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Silverman AF, Westlake MA, Hinds OM, Harris SJ, Abraham AJ, Grogan CM, Andrews CM. Substance use disorder treatment carve outs in Medicaid managed care. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2024; 161:209357. [PMID: 38554998 PMCID: PMC11090713 DOI: 10.1016/j.josat.2024.209357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 02/19/2024] [Accepted: 03/18/2024] [Indexed: 04/02/2024]
Abstract
INTRODUCTION Medicaid managed care organizations (MCO) play a major role in addressing the nation's epidemic of drug overdose and mortality by administering substance use disorder (SUD) treatment benefits for over 50 million Americans. While it is known that some Medicaid MCO plans delegate responsibility for managing SUD treatment benefits to an outside "carve out" entity, the extent and structure of such carve out arrangements are unknown. This is an important gap in knowledge, given that carve outs have been linked to reductions in rates of SUD treatment receipt in several studies. To address this gap, we examined carve out arrangements used by Medicaid MCO plans to administer SUD treatment benefits in ten states. METHODS Data for this study was gleaned using a purposive sampling approach through content analysis of publicly available benefits information (e.g., member handbooks, provider manuals, prescription drug formularies) from 70 comprehensive Medicaid MCO plans in 10 selected states (FL, GA, IL, MD, MI, NH, OH, PA, UT, and WV) active in 2018. Each Medicaid MCO plan's documents were reviewed and coded to indicate whether a range of SUD treatment services (e.g., inpatient treatment, outpatient treatment, residential treatment) and medications were carved out, and if so, to what type of entity (e.g., behavioral health organization). RESULTS A large majority of Medicaid MCO plans carved out at least some (28.6 %) or all (40.0 %) SUD treatment services, with nearly all plans carving out some (77.1 %) or all (14.3 %) medications, mainly due to the carving out of methadone treatment. Medicaid MCO plans most commonly carved out SUD treatment services to behavioral health organizations, while most medications were carved out to state Medicaid fee-for-service plans. CONCLUSIONS Carve out arrangements for SUD treatment vary dramatically across states, across plans, and even within plans. Given that some studies have linked carve out arrangements to reductions in treatment access, their widespread use among Medicaid MCO plans is cause for further consideration by policymakers and other key interest groups. Moreover, reliance on such complex arrangements for administering care may create challenges for enrollees who seek to learn about and access plan benefits.
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Affiliation(s)
- Allie F Silverman
- Heller School for Social Policy and Management, Brandeis University, Schneider Building, 415 South Street, Waltham, MA 02453, United States of America.
| | - Melissa A Westlake
- Department of Health Services Policy and Management, Arnold School of Public Health, University of South Carolina, 915 Greene Street, Columbia, SC 29208, United States of America
| | - Olivia M Hinds
- Department of Health Services Policy and Management, Arnold School of Public Health, University of South Carolina, 915 Greene Street, Columbia, SC 29208, United States of America
| | - Samantha J Harris
- Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, 615 North Wolfe Street, Baltimore, MD 21205, United States of America
| | - Amanda J Abraham
- School of Public and International Affairs, University of Georgia, Candler Hall, 202 Herty Drive, Athens, GA 30602, United States of America
| | - Colleen M Grogan
- Center for Health Administration Studies, Crown School of Social Work, Policy, and Practice, 969 East 60th Street, Chicago, IL 60637, United States of America
| | - Christina M Andrews
- Department of Health Services Policy and Management, Arnold School of Public Health, University of South Carolina, 915 Greene Street, Columbia, SC 29208, United States of America
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McConnell KJ, Edelstein S, Hall J, Levy A, Danna M, Cohen DJ, Lindner S, Unützer J, Zhu JM. The effects of behavioral health integration in Medicaid managed care on access to mental health and primary care services-Evidence from early adopters. Health Serv Res 2023; 58:622-633. [PMID: 36635871 PMCID: PMC10154169 DOI: 10.1111/1475-6773.14132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
