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Liu Y, Deng Y, Wang H, Liu W, He X, Zeng H. A nomogram for predicting echocardiogram prescription in outpatients: an analysis of the NAMCS database. Front Cardiovasc Med 2023; 10:1183504. [PMID: 37908500 PMCID: PMC10613676 DOI: 10.3389/fcvm.2023.1183504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 09/19/2023] [Indexed: 11/02/2023] Open
Abstract
Background and objective Cardiovascular disease is the leading cause of morbidity and mortality globally. Echocardiography is a commonly used method for assessing the condition of patients with cardiovascular disease. However, little is known about the population characteristics of patients who are recommended for echocardiographic examinations. Methods The National Ambulatory Medical Care Survey was a cross-sectional survey previously undertaken in the USA. In this study, publicly accessible data from the National Ambulatory Medical Care Survey database (for 2007-2016 and 2018-2019; data for 2017 was not published) were utilized to create a nomogram based on significant risk predictors. The study was performed in accordance with the relevant guidelines and regulations stipulated in the National Ambulatory Medical Care Survey database. Patients were randomly assigned to one of two groups: training cohort or validation cohort. The latter was used to assess the reliability of the prediction nomogram. Decision curve analysis was performed to evaluate the net benefit. Propensity score matching analysis was used to evaluate the relevance of echocardiography to clinical decision-making. Results A total of 217,178 outpatients were enrolled. Multivariable logistic regression analysis demonstrated that hypertension, hyperlipidemia, coronary artery disease/ischemic heart disease/history of myocardial infarction, congestive heart failure, major reason for visit, metropolitan statistical area, cerebrovascular disease/history of stroke or transient ischemic attack, previously assessed, insurance, referred, diagnosis, and reason for visit were all predictors of echocardiogram prescription in outpatients. The reliability of the predictive nomogram was confirmed in the validation cohort. After propensity score matching, there was a significant difference in new cardiovascular agent prescriptions between the echocardiogram and no echocardiogram groups (P < 0.01). Conclusion In this cohort study, a nomogram based on the characteristics of outpatients was developed to predict the possibility of prescribing echocardiography. The echocardiogram group was more likely to be prescribed new cardiovascular agents. These findings may contribute to providing information about the gap between actual utilizations and guidelines and the actual outpatient practice, as well as meeting the needs of outpatients.
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Affiliation(s)
- Yujian Liu
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Hubei Provincial Engineering Research Center of Vascular Interventional Therapy, Wuhan, China
| | - Yanhan Deng
- Department of Rheumatology and Immunology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Hongjie Wang
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Hubei Provincial Engineering Research Center of Vascular Interventional Therapy, Wuhan, China
| | - Wanjun Liu
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Hubei Provincial Engineering Research Center of Vascular Interventional Therapy, Wuhan, China
| | - Xingwei He
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Hubei Provincial Engineering Research Center of Vascular Interventional Therapy, Wuhan, China
| | - Hesong Zeng
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Hubei Provincial Engineering Research Center of Vascular Interventional Therapy, Wuhan, China
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Association of Follow-Up After an Emergency Department Visit for Mental Illness with Utilization Based Outcomes. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2021; 48:718-728. [PMID: 33438094 DOI: 10.1007/s10488-020-01106-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/17/2020] [Indexed: 10/22/2022]
Abstract
Follow-up within 30 days of an emergency department (ED) visit for mental illness is a new and widely-used quality measure. However, no empirical evidence validates associations between follow-up and subsequent utilization based outcomes. Using Massachusetts all payer claims data, we identified insured individuals with an ED visit for mental illness. Multivariate regression analysis estimated associations between follow-up within 30 days after an ED visit for mental illness with costs, hospitalizations, and additional ED visits in 180 days following the index visit. 63,814 index ED visits were included (56.5% female, mean [SD] age 38.0 [12.1] years, 48% Medicaid covered). 31% of index ED principal diagnoses were for major depressive disorder, 3% schizophrenia, 5% bipolar disorder, 34% anxiety disorder, 0.6% post-traumatic stress disorder, 8% other psychoses, and 19% other mental illness diagnoses. Only 33% of patients had a follow-up visit for mental illness within 30 days. Adjusted regression analyses show timely follow-up is associated with increased costs in the 180 days after (average marginal effect = $1622; 95% confidence interval [CI] 1459, 1786), an increased probability of inpatient hospitalization (2.7 percentage points; 95% CI 0.021, 0.032), and a small reduction in the probability of at least one additional ED visit (- 1.7 percentage points; 95% CI - 0.026 to 0.009). Overall follow-up rates are low; follow-up within 30 days of an ED visit for mental illness is associated with increased costs and increased probability of hospitalization in the follow-up period. It is not known whether increased rates of utilization improve patient outcomes, potentially by receiving appropriate more intensive care.
