Behavioral Health/Substance Abuse Awards: Addendum to the Third Annual Report

222 Pages·2017·4.04 MB·English

by  Mathematica Policy Research

THIRD ANNUAL REPORT ADDENDUM
Evaluating the HCIA – Behavioral
Health/Substance Abuse Awards:
Addendum to the Third Annual Report
July 14, 2017

Jennifer Lyons
Henry Ireys
Rachel Miller
Ellen Bouchery
Brenda Natzke
Crystal Blyler
Laura Ruttner
Tricia Higgins
Allison Siegwarth
Michael Barna
Michaela Vine
Dan Friend
Aparajita Zutshi
Matt Kehn
Submitted to:
Center for Medicare & Medicaid Innovation
Social Science Research Analyst Rapid Cycle Evaluation Group
WB 18-13 7205 Windsor Blvd
Baltimore, MD 21244
Project Officer: Vetisha McClair, Ph.D.
Contract Number: HHSM-500-2010-00025I
Submitted by:
Mathematica Policy Research
1100 1st Street, NE, 12th Floor
Washington, DC 20002-4221
Telephone: [phone]
Facsimile: [phone]
Project Director: Henry T. Ireys, Ph.D.
Reference Number: 40271.E20
This page has been left blank for double-sided copying.
MATHEMATICA POLICY RESEARCH
CONTENTS
EXECUTIVE SUMMARY .............................................................................................................................. ix
I. INTRODUCTION .............................................................................................................................. 1
A. The HCIA initiative ..................................................................................................................... 1
B. Overview of the behavioral health awardees ............................................................................ 1
C. Evaluation goals ........................................................................................................................ 3
D. Evaluation methods ................................................................................................................... 3
E. Road map to the report .............................................................................................................. 7
II. FUND FOR PUBLIC HEALTH IN NEW YORK ................................................................................ 9
A. Introduction ................................................................................................................................ 9
1. Enrollment ......................................................................................................................... 10
2. Participants’ demographic characteristics ........................................................................ 11
B. Methods ................................................................................................................................... 12
1. Quantitative methods ........................................................................................................ 12
C. Summative findings ................................................................................................................. 14
1. Descriptive analyses ......................................................................................................... 14
2. Description of impact estimates ........................................................................................ 18
3. Limitations of the analysis ................................................................................................. 20
D. Conclusions ............................................................................................................................. 20
III. KITSAP MENTAL HEALTH SERVICES (KMHS) .......................................................................... 21
A. Introduction .............................................................................................................................. 21
1. Enrollment ......................................................................................................................... 22
2. Clients’ demographic characteristics ................................................................................ 22
B. Methods ................................................................................................................................... 25
1. Quantitative methods ........................................................................................................ 25
C. Summative findings ................................................................................................................. 28
1. Results of Medicare analyses ........................................................................................... 28
2. Results from Medicaid analyses ....................................................................................... 33
D. Conclusions ............................................................................................................................. 37
IV. MAIMONIDES MEDICAL CENTER ............................................................................................... 41
A. Introduction .............................................................................................................................. 41
1. Enrollment ......................................................................................................................... 42

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CONTENTS MATHEMATICA POLICY RESEARCH
2. Demographic characteristics ............................................................................................. 43
B. Methods ................................................................................................................................... 45
1. Quantitative methods ........................................................................................................ 45
C. Summative findings ................................................................................................................. 48
1. Descriptive analysis of service use by Medicare and Medicaid participants .................... 48
2. Impact estimates for CMMI’s core measures: Medicare ................................................... 51
3. Impact estimates for CMMI’s core measures: Medicaid ................................................... 55
4. Pre-post analysis of intervention group Medicaid expenditures by type of service .......... 61
5. Analytic limitations ............................................................................................................. 61
D. Conclusions ............................................................................................................................. 62
V. VALUEOPTIONS ........................................................................................................................... 65
A. Introduction .............................................................................................................................. 65
1. Program goals ................................................................................................................... 65
2 Enrollment ......................................................................................................................... 66
B. Methods ................................................................................................................................... 68
1. Quantitative methods ........................................................................................................ 68
C. Summative findings ................................................................................................................. 69
1. Descriptive analysis: service use and expenditures ......................................................... 69
2. Impact analysis: service use and expenditures ................................................................ 73
3. Descriptive and impact analysis: initiation of and engagement with treatment ................ 74
4. Analytic limitations ............................................................................................................. 75
D. Conclusions ............................................................................................................................. 76
APPENDIX A: FPHNY TECHNICAL METHODS ...................................................................................... A.1
APPENDIX B: KMHS TECHNICAL METHODS........................................................................................ B.1
APPENDIX C: MMC TECHNICAL METHODS .........................................................................................C.1
APPENDIX D: VALUEOPTIONS TECHNICAL METHODS ......................................................................D.1
APPENDIX E: REFERENCES NOTED IN APPENDICES A-D ................................................................ E.1