OBJECTIVE To evaluate the impacts of a transition to an "integrated managed care" model, wherein Medicaid managed care organizations moved from a "carve-out" model to a "carve-in" model integrating the financing of behavioral and physical health care. DATA SOURCES/STUDY SETTING Medicaid claims data from Washington State, 2014-2019, supplemented with structured interviews with key stakeholders. STUDY DESIGN This mixed-methods study used difference-in-differences models to compare changes in two counties that transitioned to financial integration in 2016 to 10 comparison counties maintaining carve-out models, combined with qualitative analyses of 15 key informant interviews. Quantitative outcomes included binary measures of access to outpatient mental health care, primary care, the emergency department (ED), and inpatient care for mental health conditions. DATA COLLECTION Medicaid claims were collected administratively, and interviews were recorded, transcribed, and analyzed using a thematic analysis approach. PRINCIPAL FINDINGS The transition to financially integrated care was initially disruptive for behavioral health providers and was associated with a temporary decline in access to outpatient mental health services among enrollees with serious mental illness (SMI), but there were no statistically significant or sustained differences after the first year. Enrollees with SMI also experienced a slight increase in access to primary care (1.8%, 95% CI 1.0%-2.6%), but no sustained statistically significant changes in the use of ED or inpatient services for mental health care. The transition to financially integrated care had relatively little impact on primary care providers, with few changes for enrollees with mild, moderate, or no mental illness. CONCLUSIONS Financial integration of behavioral and physical health in Medicaid managed care did not appear to drive clinical transformation and was disruptive to behavioral health providers. States moving towards "carve-in" models may need to incorporate support for practice transformation or financial incentives to achieve the benefits of coordinated mental and physical health care.
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Affiliation(s)
- K. John McConnell
- Center for Health Systems EffectivenessOregon Health & Science UniversityPortlandOregonUnited States
| | - Sara Edelstein
- Center for Health Systems EffectivenessOregon Health & Science UniversityPortlandOregonUnited States
| | - Jennifer Hall
- Department of Family MedicineOregon Health & Science UniversityPortlandOregonUnited States
| | - Anna Levy
- Center for Health Systems EffectivenessOregon Health & Science UniversityPortlandOregonUnited States
| | - Maria Danna
- Department of Family MedicineOregon Health & Science UniversityPortlandOregonUnited States
| | - Deborah J. Cohen
- Department of Family MedicineOregon Health & Science UniversityPortlandOregonUnited States
| | - Stephan Lindner
- Center for Health Systems EffectivenessOregon Health & Science UniversityPortlandOregonUnited States
| | - Jürgen Unützer
- Department of Psychiatry & Behavioral SciencesUniversity of WashingtonSeattleWAUnited States
| | - Jane M. Zhu
- Division of General Internal MedicineOregon Health & Science UniversityPortlandOregonUnited States
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Davis MT, Bohler R, Hodgkin D, Hamilton G, Horgan C. The role of health plans in addressing the opioid crisis: A qualitative study. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2023; 149:209022. [PMID: 36935064 PMCID: PMC10198902 DOI: 10.1016/j.josat.2023.209022] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 02/16/2023] [Accepted: 03/13/2023] [Indexed: 03/19/2023]
Abstract
INTRODUCTION Health plans are key players in substance use treatment in the United States, and the opioid crisis presents new challenges for them. This article is part of the HEALing Communities Study (HCS) funded by NIH, which seeks to facilitate communities' adoption of activities that might reduce overdose deaths, including overdose prevention education and naloxone distribution, medication for opioid use disorder, and safer opioid prescribing. We examine how health plans in one state (Massachusetts) are adapting to encourage and sustain activities that help communities to address opioid use disorder (OUD). METHODS We conducted semi-structured interviews with managers of behavioral health services at eight health plans in Massachusetts that that have Medicare, Medicaid, and commercial lines of business. Two plans in this sample contract with a specialized behavioral health organization ("carve-out"). The interviewees also completed a survey on policies regarding access to treatment and opioid prescribing. Interviews were recorded and transcribed and analyzed using thematic analysis. Analysis of the data included intended influence of the policies at three levels: member level (micro), group or community level (meso), and system or institutional level (macro). RESULTS All health plans developed strategies to increase access to treatment for OUD, primarily through eliminating or decreasing cost-sharing, eliminating pre-authorization for MOUD, and increasing supply of providers. Health plans encourage qualified practitioners to offer MOUD, but most do not provide incentives or training. Identifying high risk populations is a focus of health plans in this sample. Naloxone is a covered benefit in all health plans, although with variation in monthly limits and cost-sharing. Most health plans take measures to influence opioid prescribing. Health plans' activities are predominately aimed at the micro (member) level with little ability to influence at the macro (wider system-level changes). CONCLUSION This study provides insight into how health plans develop strategies to address the rise in OUD and fatal opioid overdoses, many of which are key in the HCS initiative. How active a role health plans play in addressing the opioid crisis varies, even within the insurance industry in one state (Massachusetts).
