Early Intervention Financing and Resources: Final Report. 1. Background and Motivation


The objective of this project is to study the implementation of coordinated specialty care services in NAVIGATE, the active treatment intervention in the National Institute of Mental Health's (NIMH's) Recovery After an Initial Schizophrenia Episode (RAISE) Early Treatment Program (ETP). The focus of this project is on the important issues of financing coordinated specialty care services for first-episode psychosis within communities. The report discusses some of the implications of the Affordable Care Act (ACA) for these financing concerns. The Office of the Assistant Secretary for Planning and Evaluation (ASPE) expects to disseminate the practical lessons of the RAISE initiative, so that early psychosis services can be implemented throughout the United States in the event that their effectiveness has been established by the RAISE study.

RAISE is intended to transform behavioral health services, as recommended by the President's New Freedom Commission on Mental Health (2003). Schizophrenia, with its associated disabling symptoms and poor prognosis, has long challenged the mental health service system to provide humane and effective services. Recently, the finding that outcomes in schizophrenia may not be uniformly negative over time has sparked a new emphasis on “recovery” and with it a more hopeful expectation that with proper treatment, individuals with schizophrenia can function in their communities, byparticipating in work, school, and social relationships. (New Freedom Commission on Mental Health, 2003) Furthermore, this degree of social inclusion and symptomatic recovery is thought to be more likely if treatment occurs early in the course of the illness. (McCoy, Patton, and Goldman, 2010)

The RAISE study will assess the effectiveness of a menu of evidence-based services when marshaled together in real-world, community settings early in the course of schizophrenia, when psychotic symptoms first appear. NAVIGATE is a multi-component intervention delivered in a team approach. The components include Individual Resilience Training (IRT), supported employment and education (SEE), family psycho-education, and individualized medication management.

NAVIGATE participants are individuals aged 15-40 years old who have a first psychotic episode of any duration, so long as they have taken antipsychotic medication for a cumulative period of no longer than six months. The specific set of eligible diagnostic categories is determined using the SCID in a centralized assessment process. Individuals with schizophrenia, schizo-affective disorder, schizophreniform disorder, brief psychotic disorder, and psychotic disorder, not otherwise specified may be included, and those whose psychosis is deemed secondary to a general medical condition, such as significant head trauma or a neurological disorder, are excluded from NAVIGATE and the ETP study.

Interventions are offered to prospective patients within a shared decision-making framework. Thus, participants do not necessary receive every NAVIGATE service, but only those selected to facilitate personal recovery goals. The hypothesis is that early team-based treatment with evidence-based services can prevent disability and improve long-term functional outcomes in people with first-episode schizophrenia.

From the beginning of the RAISE initiative, the project has focused on implementing first-episode services in real-world community settings, rather than academic medical centers. NIMH hoped that a practical clinical trial of the magnitude, visibility, and scientific rigor of RAISE ETP would lead to the rapid implementation of evidence-based, first-episode services throughout the United States, should the RAISE ETP intervention prove effective. Other countries, such as the United Kingdom, Canada, and Australia, have implemented such services on a widespread basis, but they have been neither implemented nor evaluated extensively in the United States. Those other countries all have universal health insurance and cover the services, even some non-traditional supportive services, within their public mental health systems. Policymakers in the United States may need to see evidence of the effectiveness of first-episode services when delivered in typical community settings in the United States prior to supporting their wide-scale adoption. To speed the likely implementation of first-episode psychosis treatment services, the original RAISE request for proposal required that the proposed RAISE study sites use mainstream and readily available funding mechanisms in ecologically valid service systems and their community clinics and mental health centers. The project was launched prior to the passage of the ACA, and some provisions of the health reform law have implications for first-episode services.

One of the main financing challenges of RAISE is related to the historic link of Medicaid eligibility to Supplemental Security Income (SSI) disability status, prior to health care reform. It is expected that most of the early psychosis patients will not qualify for SSI, as they are not expected to be significantly disabled at this early phase of their psychotic illness, and so they are not likely to be on Medicaid. (Some individuals in the early stages of psychosis may have qualified for SSI on the basis of a general medical condition or a disabling mental disorder prior to a first psychotic episode. Some individuals in the midst of a first psychotic illness long enough to qualify for SSI could be eligible for the ETP, if they did not receive antipsychotic medication for more than six cumulative months.) The SSI disability requirement for eligibility for Medicaid will change in 2014, when implementation of health care reform will increase Medicaid enrollments of non-disabled individuals through the so-called Medicaid expansion. Meanwhile, some participants in NAVIGATE will be able to remain on parents' health insurance for longer because of the ACA; others will have more opportunities for private insurance coverage without fear of being disqualified based on psychosis as a pre-existing condition.

Shortly after NIMH initiated RAISE, ASPE awarded Westat with two Task Orders related to important policy questions facing the full implementation of first-episode psychosis services. One of the projects focused on supported employment, and the other on financing RAISE services more broadly.

In 2010, Westat was awarded the study that generated the report “Evaluation of the Financing Mechanisms of the Connection and NAVIGATE Programs (in RAISE),” as a first step in addressing the questions about financing first-episode psychosis services in the United States. This study documented the diverse approaches to funding services planned for the RAISE sites. The NAVIGATE teams, composed of clinicians already engaged in service delivery to a mix of patients, were to be funded primarily with available insurance and other mostly public resources. It was expected that insurance funds would be supplemented by resources from the NIMH-funded ETP to pay for non-traditional services, such as supported employment, and from locally available resources for individuals lacking health insurance. (Patton, Ratner and Salkever, 2010)

What was clear from the initial ASPE study of RAISE financing was how diverse and site-specific many of the NAVIGATE funding strategies would need to be if they were to be successful. Following the passage of health reform, the problem of serving uninsured service users in the future became less of a concern. The strategies for funding by the ETP with insurance are more likely to generalize to other real-world community mental health settings in a reformed health care system. NAVIGATE sites, however, still have highly specific and idiosyncratic approaches for financing some of their services, such as SEE, as well as some other recovery and case management services. This latest project investigated the diverse financing strategies in the NAVIGATE sites to inform other similar settings across the United States.

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