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AnEvaluationoftheConnecticutGeneralAssistanceManagedBehavioralHealthCare PilotProgram ADissertation PresentedtotheFacultyoftheGraduateSchool of YaleUniversity inCandidacyfortheDegreeof DoctorofPhilosophy by NeilM.Thakur DissertationDirector:MarkSchlesinger,Ph.D. December1998 Abstract AnEvaluationoftheConnecticutGeneralAssistance ManagedBehavioralHealthCarePilotProgram NeilM.Thakur 1998 ThisdissertationwillevaluatetheConnecticutDepartmentofMentalHealthand AddictionServices(DMHAS)GeneralAssistancePilot(GAP)programthatprovided managedmentalhealthandsubstanceabuseservicestoGeneralAssistance(GA)clients. TheGAPwasdesignedtoincreaseaccesstocareandlowercostsbycollocating cliniciansatwelfareoffices,creatingprovidernetworks,andmanagingutilization. TheevaluationfocusesonthethreelargestandoldestGAPsites:Bridgeport; Hartford;andNewHaven. Keyinformantinterviewsandarchivalanalysisareusedto qualitativelyexploreorganizationalimpactsofthecollocationstrategy. Quantitative analysisofelectronicGAandDMHASrecordsfrom1992-1996explorethecasefinding andutilizationmanagementprocesses. Thisdissertationexplorestwopolicyissues. Thefirstconcernsintegratingthe deliveryofsocialservicesacrossagencieswithdifferenttraining,expertise,funding,and missions. Resultsindicatethatcollocationfirstledtotensionbetweenclinicaland welfarestaff,butlaterresultedinproductivecollaboration. GARecipientsfromHartford andNewHavenweremorelikelytoaccessDMHAScareafterimplementationofthe GAPiftheirGAbenefitswereactive. TheGAPaccessprocesswasmostefficientin siteswiththemostintensecollocation. Thesecondpolicyissueisthatofstateagenciesdirectlymanagingtheirown services. Qualitativedataanalysissuggestspubliclyoperatedmanagedcareprograms mayhaveweakeroversightandmanagenetworkproviderslessaggressivelythanother publicmanagedcaremodels. ThoughcostsofDMHASservicesforGAclientsdroppedafterimplementationof theGAP,DMHAScostsalsofellforthesesameclientswhiletheircarewasnotmanaged bytheGAP. Themainreasonforcostsdeclinesmaybeareductioninthenumberof DMHASmentalhealthinpatientbeds,andtheimplementationofapriorauthorization programforallinpatientadmissionspriortoimplementationoftheGAP. Thoughsometheseoffindingsaremixed,theGAPdoessuggestaviablemodel forpubliclyoperatedmanagedcare. WaystocorrectsomeoftheGAP'sshortcomings willalsobeconsidered. ©1998byNeilM.Thakur Allrightsreserved. Acknowledgments Thisworkwouldnothavebeenpossiblewithoutthewisdom,time,andresources ofmanydifferentpeople. Iespeciallyappreciatethesupportfrommydissertation advisors:MarkSchlesinger;JoeMorrissey;andWilliamSledge. Ialsogratefully acknowledgefinancialsupportfromtheNIMHservicestraininggrant,theHealthCare FinanceAdministration,theDepartmentofMentalHealthandAddictionServices,and theYaleUrbanHealthInitiative. SpecialthankstoJoeGouletandDebSullivanforprogrammingassistance; MarilynStolarandDanZeltermanforstatisticalconsultation;RaniHoffforgrantwriting adviceandeditorialcomments; TomHelminiak,NancyWolff,andJackTebesforcost estimates;andPamDaltonandJimCatalanottoforadviceandprotection. Myinterviewees'honesty,insight,andfeedbackwereinvaluable,andIam gratefulfortheirpatiencewithmymanyfollow-upquestions. Outofrespectfortheir privacy,Iwillnotnamethem. Thefollowingpeoples'professionalassistancewereinstrumentalincompleting thisproject: FromYaleUniversity:DaveBruce,AnnGreen,RayLoomis,MartinMador. FromtheCityofNewHaven: TomNguyen,ArtSickle. FromtheCityofBridgeport: