that links records for the same c lients across different data systems, and that does so consistently across States. The proce ss also can be automated to reduce the costs of data processing. States interested in integrating their own MH /SA-related data can find the architecture and linking me thods on the project Web site ( http://www.samhsa.gov/centers /csat/content/idbse/index.html ). The advantages of such an undertaking are many. States would be able to use an IDB structure to analyze the delivery of services across organizations within the State, much as we have done here – who received serv ices, through which agency, and for what purposes. States could assess the impact of in itiatives, such as polic y changes that affect managed care and other programs, and understand these impacts across State organizations. States could use their IDB to support joint case management and cost review for clients who receive care across hea lth care agencies. States could share data more easily with other States to understand the strengths and weaknesses of different State programs and to identif y the best practices. In addition, with a uniform IDB-type struct ure, States could be tter coordinate data collection among themselves so that intra-State analyses are more defensible and conclusive. Currently, each State and each organization involved in supporting MH/SA services within a State has a history of almost complete separation. This analysis showed 66 the difficulty of making valid comparisons when data are incomplete or defined differently. For example, the incomplete availability of diagnoses affected several analyses. First, questions of which system (the MH or SA treatment system) was treating MH-only and SA-only clients could not be answered effectively because diagnoses frequently were not collected for agency data bases. The study had to assume MH or SA diagnoses for clients treated by some MH and SA agencies and this meant that the type of client condition and type of treatment system could not be identified independently of each other. Thus, the study could not always determine which diagnoses were being handled by which treatment system. Second, de spite the fact that only Medicaid claims consistently collected diagnoses across a ll three States, diagno ses sometimes were missing on monthly Medicaid capit ation claims. At least partly because Delaware provided diagnoses for monthly Medicaid ma naged care claims for jointly served Medicaid and DSCYF youth, many more Medi caid services related to MH and SA treatment for youth were identified in Delaware . With a coordinated State effort on data collection, such inconsistencies might be redu ced and more conclusive analyses could be conducted. In addition to these lessons, the IDB showed that considerable knowledge can be gained from analyzing MH and SA services across agencies within a State. Results of the First Analysis of the IDB The information presented in this report be gins to answer important questions about public MH/SA services. This study focu ses on organizational or departmental differences – MH and SA agencies a nd the Medicaid program – differences within each State rather than State-level or other types of comparisons . Sometimes generalizations were made across States when patterns were similar. Other non-part icipating States might use these results as benchmarks agai nst which to compare their own data. To stimulate discussion about State organizati ons delivering services to MH/SA clients, several questions about these entities were addressed: Which State organizations (MH/SA agenci es versus the Medicaid program) support which MH/SA clients? What are the characteristics of clie nts who receive treatment under State organizations, including age, race/ethnicity, gender, and ty pes of clinical conditions? Where – in what settings – do clients receiv e services? Do the settings differ by the State organization managing the care? How many types of services are provided to clients under different State entities? Which State Organizations Support Which MH/SA Clients? A significant proportion (26 to 52 percent) of MH-only client s received care only under the Medicaid program across the three States. SA-only clients were treated predominantly under State SA agencies – 65 to 97 percent of those SA clients. Only in one State did Medicaid alone cover a quarter of the client s with dual MH+SA disorders, 67 the most complicated and costly to treat. Both Medicaid and MH/SA agencies of the States jointly served from 22 to 75 pe rcent of those with dual disorders. For clients with dual MH+SA disorders, use of services under th e State MH as opposed to the State SA agency could be compare d. A substantial proportion of dual MH+SA clients (41 to 52 percent across the States) received services under both the MH and the SA agency. A small proportion (6 to 17 pe rcent across the States) received treatment only under the SA agency. The remainder (31 to 48 percent) received care only in the State MH agency. What are the Characteristics of Client s Receiving MH/SA Treatment under State Auspices? About 70 percent or more of SA-only clients in each State are adults , as are clients with dual MH+SA. However, a high proportion of MH -only clients (close to 70 percent) in one State system are young. Youth clients are predominantly males, whether they have MH, SA, or dual MH+SA disorders. Adult clie nts are more equally split between female and male if they have SA or dual MH+SA di sorders and are treated outside of the State MH or SA agency. However, adult clients in the State SA agencies are much more likely to be male than female, and adult MH-only clients are much more likely to be female. Finally, the proportion of minorities (that is, clients of other than non-Hispanic white origins) among young clients who have MH- only, SA-only, or dual MH+SA disorders generally is larger than the proportion of minorities in the tota l youth population of each State. For adults, the minority proportions are more similar to the State populations, except for the SA-only clients who include proportionately more minorities than the general population, although th e results vary by State. What MH/SA Disorders Are Treated across State Organizations? For the total study population, 68 percent received