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MATHEMATICA POLICY RESEARCH
TABLES
ES.1 Awardees in the field of behavioral health and substance abuse .................................................... ix
ES.2 Evaluation design features for four behavioral health/substance abuse awardees ....................... xii
ES.3 Impacts of four awardees’ programs on CMMI core measures ..................................................... xiv
I.1 Behavioral health and substance abuse awardees ......................................................................... 2
I.2 Evaluation design features for four behavioral health/substance abuse awardees ........................ 5
II.1 Demographic characteristics at initial service use, FPHNY Medicaid beneficiaries
included in analyses, January 2013–November 2015a .................................................................. 12
II.2 Medicaid impacts attributo FPHNY’s program ............................................................................... 19
III.1 Demographic characteristics of groups included in analyses ........................................................ 24
III.2 Diagnoses of KMHS clients ........................................................................................................... 25
III.3 Medicare impacts attributo KMHS’s program ................................................................................ 32
III.4 Medicaid impacts attributo KMHS’ program................................................................................... 36
IV.1 Demographic characteristics of MMC Medicare and Medicaid analytic groups ............................ 44
IV.2 New York State Medicaid health home services ........................................................................... 49
IV.3 Summary of service use................................................................................................................. 50
IV.4 Medicare impacts attributo MMC’s program .................................................................................. 55
IV.5 Medicaid impacts attributo MMC’s program................................................................................... 59
V.1 Demographic characteristics of MBHP participants and comparison group members,
March 2013–December 2015 ........................................................................................................ 67
V.2 Medicaid impacts attributo ValueOptions’ program ....................................................................... 74
V.3 Impact estimates for changes in initiation of and engagement with treatment .............................. 75
A.1 ICD-9 behavioral health diagnosis codes ........................................................................................ 4
A.2 Service use leading to program enrollment ..................................................................................... 6
A.3 Frequency of ratio of intervention to comparison group members for each matched set
(FPHNY) ........................................................................................................................................... 9
A.4.a Balance before and after matching (FPHNY, CRC subgroup) ...................................................... 14
A.4.b Balance before and after matching (FPHNY, NA-MCT subgroup) ................................................ 20
A.5 Impact analysis model control variable specifications—FPHNY ................................................... 28
A.6 Impacts attributo the FPHNY program in year 1 ............................................................................ 31
A.7 Impacts attributo the FPHNY program in year 2 ............................................................................ 32
B.1 Codes used to identify mental health services (KMHS Medicare) ................................................... 7

