HS 572a. Economics of Behavioral Health
Spring 2015
Heller School for Social Policy and Management, BrandeisUniversity
Instructor:Dominic HodgkinOffice:Heller 264
Phone:(781) 736-8551E-mail:
Description: This course focuses on the institutions, organization and financing of mental health and substance abuse care. Economic analysis will be applied to the study of policy and research issues in the behavioral health sector. We will discuss topics where economic insights add to our understanding of behavioral health issues (for example, why insurers place more restrictions on behavioral health treatment than on medical care). We will also review special features of the behavioral health sector which must be considered when applying economic analyses (for example,externalities, chronicity of disease, nonmedical needs).
Prerequisites: basic understanding of multivariate statistics.
Requirements: The course grade will be determined by homework (20%), an in-class presentation (5%), a term paper (35%), and a final exam (40%). The paper will apply economic analysis to a policy or research issue which interests you, in mental health or substance abuse. Students will be given feedback on their progress through written comments on homework and the term paper, and through meeting with instructor on request.
If you are a student with a documented disability on record at BrandeisUniversity and wish to have a reasonable accommodation made for you in this class, please see me immediately.
READING LIST
The main readings for this course are papers from journals, listed below by day. In addition, these two readings are highly recommended:
Frank RG, Glied S (2006). Better but not well: Mental health policy in the United States since 1950. Johns Hopkins Press.
Frank RG, McGuire TG (2000). Economics and mental health. Chapter 16 in: Culyer A and Newhouse JP (ed.): Handbook of Health Economics. (on Latte, and referenced at various points in this syllabus).
In addition this book provides good historical perspective on much of the course material:
Mechanic, D. McAlpine DD, Rochefort DA (2013). Mental health and social policy: Beyond Managed Care.
Also, a textbook chapter reviewing microeconomic concepts is on Latte:
Folland S., Goodman A. and Stano M., Economics of Health and Health Care. 6th edition. Pearson Prentice-Hall, 2010. [Chapter 2]
WEEKLY SCHEDULE
1. Overview of the mental health and substance abuse sectorJan 15
Total spending; people in treatment; differences from medical system; large public role.
Garfield RL (2011). Mental Health Financing in the United States: A Primer. Kaiser Commission on Medicaid and the Uninsured.
Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. (September 4, 2014). The NSDUH Report: Substance Use and Mental Health Estimates from the2013 National Survey on Drug Use and Health: Overview of Findings. Rockville, MD.
Levit, K. R., Mark, T. L., Coffey, R. M., Frankel, S., Santora, P., Vandivort-Warren, R., & Malone, K. (2013). Federal spending on behavioral health accelerated during recession as individuals lost employer insurance. Health Affairs, 32(5), 952-962.
Frank and McGuire (Handbook, 2000), pp. 895-904 (‘Intro’, ‘Institutional context’)
2. Cost/burden of mental illness and substance abuseJan 22
Treatment costs and social costs; externalities; economic impacts.
Meara E, Frank RG. Spending on substance abuse treatment: how much is enough? Addiction. 2005 Sep;100(9):1240-8.
Whiteford, H. A., Degenhardt, L., Rehm, J., Baxter, A. J., Ferrari, A. J., Erskine, H. E., ... & Vos, T. (2013). Global burden of disease attributable to mental and substance use disorders: findings from the Global Burden of Disease Study 2010. The Lancet, 382(9904), 1575-1586.
Bouchery, E. E., Harwood, H. J., Sacks, J. J., Simon, C. J., & Brewer, R. D. (2011). Economic costs of excessive alcohol consumption in the US, 2006. American Journal of Preventive Medicine, 41(5), 516-524.
Kessler RC, Heeringa S, Lakoma MD, et al (2008). Individual and Societal Effects of Mental Disorders on Earnings in the United States: Results From the National Comorbidity Survey Replication. Am J Psychiatry 165:703-711.
Busch SH, Barry CL (2007). Mental Health Disorders In Childhood: Assessing The Burden On Families. Health Affairs 26(4): 1088-1095.
3. Technology of treatment Jan 29
What are the inputs (professional services, pills...)? What treatment combinations/ durations work best? and for whom?; substitutability among inputs; returns to scale.
Simon G (2001). Choosing a first-line antidepressant: equal on average does not mean equal for everyone. JAMA 286: 3003-3004.