services for a mental disorder only, 21 percent were treated for a substance disord er only and 11 percent received services for both a mental and substance disorder. B ecause missing diagnoses were a significant problem in this study, the following are te ntative findings related to diagnostic distributions. As expected, youth with MH-only disorders are most likely to be diagnosed with childhood disorders. In comparison to adults, youth are much less likely to be diagnosed with serious mental disorders, such as sc hizophrenia, major depression, and psychoses. Adults with MH-only disorder s are most likely to be di agnosed with those serious disorders, reflecting the age at onset of such disorders. Of those with SA-only disorders or dual MH +SA disorders, youth are more likely to use illicit drugs, while adults are more likely to use alcohol as a primary substance. However, adults with dual MH+SA disorders generally are equally as likely to have a primary drug disorder as a primary alcohol diso rder. The exception is in Delaware where adults with dual disorders are more like ly to use illicit dr ugs than alcohol. 68 The IDB also enabled the study of distributions of primary diagnoses among clients with dual MH+SA disorders and identified in the data base. Of clients with dual MH+SA disorders who have primary alcohol disorders, they have the same distribution of mental disorders as those diagnosed with a primary drug abuse disorders. Regardless of mental disorder, whether it be schizophr enia, psychoses, or some othe r mental illness, the group with dual MH+SA diagnoses have nearly the sa me propensity to primary drug abuse as to primary alcohol abuse. Do settings of Service for MH/SA Clie nts Differ by State Organization? A substantial portion of MH-only clients is treated in outpatie nt settings only. SA-only clients also are treated predominantly in out patient settings only, but a larger proportion of those clients is treated in multiple setti ngs (compared to MH-only clients). Clients with dual MH+SA disorders are frequently trea ted in multiple settings, attesting to their need for a more complete spectrum of care. Few clients of either diagnostic type are treated exclusively in inpatient or residential facilities. How Many Services Are Provided to Clie nts under Different State Organizations? The number of hospitalizations for every 1000 State MH-only clients in 1996 varied considerably across the States, State orga nizations supporting treatment, and age of clients. The rates were as low as 3 pe r 1000 Washington Medicaid-only youth clients to as high as 503 per 1000 Delaware youth clie nts who received serv ices under both the State MH agency and Medicaid auspices. A dult hospitalization rate s were more uniform across the States with a relatively cons istent pattern by State organization. State youth clients with SA- only disorders were rarely hospitalized, regardless of the State or organization supporting the treatment. State adult c lients with SA-only disorders were much more likely (than such youth) to be hospitalized, but the rate varied considerably by organization managing the care , and in several instances the rate was lower than for MH-only clients. State clients with dual MH+SA were frequen tly hospitalized, especially when treated under joint auspices of the Stat e MH/SA agency and Medicaid – often in the range of 700 to 800 hospitalization per 1000 clients per year , depending on the State and organization. Most of these clients had only one hospitaliz ation during the year (71 percent), but the remainder had multiple hospitalizations during the year. Comparing the overall hospitalization rate averag ed by type of client , shows that clients with dual MH+SA disorders were the most likely to be hospitalized by far – 456 per 1000 MH+SA clients had hospital stays during 1996 – regardless of State, organization, or age group. Clients with MH-only disorders had a rate of 87 stays per 1000 clients. In contrast, clients with SA-only di sorders were least likely to be hospitalized - at a rate of 23 stays per 1000 clients. Few clients with MH-only diso rders received resi dential services in 1996. Clients with SA only were more likely to be in residentia l treatment – in the range of 200 to 600 stays per 1000 clients depending on the organization and State. Clients with dual MH+SA 69 disorders were as likely as clients with SA onl y to be in residential facilities. The Federal prohibition on Medicaid spending for treatment in Institutions for Mental Diseases is evident in the analyses, especially for adult clients. Virtually no adults under Medicaid- only auspices received residential services in these data, although States differed in how they accounted for residential treatment – tw o States counted it as inpatient care under some auspices. Despite that, those two Stat es did not have higher hospitalization rates, suggesting that residential treatme nt was relatively rare in 1996. Limitations Some conclusions should be considered te ntatively given limitations of the data. Availability of diagnoses a nd classification of residential care are two such data problems. While diagnoses from Medicaid claims were generally available for analysis, diagnoses on State MH or SA agency data were sometime s not available for an entire organization. When that organization treated one type of client (MH or SA), all clients under that organization were assigned to the appropriate general category of MH or SA. Finally, the highly variable rate of missing diagnose s across States, orga nizations supporting treatment, and types of clients co uld lead to biased conclusions. Because of the diagnosis problem, some c onclusions of this study affected by that problem should be considered carefully. For example: Analyses of specific diagnostic detail (e .g., drug versus alcohol disorders) are tentative because not all MH/SA clients c ould be included due to missing detailed diagnoses. Clients with dual disorders were likely unde restimated and their distribution between State MH and SA agencies distorted, becau se some State agencies did not collect diagnoses. Because of differences in labeling and classifi cation of residential tr eatment, the counts of residential services are not comparable across the States. Because two of the States count