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Fung V, Price M, Nierenberg AA, Hsu J, Newhouse JP, Cook BL. Assessment of Behavioral Health Services Use Among Low-Income Medicare Beneficiaries After Reductions in Coinsurance Fees. JAMA Netw Open 2020; 3:e2019854. [PMID: 33030552 PMCID: PMC7545309 DOI: 10.1001/jamanetworkopen.2020.19854] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Medicare has historically imposed higher beneficiary coinsurance for behavioral health services than for medical and surgical care but gradually introduced parity between 2009 and 2014. Although Medicare insures many people with serious mental illness (SMI), there is limited information on the impact of coinsurance parity in this population. OBJECTIVE To examine the association between coinsurance parity and outpatient behavioral health care use among low-income beneficiaries with SMI. DESIGN, SETTING, AND PARTICIPANTS This cohort study used Medicare claims data for a 50% national sample of lower-income Medicare beneficiaries from January 1, 2007, to December 31, 2016. The study sample included patients with SMI (schizophrenia, bipolar disorder, or major depressive disorder). Data analysis was performed from August 1, 2018, to July 15, 2020. EXPOSURES Reduction in behavioral health care coinsurance from 50% to 20% between January 1, 2009, and January 1, 2014. MAIN OUTCOMES AND MEASURES Total annual spending for outpatient behavioral health care visits and the percentage of beneficiaries with an annual outpatient behavioral health care visit overall, with a prescriber, and with a psychiatrist. A difference-in-difference approach was used to compare outcomes before and after the reduction in coinsurance for beneficiaries with and without cost-sharing decreases. Linear regression models with beneficiary fixed effects that adjusted for time-changing beneficiary- and area-level covariates were used to examine changes in outcomes. RESULTS The study included 793 275 beneficiaries with SMI in 2008; 518 893 (65.4%) were younger than 65 years (mean [SD] age, 57.6 [16.1] years), 511 265 (64.4%) were female, and 552 056 (69.6%) were White. In 2008, the adjusted percentage of beneficiaries with an outpatient behavioral health care visit was 40.7% (95% CI, 40.4%-41.0%) among those eligible for the cost-sharing reduction and 44.9% (95% CI, 44.9%-45.0%) among those with free care. The mean adjusted out-of-pocket costs for outpatient behavioral health care visits decreased from $132 (95% CI, $129-$136) in 2008 to $64 (95% CI, $61-$66) in 2016 among those with reductions in cost-sharing. The adjusted percentage of beneficiaries with behavioral health care visits increased to 42.2% (95% CI, 41.9%-42.5%) in the group with a reduction in coinsurance and to 47.2% (95% CI, 47.0%-47.3%) in the group with free care. The cost-sharing reduction was not positively associated with visits (eg, relative change of -0.76 percentage points [95% CI, -1.12 to -0.40 percentage points] in the percentage of beneficiaries with outpatient behavioral health care visits in 2016 vs 2008). CONCLUSIONS AND RELEVANCE This cohort study found that beneficiary costs for outpatient behavioral health care decreased between 2009 and 2014. There was no association between cost-sharing reductions and changes in behavioral health care visits. Low levels of use in this high-need population suggest the need for other policy efforts to address additional barriers to behavioral health care.