KathyHunter. From theCityofHartford: NeeruOhri,BarbaraZebrowski,VernonJohnson. FromEDS: DianeValegorski,HelenWu,RichBatza. FromDSS: DavidParella,BillRufleth,MarshaMains,ClaudetteCarveth,Alice Franculli. FromDMHAS: MelodiePeet,DavidHunter,JillBenson,LeslieLemert,SandySalus, KenMarcus,MichaelLevine,SueGraham,SteveLynch,DebBurr,CherylCroll, DickTurzo,KarenSnyder,WillieRamierez,SheilaAmdur,PaulPotamianos. Mostofall,Iwishtothankmyfamilyandfriendsfortheirsupport. TableofContents CHAPTER1:INTRODUCTION n 231...PIImnrptoergtorudasumcftodireosrncertfiopotpriumobnlicsectorbehavioralhealthsystem ""111314 4.PolicyIssues 16 CHAPTER2:REVIEWOFTHELITERATURE 19 1.BehavioralHealthSystemOverview 20 A.Clientneed. -)q B.Difficultyinintegratingsubstanceabuseandmentalhealthcaremodels 22 2.Administrativeshortcomingsinsocialservicedelivery 25 A.Federallevelincomeassistance 25 B.Stateandlocallevel. 27 3.TA.heCaGnAPintaengrdatSiyosntiemmpsroIvnetseegrrvaicteiso?n *2789 B.Whatisneededforintegration 34 C.ImplicationsfortheGAP j£ 4.ManagingCare 37 A.ManagedcareprinciplesintheGAP 37 B.AnalyticFramework 45 C.Implicationsoftheframework. jj D.Managedcareeffectsonminorityenrollees 54 5.Conclusions 56 CHAPTER3:PROGRAMDESCRIPTIONANDHYPOTHESES 57 1.GeneralDescriptionoftheGAPmodel ..57 A.AccessingservicesandmanagingutilizationpriortotheGAP 57 B.GenericGAPModel 50 2.SCi.teMaDnesacgreidptCiaornesHypotheses ; 6585 A.Bridgeport 59 B.Hartford. 75- C.NewHaven 77 3.CA.roOsrsgasniitzeactoiomnpaalrriessoenarschquestions _§842 B.Inter-sitevariationandmanagedcareoutcomes 85 4.Conclusion 86 CHAPTER4:METHODS 87 1.ParticipantObservation 87 2.Qualitativedatacollectionandhypotheses 88 A.Datasourcesandmethods #9 B.OrganizationalAnalyses qq C.KeyInformantInterviews 97 D.Limitations 97 3.Quantitativedatacollectionandhypotheses 99 A.Obtainingthedata 99 B.Linkingthedata JQ2 C.AccesstoCareAnalysis /05 D.TargetEfficiencyanalyses 722 E.Modelingtotaldirectcosts 725 4.Analysisofoutcomesbyracialsubgroups 136 5.Conclusions 136 1 CHAPTER5:QUALITATIVEANALYSISANDFINDINGS 139 1.Introduction 139 2.Integrationmethods 141 A.ProcessofIntegration ]4j BC.IInntterra--oorrggaanniizzaattiioonnaallcroenlfaltiicto.ns J1S4O4 3.Publiclyoperatedmanagedcare 16 4.Conclusion 165 CHAPTER6:QUANTITATIVERESULTS 167 1.Accesstocare 167 A.Onewaymodelsandfrequencies 168 B.Accessmodelselection /74 C.FinalAccessmodels 184 D.Cross-Sitecomparisons 190 2.TargetEfficiencyAnalysis 192 A.Onewayfrequenciesandmodels 193 B.TargetEfficiencymodelselection. 196 C.FinalTargetEfficiencymodels 201 3.Modelingcostsofcare 204 A.Onewayfrequenciesandcostmodels 204 B.Costsmodelselection 208 C.Finalcostmodels 214 4.RaceandManagedcare 229 A.Noconclusivedifferencesincostmodels 229 B.RaceandaccesstocareinHartford 229 CHAPTER7:DISCUSSION 234 1.TheGAPasaServiceIntegrationmechanism 234 A.InteragencyaspectsoftheGAP 234 B.Intra-agencyeffects 238 2.Managedcarepractices 240 A.Findings 240 B.Minoritydifferencesandmanagedcare 241 C.DMHAScostsversusprivatecosts 242 3.Theutilityofstatesdirectlyadministeringmanagedcareprograms 243 A.Problemswithstatesmanagingcare 243 B.Planningprocess 245 C.Operationalprocess 249 4.Waystominimizeproblemsendemictopubliclyoperatedmanagedcare 250 A.Increasingexpertise 253 B.Increasingexpertiseandaccountability 254 5.Conclusions 255 APPENDIX—DataHandlingAndRecordLinkageProcedures 259 21..TThheeNHaerwtHfaovrdenGGAARoRsotsetrer 226509 3.DMHASUtilizationRecords 261 4.MergingDMHASandGArecords 264 BIBLIOGRAPHY 268 ListofTables Table3-1: SummaryofGAPsitedifferences 83 Table4-1:ListingofIntervieweesJobTitlesbyGAPSite 92 Table4-2: Listingofinterviewerpromptsandgoalsforsemi-structuredKeyInformant interviews 94 TTTTaaaabbbblllleeee4444----5643::::NSHSaueurmbwtmpfaeoHrrraiidvzoGedinAndgPaGtDAePsPSolaMiPncodyCliolPcdeeynergsiPtoehdrsifoordsaccessanalysis "ZZZZZ"! 