residential stays as inpatient stays, the hospitalization rates also are potentially affected. However, this does not inva lidate comparison of these rates across organizations within the States. A complex probabilistic linking methodology wa s used in the IDB development which resulted in the identification of more links than other methods might have (see Whalen et al., 2001) and enabled identific ation of clients receiving se rvices across and within systems. Even so, such algorithms are neve r as accurate as having unique identifiers within and across systems of record keepi ng. Rarely did the States have unique identifiers for clients across pr ograms. None of the States had unique identifiers across all systems of care. As a result, the proce ss of matching individuals across organizations probably missed some clients who received services from multiple sources. The type of data available also limits the understanding of the differences observed between organizations and States. For exampl e, even when diagnoses were available, 70 little information on the clinical severity of the client was available, and thus, some variations across States, organizations, and client subgroups may be due to unknown clinical severity or underlyi ng epidemiology. Results of th e National Household Survey on Drug Abuse, which has estimated illicit subs tance use suggests th at this may be the case across the three Stat es studied here. Future Directions The analyses presented in this report answer ed some questions and raise others. The analyses presented a view of the clients us ing publicly supported MH/SA care managed by the States and the services those clients used in 1996. This was examined in the context of State MH and/or SA systems, Me dicaid, and shared clients across systems. Additional issues can be studied with these data and the soon-to- be-added data for 1997 and 1998. One priority is the analysis of e xpenditures across organizations, because the identification of duplicate r ecords for this project provi des a unique opportunity to examine costs in a way that avoids multiple accounting of spending across organizations. In addition, perspectives other than the State-organization view can be taken to design studies. For example, the providers’ points of view can be taken to design more in-depth studies of particular settings of care. Some of the questions that are likely to be addresse d in the future with the IDB are: What are the costs of services provid ed under the State MH/SA systems and the Medicaid program? How much of the spending accounted for by separate State organizations is “shared spe nding” that would overestimate the total cost of MH/SA spending if simply added together? How do State MH/SA agency and Medicaid expenses compare for clients with similar disorders and complex ities? How does this spendi ng differ by type of service provided? For example, how does the cost of psychotropic drugs influence the overall spending on MH services? What are the patterns of outpatient services for clients who were hospitalized during the year under the State MH/SA agencies and Medicaid? Is hos pitalization preceded and followed with outpatient treatment? Or does hospitalization serve as an entry point for State MH/SA services? What is the Medicaid role in outpatient versus hospital-based treatment? What is the pattern of residential treatment over the course of a year or three years? Are residential services combined with outpa tient services? Is residential treatment associated with less acute inpatient care? How is SA detoxification as preparati on for treatment handled in State MH/SA agencies versus Medicaid? How many detoxi fication services are provided in acute inpatient, residential, and/ or outpatient settings? What are the patterns of follow-up treatment for different settings under State MH/SA agencies and Medicaid? 71 How do patterns of treatment, volume of se rvices, and expenses differ by type and severity of mental illness, substance of abuse, and classes of comorbidities? What are the effects of SA comorbidities on service utilization and costs for MH and medical services? For what other conditions are clients with MH/SA disorders likely to require treatment? For example, are trau ma and HIV/AIDS costly and/or frequent problems associated with substance abuse? What are the most frequent and costly? What are the patterns of Medicaid elig ibility over one, two, and three years for patients with MH/SA disorders who, at some time during the period, are under the care of the State MH/SA agencies? Does us e of State MH/SA agency services occur primarily when Medicaid eligibility vani shes or when Medi caid benefits are exhausted? Or do those Medicaid events trigger first use of State MH/SA services? To what extent are SA clients served by MH care providers? If persons with SA disorders are served by MH providers, what services and volume of services are provided, compared to treatment by SA pr oviders? How does the cost of care provided by MH providers compare to similar care given by specialized SA providers? Conversely, to what extent do SA providers tr eat clients with mental illness? What types of treatment do those clients receive a nd at what cost, compared to services in the MH care system? Certainly, these and many other questions could be explored in future studies. The IDB with its uniformity of data across three diffe rent States provides an opportunity for these issues to be explored more accurately than th ey have been able to be in the past. The IDB-architecture also is a framework for linki ng State MH/SA data to other data systems, such as the State criminal justice or school systems. Such investments in integrated information would enable the States to answer questions about other shared services and clients and to better manage the broad issues of costs and effective delivery of State social services in an environment of comple x funding streams from Federal, State, county and municipal budgets. 