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Affiliation(s)
- Vicki Fung
- The Mongan Institute, Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, Massachusetts
| | - Mary Price
- The Mongan Institute, Massachusetts General Hospital, Boston
| | - Andrew A. Nierenberg
- Harvard Medical School, Boston, Massachusetts
- Department of Psychiatry, Massachusetts General Hospital, Boston
| | - John Hsu
- The Mongan Institute, Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, Massachusetts
| | - Joseph P. Newhouse
- Harvard Medical School, Boston, Massachusetts
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Harvard Kennedy School, Cambridge, Massachusetts
| | - Benjamin L. Cook
- Harvard Medical School, Boston, Massachusetts
- Health Equity Research Lab, Cambridge Health Alliance and Harvard Medical School, Cambridge, Massachusetts
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Cook BL, Flores M, Zuvekas SH, Newhouse JP, Hsu J, Sonik R, Lee E, Fung V. The Impact Of Medicare's Mental Health Cost-Sharing Parity On Use Of Mental Health Care Services. Health Aff (Millwood) 2020; 39:819-827. [PMID: 32364860 PMCID: PMC7745666 DOI: 10.1377/hlthaff.2019.01008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Before the implementation of cost-sharing parity in Medicare, beneficiaries faced higher cost sharing for mental health services than for other medical services. The Medicare Improvements for Patients and Providers Act of 2008 phased in cost-sharing reductions in Medicare for outpatient mental health services in the period 2010-14. Using data for 2006-15 from the Medical Expenditure Panel Survey and difference-in-differences analyses, we assessed whether this reduction in mental health cost sharing was associated with changes in specialty and primary care outpatient mental health visits and psychotropic medication fills. We compared people with Medicare and with private insurance before and after parity implementation. Medicare beneficiaries' use of psychotropic medication increased after the implementation of cost-sharing parity, but we did not detect a change in visits. Changes in the use of psychotropic medications were greater among people with probable serious mental illness and among Medicare beneficiaries who did not report having supplemental coverage. The increased medication use could signal improvements in mental health care access among Medicare beneficiaries, especially among the subgroups most likely to benefit from the policy change.
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Affiliation(s)
- Benjamin Lê Cook
- Benjamin Lê Cook ( bcook@cha. harvard. edu ) is director of the Health Equity Research Lab, Cambridge Health Alliance, in Cambridge, Massachusetts, and an associate professor in the Department of Psychiatry at Harvard Medical School, in Boston, Massachusetts
| | - Michael Flores
- Michael Flores is an instructor in the Department of Psychiatry at Harvard Medical School and a research scientist at the Health Equity Research Lab, Cambridge Health Alliance
| | - Samuel H Zuvekas
- Samuel H. Zuvekas is a senior economist in the Center for Financing, Access, and Cost Trends, Agency for Healthcare Research and Quality, in Rockville, Maryland
| | - Joseph P Newhouse
- Joseph P. Newhouse is the John D. MacArthur Professor of Health Policy and Management in the Department of Health Care Policy, Harvard Medical School; the Department of Health Policy and Management at the Harvard T. H. Chan School of Public Health, in Boston; and the Harvard Kennedy School, in Cambridge. He is also a faculty research fellow at the National Bureau of Economic Research in Cambridge
| | - John Hsu
- John Hsu is director of the Clinical Economics and Policy Analysis Program at the Mongan Institute Health Policy Center, Massachusetts General Hospital, in Boston, and an associate professor in the Departments of Medicine and of Health Care Policy, Harvard Medical School
| | - Rajan Sonik
- Rajan Sonik is director of research at AltaMed Institute for Health Equity, in Los Angeles, California
| | - Esther Lee
- Esther Lee is a project manager at the Health Equity Research Lab, Cambridge Health Alliance
| | - Vicki Fung
- Vicki Fung is a senior scientist at the Mongan Institute Health Policy Center, Massachusetts General Hospital, and an assistant professor in the Department of Medicine at Harvard Medical School
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Sun KS, Lam TP, Lam KF, Lo TL. Barriers and facilitators for psychiatrists in managing mental health patients in Hong Kong-Impact of Chinese culture and health system. Asia Pac Psychiatry 2018; 10. [PMID: 28371455 DOI: 10.1111/appy.12279] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Revised: 01/02/2017] [Accepted: 02/27/2017] [Indexed: 11/29/2022]
Abstract
INTRODUCTION This study investigated the barriers and facilitators for psychiatrists in managing mental health patients under a Chinese context and a mixed private-public health system. METHODS Two focus group interviews were conducted to explore the in-depth opinions of psychiatrists in Hong Kong. The themes identified from the focus groups were investigated in a questionnaire survey with data from 83 psychiatrists working in public and private sectors. RESULTS No insurance coverage of mental health problems, patients' poor compliance of medication, and stigma of seeing psychiatrists were rated as the top barriers in the survey. Some psychiatrists mentioned in focus groups that they might write down the associated physical symptoms of the patients rather than the mental disorder diagnoses on the medical certificate. They observed some patients suspecting that psychiatric drugs were prescribed to control their behavior and make them more muddleheaded. The survey also found that consultation time constraint, long patient waiting list, and difficulty in discharging patients to primary care mostly affected public psychiatrists rather than private ones. However, they perceived similar facilitators, including public campaign to promote positive results of help-seeking, adequate explanation by other health professionals to the patients before referrals, handling severe cases by casework approach, and having a regular primary care physician. DISCUSSION The top barriers are related to insufficient public awareness and negative attitudes towards mental illness and its treatment. Major solutions include promoting positive results of help seeking, enhancing collaboration with primary care physicians, and follow-up of severe cases by a casework approach.