Gaynes BN, Rush AJ, Trivedi MH, Wisniewski SR, Spencer D, Fava M (2008). The STAR*D study: treating depression in the real world. Cleve Clin J Med. 75(1):57-66.
Wang PS, Ulbricht CM, Schoenbaum M (2009). Improving mental health treatments through comparative effectiveness research. Health Affairs 28(3):783-91.
Dallery J, Budney AJ, and Meredith SE (2012). Contingency Management in Substance Abuse Treatment. In: Walters ST, Rotgers F (ed.), Treating Substance Abuse: Theory and Technique. Guilford: New York.
Stefos, T., Burgess, J. F., Cohen, J. P., Lehner, L., & Moran, E. (2012). Dynamics of the mental health workforce: investigating the composition of physicians and other health providers. Health Care Management Science, 1-12.
Cook, J., Russell, C., Grey, D., & Jonikas, J. (2008). A self-directed care model for mental health recovery. Psychiatric Services, 59(6), 600-602.
4. Economic evaluationFeb 5
Measuring cost; principles of cost effectiveness; cost-benefit analysis; how they differ.
Rosenheck RA, Leslie DL, Sindelar J (2006). Cost-Effectiveness of Second-Generation Antipsychotics and Perphenazine in a Randomized Trial of Treatment for Chronic Schizophrenia. Am J Psychiatry 163:2080-2089.
Rosenheck RA, Leslie DL, Doshi JA. (2008). Second-Generation Antipsychotics: Cost-Effectiveness, Policy Options, and Political Decision Making.Psychiatr Services 59(5):515-520.
Meltzer, D. O., Basu, A., & Meltzer, H. Y. (2009). Comparative effectiveness research for antipsychotic medications: how much is enough?Health Affairs, 28(5), w794-w808.
Chisholm, D. (2005). Choosing cost-effective interventions in psychiatry: results from the CHOICE programme of the World Health Organization. World Psychiatry, 4(1), 37-44.
Lynch, F. L., Dickerson, J. F., Clarke, G., Vitiello, B., Porta, G., Wagner, K. D., ... & Brent, D. (2011). Incremental cost-effectiveness of combined therapy vs medication only for youth with selective serotonin reuptake inhibitor-resistant depression. Archives of General Psychiatry, 68(3), 253.
Ettner, S. L., Huang, D., Evans, E., Rose Ash, D., Hardy, M., Jourabchi, M., & Hser, Y. I. (2005). Benefit–Cost in the California Treatment Outcome Project: Does Substance Abuse Treatment “Pay for Itself”?. Health Services Research, 41(1), 192-213.
5. Demand for treatment Feb 12
Response to insurance (moral hazard); other determinants of demand; advertising; the moral hazard/risk protection tradeoff; agency and information asymmetry.
Manning WG, Wells KB et al. (1989). Effects of mental health insurance: evidence from the Rand Health Insurance Experiment. RAND report R-3815-NIMH/HCFA.
Frank and McGuire (Handbook, 2000), pp. 907-912 (‘Private insurance markets...’)
Busch, S. H., Epstein, A. J., Harhay, M. O., Fiellin, D. A., Un, H., Leader Jr, D., & Barry, C. L. (2014). The effects of federal parity on substance use disorder treatment. The American journal of managed care, 20(1), 76-82.
Domino, ME, Farley JF. (2009). Economic Issues in Psychotropic Medication use. In Mental Health Services: A Public Health Perspective, by Bruce Lubotsky Levin et al (Editors), Oxford University Press.
Zhang, Y., Baik, S. H., Zhou, L., Reynolds III, C. F., & Lave, J. R. (2012). Effects of Medicare Part D Coverage Gap on Medication and Medical Treatment Among Elderly Beneficiaries With Depression. Arch Gen Psychiatry, 69(7), 672-679.
Meyerhoefer, CD, Zuvekas SH. (2010). New estimates of the demand for physical and mental health treatment. Health Economics, 19(3), 297-315.
6. Paying providersFeb 26
Different ways payers pay providers (e.g. capitation, per case etc.); differing incentives that result; responsiveness to incentives; behavior of nonprofit and public providers.
Frank and McGuire (Handbook) pp. 918-921 (‘Managed care, supply-side incentives)
Conrad DA, Perry L (2009). Quality-based financial incentives in health care: can we improve quality by paying for it? Annual Review of Public Health. 29;30:357-71.