72 73 References Coffey RM, Mark T, King E, Harwood H, Mc Kusick D, Genuardi J, Dilonardo J, Buck JA. National estimates of expenditures for ment al health and substance abuse treatment, 1997. SAMHSA Publication No. SMA-00-3499. Ro ckville, MD: Center for Substance Abuse Treatment and Center for Mental Hea lth Services, Substance Abuse and Mental Health Services Ad ministration, July 2000. Epstein J, Gfroerer J. Changes affecting NHSDA estimates of treatment need for 1994- 1996. In Office of Applied Studies, Analyses of substance abuse and treatment need issues. DHHS Publication No. SMA-98-3227, 127-145. Rockville, MD: Substance Abuse and Mental Health Services Administration, 1998. Health Care Financing Administration (H CFA). Medicaid managed care State enrollment. Available on: h ttp://www.hcfa.gov/medicaid/pntrtn3.htm (viewed May 17, 2001a). Health Care Financing Administration (H CFA). Personal comm unication on mandated and optional Medicaid services from Sharon Giles (April 16, 2001b). Institute of Medicine (IOM). Treating drug problems, Volume I. Washington, DC: National Academy Press, 1990a. Institute of Medicine (IOM). Broadening the base of treatment for alcohol problems. Washington, DC: National Academy Press, 1990b. Kesseler RC, Melson CB, McGonagle KA, Edlund MJ, Frank RG, Leaf PJ. The epidemiology of co-occurring addictive and ment al disorders: Implications for prevention and service utilization. American Journal of Orthopsychaitry 66(1): 17-31, January 1996. Lamphere J, Brangan N, Bee S, Griffin K. Reforming the Health Care System: State Profiles 1999. Washington DC: AARP, 1999. McKay JR, Donovan DD, McLellan T, Krupski A, Hansten M, Stark KD, Geary K, Cecere J. Evaluation of full vs. partial continuum of care in the treatment of publicly- funded substance abusers in Washington State. American Journal of Drug and Alcohol Abuse (forthcoming). National Alliance for the Mentally Ill (NAM I). Current Medicaid law from NAMI. Available on: http://www.nami.org/update/imd2.html (viewed May 10, 2001). 74 National Institute on Alcohol A buse and Alcoholism (NIAAA). Ninth Special Report to the U.S. Congress on Alcohol and Health: From the Secretary of Health and Human Services. NIH Publication No. 97-4017. Bethesda, Maryland: National Institutes of Health, 1997. Office of Applied Studies (OAS). National Household Survey on Drug Abuse, main findings 1997. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, 1999a. Office of Applied Studies (OAS). Treatment Episode Data Set (TEDS): 1992-1994: National admissions to subst ance abuse treatment services . DHHS Publication No. SMA-00-3324 . Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Hea lth Services Administration, 1999b. Substance Abuse and Mental Health Services Administration (SAMHSA). SAMHSA IDBSE Web site . U.S. Department of Health a nd Human Services. Available on: http://www.samhsa.gov/centers/csat/content/idbse (viewed May 21, 2001). U.S. Census Bureau. U.S. Census Bureau Web Site. U.S. Department of Commerce. Available on: http://www.census.gov/population/pr ojections/state/stpjpop.txt (viewed February 8, 2001). U.S. Department of Health and Human Services . Mental health: A report of the Surgeon General , Rockville, MD: Substance Abuse and Me ntal health Services Administration, Center for Mental Health Services and National Institutes of Health, National Institutes of Mental Health, 1999. Whalen D, Pepitone A, Graver L, Busch JD. Linking client records from substance abuse, mental health and Medicaid State agencies . SAMHSA Publication No. SMA-01- 3500. Rockville, MD: Center for Substance Abuse Treatment and Center for Mental Health Services, Substance A buse and Mental Health Servic es Administration, July 2001. 75 Appendix A. Advisory Panel Robert Anderson Director, Research and Program Applications National Association of State Alcohol and Drug Abuse Directors, Inc. Richard Boyesen Department of Social & Health Services Washington Medical Assistance Administration Gary Coats Department of Social & Health Services Washington Medical Assistance Administration David Cross Management Analyst Division of Medicaid Delaware Department of Health and Social Services Steve Davis Director of Evaluation and Data Analysis Oklahoma Department of Mental Health and Substance Abuse Services Carol Knobel-Ames State Mental Health Agency Mental Health Division Washington Department of Social and Health Services Toni Krupski Research Supervisor Division of Alcohol and Substance Abuse Washington Department of Social and Health Services Mary Jo Larson Senior Research Associate New England Research Institute Tracy Leeper Grants Project Manager Oklahoma Department of Mental Health and Substance Abuse Matt Lucas Director of Program Design and Evaluation Medicaid Division Oklahoma Health Care Authority Theodore Lutterman Director of Research Analysis National Association of State Mental Health Program Directors Re search Institute Maurice Tippett Manager of Computer and Application Support Delaware Department of Health and Social Services Division of Alcoholism, Drug Abuse, and Mental Health John Whitbeck Director of Research Mental Health Division Washington Department of Social and Health Services Nancy Widdoes Managed Care Administrator Delaware Department of Services for Children, Youth and Their Families Division of Child Mental Health Services 76 77 Appendix B. Detailed Methods of Data Development for this Study Selection of Clients for the Integrated Data Base (IDB) To understand the criteria for selecting clients in to the analyses of th is report, the reader should first understand the selecti on criteria for the IDB. The criteria are shown in Table B.1. For clients without a diagnosis, those fr om the State substance abuse (SA) agency were assigned a general desi gnation of SA (service without diagnosis) and those from the State mental health (MH) agency were as signed a general category of MH (service without diagnosis). In add ition, all records (medical or MH/SA-related) for Medicaid clients with at least one MH/SA diagnosis-rel ated indication were included in the IDB. Table B.1: Diagnoses Used as Selection Criteria for the IDB Major Category Description Mental Health Diagnoses:* Schizophrenia (295) Major depression (296.2, 296.3) Other Affective Psychoses (296.0, 296.1, 296.4-296.99) Serious Mental Illness Other Psychoses (297, 298, 299) Stress and Adjustment Disorders (308, 309) Personality Disorders (301, excluding 301.13) Childhood Disorders (307, 312-314) Other Mood Disorders and Anxiety (300, 301.13, 311) Other Mental Illness Other Mental Disorders (302, 306, 310, 648.4-648.49) Substance