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Affiliation(s)
- Kai Sing Sun
- Department of Family Medicine and Primary Care, The University of Hong Kong, Hong Kong, China
| | - Tai Pong Lam
- Department of Family Medicine and Primary Care, The University of Hong Kong, Hong Kong, China
| | - Kwok Fai Lam
- Department of Statistics and Actuarial Science, The University of Hong Kong, Hong Kong, China
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Li Q, Keohane LM, Thomas K, Lee Y, Trivedi AN. Association of Cost Sharing With Use of Home Health Services Among Medicare Advantage Enrollees. JAMA Intern Med 2017; 177:1012-1018. [PMID: 28492826 PMCID: PMC5662935 DOI: 10.1001/jamainternmed.2017.1058] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Several policy proposals advocate introducing copayments for home health care in the Medicare program. To our knowledge, no prior studies have assessed this cost-containment strategy. OBJECTIVE To determine the association of home health copayments with use of home health services. DESIGN, SETTING, AND PARTICIPANTS A difference-in-differences case-control study of 18 Medicare Advantage (MA) plans that introduced copayments for home health care between 2007 and 2011 and 18 concurrent control MA plans. The study included 135 302 enrollees in plans that introduced copayment and 155 892 enrollees in matched control plans. EXPOSURES Introduction of copayments for home health care between 2007 and 2011. MAIN OUTCOMES AND MEASURES Proportion of enrollees receiving home health care, annual numbers of home health episodes, and days receiving home health care. RESULTS Copayments for home health visits ranged from $5 to $20 per visit, which were estimated to be associated with $165 (interquartile range [IQR], $45-$180) to $660 (IQR, $180-$720) in out-of-pocket spending for the average user of home health care. The increased copayment for home health care was not associated with the proportion of enrollees receiving home health care (adjusted difference-in-differences, -0.15 percentage points; 95% CI, -0.38 to 0.09), the number of home health episodes per user (adjusted difference-in-differences, 0.01; 95% CI, -0.01 to 0.03), and home health days per user (adjusted difference-in-differences, -0.19; 95% CI, -3.02 to 2.64). In both intervention and control plans and across all levels of copayments, we observed higher disenrollment rates among enrollees with greater baseline use of home health care. CONCLUSIONS AND RELEVANCE We found no evidence that imposing copayments reduced the use of home health services among older adults. More intensive use of home health services was associated with increased rates of disenrollment in MA plans. The findings raise questions about the potential effectiveness of this cost-containment strategy.
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Affiliation(s)
- Qijuan Li
- Department of Health Services, Policy, and Practice, Brown University, Providence, Rhode Island
| | - Laura M Keohane
- Department of Health Policy, Vanderbilt University, Nashville, Tennessee
| | - Kali Thomas
- Department of Health Services, Policy, and Practice, Brown University, Providence, Rhode Island3Providence VA Medical Center, Providence, Rhode Island
| | - Yoojin Lee
- Department of Health Services, Policy, and Practice, Brown University, Providence, Rhode Island
| | - Amal N Trivedi
- Department of Health Services, Policy, and Practice, Brown University, Providence, Rhode Island3Providence VA Medical Center, Providence, Rhode Island
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Effects of mental health benefits legislation: a community guide systematic review. Am J Prev Med 2015; 48:755-66. [PMID: 25998926 PMCID: PMC4700502 DOI: 10.1016/j.amepre.2015.01.022] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2014] [Revised: 01/05/2015] [Accepted: 01/30/2015] [Indexed: 11/21/2022]
Abstract
CONTEXT Health insurance benefits for mental health services typically have paid less than benefits for physical health services, resulting in potential underutilization or financial burden for people with mental health conditions. Mental health benefits legislation was introduced to improve financial protection (i.e., decrease financial burden) and to increase access to, and use of, mental health services. This systematic review was conducted to determine the effectiveness of mental health benefits legislation, including executive orders, in improving mental health. EVIDENCE ACQUISITION Methods developed for the Guide to Community Preventive Services were used to identify, evaluate, and analyze available evidence. The evidence included studies published or reported from 1965 to March 2011 with at least one of the following outcomes: access to care, financial protection, appropriate utilization, quality of care, diagnosis of mental illness, morbidity and mortality, and quality of life. Analyses were conducted in 2012. EVIDENCE SYNTHESIS Thirty eligible studies were identified in 37 papers. Implementation of mental health benefits legislation was associated with financial protection (decreased out-of-pocket costs) and appropriate utilization of services. Among studies examining the impact of legislation strength, most found larger positive effects for comprehensive parity legislation or policies than for less-comprehensive ones. Few studies assessed other mental health outcomes. CONCLUSIONS Evidence indicates that mental health benefits legislation, particularly comprehensive parity legislation, is effective in improving financial protection and increasing appropriate utilization of mental health services for people with mental health conditions. Evidence was limited for other mental health outcomes.