Frank RG, Huskamp HA, Pincus HA (2003). Aligning incentives in the treatment of depression in primary care with evidence-based practice. Psychiatric Services 54:682-687.
Rosenau PV and Linder SH (2003). A comparison of the performance of for-profit and nonprofit U.S. psychiatric inpatient care providers since 1980. Psychiatric Services 54:183-187.
Douven, R., Remmerswaal, M., & Mosca, I. (2014). Unintended effects of reimbursement schedules in mental health care (No. 292). CPB Netherlands Bureau for Economic Policy Analysis.
Watts, B. V., Shiner, B., Klauss, G., & Weeks, W. B. (2011). Supplier-induced demand for psychiatric admissions in Northern New England. BMC Psychiatry, 11(1), 146.
7. Insurance marketsMar 5
Adverse selection (theory and evidence); purchasers and insurers; benefit mandates, parity laws.
Frank and McGuire (Handbook) pp. 925-931 (‘Insurance markets...’)
Hermann RC, Rollins CK, Chan JA (2007). Risk-adjusting outcomes of mental health and substance-related care: a review of the literature. Harv Rev Psychiatry 15(2):52-69.
Barry, C. L., Weiner, J. P., Lemke, K., & Busch, S. H. (2012). Risk adjustment in health insurance exchanges for individuals with mental illness. American Journal of Psychiatry, 169(7), 704-709.
Huskamp, H. A., Keating, N. L., Dalton, J. B., Chernew, M. E., & Newhouse, J. P. (2014). Drug plan design incentives among Medicare prescription drug plans. The American journal of managed care, 20(7), 562-562.
Beronio, K., Glied, S., & Frank, R. (2014). How the Affordable Care Act and Mental Health Parity and Addiction Equity Act Greatly Expand Coverage of Behavioral Health Care. Journal of behavioral health services & research, 1-19.
8. Managed care/ system designMar 12
Utilization management, networks, payment arrangements; how different types of plan combine the techniques; carve-outs. Evidence on managed care’s impact.
Frank and McGuire (2000), pp. 921-925 (‘Rationing in managed care’)
Goldman HH, Frank RG, Burnam MA, et al (2006). Behavioral health insurance parity for federal employees. N Engl J Med 354(13):1378-86.
Schlesinger M, Wynia M, Cummins D (2000). Some distinctive features of the impact of managed care on psychiatry. Harvard Review of Psychiatry 8: 216-230.
Frank RG, Garfield RL (2007). Managed behavioral health care carve-outs: past performance and future prospects. Annu Rev Public Health;28:303-20.
Bao, Y., Casalino, L. P., & Pincus, H. A. (2013). Behavioral health and health care reform models: patient-centered medical home, health home, and accountable care organization. The journal of behavioral health services & research, 40(1), 121-132..
9. Public sector role in behavioral healthMar 19
Rationales for public role; forms (funder/provider/regulator); objectives; incentives created by different funding mechanisms.
Cowell A, McCarty D, Woodward A (2003). Impact of federal substance abuse block grants on state substance abuse spending: literature and data review. J Ment Health Policy Econ 6(4):173-9.
Sinaiko, A. D., & McGuire, T. G. (2006). Patient inducement, provider priorities, and resource allocation in public mental health systems. Journal of Health Politics, Policy and Law, 31(6), 1075-1106.
Buck, J. A. (2011). The looming expansion and transformation of public substance abuse treatment under the Affordable Care Act. Health Affairs, 30(8), 1402-1410.
Garfield, R. L., Lave, J. R., & Donohue, J. M. (2011). Health reform and the scope of benefits for mental health and substance use disorder services. Psych Services, 61, 11.
Ali, M. M., Teich, J., Woodward, A., & Han, B. (2014). The Implications of the Affordable Care Act for Behavioral Health Services Utilization. Administration and Policy in Mental Health and Mental Health Services Research, 1-12.
10. Disparities in treatmentMar 26
Extent of race/ethnicity/gender differences in utilization; quantifying disparities; explanations for differences and disparities; solutions.
Snowden LR (2003). Bias in mental health assessment and intervention: theory and evidence. American Journal of Public Health 93(2): 239-243.
Smith, K. L., Matheson, F. I., Moineddin, R., Dunn, J. R., Lu, H., Cairney, J., & Glazier, R. H. (2013). Gender differences in mental health service utilization among respondents reporting depression in a national health survey. Health, 5, 1561.