Abuse Diagnoses:* Alcoholic Psychoses (291) Alcohol Diagnosis Alcohol Dependence/ Nondependent Abuse (303, 305.0) Drug Psychoses and Mood Disorders (292) Drug Dependence/ Nondependent Abuse (304, 305.2-305.9) Drug Diagnosis Other Alcohol and Drug Related Disorders and Conditions (265.2, 357.5, 357.6, 425.5, 535.3, 571.0-571.3, 648.3, 655.4, 655.5, 760.7, 779.5, 962.0, 965.0, 967-969, 977.0, 977.3, 980) Special Conditions of interest: Other Substance Abuse DiagnosisTobacco Use Disorder (305.1) *Note: This table clarifies the use of diagnosis only. All clients from State SA and MH agencies are included in the IDB. Lacking a diagnosis, r ecords from the State SA agency were assigned a category of SA and records from the State MH agency were assigned a category of MH. Selection of Study Population from the IDB To be included in the study population, clients had to have at least one service record for a primary MH and/or SA service at some time during 1996. A primary MH/SA service record was defined as one with one of eight primary MH diagnostic categories or one of two primary SA diagnostic categories as cla ssified in Table B.2. These categories were selected because they are defini tive MH or SA disorders rath er than possibly related to a MH or SA disorder. For example, cirrhosis of the liver, which is one of the “other alcohol and drug related disord ers and conditions” in Table B .1, may or may not indicate 78 a SA problem. Therefore, such diagnoses are excluded from the selection criteria (Table B.2) for the study population. A primary MH/S A client also was defined by a service record from a provider that only provides MH and/or SA services. Table B.2: Diagnosis Categories Used as Inclusion Criteria for the Study Major Category Description Mental Health Diagnoses:* Schizophrenia Schizophrenia (295) Major Depression Major Depression (296.2, 296.3) Psychoses Other Affective Psychoses (296.0, 296.1, 296.4-296.99) Psychoses Other Psychoses (297, 298, 299) Stress Disorders Stress and Adjustment Disorders (308, 309) Childhood Disorders Childhood Disorders Childhood Disorders, ADD Chil dhood disorders, ADD ( 314.0, 314.00, 314.01) Childhood Disorders, Other Childhood disorders, Other 307, (312-313, 314, 314.02-314.99) Mood Disorders Other Mood Disorders and Anxiety (300, 301.13, 311) Other Mental Disorders (302, 306, 310) All Other Disorders Personality Disorders (301, excl. 301.13) Substance Abuse Diagnoses:* Alcoholic Psychoses (291) Alcohol Alcohol Dependence/ Nondependent Abuse (303, 305.0) Drug Psychoses and Mood Disorders (292) Drug Drug Dependence/ Nondependent Abuse (304, 305.2-305.9) *Note: This table clarifies the use of diagnosis only. All clients from State SA and MH agencies were included in the IDB. Lacking a diagnosis, records from the State SA agency were assigned a category of SA and records from the State MH agency were assigned a category of MH. Each service or admission record for each clie nt in the IDB was examined for whether or not it contained codes for a primary MH or SA diagnosis/service category. If so, the client was included in the firs t cut of the study population. Age restrictions were then applied so that all clients of unknown age and of age 65 or older by the end of 1996 were dropped from the study group. The numbers of records dropped because of diagnosis and age exclusions are shown in Table 2.1 in Chapter 2. Diagnostic Categorization Each client in the study sample, based on th e inclusion criteria, had at least a MH condition or a SA condition, or possibly bot h conditions. If a client had any MH condition(s), he/she was assigne d to one of eight MH dia gnosis categories or one MH service category, otherwise the MH category of “none” was assi gned. If a client had any SA condition(s), he/she was likewise assigned to one of two SA diagnosis categories, one SA service category, or to “none.” In situations where clients had services that fell into more than one MH condition category or more than one SA condition categor y, an algorithm was applied to select one of the categories to represent the main or most significant condition for the client. For each client, the algorithm compiled counts, cost s, and dates (admission date or start of 79 service date) for service reco rds or admission records, whic h had a primary diagnosis for MH or SA. These counts were partitioned into each of the distinct diagnosis groupings of Table B.2 and were further spl it into levels of acute care and non-acute care. Inpatient and inpatient psychiatric services were cons idered acute care; all other services were considered non-acute. The algorithm selected diagnostic evidence re lated to any acute care over that for non- acute care. This was done for two reasons. First, acute care usually relates to more serious conditions, and second, more accurate di agnosis is likely when a client is under 24-hour observation by highly trai ned staff. If a client had any acute-care, primary diagnosis-related evidence for MH , then it was used to determine the client’s “main” condition category, and diagnostic evidence relate d to non-acute care was ignored. This same logic was applied to evidence of SA condition(s). The algorithm also checked for the MH category that had the highest record count, which was then assigned as the “main” MH condition for the client. If there were two or more diagnosis category that tied for most frequent count, then the algorithm selected between them based on the highest reported costs. If costs were tied, the algorithm selected the diagnosis category having the ea rliest date. The same logic was applied independently to SA categories, and a “main” SA condition was selected, if appropriate . Some clients had records with primary diagnoses that fell into more than one MH category, or into more than one SA category. In these cases, in a ddition to selecting one ‘main’ category, the patient was flagged as having multiple MH and/or multiple SA conditions. Some clients may have service records for MH or SA services from a MH or SA agency, respectively, that always lack primary diagnosis . It is assumed that these clients do have a MH condition and/or SA condition, but cannot be categorized further. Such clients were assigned to a category of “MH serv ice without diagnosis” and/or “SA service without