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Washington State Institute for Public Policy
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Primary care in behavioral health settings (community-based settings)

Adult Mental Health: Serious Mental Illness
Benefit-cost methods last updated December 2019.  Literature review updated May 2014.
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Behavioral health settings (mental health and substance abuse treatment centers) provide primary care for patients on site or nearby. This collection of studies evaluate this practice at community-based treatment centers.
The estimates shown are present value, life cycle benefits and costs. All dollars are expressed in the base year chosen for this analysis (2018). The chance the benefits exceed the costs are derived from a Monte Carlo risk analysis. The details on this, as well as the economic discount rates and other relevant parameters are described in our Technical Documentation.
Benefit-Cost Summary Statistics Per Participant
Benefits to:
Taxpayers ($9) Benefits minus costs ($489)
Participants ($132) Benefit to cost ratio ($0.72)
Others $58 Chance the program will produce
Indirect ($122) benefits greater than the costs 27 %
Total benefits ($205)
Net program cost ($284)
Benefits minus cost ($489)
1In addition to the outcomes measured in the meta-analysis table, WSIPP measures benefits and costs estimated from other outcomes associated with those reported in the evaluation literature. For example, empirical research demonstrates that high school graduation leads to reduced crime. These associated measures provide a more complete picture of the detailed costs and benefits of the program.

2“Others” includes benefits to people other than taxpayers and participants. Depending on the program, it could include reductions in crime victimization, the economic benefits from a more educated workforce, and the benefits from employer-paid health insurance.

3“Indirect benefits” includes estimates of the net changes in the value of a statistical life and net changes in the deadweight costs of taxation.
Detailed Monetary Benefit Estimates Per Participant
Benefits from changes to:1 Benefits to:
Taxpayers Participants Others2 Indirect3 Total
Labor market earnings associated with smoking ($58) ($137) $0 $0 ($195)
Health care associated with smoking ($16) ($5) ($17) ($8) ($46)
Health care associated with general hospitalization $42 $2 $41 $21 $106
Health care associated with emergency department visits $23 $6 $33 $11 $74
Labor market earnings associated with obesity $1 $1 $0 $0 $2
Mortality associated with smoking $0 $0 $0 ($4) ($5)
Mortality associated with obesity $0 $0 $0 $0 $0
Adjustment for deadweight cost of program $0 $0 $0 ($142) ($142)
Totals ($9) ($132) $58 ($122) ($205)
Detailed Annual Cost Estimates Per Participant
Annual cost Year dollars Summary
Program costs $270 2014 Present value of net program costs (in 2018 dollars) ($284)
Comparison costs $0 2014 Cost range (+ or -) 20 %
According to Samet et al. (2003). Linking alcohol- and drug-dependent adults to primary medical care: A randomized controlled trial of a multi-disciplinary health intervention in a detoxification unit. Addiction, 98(4), 509-516, patients in the treatment group received an average of 1 more primary care visit in 12 months than did those in the comparison group. The average visit cost for primary care visit at Navos in Seattle (an example of a community-based treatment center) is $270 (per email from Paul Tagenfeldt to M. Miller, April 25, 2014).
The figures shown are estimates of the costs to implement programs in Washington. The comparison group costs reflect either no treatment or treatment as usual, depending on how effect sizes were calculated in the meta-analysis. The cost range reported above reflects potential variation or uncertainty in the cost estimate; more detail can be found in our Technical Documentation.
Estimated Cumulative Net Benefits Over Time (Non-Discounted Dollars)
The graph above illustrates the estimated cumulative net benefits per-participant for the first fifty years beyond the initial investment in the program. We present these cash flows in non-discounted dollars to simplify the “break-even” point from a budgeting perspective. If the dollars are negative (bars below $0 line), the cumulative benefits do not outweigh the cost of the program up to that point in time. The program breaks even when the dollars reach $0. At this point, the total benefits to participants, taxpayers, and others, are equal to the cost of the program. If the dollars are above $0, the benefits of the program exceed the initial investment.

^WSIPP’s benefit-cost model does not monetize this outcome.

Meta-analysis is a statistical method to combine the results from separate studies on a program, policy, or topic in order to estimate its effect on an outcome. WSIPP systematically evaluates all credible evaluations we can locate on each topic. The outcomes measured are the types of program impacts that were measured in the research literature (for example, crime or educational attainment). Treatment N represents the total number of individuals or units in the treatment group across the included studies.

An effect size (ES) is a standard metric that summarizes the degree to which a program or policy affects a measured outcome. If the effect size is positive, the outcome increases. If the effect size is negative, the outcome decreases.

Adjusted effect sizes are used to calculate the benefits from our benefit cost model. WSIPP may adjust effect sizes based on methodological characteristics of the study. For example, we may adjust effect sizes when a study has a weak research design or when the program developer is involved in the research. The magnitude of these adjustments varies depending on the topic area.

WSIPP may also adjust the second ES measurement. Research shows the magnitude of some effect sizes decrease over time. For those effect sizes, we estimate outcome-based adjustments which we apply between the first time ES is estimated and the second time ES is estimated. We also report the unadjusted effect size to show the effect sizes before any adjustments have been made. More details about these adjustments can be found in our Technical Documentation.

Meta-Analysis of Program Effects
Outcomes measured Treatment age No. of effect sizes Treatment N Adjusted effect sizes(ES) and standard errors(SE) used in the benefit - cost analysis Unadjusted effect size (random effects model)
First time ES is estimated Second time ES is estimated
ES SE Age ES SE Age ES p-value
Blood pressure^ 41 1 441 -0.022 0.194 41 n/a n/a n/a -0.022 0.909
Blood sugar (HbA1c)^ 41 1 321 -0.015 0.198 41 n/a n/a n/a -0.015 0.940
Cholesterol^ 41 1 370 -0.188 0.196 41 n/a n/a n/a -0.188 0.338
Emergency department visits 41 6 6585 -0.081 0.051 41 0.000 0.000 42 -0.081 0.117
Hospitalization 41 4 852 -0.052 0.092 41 0.000 0.000 42 -0.052 0.572
Obesity 41 1 435 -0.002 0.194 41 n/a n/a n/a -0.002 0.992
Primary care visits^ 41 5 944 0.111 0.197 41 n/a n/a n/a 0.111 0.020
Regular smoking 41 1 453 0.116 0.194 41 0.000 0.000 42 0.116 0.548

Citations Used in the Meta-Analysis

Friedmann, P.D., Hendrickson, J.C., Gerstein, D.R., Zhang, Z., & Stein, M.D. (2006). Do Mechanisms That Link Addiction Treatment Patients to Primary Care Influence Subsequent Utilization of Emergency and Hospital Care?. Medical Care, 44(1), 8-15.

Laine, C., Hauck, W.W., & Turner, B.J. (2005). Availability of Medical Care Services in Drug Treatment Clinics Associated with Lower Repeated Emergency Department Use. Medical Care, 43(10), 985-995.

Scharf, D.M, Eberhart, N.K., Horvitz-Lennon, M., R. Beckman, Han, B., Lovejoy, S., Pincus, H.A., Burnam, M.A. (2013). Evaluation of the SAMHSA Primary and Behavioral ehalth Care Integration Program: Final report. Rand Corporation.

Umbricht-Schneiter, A., Ginn, D.H., Pabst, K.M., & Bigelow, G.E. (1994). Providing medical care to methadone clinic patients: referral vs on-site care. American Journal of Public Health, 84(2), 207-210.