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Affiliation(s)
- Margot Trotter Davis
- Institute for Behavioral Health, Schneider Institutes for Health Policy, Heller School for Social Policy and Management, Brandeis University, United States of America.
| | - Robert Bohler
- Institute for Behavioral Health, Schneider Institutes for Health Policy, Heller School for Social Policy and Management, Brandeis University, United States of America
| | - Dominic Hodgkin
- Institute for Behavioral Health, Schneider Institutes for Health Policy, Heller School for Social Policy and Management, Brandeis University, United States of America
| | - Greer Hamilton
- Boston University School of Social Work, United States of America
| | - Constance Horgan
- Institute for Behavioral Health, Schneider Institutes for Health Policy, Heller School for Social Policy and Management, Brandeis University, United States of America
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McConnell KJ, Watson K, Choo E, Zhu JM. Geographical Variations In Emergency Department Visits For Mental Health Conditions For Medicaid Beneficiaries. Health Aff (Millwood) 2023; 42:172-181. [PMID: 36745838 PMCID: PMC11203219 DOI: 10.1377/hlthaff.2022.00796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Despite Medicaid's importance as a payer and source of coverage for mental health care, relatively little is known about how prevalence, access, and quality might vary among Medicaid beneficiaries. This study used national Medicaid data from 2018 to assess regional variations in emergency department (ED) visits for mental health conditions, a measure that may reflect unmet needs for behavioral health care. We found substantial variations, with rates in the region with the highest visit rates eight times higher than those in the region with the lowest rates. Many regions with high rates of ED visits for mental health conditions also had high rates of outpatient mental health use. Regional patterns differed substantially, with some regions exhibiting high rates of ED visits related to anxiety but low rates for schizophrenia and vice versa. The presence of large variations in ED visits for mental health conditions, with substantial differences in the composition across regions, suggests a need for context-specific solutions, including assessments of the ways in which mental health benefits are structured at the state Medicaid agency level and of differences in provider accessibility and an understanding of the types of mental illness underlying high rates of use.
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Affiliation(s)
- K John McConnell
- K. John McConnell , Oregon Health & Science University, Portland, Oregon
| | | | - Esther Choo
- Esther Choo, Oregon Health & Science University
| | - Jane M Zhu
- Jane M. Zhu, Oregon Health & Science University
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Grosse SD, Nichols P, Nyarko K, Maenner M, Danielson ML, Shea L. Heterogeneity in Autism Spectrum Disorder Case-Finding Algorithms in United States Health Administrative Database Analyses. J Autism Dev Disord 2022; 52:4150-4163. [PMID: 34581918 PMCID: PMC9077262 DOI: 10.1007/s10803-021-05269-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/01/2021] [Indexed: 12/19/2022]
Abstract
Strengthening systems of care to meet the needs of individuals with autism spectrum disorder (ASD) is of growing importance. Administrative data provide advantages for research and planning purposes, including large sample sizes and the ability to identify enrollment in insurance coverage and service utilization of individuals with ASD. Researchers have employed varying strategies to identify individuals with ASD in administrative data. Differences in these strategies can limit the comparability of results across studies. This review describes implications of the varying strategies that have been employed to identify individuals with ASD in US claims databases, with consideration of the strengths and limitations of each approach.