diagnosis.” After each client, based on primary diagnoses or primary service, was assigned to either one MH category or “none,” or assigned to one SA category or “none,” then an algorithm examined all records for the client to de termine if any of the available secondary diagnosis codes fell into one of the MH categories or into one of the SA categories. Then, each client’s reason for treatment (MH, SA, or MH+SA) was assigned as follows. If a client had been assigned to both 1) a MH category (other then “none”) or had any evidence of secondary MH diagnosis and 2) a SA category (other than “none”) or had any evidence of any secondary SA diagnosis, then the client’s reason for treatment was assigned as “MH+SA.” This was a client with dual MH and SA disord ers. Otherwise, the client’s reason for treatment was assigned to either “MH only” or “SA only,” based on the client’s assignment to a MH category only or a SA category only. Number in the Study Population The number of clients in the study after the exclusions and diagnostic classifications are shown in Table B.3. The table is organized by the categories analyzed in the main text of this report and contains the denominators of cl ients for the rates pres ented in the report. The report examines measures by clients’ reason for treatment (MH only, SA only, or 80 MH+SA), age group, State, and organizati on supporting the treatm ent (State MH/SA agency only, Medicaid, or both auspices). MH only clients are 68 percent of the study population, SA only clients are 21 percent, and MH+SA client s are 11 percent. Youth represent 30 percent of the study and adults 70 percent. Delaware cl ients are 6 percent of the study population, Oklahoma’s are 42 percent, and Washington’s 52 percent. Clients treated only under State MH/SA agencies ar e 58 percent of the study population, clients treated only under Medicaid are 22 percent, and those under both a State MH/SA agency and Medicaid are 20 percent. Number in the Study Population without Detailed Diagnoses Lack of diagnostic detail at the level of specific type of mental illness or specific type of substance abused creates potential for bias in other results that cannot be determined easily. For example, meaningful interpretati on of differences in services, such as the hospitalization rate, across organizations or States depends on the underlying epidemiology and severity of the cases treated by each organization. The rate of missing detailed diagnoses by State and organization and by client characteristics is shown in Table B.4. The rate of missing diagnostic detail varies considerably across organizati ons. Medicaid records almost always included diagnostic detail because it is required for payment. In contrast, the State MH organization in Washington had virtually no c lients with detailed diagnoses in 1996; in Oklahoma the same type of organization had about 60 percen t of clients without such diagnoses whether adult or youth clients. In Delaware, nearly all MH-only and SA-only youth had diagnostic detail, as well as nearly all SA -only adults; for MH-only adults, almost 80 percent of records had diagnostic detail. Th e available diagnostic information on records of clients with a mix of State agency and Medicaid records varies markedly. Service Categorization Each service record was assigned to a “servi ce category” during the data development of the IDB based on selected claim type, servi ce codes, procedure codes, revenue codes, type of provider codes, and other informati on available on a record (see Table B.5). The information used for service category va ried by State and the type of record. Service records were partitioned into one of three categories: MH records, SA records, or other “medical” records (available only for Medicaid clients). This partition was based on the primary diagnosis, if available. O ccasionally, State-specific procedure codes, which were specific to MH or SA service programs, were used in lieu of primary diagnosis. Service records that lacked both primary diagnosis and selected procedure codes, were assigned as MH or SA records if they were from an agency that only provided MH or SA services, respectively. Fi nally, Medicaid service records that had not been assigned to MH or SA categorie s were assigned as medical records. MH and SA records (see above) were used to develop two levels of service provider profiles for each client. An agency-level profile was set based on whether Medicaid 81 Table B.3: Number of Client Records for Analysis of MH/SA S ervices by Type of Client, State, and Organization Supporting Treat ment Delaware Oklahoma Washington Three States Client MH/SA Agency only Medi- caid only Both Total MH/SA Agency only Medi- caid only Both Total MH/SA Agency only Medi- caid only Both Total Total MH Only: Youth 539 3,719 7234,98114,76011,9144,09330,767 20,1439,0175,66134,82170,569 Adult 2,622 1,656 9955,27332,11510,8415,89748,853 30,34816,73416,42263,504117,630 Total MH Only 3,161 5,375 1,71810,25446,87522,7559,99079,620 50,49125,75122,08398,325188,199 SA Only: Youth 302 96 8147921229432,219 2,7541,1301,0224,9067,604 Adult 4,436 322 1894,94717,2215356217,818 18,5672,5656,84927,98150,746 Total SA Only 4,738 418 2705,42619,3436296520,037 21,3213,6957,87132,88758,350 MH+SA: Youth 42 131 1603331,0434426292,114 2921331,1791,6044,051 Adult 690 351 5751,61611,0339043,22115,158 1,6089628,04610,61627,390 Total MH+SA 732 482 7351,94912,0761,3463,85017,272 1,9001,0959,22512,22031,441 Total Sample 8,631 6,275 2,72317,62978,29424,73013,905116,929 73,71230,54139,179143,432277,990 82 Table B.4: Percent of MH/SA Client Records with Missing Detailed Diagnosis-Related Data,* by Type of Client, State, and Organization Supporting Treatment Delaware Oklahoma Washington Client MH/SA Agency only Medicaid only BothMH/SA Agency only Medicaid only Both MH/SA Agency only Medicaid only Both MH Only: Youth Total N 539 3,719 723 14,760 11,914 4,093 20,143 9,017 5,661 Missing N 5 0 0 9,806 0 3 20,057 0 50 Missing % 1% 0% 0% 66% 0% 0% 100% 0% 1% Adult Total N 2,622 1,656 995 32,115 10,841 5,897 30,348 16,734 16,422 Missing N 322 0 77 18,980 0 59 29372 0 367 Missing % 12% 0% 8% 59% 0% 1% 97% 0% 2% SA Only: Youth Total N 302 96 81 2,122 94 3 2,754 1,130 1,022 Missing N 2 0 1 1,447 0 1 17 0 0 Missing % 1% 0% 1% 68% 0% 33% 1% 0% 0% Adult Total N 4,436 