Patterns and predictors of compliance with utilization management guidelines supporting a state policy to improve the quality of youth mental health services

Impact of Illness Severity Tools on Adolescent Psychiatric Managed Care in California

Youth with mental illness struggle to receive essential behavioral health care. One obstacle is denial of coverage by insurance. In California, managed care consumers may apply for independent medical review (IMR) which potentially overturns an insurance denial through the California Department of Managed Healthcare (CDMHC). The authors aim to analyze IMR appeals for psychiatric treatment among adolescents and elucidate factors associated with obtaining coverage of care. We performed an analysis to identify factors that are associated with depression and substance use disorder (SUD) treatment claim denials in 11-20-year-olds from 2001 to 2022 using CDMHC data. Logistic regression modeling was used to identify specific factors related to claim characteristics and medical society instruments that are significantly associated with overturning a denial by IMR. Behavioral health IMRs are overturned at a higher rate than non-behavioral health claims. 54.5% of those with depression and 36.3% of those with SUD initially denied care coverage were overturned by IMR. For those seeking depression treatment, we found a significantly greater odds of overturn by IMR if there was a reference of CALOCUS [1.64, 95%CI (1.06-2.5)]. The odds of a SUD treatment denial being overturned was significantly greater if referencing CALOCUS [3.85 (1.54-9.62)] or ASAM [2.47, [4.3 (1.77-10.47)]. After the standardized implementation of illness severity tools in IMRs, the odds of a medically necessary claim being overturned was 2.5 times higher than before the standards. With a high percentage of claims being overturned after IMR, the findings suggest that health plans inappropriately deny medically necessary behavioral health treatment. The use of medical society instruments was associated with higher odds of overturning a denial. The recent decision of CDMHC to implement standard use of CALOCUS and similar illness severity criteria is supported by our findings and may facilitate more equitable care.

Implementation of Evidence-Based Practices within Treatment-As-Usual and Evidence-Based Practice Initiatives

Publicly funded initiatives are underway to improve implementation of evidence-based practices (EBP) in youth mental health services. However, we know little about the success of these initiatives or about EBP implementation independent of such initiatives. We examined EBP implementation in a treatment as usual (TAU) state and in six states with publicly funded EBP initiatives (EBPIs). In Study 1, we examined providers' use of practices derived from the evidence base (PDEB) and their predictors among 780 providers in a TAU state. In Study 2, we conducted a systematic review of implementation strategies, outcomes, and predictors of EBP use in six state funded EBPIs. Study 1 suggests TAU providers use PDEB alongside practices without consistent research support; provider racial/ethnic minority status, learning theory orientation, and manual use predict greater PDEB use. Study 2 indicates EBPIs employ multiple recommended implementation strategies with variable outcomes across studies and measurement approaches. Predictors of EBP use in EBPIs also varied, though training, setting, and youth age were consistent predictors across studies. While sample differences and inconsistent measurement across studies made direct comparisons somewhat tenuous, rates of PDEB use in the TAU sample appeared similar to those in publicly funded EBPIs. However, two states reported comparisons with TAU samples and found higher EBP implementation under EBPI. Different predictors impacted EBP use in TAU versus EBPIs. Our findings highlight the need for improved evaluation of EBPIs including clear reporting standards for outcomes and more consistent, standardized measurement of EBP use in order to better understand and improve EBPIs.

Evaluating quality in adolescent mental health services: a systematic review

OBJECTIVES

To evaluate the quality of adolescent mental health service provision globally, according to the WHO Global Standards of adolescent mental health literacy, appropriate package of services and provider competencies.

DESIGN AND DATA SOURCES

Systematic review of 5 databases, and screening of eligible articles, from 1 January 2008 to 31 December 2020.

STUDY ELIGIBILITY CRITERIA

We focused on quantitative and mixed-method studies that evaluated adolescent mental health literacy, appropriate package of services and provider competencies in mental health services, and that targeted depression, anxiety and post-traumatic stress disorder among adolescents (10-19 years). This included adolescents exposed to interventions or strategies within mental health services.

STUDY APPRAISAL AND SYNTHESIS METHODS

Study quality was assessed using the National Institutes for Health Study Quality Assessment Tools. Data were extracted and grouped based on WHO quality Standards.