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Affiliation(s)
- Scott D Grosse
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, 4770 Buford Highway NE, Mail Stop S106-4, Atlanta, GA, 30341, USA.
| | - Phyllis Nichols
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, 4770 Buford Highway NE, Mail Stop S106-4, Atlanta, GA, 30341, USA
| | - Kwame Nyarko
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, 4770 Buford Highway NE, Mail Stop S106-4, Atlanta, GA, 30341, USA
| | - Matthew Maenner
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, 4770 Buford Highway NE, Mail Stop S106-4, Atlanta, GA, 30341, USA
| | - Melissa L Danielson
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, 4770 Buford Highway NE, Mail Stop S106-4, Atlanta, GA, 30341, USA
| | - Lindsay Shea
- Policy and Analytics Center, A.J. Drexel Autism Institute, Drexel University, Philadelphia, PA, USA
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Risk-based contracting for high-need Medicaid beneficiaries: The Arkansas PASSE program. HEALTH POLICY OPEN 2021. [DOI: 10.1016/j.hpopen.2020.100023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Charlesworth CJ, Zhu JM, Horvitz-Lennon M, McConnell KJ. Use of behavioral health care in Medicaid managed care carve-out versus carve-in arrangements. Health Serv Res 2021; 56:805-816. [PMID: 34312839 DOI: 10.1111/1475-6773.13703] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 04/01/2021] [Accepted: 04/14/2021] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To evaluate differences in access to behavioral health services for Medicaid enrollees covered by a Medicaid entity that integrated the financing of behavioral and physical health care ("carve-in group") versus a Medicaid entity that separated this financing ("carve-out group"). DATA SOURCES/STUDY SETTING Medicaid claims data from two Medicaid entities in the Portland, Oregon tri-county area in 2016. STUDY DESIGN In this cross-sectional study, we compared differences across enrollees in the carve-in versus carve-out group, using a machine learning approach to incorporate a large set of covariates and minimize potential selection bias. Our primary outcomes included behavioral health visits for a variety of different provider types. Secondary outcomes included inpatient, emergency department, and primary care visits. DATA COLLECTION We used Medicaid claims, including adults with at least 9 months of enrollment. PRINCIPAL FINDINGS The study population included 45,786 adults with mental health conditions. Relative to the carve-out group, individuals in the carve-in group were more likely to access outpatient behavioral health (2.39 percentage points, p < 0.0001, with a baseline rate of approximately 73%). The carve-in group was also more likely to access primary care physicians, psychologists, and social workers and less likely to access psychiatrists and behavioral health specialists. Access to outpatient behavioral health visits was more likely in the carve-in arrangement among individuals with mild or moderate mental health conditions (compared to individuals with severe mental illness) and among black enrollees (compared to white enrollees). CONCLUSIONS Financial integration of physical and behavioral health in Medicaid managed care was associated with greater access to behavioral health services, particularly for individuals with mild or moderate mental health conditions and for black enrollees. Recent changes to incentivize financial integration should be monitored to assess differential impacts by illness severity, race and ethnicity, provider types, and other factors.
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Affiliation(s)
- Christina J Charlesworth
- Center for Health Systems Effectiveness, Oregon Health & Science University, Portland, Oregon, USA
| | - Jane M Zhu
- Division of General Internal Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Marcela Horvitz-Lennon
- RAND Corporation, Cambridge Heath Alliance and Harvard Medical School, Boston, Massachusetts, USA
| | - K John McConnell
- Center for Health Systems Effectiveness, Oregon Health & Science University, Portland, Oregon, USA
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Hamersma S, Maclean JC. Do expansions in adolescent access to public insurance affect the decisions of substance use disorder treatment providers? JOURNAL OF HEALTH ECONOMICS 2021; 76:102434. [PMID: 33578327 DOI: 10.1016/j.jhealeco.2021.102434] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Revised: 01/14/2021] [Accepted: 01/15/2021] [Indexed: 06/12/2023]
Abstract
We apply a mixed-payer economy model to study the effects of changes in the generosity of children's public health insurance programs - measured by Medicaid and Children's Health Insurance Program income thresholds - on substance use disorder (SUD) treatment provider behavior. Using government data on specialty SUD treatment providers over the period 1997-2011 combined with a two-way fixed-effects model and local event study, we show that increases in the generosity of children's public health insurance induce providers to participate in some, but not all, public markets. Our effects appear to be driven by non-profit and government providers. Non-profit providers also appear to increase treatment quantity slightly in response to coverage expansions.