322 189 17,221 535 62 18,567 2,565 6,849 Missing N 126 0 0 7,583 0 1 45 0 0 Missing % 3% 0% 0% 44% 0% 2% 0% 0% 0% MH+SA: Youth Total N 42 131 160 1,043 442 629 292 133 1,179 MH Dxs Missing N 5 4 2 555 18 17 291 11 531 Missing % 12% 3% 1% 53% 4% 3% 100% 8% 45% SA Dxs Missing N 1 79 19 731 273 414 11 15 53 Missing % 2% 60% 12%70% 62% 66% 4% 11% 4% MH or SA Dxs** Missing N** 5 83 21 906 291 430 292 26 584 Missing %** 12% 63% 14%87% 66% 68% 100% 20% 50% Adult Total N 690 351 575 11,033 904 3,221 1,608 962 8,046 MH Dxs Missing N 306 72 88 3,728 123 358 1,531 55 1,629 Missing % 44% 21% 15%34% 14% 11% 95% 6% 20% SA Dxs Missing N 211 161 168 4,414 404 1,549 151 368 1,390 Missing % 31% 46% 29%40% 45% 48% 9% 38% 17% MH or SA Dxs** Missing N** 494 233 251 7,470 527 1,907 1,533 423 2,978 Missing %** 72% 66% 44%68% 58% 59% 95% 44% 37% Total Missing N** 954 316 350 46,192 818 2,401 51,316 449 3,979 Grand Total N 8,631 6,275 2,72378,294 24,730 13,90573,712 30,541 39,179 Total Percent Missing** 11% 5% 13%59% 3% 17% 70% 1% 10% Source: CSAT/CMHS IDB Project, 1996 data. *Based on primary diagnosis or primary substance used (a field on MH/SA Agency admission records). **Counted as missing for MH+SA persons if either MH or SA diagnosis-related data are missing, which shows the uni que number of clients with a missing diagnosis of either type. 83 and/or State MH/SA agencies provided any MH or SA services to the client. The categories were: “Medicaid Only,” “State MH/SA Agency Only,” or “Both Auspices” (Medicaid and State MH/SA Agency). A service setting profile was based on the pe rmutations of settings where a client received MH or SA services in 1996 (Table B.5). Service setting were: I = inpatient care at a general or community inpatient facility or care at an inpatient psychiatric facility, R = care at a residential facility (non-Medicaid only), or care at a l ong-term-care facility (which existed under Medicaid only), and O = care in outpatient settings or any ot her service such as transportation. In counting hospitalizations ove r time, over-lapping or split service records had to be reconciled. Billing for some hospitalizations can occur in separate claims or patients can be discharged for a home visit with a schedul ed return for treatment a day later. When the dates of service for seemingly separate hospital stays overlap or occur on adjacent dates, then those hospitalizati ons are counted as one stay. Identification and Flagging of Duplicate Services The IDB combines service data from mu ltiple sources: Medicaid and State MH/SA agencies. Records of these services are co llected independently by separate agencies. Sometimes the same service is captured by more than one agency. As a result, the IDB contains duplicate service records, duplicates that are difficult to identify because the agencies collect data in di fferent ways for unique purposes. Without some mechanism for linking services, analysis of the IDB woul d overstate service counts because of this duplication. In general, service linking identified overl aps between State agency MH/SA service files and the Medicaid service files. (See Chapter 1 for a description of the files.) For example, the services from the Outpatient MH Service File, the SA Service File, and the Medicaid Outpatient and Other Services Fi le (ignoring any dent al, transportation, or DME Medicaid services) were compared against each other. This was done for the institutional files as well. Th e criteria for identifying duplicat e services were specific to each State and often to specific data sour ces within each State, as noted below. Delaware: Identification of duplicate services required a match on client and an overlap of service dates. Othe r criteria for overlapping records varied by organization and service setting: Adult Institutional: 1) When a service from the Institutional MH Se rvice File (or from the SA Service File) overlapped with a service on the Medicaid Long-Term-Care File and providers matched, or 84 Table B.5: Service Categories Setting of Service MH/SA Service Categorization Service Setting Label Service Category MH, SA Agency or Medicaid Description 01 All Inpatient Hospital Services, NEC Acute Care Inpatient 51 SA Hospital Based Detoxification 02 All Inpatient Psychiatric Services 65 MH Other MH Inpatient Treatment I Inpatient Psychiatric Any M Any other inpatient hospital record 52 SA Detoxification, Fr eestanding, Residential 54 SA SA Rehab, Short Term Re sidential (30 days or less) 55 SA SA Rehab, Long Term Re sidential (more than 30 days) 66 MH Residential MH 03 M Long-Term-Care Psychiatric Services 04 M Nursing Facility Services 05 M Intermediate Care Facility for the Mentally Retarded Services 06 M Religious Non-Medical Health Care Institutional Services R Residential Any All Local procedure code indicating resi dential care 07 M Physician Services, NEC 08 M Dental Services 09 M Other Practitioner Services, NEC 10 M Ambulatory Faci lity Services, NEC 11 M Rehabilitation Services 12 M Physical, Occupational, Speech , Hearing, and Language Services 13 M Home Health Services 14 M Hospice Services 15 M Personal Care Services 16 M Family Planning Services 17 M EPSDT Services 18 M Laboratory and X-ray Services 19 M Prescribed Drugs 20 M Transportation Services 21 M Durable Medica l Equipment (DME) 22 M Waiver Services 23 M Targeted Case Management Services 24 M Capitated Services 25 M Other Care Services 56 SA Intensive SA outpatient treatment 57 SA SA outpatient treatment 58 SA Detoxification, ambulatory 59 SA Other SA treatment, NEC 61 MH Partial day treatment (MH) 62 MH MH diagnosis and assessment 63 MH MH consultation and education 67 MH MH crisis stabilization/intervention 68 MH MH counseling services 69 MH Center-based MH outpatient services 70 MH Medication monitoring/administration (MH) 71 MH MH therapy, psycho/social 72 MH MH rehabilitation services 73 MH Administrative services 74 MH Support services 75 MH Case Management/Clinical Coordination 76 MH Other MH treatment, NEC 97 All Unknown 98 All Unavailable O Outpatient/ Other Services 99 All Invalid NEC = Not Elsewhere Classified. EPSDT = Early, Periodic, Screening, Detection, and Treatment. 