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Special Report
Preventive Interventions
Under Managed Care: Mental Health
and Substance Abuse Services
Conclusions
This literature review presents the research foundation that
provides an affirmative answer to the two questions posed
in Chapter 1: (1) Are preventive behavioral health interventions
effective? (2) Can they produce cost savings, or can they be
provided without increasing the net cost of care?
While the establishment and continuing
expansion of this knowledge base is encouraging,
the substance abuse and mental health
arena is vast, the focus on prevention is relatively
new, and funding for prevention intervention
research is insufficient to produce
the quality and quantity of data needed to
make an irrefutable case for effectiveness and
cost offset. Less than one-quarter of the articles
that met the criteria for inclusion in this
review specified the cost impact of the target
intervention. Many more studies focused on
adult subjects than on infants and children.
At this time, the available literature more
resembles a collection of independent studies
than a cohesive, developing body of work.
Because the search for this literature was
extensive but not exhaustive, some studies
meeting review criteria may not have been
identified. The search did not identify
research not yet published as of the date this
report was written. In addition, there is
research on school-based preventive interventions
that lies outside the scope of this
review. While schools are an obvious and
important setting for preventive intervention
in substance abuse and mental health, health
care providers in general and managed care
organizations in particular still have vital
roles to play in this regard for the youth to
whom they provide services.
The dispersion of the literature on preventive
behavioral health services has complicated
the process of its identification. Although
investigators in the fields of mental health,
drug and alcohol abuse, and tobacco use traditionally
have worked within separate,
poorly integrated domains, increased interdisciplinary
communication and collaboration
have advanced research in these areas.
While this research has been enriched by its
multidisciplinary nature, published articles
are scattered among journals in the public
health, medical, mental health, substance
abuse, and developmental fields. Locating
relevant literature requires the search of
many databases and an understanding of
their lexicons, because they may use different
keywords to describe similar content.
When intervention research yields positive
findings, those results are strengthened by
subsequent replication studies and, where
appropriate, adaptation of the intervention
to other populations and settings. For this to
happen, investigators must be interested in
pursuing the research question, and must
have resources to support further study.
Unless followup studies are undertaken and published by the author of the original
research, it is difficult to determine whether
replication has occurred and whether results
were confirmed. In addition, replication
studies that do not reproduce initial findings
may not be published at all, in which case
there would be nothing in the peer-reviewed
literature to refute original results.
The published literature does not necessarily
provide specific data that can inform
MCO decision makers about implementation,
effectiveness, and cost of preventive
behavioral health services in their settings.
To be publishable, articles must conform to
the requirements of peer-reviewed journals.
The result is that the subjects and settings of
published research may not be generalizable
to MCO populations; the interventions may
not be described in sufficient detail to determine
appropriate targeting and staffing, likely
penetration and other important considerations;
and the findings may not translate
well to the kinds of outcomes in which
MCOs are interested. The application of this
research to practice in MCOs will require
improved communication and greater collaboration
among researchers, decision makers,
planners, providers, and evaluators.
One way to address the latter gap would
be to provide estimates of the cost to an
MCO to cover selected preventive behavioral
health services. Using a prospective modeling
computer simulation technique, intervention
costs can be projected, including aggregate
costs to the MCO; cost per user of the intervention;
and cost per member per month for
various MCO sizes, enrollment mixes, and
contractual arrangements. CMHS is currently
producing such estimations for the six
services recommended in this report.
A foundation of empirical evidence supporting
the value of preventive behavioral
health interventions has been established and
is growing, but many questions about their
effectiveness and effect on cost are yet to be
answered. Additional steps that can be taken
to strengthen this knowledge base and to
generate more persuasive data on preventive
behavioral health interventions to stimulate
increased MCO coverage are as follows:
Expand funding for research on the efficacy,
effectiveness, and cost impact of preventive
behavioral health interventions,
especially in health care settings.
Encourage investigators to undertake relevant
research in managed care organizations.
Fund graduate and postgraduate research
in this arena to increase the number of
new investigators who pursue substance
abuse and mental health prevention
research as a primary career focus.
Require analysis of cost impact as a condition
of intervention research funding.
Encourage MCOs to partner with
SAMHSA and with universities to conduct
intervention research projects within their
populations.
Where possible, work with researchers
whose publications do not contain cost
information to generate cost projections
based on unpublished data.
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