RESULTS

Of the 20 104 studies identified, 20 articles were included. The majority of studies came from high-income countries, with one from a low-income country. Most of the studies did not conceptualise quality. Results found that an online decision aid was evaluated to increase adolescent mental health literacy. Studies that targeted an appropriate package of services evaluated the quality of engagement between the therapist and adolescent, patient-centred communication, mental health service use, linkages to mental health services, health facility culture and intensive community treatment. Provider competencies focused on studies that evaluated confidence in managing and referring adolescents, collaboration between health facility levels, evidence-based practices and technology use.

CONCLUSIONS AND IMPLICATIONS

There is limited evidence on quality measures in adolescent mental health services (as conforms to the WHO Global Standards), pointing to a global evidence gap for adolescent mental health services. There are several challenges to overcome, including a need to develop consensus on quality and methods to measure quality in mental health settings.

PROSPERO REGISTRATION NUMBER

CRD42020161318.

Using the Hub and Spoke Model of Telemental Health to Expand the Reach of Community Based Care in the United States

Community-based agencies are challenged with providing mental health care services with limited resources. When services are not provided, children are at increased risk for ongoing symptoms. The purpose of this study was to determine the effectiveness of the hub and spoke model of telemental services on the quality of function, access to care, and medication management. A retrospective case controlled design was used to examine study objectives. Five hundred and fifty-seven charts were reviewed for persons aged 6 to 17 from January 1, 2010 to December 31, 2015 and after propensity score matching was applied, 86 remained for analysis. Seventy-nine persons out of 301 (26%) in the comparison group; 43 persons out of 256 (17%) in the treatment group were selected due to having complete records. Results of the T-test suggested that telemental services were not inferior to face to face services. Access to care, analyzed via the Chi-Squared test, increased significantly across geographic regions and among person with different living arrangements. A T-test was conducted to compare medication non-adherence between groups; no statistical significance was noted. Telemental services are a viable option to increase access to community-based care and increase quality of function.

State Strategies for Enhancing Access and Quality in Systems of Care for Youth with Complex Behavioral Health Needs

The investigators conducted a qualitative study with state administrators and policymakers about the financing and policies that structure public systems of care for children with complex behavioral healthcare needs. The objective was to characterize diverse strategies states employed to enhance funding for, access to, and quality and effectiveness of home and community-based services (HCBS) for these youth. States report using a wide variety of creative solutions while navigating the unique needs and constraints of their political and economic environments. Findings can benefit public officials, researchers, and advocates by advancing knowledge-sharing of public policy-making and resourceful problem-solving.

Health Care Utilization and Spending for Children With Mental Health Conditions in Medicaid

OBJECTIVE

To examine how characteristics vary between children with any mental health (MH) diagnosis who have typical spending and the highest spending; to identify independent predictors of highest spending; and to examine drivers of spending groups.

METHODS

This retrospective analysis utilized 2016 Medicaid claims from 11 states and included 775,945 children ages 3 to 17 years with any MH diagnosis and at least 11 months of continuous coverage. We compared demographic characteristics and Medicaid expenditures based on total health care spending: the top 1% (highest-spending) and remaining 99% (typical-spending). We used chi-squared tests to compare the 2 groups and adjusted logistic regression to identify independent predictors of being in the top 1% highest-spending group.

RESULTS

Children with MH conditions accounted for 55% of Medicaid spending among 3- to 17-year olds. Patients in the highest-spending group were more likely to be older, have multiple MH conditions, and have complex chronic physical health conditions (P <.001). The highest-spending group had $164,003 per-member-per-year (PMPY) in total health care spending, compared to $6097 PMPY in the typical-spending group. Ambulatory MH services contributed the largest proportion (40%) of expenditures ($2455 PMPY) in the typical-spending group; general health hospitalizations contributed the largest proportion (36%) of expenditures ($58,363 PMPY) in the highest-spending group.

CONCLUSIONS

Among children with MH conditions, mental and physical health comorbidities were common and spending for general health care outpaced spending for MH care. Future research and quality initiatives should focus on integrating MH and physical health care services and investigate whether current spending on MH services supports high-quality MH care.