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Affiliation(s)
- Sarah Hamersma
- Department of Public Administration and International Affairs, Syracuse University, Senior Research Associate, Center for Policy Research, Syracuse, NY, USA.
| | - Johanna Catherine Maclean
- National Bureau of Economic Research, Cambridge, MA, USA; Institute for the Study of Labor, Bonn, Germany.
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Friedman S, Xu H, Azocar F, Ettner SL. Carve-out plan financial requirements associated with national behavioral health parity. Health Serv Res 2020; 55:924-931. [PMID: 32880927 DOI: 10.1111/1475-6773.13542] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVES To examine changes in carve-out financial requirements (copayments, coinsurance, use of deductibles, and out-of-pocket maxima) following the Mental Health Parity and Addiction Equity Act (MHPAEA). DATA SOURCE/STUDY SETTING Specialty mental health benefit design information for employer-sponsored carve-out plans from a national managed behavioral health organization's claims processing engine (2008-2013). STUDY DESIGN This pre-post study reports linear and logistic regression as the main analysis. DATA COLLECTION/EXTRACTION METHODS NA. PRINCIPAL FINDINGS Copayments for in-network emergency room (-$44.9, 95% CI: -78.3, -11.5; preparity mean: $56.2), outpatient services (eg, individual psychotherapy: -$7.4, 95% CI: -10.5, -4.2; preparity mean: $17.8), and out-of-network coinsurance for emergency room (-11 percentage points, 95% CI: -16.7, -5.4; preparity mean: 38.8 percent) and outpatient (eg, individual psychotherapy: -5.8 percentage points, 95% CI: -10.0, -1.6; preparity mean 41.0 percent) decreased. Probability of family OOP maxima use (29 percentage points, 95% CI: 19.3, 38.6; preparity mean: 36 percent) increased. In-network outpatient coinsurance increased (eg, individual psychotherapy: 4.5 percentage points, 95% CI: 1.1, 7.9; preparity mean: 2.7 percent), as did probability of use of family deductibles (15 percentage points, 95% CI: 6.1, 23.3; preparity mean: 38 percent). CONCLUSIONS MHPAEA was associated with increased generosity in most financial requirements observed here. However, increased use of deductibles may have reduced generosity for some patients.
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Affiliation(s)
- Sarah Friedman
- School of Community Health Sciences, University of Nevada, Reno, Nevada
| | - Haiyong Xu
- Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, California
| | | | - Susan L Ettner
- Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, California.,Department of Health Policy and Management, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, California
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10
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Coverage mandates and market dynamics: employer, insurer and patient responses to parity laws. HEALTH ECONOMICS POLICY AND LAW 2018; 15:173-195. [DOI: 10.1017/s1744133118000294] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractParity in coverage for mental health services has been a longstanding policy aim at the state and federal levels and is a regulatory feature of the Affordable Care Act. Despite the importance and legislative effort involved in these policies, evaluations of their effects on patients yield mixed results. I leverage the Employee Retirement Income Security Act and unique claims-level data that includes information on employers’ self-insurance status to shed new light in this area after the implementation of two state parity laws in 2007 and federal parity a few years later. My empirics reveal evidence of strategic avoidance on behalf of insurers in both states prior to the passage of state parity, as well as positive increases in mental health care utilization after parity laws are implemented – but context matters. Policy heterogeneity across states and strategic behaviors by employers and commercial insurers substantively shape the benefits that ultimately flow to patients. Insights from this research have broad relevance to ongoing health policy debates, particularly as states retain great discretion over many health coverage decisions and as federal policy continues to evolve.
