Grimes Katherine E, Schulz Margaret F, Cohen Steven A, Mullin Brian O, Lehar Sophie E, Tien Shelly
Department of Psychiatry, Harvard Medical School, Cambridge Health Alliance, Cambridge, MA, USA.
J Ment Health Policy Econ. 2011 Jun;14(2):73-83.
Mental health advocates seek to expand children's services, noting widespread failure to meet the needs of public sector youth suffering from serious emotional disturbance (SED). However, state and national budgets face deepening cuts, with rising health care costs taking the blame. As the gap between needs and finances widens, identification of cost-effective treatments that will benefit children with SED and their families is of increasing importance. Community-based interventions for this population, such as the wraparound approach and systems-of-care, are being disseminated but literature is scant regarding effects on expense. The Mental Health Services Program for Youth (MHSPY) model is aligned philosophically with wraparound and systems-of-care but unique in blending public agency dollars to deliver integrated medical, mental health and social services. MHSPY's linked clinical and expense data is useful to study community-based treatment cost-effectiveness.
To examine the cost-effectiveness of an intensively integrated, family and community-based clinical intervention for youth with mental health needs in comparison to "usual care.''
Study and reference populations were matched on age, gender, community, psychiatric diagnosis, morbidity and insurance type. Claims analyses included patterns of service utilization and medical expense for both groups. Using propensity score matching, results for study youth are compared with results for the population receiving "usual care.'' Clinical functioning was measured for the intervention group at baseline and 12 months.
The intervention group used lower intensity services and had substantially lower claims expense (e.g. 32% lower for emergency room, 74% lower for inpatient psychiatry) than their matched counterparts in the "usual care'' group. Intervention youth were consistently maintained in least restrictive settings, with over 88% of days spent at home and showed improved clinical functioning on standard measures.
The intensive MHSPY model of service delivery offers potential as a cost-effective intervention for complex youth. Its integrated approach, recognizing needs across multiple life domains, appears to enhance engagement and the effectiveness of mental health treatment, resulting in statistically significant clinical improvements. Functional measures are not collected in "usual care,'' limiting comparisons. However, claims expense for intervention youth was substantially lower than claims expense for Medicaid comparison youth, suggesting clinical needs for intervention youth post-enrollment were lower than for those receiving "usual care.''
The MHSPY model, which intentionally engages families in "clustered'' traditional and non-traditional services, represents a replicable strategy for enhancing the impact of clinical interventions, thereby reducing medical expense.
Blending categorical state agency dollars and insurance funds creates flexibility to support community-based care, including individualized services for high-risk youth. Resulting expenses total no more, and are often less, than "treatment as usual'' but yield greater clinical benefits.
Further research is needed regarding which intervention elements contribute the most towards improved clinical functioning, as well as which patients are most likely to benefit. A randomized trial of MHSPY vs. "usual care,'' including examination of the sustainability of effects post-disenrollment, would provide a chance to further test this innovative model.
心理健康倡导者们寻求扩大儿童服务，指出公共部门中患有严重情绪障碍（SED）的青少年的需求普遍未得到满足。然而，州和国家预算面临着不断加深的削减，医疗保健成本上升被归咎于此。随着需求与资金之间的差距不断扩大，确定对患有SED的儿童及其家庭有益的具有成本效益的治疗方法变得越来越重要。针对这一人群的基于社区的干预措施，如全方位服务模式和照护系统，正在得到推广，但关于其对费用影响的文献却很少。青少年心理健康服务项目（MHSPY）模式在理念上与全方位服务模式和照护系统相一致，但独特之处在于将公共机构资金融合起来，以提供综合的医疗、心理健康和社会服务。MHSPY相关的临床和费用数据对于研究基于社区的治疗的成本效益很有用。
与“常规护理”相比，研究针对有心理健康需求的青少年的强化综合、基于家庭和社区的临床干预措施的成本效益。
研究人群和参照人群在年龄、性别、社区、精神科诊断、发病率和保险类型方面进行了匹配。索赔分析包括两组的服务利用模式和医疗费用。使用倾向得分匹配法，将研究青少年的结果与接受“常规护理”人群的结果进行比较。在基线和12个月时对干预组的临床功能进行了测量。
与“常规护理”组中匹配的青少年相比，干预组使用的服务强度较低，索赔费用大幅降低（例如，急诊室费用降低32%，住院精神科费用降低74%）。干预组的青少年始终被安置在限制最少的环境中，超过88%的时间在家中度过，并且在标准测量中临床功能有所改善。
强化的MHSPY服务提供模式作为一种针对复杂青少年的具有成本效益的干预措施具有潜力。其综合方法认识到多个生活领域的需求，似乎增强了参与度和心理健康治疗的效果，从而在统计学上带来了显著的临床改善。“常规护理”中未收集功能测量数据，限制了比较。然而，干预组青少年的索赔费用大大低于医疗补助对照青少年的索赔费用，这表明干预组青少年入学后的临床需求低于接受“常规护理”的青少年。
MHSPY模式有意让家庭参与“集群式”传统和非传统服务，是增强临床干预效果从而降低医疗费用的一种可复制策略。
将州分类机构资金和保险基金融合起来，为支持基于社区的护理创造了灵活性，包括为高危青少年提供个性化服务。由此产生的费用总额不超过“常规治疗”，而且往往更低，但能带来更大的临床益处。
需要进一步研究哪些干预要素对改善临床功能贡献最大，以及哪些患者最可能从中受益。对MHSPY与“常规护理”进行随机试验，包括检查退出登记后效果的可持续性，将为进一步测试这一创新模式提供机会。
