© 2011 Community Care

Community CareCommunity CareA Non-profit Behavioral Health Managed Care CompanyA Non-profit Behavioral Health Managed Care Company

BEHAVIORAL HEALTHAND DIVERSITY

Salim Chowdhury, MDCurtis Upsher Jr., M.S.

About Community Care

• Incorporated in 1996 primarily to support HealthChoices.

• Part of the UPMC Insurance Services Division.

• 501(c)(3) nonprofit behavioral health managed care organization.

• Licensed as a risk-bearing PPO.

• Implemented HealthChoices in:

– Allegheny County (1999).

– York, Adams, and Berks Counties (2001).

– Chester County (2004).

– Lackawanna, Luzerne, Susquehanna, and Wyoming Counties (2006).

– 23-County North Central Region (2007).

– Carbon, Monroe, and Pike Counties (2007).

• Implemented a Care Monitoring Initiative in New York City (2009).2

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Erie

Crawford

Mercer

Washington

GreeneFayette

Allegheny

Westmoreland

Butler

Armstrong

Clarion

VenangoForest

Warren McKean Potter

CameronElk

Jefferson

Clearfield

Indiana

Cambria

SomersetBedford

Blair

Centre

Clinton

Huntingdon

Fulton FranklinAdams

Cumberland

Perry

MifflinSnyder

Union

Lycoming

Tioga Bradford

Columbia

Montour

Northumberland

Dauphin

York

Lancaster Chester

Berks Lebanon

Schuylkill

Luzerne

Wyoming

Susquehanna

Lackawanna

Wayne

Pike

Monroe

Carbon

Lehigh

Northampton

Bucks

Montgomery

DelawarePhiladelphia

Juniata

Sullivan

Pennsylvania Counties Servedby Community Care

County Served by Community Care Community Care Office

Disparities and Behavioral Health

• The impact of race, sex, and ethnicity on engagement in treatment of behavioral disorders.

• The impact of behavioral health disorders on engagement in wellness activities and physical health care.

• Top diagnostic categories of members in treatment.

• Identification of utilization trends, areas for improvement and program development.

Prevalence of BehavioralHealth Disparities

• The prevalence of mental disorders appears to be higher among African Americans than among whites. (Surgeon General’s Report).

• The difference in disparities seems to be more related to socioeconomic factors as opposed to intrinsic racial or ethnic differences. (Surgeon General’s Report, PA Report).

• 38% of African Americans and 34% of Latinos reported high levels of stress related to racial and income discrimination compared to 26% of whites. (Collins, Hall, and Neuhaus, U.S. Minority Health: A Chartbook. Chart 3-12).

Prevalence Data

Depression• 8.2% of white non-Latinos reported frequent “mental

distress” compared to 11.2% of African Americannon-Latinos and 12.0% of Latinos. (2000 Pennsylvania Behavioral Risk Factor Surveillance Survey (BRFSS)).

• 36% of Latino males reported suffering from moderate to severe depression within the previous week compared to 32% of African American males, and 23% of white males. 53% of Latino females suffered from moderate to severe depression within the previous week compared to 47% of African American females and 37% of white females.

* Collins, Hall, and Neuhaus, U.S. Minority Health: A Chartbook. Chart 3-12.

Prevalence Data

Suicide• As research indicates that most persons who

commit suicide have mental disorders, suicide rates indicate the potential need for mental health care for those populations at high risk for depression and other mental disorders.– The age adjusted rate for suicide in Pennsylvania

was 10.7 per 100,000 for whites, 9.9 for Latinos, and 7.4 for African Americans. (PA DOH, Bureau of Health Statistics, the bureau’s data table generator for mortality data).

Prevalence Data

Suicide• The risk of suicide for young (10-14) African

American men is presently comparable to that of young white males. – Between 1980 and 1995, rates of suicide

for African American youth ages 10-14 increased 233%, as compared to 120% for whites.

Prevalence Data

Substance Abuse• In Pennsylvania, data suggest that substance abuse (SA) among minorities does not in general exceed that of whites.• “However, levels of SA continues to be unacceptably high and the negative impact of SA on families and communities, as well as its economic costs to society as a whole, is well documented.*”

* PA Department of Health. State Health Improvement Plan: Special Report on the Health Status of Minorities in Pennsylvania, 2002.

Prevalence Data

Substance Abuse • In 1999 and 2000, whites represented 60% of all treatment

admissions and African Americans comprised 25%.

• From 1994-1997 national treatment admissions declined, peaked in 1998, and declined again for African Americans between 1998 and 2002 (382,772 to 373,003).