McGuire TG, Alegria M, Cook BL (2006). Implementing the Institute of Medicine definition of disparities: an application to mental health care. Health Services Research 41(5):1979-2005.
Saloner, B., & Lê Cook, B. (2013). Blacks and Hispanics are less likely than whites to complete addiction treatment, largely due to socioeconomic factors. Health Affairs, 32(1), 135-145.
11. International comparisonsApr 2
Comparing financing systems, utilization, spending; developed countries/ developing countries.
Demyttenaere, K. et al (2004). Prevalence, severity, and unmet need for treatment of mental disorders in the World Health Organization World Mental Health Surveys." JAMA 291: 2581-90.
Frank R.G. (2011). Economics and Mental Health: An International Perspective. In: Glied, S., & Smith, P. C. (eds.). The Oxford handbook of health economics.
Dixon A, McDaid D, Knapp M, et al (2006). Financing mental health services in low- and middle-income countries. Health Policy & Planning 21(3):171-82.
Medeiros, H. D., McDaid, M., & Knapp, S. (2008). MHEEN group. Shifting care from hospital to the community in Europe: Economic challenges and opportunities. London: Personal Social Services Research Unit, Kings College.
Saraceno B, van Ommeren M, Batniji R, Cohen A, et al (2007). Barriers to improvement of mental health services in low-income and middle-income countries. Lancet. 370(9593):1164-74.
Everard, M. (Ed.). (2005). Improving access and use of psychotropic medicines. World Health Organization.
Rosen, B., Nirel, N., Gross, R., Bramali, S., & Ecker, N. (2008). The Israeli mental health insurance reform. Journal of Mental Health Policy and Economics, 11(4), 201.
12. Income supportApr 16
How does the government provide income support to those with mental health/substance abuse problems? Program design, work incentives.
Goldman HH (2003). ‘How do you pay your rent?’ Social policies and the President’s Mental Health Commission. Health Affairs 22(5): 65-72.
Chatterji P, Meara E (2010). Consequences of eliminating federal disability benefits for substance abusers. J Health Econ 29(2):226-40.
Drake RE, Skinner JS, Bond GR, Goldman HH (2009). Social security and mental illness: reducing disability with supported employment. Health Affairs 28(3):761-70.
Drake, R. E., Frey, W., Bond, G. R., Goldman, H. H., Salkever, D., Miller, A., ... & Milfort, R. (2013). Assisting Social Security Disability Insurance beneficiaries with schizophrenia, bipolar disorder, or major depression in returning to work. American Journal of Psychiatry, 170(12), 1433-1441.
13. Economic influences on prevalenceApr 23
Theories of addiction/demand for alcohol and drugs; economic determinants of mental health
Kenkel DS, Sindelar J (2011). Economics of Health Behaviours and Addictions. In: Glied, S., & Smith, P. C. (eds.). The Oxford handbook of health economics.
Xu, X., & Chaloupka, F. J. (2011). The effects of prices on alcohol use and its consequences. Alcohol research and health, 34(2), 236.
Goldman-Mellor, S. J., Saxton, K. B., & Catalano, R. C. (2010). Economic contraction and mental health. International Journal of Mental Health, 39(2), 6-31.
14. PreventionApr 23
Primary/secondary prevention of chronic disease; economic models of effectiveness; incentives and barriers to prevention; insurance coverage.
O'Connell, ME, Boat, T., & Warner, KE (Eds.).(2009). Preventing mental, emotional, and behavioral disorders among young people: Progress and possibilities. Washington, DC: Institute of Medicine; National Research Council
Zarkin GA, Hubbard RL (1998). Analytic issues for estimating the benefits and costs of substance abuse prevention. National Institute on Drug Abuse, NIH Publication No. 98-4021.
Galloway, I. (2014). Using pay-for-success to increase investment in the nonmedical determinants of health. Health Affairs, 33(11), 1897-1904.
Goldman, H. H., Karakus, M., Frey, W., & Beronio, K. (2013). Economic grand rounds: financing first-episode psychosis services in the United States. Psychiatric Services, 64(6), 506-508.
Cook PJ (2007). Paying the Tab: The Costs and Benefits of Alcohol Control. Princeton, NJ: Princeton University Press, 2007, Chapter 11.