The Fort Bragg demonstration and evaluation

B ickman's (1996) study appears to debunk or at least call into serious question strongly held convictions, if not catechisms, about the ways in which health services should be structured and provided. But does it really? His research, an evaluation of a highly visible demonstration project with national import, looked at the effects of unlimited access, continuity of care, freedom from benefit limitations, availability of a full range of services, case management, and presumably managed care on clinical outcomes and costs. It concluded that, at least with regard to the Fort Bragg study, the conventional wisdom about the positive effects of all these things was wrong, or at least clouded; he found no evidence that they resulted in better clinical outcomes or reduced costs, at least not of any significance. This is of course not good news for those who believe so strongly in the things that Bickman's (1996) study found suspect. And because strongly held beliefs do not bend easily, the temptation is to find fault with the study, to worry about the methodology, to question hypotheses, and thereby to dismiss its conclusions. There are, as in all such studies, important questions about methodology. But the major issues raised by Bickman 's (1996) study are not so much about how it was done but rather about what was studied. The negative conclusions, at least about costs, were almost inevitable given the way in which the demonstration's health services were structured and provided. As Bickman (1996) pointed out, it is no surprise that the Fort Bragg Demonstration Project, because of increased access, was far more expensive in the aggregate than in the comparison. But even with a sharp decline in inpatient utilization and what appeared to be the substitution of less expensive community services for hospital care, it was only slightly less so on a per patient basis. How could this be? Here one has, at least superficially, the design of an ideal service system, one that would be loudly applauded by most mental healthers. Theoretically, it should have resulted in better clinical outcomes at lower cost. But it didn't! Why not? Because on closer examination, it had major problems: It was not really managed care, or at best only one form of managed care (case management to facilitate continuity is useful but it is not really managed care, certainly not as it is and should be done); there were no financial incentives to use resources or services cost effectively (in fact, the opposite was the case-cos t -based reimbursement in an I I I

Emergency and Acute Care Studies · Healthcare Policy and Management · Primary Care and Health Outcomes · Psychology

• Resolving issues raised by the Fort Bragg evaluation

  Leonard Bickman•American Psychologist•1997

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• Program Strength and Fidelity in Evaluation

  Wm Thomas Summerfelt•Applied Developmental Science•2003

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• A continuum of care

  Leonard Bickman•American Psychologist•1996

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