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TABLES MATHEMATICA POLICY RESEARCH
B.2 ICD-9 Mental health diagnosis codes (KMHS Medicare) ................................................................ 7
B.3 Frequency of ratio of treatment beneficiaries to comparison beneficiaries for each
matched set (KMHS Medicare) ........................................................................................................ 9
B.4 Balance before and after matching (KMHS Medicare) .................................................................. 12
B.5 Codes used to identify mental health services (KMHS Medicaid) ................................................. 16
B.6 ICD-9 mental health diagnosis codes (KMHS Medicaid) ............................................................... 16
B.7 ICD-9 primary care and substance abuse diagnosis codes (KMHS Medicaid) ............................. 17
B.8 Frequency of ratio of treatment beneficiaries to comparison beneficiaries for each
matched set (KMHS) ...................................................................................................................... 20
B.9 Balance before and after matching (KMHS Medicaid) ................................................................... 23
B.10 Office visit services ........................................................................................................................ 32
B.11 Impact analysis model control variable specifications—KMHS Medicare ..................................... 32
B.12 Impact analysis model control variable specifications—KMHS Medicaid ...................................... 33
C.1 Diagnoses codes used to identify qualifying condition categories in treatment and
comparison groups ........................................................................................................................... 5
C.2 Characteristics of major metropolitan areas nation-wide without Medicaid Health Home
Program ........................................................................................................................................... 8
C.3 Frequency of ratio of treatment beneficiaries to comparison beneficiaries for each
matched set (Medicare) ................................................................................................................. 12
C.4 Balance before and after matching (MMC Medicare) .................................................................... 15
C.5 Frequency of ratio of treatment beneficiaries to comparison beneficiaries for each
matched set (Medicaid) .................................................................................................................. 24
C.6 Balance before and after matching (MMC Medicaid) .................................................................... 27
C.7 Impact analysis model control variable specifications—MMC Medicare analysis ......................... 38
C.8 Impact analysis model control variable specifications—MMC Medicaid analysis ......................... 39
D.1 Codes to identify the post-intervention detoxification stay ............................................................... 6
D.2 Codes to identify the baseline detoxification stay ............................................................................ 6
D.3 Codes to Identify AUD and OUD ..................................................................................................... 7
D.4 Codes to Identify Inpatient, Outpatient, Intensive Outpatient and Partial Hospitalization
Visits ................................................................................................................................................. 8
D.5 Codes to Identify AUD Medication use ............................................................................................ 9
D.6 Codes to Identify OUD Medication use .......................................................................................... 10
D.7 Impact analysis model control variable specifications—ValueOptions .......................................... 10

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MATHEMATICA POLICY RESEARCH
FIGURES
II.1 Percent of target enrollment achieved by quarter .......................................................................... 11
II.2 Total Medicaid expenditures per FPHNY CRC participant per 6-month period ............................ 16
II.3 Total Medicaid expenditures per FPHNY NA-MCT participant per 6-month period ...................... 16
II.4 Hospitalizations per FPHNY CRC participant per 6-month period ............................................... 17
II.5 Hospitalizations per FPHNY NA-MCT participant per 6-month period ......................................... 17
II.6 ED visits per FPHNY CRC participant per 6-month period ............................................................ 18
II.7 ED visits per FPHNY NA-MCT participant per 6-month period ..................................................... 18
III.1 Total Medicare expenditures per client per 6-month period: Beginning of baseline to end
of intervention ................................................................................................................................. 28
III.2 Hospitalizations per Medicare client per 6-month period: Beginning of baseline period to
end of intervention period .............................................................................................................. 29
III.3 Emergency department visits per Medicare client per 6-month period: Beginning of
baseline period to end of intervention period ................................................................................. 30
III.4 Office visits per Medicare client per 6-month period: Beginning of baseline period to end
of intervention period ...................................................................................................................... 31
III.5 Hospitalizations per Medicaid client per 6-month period: Beginning of baseline period to
end of intervention period .............................................................................................................. 34
III.6 Emergency department visits per Medicaid client per 6-month period: Beginning of
baseline period to end of intervention period ................................................................................. 35
IV.1 Percent of target enrollment achieved by quarter, Q1–Q12 .......................................................... 42
IV.2 Percentage of Medicare participants using different service types, by number of months
enrolled .......................................................................................................................................... 50
IV.3 Percentage of Medicaid participants using different service types, by number of months
enrolled .......................................................................................................................................... 50
IV.4 Total Medicare expenditures per patient per 6-month period: two years before and two
years after program start ................................................................................................................ 52
IV.5 Hospitalizations per Medicare patient per 6-month period: two years before and two years
after program start .......................................................................................................................... 53
IV.6 Readmissions per Medicare patient per 6-month period: two years before and two years
after program start .......................................................................................................................... 53
IV.7 Emergency department (ED) visits per Medicare patient per 6-month period: two years
before and two years after program start ....................................................................................... 54
IV.8 Total Medicaid expenditures per patient per 6-month period: two years before and two
years after program start ................................................................................................................ 56