• In PA, by 2000 and 2002, treatment admissions for whites climbed from 70-75% respectively, while African American treatment admissions dropped from 23% in 2000 to 20% in 2002.

* SAMHSA, Office of Applied Studies National Admissions to Substance Abuse Treatment Services, Treatment Episodes Data Set (TEDS) 1992-2000.

Prevalence Data

Substance Abuse U.S. Department of Health & Human Services new

Release, Sept. 5, 2003 reports:• 4 million adults in 2002 have both a SA disorder and

serious mental illness (SMI). An estimated 17.5 million adults 18 or older had SMI (8.3% of all adults).

• Over 23% of adults with SMI were dependent on, or abused alcohol, or illicit drugs. The rate among adults without serious mental illness was 8.2 %.

• Among adults with substance dependence or abuse, 20.4% had SMI, compared with 7% for adults not dependent on or abusing alcohol or drugs.

Prevalence Data

Substance Abuse Disparity • The data suggests an increase in the numbers of

persons abusing and addicted to substances who are in need of treatment and unable to access treatment.

• The data* indicates that “the number of African- Americans in substance abuse treatment continues to be disproportionately represented nationally and in Pennsylvania.”

* SAMHSA, Office of Applied Studies: National Admissions to Substance Abuse Treatment Services, Treatment Episodes Data Set (TEDS) 1992-2000.

Analysis of Service Utilization Data

• To explore the extent to which service disparitiesexist among members enrolled in HealthChoices.

• To compare service utilization among its predominate racial and ethnic members and other groups.

• To observe trends in service utilization among racial and ethnic group.

• To use data analysis to observe the existence of outcome differences among racial and ethnic groups.

Analysis of Service Utilization Data

• To use data analysis to observe the existence of outcome differences among racial and ethnic groups.

• To use data analysis to consider performance standards to improve outcome differences among racial and ethnic groups.

• To use data analysis to assess benefits of interventions implemented to address disparities in access and outcomes.

HealthChoices Membership Demographics(Across All Contracts)

• 13% of all residents.

• 56% female, 44% male.

• 14% under 5 years, 35% 5-19 years.

• 17% (20-35), 22% (35-64), 12%(64+).

• 24% (<HS), 46% (HS), 30% (College).

HealthChoices MembershipDemographics

• 99% English, 1% Spanish, >0.01% other (Allegheny).

• 70% white, 17% African American, 13% all other

(All contracts).

• 7% Hispanic, 93% non-Hispanic (All contracts).

• 40% TANF, 22% Healthy Beginnings (All contracts).

• 20% SSI, 12% SSI and Medicare (All contracts).

Treatment Engagement(Across All contracts)

• 24% overall (26% of males and 22% of females).

Treatment Engagement(Across All contracts)

16% of Hispanic members; 25% of non-Hispanic members

Most Common Diagnoses(Across All contracts)

1. Major Depression

2. Dysthymia/Depression NOS

3. ADHD

4. Bipolar

5. Adjustment

6. Opioid-related disorders

7. Anxiety

8. Autism

9. Schizophrenia

10. Alcohol-related disorders

Mood Disorders(Across All Contracts)

• 3 of the 4 most common diagnoses.• Major Depression.

– Most Common diagnosis, overall.– More Common among women.– Increasingly common as the population ages.

• Dysthymia/Depression NOS.– More common than Major Depression for

Males, Children, Adults ages 20-34, Hispanic and African American Members.

ADHD

• Third most common overall.• Most common for males, school-aged children,

and African American and Hispanic members.• Less prevalent among females and Asian

members.• Among the ten most common diagnoses for

adults ages 20-34.

Autism

• The most common diagnoses for children under age 5 and Asian members.

• Less common among African American and Hispanic members.

• 4 out of 5 members with autism diagnoses are males.

Psychotic Disorders

• More common among older adults (age 35 and older).

• 2 of the 5 most common diagnoses for senior members (age 65+).

• Prevalent in all race groups.• Gender difference: schizoaffective disorder is

more commonly seen among females members; schizophrenia more commonly seen among the males.

Substance Use Disorders

• Opioid-related and alcohol-related disorders are the only Substance Use disorders among the ten most common.

• No gender variance.• The most commonly seen among members

20-34, but present for all adult age groups.• Opioid-related disorders more common among

younger adults. Alcohol-related disorders more common among older adults.

Substance Use Disorders

• Opioid-related disorders are more common among white and Native American members.

• Alcohol-related disorders more common among white, African American, Native American, and non-Hispanic members.

