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Research Questions

  1. What was the impact of PBHCI on utilization of emergency department and inpatient services?
  2. What was the impact of PBHCI on costs of care to Medicaid?
  3. What was the impact of PBHCI on the quality of health care for physical health conditions for the people treated in PBHCI grantee clinics?

This report describes an extension of the RAND Corporation's evaluation of the Substance Abuse and Mental Health Services Administration's Primary and Behavioral Health Care Integration (PBHCI) grants program. PBHCI grants are designed to improve the overall wellness and physical health status of people with serious mental illness or co-occurring substance use disorders by supporting the integration of primary care and preventive PH services into community behavioral health centers where individuals already receive care. From 2010 to 2013, RAND conducted a program evaluation of PBHCI, describing the structure, process, and outcomes for the first three cohorts of grantee programs (awarded in 2009 and 2010). The current study extends previous work by investigating the impact of PBHCI on consumers' health care utilization, total costs of care to Medicaid, and quality of care in three states. The evidence suggests that PBHCI was successful in reducing frequent use of emergency room and inpatient services for physical health conditions, reducing costs of care, and improving follow-up after hospitalization for a mental illness. However, PBHCI evidence does not suggest that PBHCI had a consistent effect on quality of preventive care and health monitoring for chronic physical conditions. These findings can guide the design of future cohorts of PBHCI clinics to build on the strengths with respect to shifting emergency department and inpatient care to less costly and more effective settings and address the continuing challenge of integrating care between specialty behavioral health providers and general medical care providers.

Key Findings

Evidence of PBHCI Effects on Utilization of Emergency Department and Inpatient Services Was Mixed Across Cohorts

  • In all cohorts, PBHCI was associated with a reduction relative to comparison clinics in the proportion of consumers having four or more emergency department or inpatient visits, and this reduction reached statistical significance in three of the five cohorts.
  • The reduction in frequent utilization was specific to utilization for physical health conditions.
  • In three of the five cohorts, PBHCI was associated with a reduction relative to comparison clinics in the proportion of consumers having four or more emergency department or inpatient visits with a primary diagnosis of a physical health condition.

PBHCI Was Associated with a Reduction Relative to Comparison Clinics in the Total Costs of Care Per Consumer in Three of the Five Cohorts

  • Reductions in cost for specific types of care varied across cohorts.
  • Statistically significant reductions in cost for outpatient services were found in two cohorts: in cost per user of emergency department services for one cohort and in cost per used or inpatient services for another cohort.
  • Countervailing increases were found for costs per user of inpatient services in one cohort and in two cohorts.
  • PBHCI was associated with higher likelihood of having emergency department--related costs in one cohort and lower likelihood of having emergency department--related costs in another.

Few of the Quality-of-Care Measures for Primary Care Services Were Impacted by PBHCI

  • An exception was a pattern of negative effects of PBHCI on quality indicators for State 3.

Recommendations

  • The finding that PBHCI clinics can substitute some of the high-cost care otherwise received in emergency departments may have implications for the design of future cohorts of PBHCI grants.
  • This role of the program might be further strengthened by providing additional services that are sometimes provided in emergency departments (e.g., stitches for small wounds), hours of access could be extended, and physical health care services could be directly targeted to consumers with a history of frequent emergency department visits.
  • The limited impact of PBHCI on quality of primary care services could be addressed through investments in more rigorous care coordination services such as comprehensive electronic disease registries (i.e., to make sure that consumers attend medical appointments, as needed) and supports to providers for the management of multiple comorbidities (e.g., additional supports for consumers with comorbid substance use disorders) that could impede the delivery of quality physical health care.

Table of Contents

  • Chapter One

    Introduction

  • Chapter Two

    Analytic Methods

  • Chapter Three

    Results

  • Chapter Four

    Discussion

  • Appendix A

    Quality and Utilization Measures Considered for Study

  • Appendix B

    Year-by-Year Estimates of PBHCI Effects on Measures of Utilization, Costs, and Quality

Research conducted by

This research was funded by the Office of the Assistant Secretary for Planning and Evaluation (ASPE) and conducted by Payment, Cost, and Coverage program within RAND Health Care.

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