Article Abstract

Online ISSN: 1099-176X    Print ISSN: 1091-4358
The Journal of Mental Health Policy and Economics
Volume 26, Issue 3, 2023. Pages: 115-130
Published Online: 1 September 2023

Copyright © 2023 ICMPE.

Perspectives on Financing Strategies for Evidence-Based Treatment Implementation in Youth Mental Health Systemse

Maddison N. North¹, Alex R. Dopp²*, Jane F. Silovsky³, Marylou Gilbert⁴, Jeanne S. Ringel²

¹MS, University of Oklahoma, Department of Psychology, Norman, OK, USA.
²PhD, RAND Corporation, Santa Monica, CA, USA.
³PhD, University of Oklahoma Health Sciences Center, Department of Pediatrics, Center on Child Abuse and Neglect, Oklahoma City, OK, USA.
⁴JD, RAND Corporation, Santa Monica, CA, USA.

Evidence-based treatments (EBTs) can effectively address youth mental health problems, but are costly for service agencies to deliver. Across two web-based surveys, we collected quantitative and qualitative data on how youth mental health system decision-makers (n = 48) viewed financing strategies that support EBT implementation and sustainment. Beyond a core set of highly relevant strategies (e.g., grants, contracts), familiarity with financing strategies was low. Generally, strategies were rated as modestly available, feasible, and effective for EBT sustainment, and as modestly adequate for sustaining various EBT components. Ratings were largely similar across representatives from service agencies, funding agencies, and intermediary organizations. Qualitative data revealed insights into challenges with using financing strategies. These findings underscore fundamental issues with chronic under-funding of U.S. mental health systems; financing strategies can help agencies navigate EBT implementation and sustainment, but must be accompanied by larger-scale policy reforms and support for use of innovative financing strategies.

Background: Evidence-based treatments (EBTs) are critical to effectively address mental health problems among children and adolescents, but costly for mental health service agencies to implement and sustain. Financing strategies help agencies overcome cost-related
barriers by obtaining financial resources to support EBT implementation and/or sustainment.

Aims: We sought to (i) understand how youth mental health system decision-makers involved with EBT implementation and sustainment view key features (e.g., relevance, feasibility) that inform financing strategy selection and (ii) compare service agency, funding agency, and intermediary representative perspectives.

Method: Two surveys were disseminated to 48 representatives across U.S. youth mental health service agencies, funding agencies, and intermediaries who were participating in a larger study of financing strategies. Quantitative and qualitative data were gathered on 23 financing strategies through quantitative ratings and open-ended responses. Data were analyzed using descriptive statistics and rapid content analysis.

Results: The financing strategies rated as most relevant include braided funding streams, contracts for EBTs, credentialing/rostering providers, fee-for-service reimbursement (regular and increased), and grant funding. All other strategies were unfamiliar to 1/3 to 1/2 of participants. The six strategies were rated between somewhat and quite available, feasible, and effective for EBT sustainment. For sustaining different EBT components (e.g., delivery, materials), the mix of financing strategies was rated as somewhat adequate. Qualitative analysis revealed challenges with strategies being non-recurring or unavailable in representatives’ regions. Ratings were largely similar across participant roles, though funding agency representatives were the most familiar with financing strategies.

Discussion: Despite the breadth of innovative financing strategies, expert representatives within the youth mental health services ecosystem had limited knowledge of most options. Experts relied on strategies that were familiar but often did not adequately support EBT implementation or sustainment. These findings underscore more fundamental issues with under-resourced mental health systems in the U.S.; financing strategies can help agencies navigate EBT use but must be accompanied by larger-scale system reforms. Limitations include difficulties generalizing results due to using a small sample familiar with EBTs, high agreement as a potential function of snowball recruiting, and limited responses to the open-ended survey questions.

Implications for Health Care Provision and Use: Although EBTs have been found to effectively address mental health problems in children and adolescents, available strategies for financing their implementation and sustainment in mental health systems are insufficient. This constraint prevents many children and adolescents from receiving high-quality services.

Implications for Health Policies: Financing strategies alone cannot solve systematic issues that prevent youth mental health service agencies from providing EBTs. Policy changes may be required, such as increased financial investment from the U.S. government into mental health services to support basic infrastructure (e.g., facility operations, measuring outcomes).

Implications for Further Research: Future work should examine expert perspectives on EBT financing strategies in different contexts (e.g., substance use services), gathering targeted feedback on financing strategies that are less well known, and exploring topics such as strategic planning, funding stability, and collaborative decision-making as they relate to EBT implementation and sustainment.