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Langheim FJ. Poor Access to Health Care as a Social Determinant of Mental Health. Psychiatr Ann 2014. [DOI: 10.3928/00485713-20140108-09] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Tabuchi T, Hoshino T, Nakayama T, Ito Y, Ioka A, Miyashiro I, Tsukuma H. Does removal of out-of-pocket costs for cervical and breast cancer screening work? A quasi-experimental study to evaluate the impact on attendance, attendance inequality and average cost per uptake of a Japanese government intervention. Int J Cancer 2013; 133:972-83. [DOI: 10.1002/ijc.28095] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2012] [Accepted: 01/28/2013] [Indexed: 11/12/2022]
Affiliation(s)
- Takahiro Tabuchi
- Center for Cancer Control and Statistics; Osaka Medical Center for Cancer and Cardiovascular Diseases; Osaka; Japan
| | | | - Tomio Nakayama
- Center for Cancer Control and Statistics; Osaka Medical Center for Cancer and Cardiovascular Diseases; Osaka; Japan
| | - Yuri Ito
- Center for Cancer Control and Statistics; Osaka Medical Center for Cancer and Cardiovascular Diseases; Osaka; Japan
| | - Akiko Ioka
- Center for Cancer Control and Statistics; Osaka Medical Center for Cancer and Cardiovascular Diseases; Osaka; Japan
| | - Isao Miyashiro
- Center for Cancer Control and Statistics; Osaka Medical Center for Cancer and Cardiovascular Diseases; Osaka; Japan
| | - Hideaki Tsukuma
- Center for Cancer Control and Statistics; Osaka Medical Center for Cancer and Cardiovascular Diseases; Osaka; Japan
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Benefits Improvement and Protection Act's impact on transplantation rates among elderly MEDICARE beneficiaries with end-stage renal disease. Transplantation 2013; 95:463-9. [PMID: 23314351 DOI: 10.1097/tp.0b013e3182774366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The Benefits Improvement and Protection Act (BIPA) expanded Medicare coverage for posttransplantation immunosuppresants for elderly patients and others eligible for Medicare beyond their end-stage renal disease (ESRD) status yet retained the 3-year limit for patients eligible solely because of ESRD status. Our objective was to determine BIPA's impact on renal transplantation among elderly patients (age ≥65 years) affected by BIPA. METHODS Medicare claims and the U.S. Renal Data System Standard Analysis Files were used to analyze the likelihood of transplantation among elderly patients, all of whom were affected by BIPA, versus the nonelderly, many of whom were unaffected by BIPA. A difference-in-differences approach and generalized logistic regressions were used to estimate BIPA's impact. RESULTS Analysis of data for 632,904 ESRD Medicare beneficiaries who met inclusion/exclusion criteria suggests that BIPA made elderly patients more likely (relative likelihood, 1.36; 95% confidence interval, 1.32-1.41) to have a transplant. The likelihood for nonelderly patients decreased following BIPA (relative likelihood, 0.93; 95% confidence interval, 0.92-0.94). CONCLUSION Transplantation rates increased among those elderly patients, all of whom were affected by BIPA by extending immunosuppressant coverage under BIPA. These results suggest that removing financial barriers to posttransplantation care may positively impact transplantation rates yet raise questions regarding whether the law shifted transplants from younger to older patients.