1P111y1492i Table4-7:1994directcostestimates pg Table4-8: Subperioddatesandlengthsforcostanalysis 130 TTTTaaaabbbblllleeee6666----4231::::NNHHaaeerrwwttffoHoHrraaddvveeuacnnncaeduascjnscuaesdbsjtasuessdebtaaemscdoecdeamescoscldemseosldmeoldsels 111177755709 TTTTaaaabbbblllleeee6666----8765::::NFHHiaeanrrawttlffoHaoracrdcvdeeaascnsncdeamscoNscdeeecswolsnsHcffoaoonvurfneobdnuointnahdcgicscenishgtseesccrhkaetcekjointmodel,Periods2-6 111198881420 Table6-9:Hartfordunadjustedefficiencyestimates 194 Table6-10:NewHavenunadjustedefficiencyestimates 195 Table6-11:HartfordandNewHavenbaseefficiencymodels 197 Table6-12:Changeindeviancetestsforefficiencymodelbuilding 198 Table6-13:HartfordEfficiencymodelconfoundingcheck 199 Table6-14:NewHavenEfficiencymodelconfoundingcheck 200 Table6-15:FinalRRregressiontargetefficiencymodelsforbothcities 201 Table6-16:Hartfordunadjusteddailyaveragecosts 206 Table6-17:NewHavenunadjusteddailyaveragecosts 207 Table6-18:Hartfordbasecostmodels 209 Table6-19:NewHavenbasecostmodels ..210 Table6-20:Hartfordcostsmodelbuilding 211 Table6-21: NewHavencostsmodelbuilding .211 Table6-22:HartfordCostsmodelsconfoundingcheck 212 Table6-23:NewHavenCostsmodelconfoundingcheck _ 213 Table6-24:FtestsforfinalHartfordcostmodels 214 Table6-25: FtestsforfinalNewHavencostmodels 214 Table6-26:Hartfordfinalcostmodels 215 Table6-27:NewHavenfinalcostmodels 217 Table6-28:Hartfordadjusteddailyaveragecostsbydiagnosticgroup 219 Table6-29:NewHavenadjusteddailyaveragecostsbydiagnosticgroup 219 Table6-30:HartfordGAandnon-GAcostcontrasts 226 Table6-31:NewHavenGAandnon-GAcostcontrasts 227 Table7-1:PercentagesofsubjectswithmissingdiagnosesatinitialDMHAScontact,by intakeunitandperiod 236 TTaabblleeAA--2l::DGAMPHAAsSseDsesmmoegnrtarpehciocrdrsecloirndksedlwiniktehdGwAithRosGtAersRosters 226667 ListofFigures Figure2-1:AFlowchartforManagedCareEvaluation 47 Figure3-1:Pre-GAPmodel 58 Figure3-2:GenericGAPmodel 61 Figure3-3: BridgeportGAPclientflow 72 Figure3-4: HartfordGAPclientflowchart 76 Figure3-5: NewHavenGAPclientflowchart 81 Figure4-1:HartfordCrudeIncidenceRatesandKeyPolicyEvents 109 Figure4-2:NewHavenCrudeIncidenceRatesandKeyPolicyEvents 11 Figure4-3:Hartfordaccesscollapsibilitytest 120 Figure4-4:NewHavenaccesscollapsibilitytest 121 Figure4-5:Hartfordcostscollapsibilitytest 135 Figure4-6:NewHavencostscollapsibilitytest 135 Figure5-1:TheorizedInteragencyCollocationEffectsOverTime 149 Figure6-1:Hartfordunadjustedaccessrates 173 Figure6-2:NewHavenunadjustedaccessrates 173 Figure6-3:Hartfordaccessfinalmodel, Period*GAstatusataccess 187 Figure6-4:NewHavenaccessfinalmodel,Period*GAStatusataccess 188 Figure6-5:HartfordadjustedOtherdiagnosiscostsbyGAstatus 223 Figure6-6:HartfordadjustedMISAcostsbyGAstatus 223 Figure6-7:HartfordadjustedAxis1costsbyGAstatus 224 Figure6-8:NewHavenadjustedMISAcostsbyGAstatus 224 Figure6-9:NewHavenadjustedAxis1costsbyGAstatus 225 Figure6-10:NewHavenadjustedsubstanceabusecostsbyGAstatus 225 Figure6-11:Hartfordraceperiodinteraction,whenGAbenefitsareinactive 231 Figure6-12:Hartfordraceperiodinteraction,whenGAbenefitsareactive 232