85 When a service from the Institutional MH Se rvices File (or from the SA Service File) overlapped with a service on the Medicaid Inpatient File and providers matched, then the MH (or SA) servi ce was flagged as duplicate. Adult Outpatient: 1) When a service from the Medicaid Outpatie nt Service File had a specified service code (Delaware-specific SA or MH service codes of WW401-WW404 or WW660- WW663) that overlapped with a service from the Outpatient MH (or SA) Service File and service quantities agreed, then the MH (or SA) service was flagged as a duplicate. Adult Managed Care: 1) When a fee-for-service record from the Medi caid Outpatient and Other Service File had a specified service code (Delaware-specific MH or SA service codes of WW664 or WW665) that overlapped with a managed-care record from the Medicaid Outpatient and Other Service File or the MH Outpatient Service File, and providers matched, or 2) When a service from the SA Service F ile had a specified service code (WW401- WW404) that overlapped with the Medicaid Outpatient and Other Service File and providers matched, then the MH (or SA) service was flagged as a duplicate. Youth Services: 1) When a record from the Department of Services for Children, Youth, and Their Families (DSCYF) from the MH Outpatient Se rvice File (or SA Service File) with a monthly capitation amount of $4239 overlapped with a service from the Medicaid Outpatient and Other Service File with an amount paid of $4239, then the MH (or SA) record and the Medicaid record were flagged as duplicates. DSCYF service detail records with service dates w ithin the timeframe of the capitation payment were not flagged as duplicates. Oklahoma: Identification of duplicat e services required a matc h on client and provider, and an overlap of service dates. Also, a Me dicaid service had to contain a MH or SA diagnosis to link with a Stat e MH or SA agency service record. When such overlaps were found, the MH (or SA) servi ce was flagged as a duplicate. Washington: Identification of duplicate services required a match on client and an overlap of service dates. Additional criteria vari ed by type of service: 1) When a “MH counseling” service from the MH Outpatient Service File and a service of a “medical doctor” or “psychologist” provider from the Medicaid Outpatient and Other Service File also had a MH (or SA) diagnosis, 2) When a service from the Institutional MH Service File overlap ped with a service from the Medicaid Long-Term-Care File and providers matched, or 3) A service from the SA Service file overla pped with a service from any Medicaid services where providers match, then the MH (or SA) service was flagged as a duplicate. 86 Medicaid Enrollment Medicaid eligibility for MH/SA clients (as fo r any clients) can change during the course of a year as people move on and off Medicaid enrollment. For this study, all Medicaid MH/SA recipients who sought care under Medicaid were in cluded in the study. Table B.6 shows the distribution of clients by whether they were continuously or discontinuously enrolled and by their length of continuous enrollment in Medicaid. Only about 8 percent or fewer (depending on the Stat e) of Medicaid client s in this study went on and off Medicaid rolls dur ing the period of 1996. Most Medicaid MH/SA clients (66 percent or more) were enrolled for 12 months continuously. Another 16-to-19 percent of these clients were enrolled for a period of from 6 to 11 months without interruption and without any other period of enro llment. Another 6-to-9 perc ent were enrolled for 2 to 5 months without interruption or re-enrollment and 1.5 percent or less were enrolled for only one month. Thus, discontinuous enrollment in Medicaid is not a significant problem for the MH/SA client population in the three States. This pattern of enrollment does not vary much by State. Table B.6: Enrollment in Medicaid for Clie nts Receiving Medicaid MH/SA Services, by State Delaware Oklahoma Washington N Percent of Medicaid Clients N Percent of Medicaid Clients N Percent of Medicaid Clients Total Medicaid Clients 8,998100.0% 38,635100.0% 69,720 100.0% Continuous versus Discontinuous Enrollment: Enrolled without interruption for 2 or more months 8,54895.0% 35,38191.6% 65,421 93.8% Enrolled discontinuously 4154.6% 2,9567.7% 4,299 6.2% Continuous Enrollment for Different Intervals: Enrolled continuously for 12 months 6,28669.9% 25,52866.1% 47,839 68.6% Enrolled continuously for 6-11 months 1,69918.9% 6,58317.0% 10,826 15.5% Enrolled continuously for 2-5 months 5636.3% 3,2708.5% 5,745 8.2% Enrolled for 1 month 350.4% 2980.8% 1,011 1.5% Source: CSAT/CMHS IDB Project, 1996 data. 87 Other Statistical Issues Specific to This Study Minimum Cell Sizes. A few categories of clients had so few patients in them that statistics could not report reliably. Whenever a rate or proportion was based on a denominator of fewer than 30 cases, the rate wa s not reported. Thirty cases is the number of cases appropriate for performi ng the standard t-test of diffe rences and a general rule of thumb for minimum cell sizes for reporting resu lts. Also, using 30 or more observations to derive every statistic prot ects the privacy of individuals, who then cannot be identified even with outside information. Missing Values. Whenever less than 10 percent of records in a category contains values for a variable of interest (for example, when only 5% of State MH agency records contains race/ethnicity), then the statistic fo r the category is not reported. A statistic is reported whenever 10 percent or more of the records have values (except for diagnosis for which a stricter standard was set that 30 pe rcent of records must have values). This could be thought of as a 10 percent sample of information. However, the 10 percent available could be a biased view of the group because the 10 pe rcent may not occur randomly in the database. Both the 10%-of-valu es rule and the 30-cell-size rule must be satisfied before results are presented here. Statistical Tests. Statistical tests are not used in this analysis because the study is based on the complete set (the census) of people w ith MH and/or SA diso rders who are treated under the auspices of the State MH and SA agencies and/or Me dicaid. Statis tical tests are not necessary to account for sampling variability because there is no sample. Further Methods Detail Available Detailed methods also can be found at http://www.samhsa.gov/cen ters/csat/csat.html .