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Evans-Lacko SE, Baum N, Danis M, Biddle A, Goold S. Laypersons' choices and deliberations for mental health coverage. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2012; 39:158-69. [PMID: 21452017 DOI: 10.1007/s10488-011-0341-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Insurance coverage for mental health services has historically lagged behind other types of health services. We used a simulation exercise in which groups of laypersons deliberate about healthcare tradeoffs. Groups deciding for their "community" were more likely to select mental health coverage than individuals. Individual prioritization of mental health coverage, however, increased after group discussion. Participants discussed: value, cost and perceived need for mental health coverage, moral hazard and community benefit. A deliberative exercise in priority-setting led a significant proportion of persons to reconsider decisions about coverage for mental health services. Deliberations illustrated public-spiritedness, stigma and significant polarity of views.
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Affiliation(s)
- Sara E Evans-Lacko
- Health Service and Population Research Department, Institute of Psychiatry, King's College London, De Crespigny Park, London, UK.
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Abstract
BACKGROUND "Parity" laws remove treatment limitations for mental health and substance-abuse services covered by commercial health plans. A number of studies of parity implementations have suggested that parity does not lead to large increases in utilization or expenditures for behavioral health services. However, less is known about how parity might affect changes in patients' choice of providers for behavioral health treatment. RESEARCH DESIGN We compared initiation and provider choice among 46,470 Oregonians who were affected by Oregon's 2007 parity law. Oregon is the only state to have enacted a parity law that places restrictions on how plans manage behavioral health services. This approach has been adopted federally in the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act. In 1 set of analyses, we assess initiation and provider choice using a difference-in-difference approach, with a matched group of commercially insured Oregonians who were exempt from parity. In a second set of analyses, we assess the impact of distance on provider choice. RESULTS Overall, parity in Oregon was associated with a slight increase (0.5% to 0.8%) in initiations with masters-level specialists, and relatively little changes for generalist physicians, psychiatrists, and psychologists. Patients are particularly sensitive to distance for nonphysician specialists. CONCLUSIONS Our results suggest that the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act may lead to a shift in the use of nonphysician specialists and away from generalist physicians. The extent to which these changes occur is likely to be contingent on the ease and accessibility of nonphysician specialists.
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Davitt JK, Gellis ZD. Integrating mental health parity for homebound older adults under the medicare home health care benefit. JOURNAL OF GERONTOLOGICAL SOCIAL WORK 2011; 54:309-324. [PMID: 21462061 DOI: 10.1080/01634372.2010.540075] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Despite high rates of mental illness, very few homebound older adults receive treatment. Comorbid mental illness exacerbates physical health conditions, reduces treatment adherence, and increases dependency and medical costs. Although effective treatments exist, many home health agencies lack capacity to effectively detect and treat mental illness. This article critically analyzes barriers within the Medicare home health benefit that impede access to mental health treatment. Policy, practice, and research recommendations are made to integrate mental health parity in home health care. In particular, creative use of medical social work can improve detection and treatment of mental illness for homebound older adults.
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Affiliation(s)
- Joan K Davitt
- School of Social Policy & Practice; and New Courtland Center for Transitions and Health, University of Pennsylvania, Philadelphia, PA 19104, USA.
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Effect of copayments on use of outpatient mental health services among elderly managed care enrollees. Med Care 2011; 49:281-6. [PMID: 21301371 DOI: 10.1097/mlr.0b013e31820399f6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Recent parity legislation will require many insurers and the federal Medicare program to reduce mental health copayments, so that they are equivalent to copayments for other covered services. The effect of changes in mental health cost sharing has not been well studied, particularly among elderly populations. OBJECTIVE To examine the consequences of increasing and decreasing copayments on the use of outpatient mental health services among the elderly. RESEARCH DESIGN Difference-in-differences (DID) design comparing the use of outpatient mental health care in Medicare plans that changed mental health copayments compared with concurrent trends in matched control plans with unchanged copayments. STUDY POPULATION A total of 1,147,916 enrollees aged 65 years and older in 14 Medicare plans that increased copayments by ≥ 25%, 3 plans that decreased copayments by ≥ 25%, and 17 matched control plans with unchanged copayments. RESULTS In 14 plans that increased mental health copayments from a mean of $14.43 to $21.07, the proportion of enrollees who used mental health services remained at 2.2% in the year before and year after the increase (adjusted DID, 0.1 percentage points; 95% confidence interval, 0.0-0.1). Among 3 plans that decreased copayments from a mean of $25.00 to $8.33, utilization rates were 1.2% before and after the decrease (adjusted DID, 0.1 percentage points; 95% confidence interval, -0.2 to 0.3). Stratified analyses by age, gender, race, and presence of a disability yielded similar results. CONCLUSIONS Few older adults in managed care plans used outpatient mental health services. Among this population, increasing or decreasing mental health copayments had negligible effects on the likelihood of using outpatient mental health care.