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FIGURES MATHEMATICA POLICY RESEARCH
IV.9 Hospitalizations per Medicaid patient per 6-month period: two years before and two years
after program start .......................................................................................................................... 57
IV.10 Emergency department (ED) visits per Medicaid patient per 6-month period: two years
before and two years after program start ....................................................................................... 57
V.1 Percent of target enrollment achieved by quarter, Q1–Q12 .......................................................... 67
V.2 Total expenditures per patient per 6-month period: 18 months before and after start of
RSN program ................................................................................................................................. 70
V.3 Emergency department visits per patient per 6-month period: 18 months before and after
start of program .............................................................................................................................. 71
V.4 Residential stays per patient per 6-month period: 18 months before and after start of
program .......................................................................................................................................... 72
V.5 Days of intensive day treatment per patient per 6-month period: 18 months before and
after start of program ...................................................................................................................... 73
A.1.a Propensity score distributions (FPHNY, CRC subgroup) ................................................................ 8
A.1.b Propensity score distributions (FPHNY, NA-MCT subgroup) .......................................................... 8
A.2.a Balance plots comparing the standardized difference for each matching variable before
and after matching (FPHNY, CRC subgroup) ................................................................................ 10
A.2.b Balance plots comparing the standardized difference for each matching variable before
and after matching (FPHNY, NA-MCT subgroup) ......................................................................... 12
B.1 Balance plot comparing the standardized difference for each matching variable before
and after matching (KMHS Medicare) ............................................................................................ 11
B.2 Propensity score distributions (KMHS Medicaid) ........................................................................... 19
B.3.a Balance plot comparing the standardized difference for each matching variable before
and after matching (KMHS Medicaid), part 1 ................................................................................. 21
B.3.b Balance plot comparing the standardized difference for each matching variable before
and after matching (KMHS Medicaid), part 2 ................................................................................. 22
C.1 Log-odds of propensity score distributions for treatment and comparison pool members
(Medicare) ...................................................................................................................................... 11
C.2 Balance plot comparing the standardized difference for each matching variable before
and after matching (Medicare) ....................................................................................................... 13
C.3 Log-odds of propensity score distributions for treatment and comparison pool members
(Medicaid) ...................................................................................................................................... 23
C.4 Balance plot comparing the standardized difference for each matching variable before
and after matching (Medicaid) ....................................................................................................... 25

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MATHEMATICA POLICY RESEARCH
EXECUTIVE SUMMARY
The Affordable Care Act authorized the Center for Medicare & Medicaid Innovation
(CMMI) in the Centers for Medicare & Medicaid Services (CMS) to test innovative health care
payment and service delivery models with the potential to lower spending on Medicare,
Medicaid, and the Children’s Health Improvement Program (CHIP) while maintaining or
improving beneficiaries’ health and the quality of care they receive. In the first round of the
HCIA initiative, 10 awardees implemented programs that focused primarily on individuals with
mental health or substance use disorders (Table ES.1).
These projects had some common goals—for example, training staff to coordinate care and
using health information technology to monitor care—but the approaches to achieving them
varied widely. The awardees also focused on different subgroups within the broad priority
population, such as individuals with schizophrenia or with serious mental illness and a chronic
physical condition. The awardees implemented their programs in settings that ranged from
primary care practices and mental health clinics to a campus serving the homeless population.
In September 2013, CMMI contracted with Mathematica Policy Research to evaluate the 10
projects described in Table ES.1. In January 2017, we submitted our third annual report with
complete evaluations of six of these awardees: the Center for Health Care Services, Felton
Institute, Feinstein Institute for Medical Research, HealthLinkNow, Institute for Clinical
Systems Improvement, and Vinfen Corporation. CMMI posted this report on its website in
March, 2017 (https://downloads.cms.gov/files/cmmi/hcia-bhsa-thirdannualrpt.pdf).1
For the remaining four awardees—the Fund for Public Health in New York, Kitsap Mental
Health Services, Maimonides Medical Center, and ValueOptions—we were able to obtain
additional quantitative data and use these data to complete the awardees’ evaluations. We report
our findings for these four awardees in this document as an addendum to the third annual report.
Thus, to obtain a full understanding of the outcomes of all 10 programs, readers should review
both the third annual report and this addendum.
Table ES.1. Awardees in the field of behavioral health and substance abuse
Enrollment
goal
Dollars (percent
Awardeea Overview of intervention Intervention population awarded achieved)
Center for Health Integrated primary care clinic Adults in San Antonio, Texas, $4,557,969 260b (100)
Care Services into behavioral health service who are homeless
(CHCS) setting
The Felton Implemented an integrated Patients (ages 14–29) with $4,703,817 140 (100)
Institute (Felton) model of early intervention for symptoms of schizophrenia,
psychosis schizoaffective disorder, or
schizophreniform disorder

