Reducing Disparities in Mental Health Expenditure Among Children in Child Welfare

说明(申请人提供)：与儿童福利机构接触的儿童构成了涉及儿童的主要公共心理健康问题。这大约580万儿童不成比例地是非白人，他们在利用精神卫生服务方面表现出相当大的种族/族裔差异。这些差距之所以特别有害，是因为几乎所有这些儿童都有权享受医疗补助。由于缺乏关于哪些因素导致不同种族/族裔儿童利用不同服务的信息，医疗补助机构缩小受益者之间这些差距的能力受到阻碍，这有可能使这一高度脆弱群体的精神健康状况恶化。在儿童福利研究领域，这个研究团队的成员第一次收集了一个独特的数据集，将儿童福利中儿童的全国调查的受访者与他们的医疗补助索赔数据以及居住县内的医疗补助和精神健康政策的信息联系起来。这种联系将调查数据中包含的丰富的人一级信息--例如使用标准化心理测量方法确定的对精神健康服务的需求--与索赔数据中包含的使用和支出信息结合在一起。在本研究中，我们建议完成这一数据集的构建，然后进行纵向数据分析，以(1)在儿童福利方面的全国样本儿童在精神卫生服务利用(门诊精神卫生服务使用、住院住院、精神药物使用、总服务量和服务的及时性)和支出方面的种族/民族差异模型；(2)估计这些儿童(0-18岁)在儿童发展周期中精神卫生服务利用和支出的种族/民族差异；以及(3)审查符合国家标准的护理在这些儿童中作为种族/族裔差异在精神卫生服务利用和支出方面的中介作用(来自目标1)，以及使用和支出轨迹(来自目标2)；和(4)医疗补助政策(假定资格、管理医疗和系统协调)对精神健康服务利用和支出的种族/民族差异的影响(来自目标1)，以及使用和支出轨迹(来自目标2)，在这些儿童中，由一名新的调查员提出的这项建议汇集了一支经验丰富的高级调查团队和一名州医疗补助政策制定者，以解决与医疗补助覆盖非常脆弱的儿童人口有关的这些突出问题。这项建议与联邦和NIH的几个优先事项保持一致，包括NIMH战略计划、卫生局局长的几份报告、医学研究所的出版物以及健康人2020年的几个拟议目标，所有这些都呼吁采取政策行动，减少和消除精神健康方面的差异。 公共卫生相关性：获得所需精神卫生服务方面的种族/族裔差异是一个国家公共卫生问题，医学研究所、卫生局局长和健康人2020目标的几份出版物强调了这一点。这些差异在儿童福利系统中的儿童中尤其普遍，儿童福利系统中的儿童是儿童人口中对心理健康服务需求最高的群体，而矛盾的是，儿童拥有享受医疗补助的权利。显然，医疗补助机构需要更好的信息，了解跨部门和随时间推移这些差距的程度，并调查哪些医疗补助政策可能会加剧这一弱势群体的差距。在儿童福利研究中，这项研究首次将儿童福利中儿童的全国调查数据与医疗补助索赔数据联系起来，以确定、量化和适当地为有风险的儿童提供服务方面的差异的照顾资源。在医疗改革的背景下，这项提案提供了一个独特的机会来研究如何通过医疗补助政策行动缩小这些儿童之间的差距。

DESCRIPTION (provided by applicant): Children coming into contact with child welfare agencies constitute what has been described as the dominant public mental health problem when it comes to children. These approximately 5.8 million children are disproportionately non-white, and display considerable race/ethnic disparities in their utilization of mental health services. What makes these disparities especially pernicious is that virtually all of these children have entitlements to Medicaid. Medicaid agencies' ability to reduce these disparities occurring among its beneficiaries is hampered by the lack of information on what factors result in differential utilization of services among children of different race/ethnicities, which has the potential risk of worsening mental health outcomes among this highly vulnerable population. For the first time in the field of child welfare research, members of this research team are assembling a unique data set that links the respondents of a national survey of children in child welfare to their Medicaid claims data, along with information on Medicaid and mental health policies within their counties of residence. Such a linkage combines the richness of person-level information contained in survey data - such as need for mental health services identified using standardized psychometric measures - with the use and expenditure information contained in claims data. In the present study, we propose to complete construction of this data set, and then conduct longitudinal data analysis to (1) model race/ethnic differences in mental health service utilization (ambulatory mental health service use, inpatient hospitalizations, psychotropic medication use, overall service volume, and timeliness of services) and expenditures among a national sample of children in child welfare; (2) estimate race/ethnic differences in mental health services utilization and expenditure trajectories over the childhood development cycle (ages 0- 18 years) among these children; and (3) examine the role of care consistent with national standards as mediators of race/ethnic differences in mental health service utilization and expenditures (from Aim 1), and use and expenditure trajectories (from Aim 2), among these children; and (4) effects of Medicaid policies (presumptive eligibility, managed care, and system coordination) on race/ethnic differences in mental health service utilization and expenditures (from Aim 1), and use and expenditure trajectories (from Aim 2), among these children This proposal by a new investigator brings together a highly experienced team of senior investigators and a state Medicaid policymaker to address these salient issues with respect to Medicaid coverage of a very vulnerable child population. This proposal is aligned to several Federal and NIH priorities, including the NIMH Strategic Plan, several reports of the Surgeon-General, publications from the Institute of Medicine, and several of the proposed objectives from Healthy People 2020, all of which call for policy action that can reduce and eliminate disparities in mental health. PUBLIC HEALTH RELEVANCE: Race/ethnic disparities in access to needed mental health services is a national public health concern, highlighted in several publications from the Institute of Medicine, the Surgeon-General, and Healthy People 2020 objectives. These disparities are especially prevalent among children in the child welfare system, a group with the highest needs for mental health services among child populations, and a group that paradoxically possesses entitlements to Medicaid. Clearly, Medicaid agencies require better information on the magnitude of these disparities both cross-sectionally and over time, as well as an investigation of which Medicaid policies may worsen disparities among this vulnerable population. For the first time in child welfare research, this study links national survey data of children in child welfare with Medicaid claims data to identify, quantify, and appropriately resource care for children at risk for disparities in access to services. In the context of health reform, this proposal provides a unique opportunity to examine how disparities among these children can be reduced through Medicaid policy action.