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Abstract
Americans are living longer than ever before in history. With age comes an increased risk for chronic mental health disorders. About 1 in 8 baby boomers is expected to be diagnosed with Alzheimer disease, which will amount to some ten million members of this age cohort. The prevalence of mental health disorders among the elderly is often unrecognized. One in four older adults lives with depression, anxiety disorders, or other significant psychiatric disorders. Mental health disorders are frequently comorbid in older adults, occurring with a number of common chronic illnesses such as in diabetes, cardiac disease, and arthritis. The public is becoming more aware of the aging of the population and the difficulties that are exacerbated by unmet services and limited access to mental health services. This article describes policy issues related to chronic mental health disorders and the older population. Mental health parity, a recent policy issue occurring at the national level, is discussed first followed by workforce issues specific to the discipline of nursing.
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Affiliation(s)
- Karen M Robinson
- School of Nursing, University of Louisville, Louisville, KY 40292, USA.
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Robinson JC. Applying Value-Based Insurance Design To High-Cost Health Services. Health Aff (Millwood) 2010; 29:2009-16. [DOI: 10.1377/hlthaff.2010.0469] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- James C. Robinson
- James C. Robinson is the Kaiser Permanente Professor of Health Economics in the School of Public Health, University of California, Berkeley
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17
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Smaldone A, Cullen-Drill M. Mental Health Parity Legislation. J Psychosoc Nurs Ment Health Serv 2010; 48:26-34. [DOI: 10.3928/02793695-20100730-06] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2010] [Accepted: 05/27/2010] [Indexed: 11/20/2022]
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Abstract
BACKGROUND When copayments for ambulatory care are increased, elderly patients may forgo important outpatient care, leading to increased use of hospital care. METHODS We compared longitudinal changes in the use of outpatient and inpatient care between enrollees in Medicare plans that increased copayments for ambulatory care and enrollees in matched control plans--similar plans that made no changes in these copayments. The study population included 899,060 beneficiaries enrolled in 36 Medicare plans during the period from 2001 through 2006. RESULTS In plans that increased copayments for ambulatory care, mean copayments nearly doubled for both primary care ($7.38 to $14.38) and specialty care ($12.66 to $22.05). In control plans, mean copayments for primary care and specialty care remained unchanged at $8.33 and $11.38, respectively. In the year after the rise in copayments, plans that increased cost sharing had 19.8 fewer annual outpatient visits per 100 enrollees (95% confidence interval [CI], 16.6 to 23.1), 2.2 additional annual hospital admissions per 100 enrollees (95% CI, 1.8 to 2.6), 13.4 more annual inpatient days per 100 enrollees (95% CI, 10.2 to 16.6), and an increase of 0.7 percentage points in the proportion of enrollees who were hospitalized (95% CI, 0.51 to 0.95), as compared with concurrent trends in control plans. These estimates were consistent among a cohort of continuously enrolled beneficiaries. The effects of increases in copayments for ambulatory care were magnified among enrollees living in areas of lower income and education and among enrollees who had hypertension, diabetes, or a history of myocardial infarction. CONCLUSIONS Raising cost sharing for ambulatory care among elderly patients may have adverse health consequences and may increase total spending on health care.
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Affiliation(s)
- Amal N Trivedi
- Department of Community Health, Alpert Medical School of Brown University, Providence, RI 02912, USA.
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19
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Ostrow L, Manderscheid R. Medicare mental health parity: a high potential change that is long overdue. J Behav Health Serv Res 2009; 37:285-90. [PMID: 19888657 DOI: 10.1007/s11414-009-9197-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2009] [Accepted: 10/06/2009] [Indexed: 11/24/2022]
Abstract
Recent changes in legislation regarding mental health parity in Medicare will revolutionize payment for mental health care and delivery systems. This commentary discusses why this policy change was essential to promote adequate care for populations served by Medicare and to address expected changes in beneficiary, provider, and plan behavior as more equitable payments by Medicare are implemented.
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Affiliation(s)
- Laysha Ostrow
- Human Services Research Institute, 2336 Massachusetts Avenue, Cambridge, MA 02140, USA.
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