Co-occurring Diagnoses

Co-Occurring

12%

Percentage of Members in Treatment with Mental Health, Co-occurring and Substance Use Disorders

Co-Occurring Diagnoses:Prevalence by Age

Co-occurring Diagnoses:Prevalence by Race and Ethnicity

Impact of Morbidity

• Quality of life due to the morbidity. • Suicide and injury account for about 30-40% of

excess mortality in people with SMI.• 60% of premature deaths in persons with

schizophrenia are due to medical conditions such as cardiovascular, pulmonary, and infectious diseases.

• About 3 out of 5 people with SMI who die prematurely die from mostly preventable diseases.

Suicide

• Suicide is the 11th leading cause of death in the U.S. (CDC).

• An estimated 2-15% of individuals diagnosed with major depression die by suicide.

• An estimated 3-20% of individuals diagnosed with bipolar disorder die by suicide.

• An estimated 6-15% of individuals diagnosed with schizophrenia die by suicide.

• Suicide is the leading cause of premature death in those diagnosed with schizophrenia.

http://mentalhealth.samhsa.gov/suicideprevention/suicidefacts.asp

PH Risks in SMI Population

• People with serious behavioral illness die earlier than the general population.

• People without SMI who have risk factors common to SMI (i.e. smoking, poverty, homelessness, obesity) also die much earlier than the general population.

• Our behavioral and physical health systems have failed to systematically address and support prevention and wellness across all populations, especially those which suffer from socioeconomic disadvantages or are minorities.

* National Association of State Mental Health Program Directors (NASMHPD) Medical Directors Council. (2006). Morbidity and Mortality in People with Serious Mental Illness. Alexandria, VA.

Inadequate Accessto Physical Health Care

• Lack of adequate access.

• Stigma and discrimination.

• Poor quality/provision of services in some areas.

• Lack of adequate health care coverage (in some

areas).

• Monitoring and treatment guidelines are underutilized

with the SMI population (as in most populations).* National Association of State Mental Health Program Directors (NASMHPD)

Medical Directors Council. (2006). Morbidity and Mortality in People with

Serious Mental Illness. Alexandria, VA.

Vulnerabilities

People with SMI are vulnerable due to higher rates of:• Homelessness.• Victimization or trauma.• Unemployment and poverty.• Incarceration.• Social Isolation.• Out-of-home placements in foster care and child

supervision by child welfare system .• In PA, at least, SMI population with Medicaid utilizes

physical health services at rates that approximate people without SMI (ongoing analysis).

* National Association of State Mental Health Program Directors (NASMHPD) Medical Directors Council. (2006). Morbidity and Mortality in People with Serious Mental Illness. Alexandria, VA.

Data Discussion

Factors and variables that may contribute to

behavioral health service disparities race/ethnic,

gender based clinical differences:• SES variables.• Penetration efforts .• Systemic race bias.• Geo-access issues.• Stigma.• Awareness.

Addressing Disparities - Interventions

Reinvestment Projects• Outreach to African American families/children. • Homeless Outreach Project.• Multi-cultural Outreach Education task force

(MOE).• University of Pittsburgh Center for Minority

Health(CMH).• Member newsletter.• Member education (MAC/FAC).

Program Interventions

• Provider Credentialing Project – – To increase provider capacity and access.– To address needs of targeted regions and

communities, and racial/ethnic populations.

CEA, Strength Inc., Growing With Trust, Operation Nehemiah, Central Outreach.

• Consumer Action Response Team (CART) – consumer/family satisfaction surveys and feedback.

• Supplemental programs.

Next Steps

• Address behavioral health disparities and increase service utilization of minority members.

• Special needs enrollment file – targeting race, sex, and ethnicity.

• Focused interviewing and telephone monitoring.• Outreach follow-up project (compliance and

outcome improvement).• Focused member education efforts.• Evidence-based interventions.

Interventions to Increase Engagement

• Outreach to minority communities to identify geographic and specialty treatment needs.

• Efforts to recruit specialty clinicians.• Information to members about service

availability. • Behavioral health therapists can work in physical

health settings.• Training of case managers and peer specialists

to assist consumers as “health navigators”.

Efforts to Improve Health Care

• More accurate assessment of member needs and serves as a foundation to develop initiatives to address them.

• Develop culturally-competent community-based treatment models.

• Partnership with community organizations and other stakeholders for health promotion.

• Develop initiatives to engage members and improve access to recovery-oriented treatments.

• Provide education to members.

Contact Information

Salim Chowdhury, MD, Senior Medical Director

Curtis Upsher Jr., M.S.,

Director of Community Relations

Community Care Behavioral HealthOne Chatham Center, Suite 700

112 Washington PlacePittsburgh, PA 15219

412-454-2120www.ccbh.com

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