1
The first and second annual reports are available at https://innovation.cms.gov/Files/reports/HCIA-BHSA-
FirstEvalRpt.pdf and https://innovation.cms.gov/Files/reports/hcia-bhsa-secondevalrpt.pdf, respectively.

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EXECUTIVE SUMMARY MATHEMATICA POLICY RESEARCH
Enrollment
goal
Dollars (percent
Awardeea Overview of intervention Intervention population awarded achieved)
Feinstein Institute Improved treatment for Patients with schizophrenia, $9,380,855 770 (66)
for Medical schizophrenia through recently discharged from the
Research training, care management, hospital and receiving
(Feinstein) and new technology community treatment in one of
eight states
Fund for Public Provided crisis intervention Individuals in Manhattan, $17,608,085 2,232 (63)
Health in New services to facilitate early Brooklyn, the Bronx, and
York (FPHNY) engagement with and Queens who have been
continuity of care—combining diagnosed with psychosis or
community-based care, severe mental illness
access to primary care, and
peer support
HealthLinkNow Provided behavioral care Patients with behavioral $7,718,636 1,534 (88)
(HLN) services via telehealth to health needs in rural areas
individuals in rural areas that with shortages of behavioral
lack access to these services health clinicians (Montana,
Washington, and Wyoming)
Institute for Implemented collaborative High-risk adult patients with $17,999,635 2,704 (100)
Clinical Systems care management for patients Medicare or Medicaid
Improvement with depression and diabetes coverage in one of eight
(ICSI) or cardiovascular disease states who have (1) active
depression and (2)
uncontrolled diabetes or
cardiovascular disease, or
both
Kitsap Mental Integrated primary care and Adults with severe mental $1,858,437 Not
Health Services care for co-occurring physical illness and one comorbidity; applicablec
(KMHS) disorders with mental health children with severe emotional
services disturbance and one physical
comorbidity; Kitsap County,
Washington
Maimonides Coordinated mental and Adults with serious mental $14,842,826 500d (100)
Medical Center physical health care through illness living in southwest
(MMC) advanced health IT Brooklyn
ValueOptions Provided support for recovery Plan members in $2,760,737 1,492b (82)
(ValueOptions) through reinforcement-based Massachusetts with two or
treatment model more detoxification
admissions
Vinfen Integrated health care Individuals in the Boston area $2,942,962 400 (54)
Corporation services into existing with serious mental illness
(Vinfen) behavioral health outreach
teams in community
Source: Enrollment targets are awardees’ self-reported enrollment goals as specified in their applications or
quarterly reports to CMMI’s technical assistance contractor (the Lewin Group). We obtained award amounts
in February 2015 from http://innovation.cms.gov/Files/x/HCIA-Project-Profiles.pdf.
a In this report, we generally use the acronym or name abbreviations in parentheses when we talk about the
awardees.
b Program participants only.
c KMHS did not specify enrollment goals. Instead, it identified cohorts of individuals within its service population for
whom it provided quantitative data on outcome measures.
d Direct participants only. MMC’s program also included 7,000 Medicaid-enrolled indirect participants.

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