Economic Evaluation of Mental Health Services and Interventions for Children and Youth

1. Economic Evaluation of Mental Health Services and Interventions for Children and Youth E. Michael Foster The Pennsylvania State University www.personal.psu.edu/emf10/ September, 2002

2. Outline • Review recent economic analyses of improved mental health services • Discuss the economic evaluation of the Fast Track intervention, a multi-site efficacy trial London

3. 1) Review Recent Economic Analyses Of Improved Mental Health Services

4. Research Questions Limited, prior research suggests that ‘better’ mental health services may not be less costly. • Are these increased expenditures offset by savings elsewhere? - child welfare - special education - juvenile justice • How do we allow for between-site differences inherent in the study design? London

5. Outline of Study (1) • Why might cost savings exist? • Methodology • Findings: Expenditures on mental health services • Findings: Expenditures in other child-serving sectors • A Reconsideration: Handling cross-site (non-)comparability London

6. 1a) Methodology • A Little Review • Service Delivery at the Sites • Data sources - Interview data - MIS data London

7. National Evaluation of Children’s Program AKA Comprehensive Community Mental Health Services for Children and Their Families AKA CASSP Program

8. Principles of the System of CareMore than just different services • Child-centered • Family-focused • Community-based/Least restrictive • Culturally competent • Integration of child-serving agencies • Case management London

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10. Evaluation Details • Variety of questions at multiple levels - System - Provider - Individual client (and his or her family) • Basic data collection at all sites; focused efforts at others • Series of comparison pairs, one of which is our focus here London

11. Service Delivery at the Ohio Pair • System of care (SOC) provider [Stark] - Offers a fully array of services - Includes service planning and case management - Arranges provision through schools • Comparison non-SOC provider [Mahoning] - Counseling center provides limited services but - More than just IP and OP London

12. MIS Data on Services and Expenditures • Track service use throughout course of the study • Good match with children and youth in the study • Per-unit costs are charges • Neither MIS includes data on - Inpatient care - Other child-serving agencies London

13. 1b) Findings: Expenditures on Core MHS

14. Expenditures on MHS London

15. 1c) Findings: A Broader Perspective

16. A Broader Perspective • Data collected from 16 agencies for 1997-2000 • Limited to year following study entry • Limitations - Comparability of costs data across providers - No data after children moved out of country London

17. Placement in Other Sectors London

18. Expenditures on MHS(Including Inpatient Services) London

19. What About the Other Child-Serving Sectors? • Reductions in juvenile justice expenditures • Modest increase in expenditures on special education • NO effect on child welfare (overall) London

20. Total Expenditures London

21. Between-Site Differences in All Child-Serving Sectors London

22. 1d) A Reconsideration: Handling cross-site (non-) comparability

23. Alternative Estimates London

24. Summary • In the simplest analysis, costs in other child-serving agencies narrow the gap in expenditures but not completely. • The better we deal with the design, the narrower the gap becomes. • This issue needs further study (larger samples, better data, etc.) London

25. So, What Do These Findings Mean? • “Please Don’t Beat Me’-- I’ll Confess” • Put away your calculator • The weight of the evidence • The bad news • The good news London

26. 2) Economic Evaluation of the Fast Track Intervention

27. Outline of Study (2) • Overview of the FT Intervention • Overview of the FT Evaluation • Results to date • Goals of the economic evaluation • Challenges to date London

28. 2a) Overview of the FT Intervention • Based in model of child development • Universal and indicated components • [U] Classroom curriculum • [U] Teachers: classroom management consultation for teachers • [I] Parents: training and home visiting • [I] Children: social skills training, academic tutoring and peer pairing • Evolving and ongoing • High levels of participation London

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30. 2b) Overview of the FT Evaluation • High-poverty areas in four study sites • 54 schools randomized between the treatment and control conditions • Samples of indicated and universal participants • Sample of 891 children • Screening London

31. Effectiveness of FT Screen London

32. Data Collection • Annual interviews • Multiple sources • Parent • Child • Teacher • Peer (sociometrics) • Administrative data • Relatively high rates of follow-up London

33. 2c) Results to Date • Modest effects on psychological constructs (such as social cognition) • Deeper analyses tend to produce larger effects • Caseness • trajectories London

34. 2c) Results to Date (cont) • Effects on service use: Reduced involvement in • special education • Juvenile justice • Some apparent variability in the impact (gender; latent classes) London

35. Some apparent variability in the impact (gender; latent classes) London

36. 2c) Results to Date (cont) • Dealing with attrition • Multiple imputation • Non-ignorable non-response London

37. 2d) Goals of the Economic Evaluation • Estimate the costs of the intervention • Identify the impact on social costs that will occur by the time participants are age 19 • Education costs and other costs of school failure • Delinquency and criminal behavior • Social services • Employment and costs related to joblessness • Impact on others • Care givers • Siblings London

38. 2d) Goals of the Economic Evaluation (cont) • Calculate cost-effectiveness ratios (net health benefits) for key outcomes • Project future social costs for study participants (when the participants are age 20 or older) • Identify subgroups of participants for whom the benefits of the intervention has been especially (cost-)effective. London

39. Challenges • Statistical Power • Combining incomplete sources of data • Better models for identifying sub-groups for whom the intervention is effective • Developing credible per-unit costs • Understanding the complexity of outcomes London