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11
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Nathenson R, Richards MR. Do coverage mandates affect direct-to-consumer advertising for pharmaceuticals? Evidence from parity laws. INTERNATIONAL JOURNAL OF HEALTH ECONOMICS AND MANAGEMENT 2018; 18:321-336. [PMID: 29380108 DOI: 10.1007/s10754-018-9234-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Accepted: 01/03/2018] [Indexed: 06/07/2023]
Abstract
Direct-to-consumer advertising (DTCA) for prescription drugs is a relatively unique feature of the US health care system and a source of tens of billions of dollars in annual spending. It has also garnered the attention of researchers and policymakers interested in its implications for firm and consumer behavior. However, few economic studies have explored the DTCA response to public policies, especially those mandating coverage of these products. We use detailed advertising expenditure data to assess if pharmaceutical firms increase their marketing efforts after the implementation of relevant state and federal health insurance laws. We focus on mental health parity statutes and related drug therapies-a potentially ripe setting for inducing stronger consumer demand. We find no clear indication that firms expect greater value from DTCA after these regulatory changes. DTCA appears driven by other considerations (e.g., product debut); however, it remains a possibility that firms respond to these laws through other, unobserved channels (e.g., provider detailing).
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Affiliation(s)
- Robert Nathenson
- University of Pennsylvania, 3440 Market Street Suite 560, Philadelphia, PA, 19146, USA.
| | - Michael R Richards
- Department of Health Policy, Vanderbilt University School of Medicine, 2525 West End, Suite 1275, Nashville, 37203, TN, USA
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Horgan CM, Stewart MT, Reif S, Garnick DW, Hodgkin D, Merrick EL, Quinn AE. Behavioral Health Services in the Changing Landscape of Private Health Plans. Psychiatr Serv 2016; 67:622-9. [PMID: 26876663 PMCID: PMC4889503 DOI: 10.1176/appi.ps.201500235] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVE Health plans play a key role in facilitating improvements in population health and may engage in activities that have an impact on access, cost, and quality of behavioral health care. Although behavioral health care is becoming more integrated with general medical care, its delivery system has unique aspects. The study examined how health plans deliver and manage behavioral health care in the context of the Affordable Care Act (ACA) and the 2008 Mental Health Parity and Addiction Equity Act (MHPAEA). This is a critical time to examine how health plans manage behavioral health care. METHODS A nationally representative survey of private health plans (weighted N=8,431 products; 89% response rate) was conducted in 2010 during the first year of MHPAEA, when plans were subject to the law but before final regulations, and just before the ACA went into effect. The survey addressed behavioral health coverage, cost-sharing, contracting arrangements, medical home innovations, support for technology, and financial incentives to improve behavioral health care. RESULTS Coverage for inpatient and outpatient behavioral health services was stable between 2003 and 2010. In 2010, health plans were more likely than in 2003 to manage behavioral health care through internal arrangements and to contract for other services. Medical home initiatives were common and almost always included behavioral health, but financial incentives did not. Some plans facilitated providers' use of technology to improve care delivery, but this was not the norm. CONCLUSIONS Health plans are key to mainstreaming and supporting delivery of high-quality behavioral health services. Since 2003, plans have made changes to support delivery of behavioral health services in the context of a rapidly changing environment.
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Affiliation(s)
- Constance M Horgan
- The authors are with the Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts (e-mail: )
| | - Maureen T Stewart
- The authors are with the Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts (e-mail: )
| | - Sharon Reif
- The authors are with the Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts (e-mail: )
| | - Deborah W Garnick
- The authors are with the Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts (e-mail: )
| | - Dominic Hodgkin
- The authors are with the Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts (e-mail: )
| | - Elizabeth L Merrick
- The authors are with the Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts (e-mail: )
| | - Amity E Quinn
- The authors are with the Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts (e-mail: )
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13
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Andersen M. Heterogeneity and the effect of mental health parity mandates on the labor market. JOURNAL OF HEALTH ECONOMICS 2015; 43:74-84. [PMID: 26210944 PMCID: PMC4591173 DOI: 10.1016/j.jhealeco.2015.06.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Revised: 06/09/2015] [Accepted: 06/30/2015] [Indexed: 06/07/2023]
Abstract
Health insurance benefit mandates are believed to have adverse effects on the labor market, but efforts to document such effects for mental health parity mandates have had limited success. I show that one reason for this failure is that the association between parity mandates and labor market outcomes vary with mental distress. Accounting for this heterogeneity, I find adverse labor market effects for non-distressed individuals, but favorable effects for moderately distressed individuals and individuals with a moderately distressed family member. On net, I conclude that the mandates are welfare increasing for moderately distressed workers and their families, but may be welfare decreasing for non-distressed individuals.
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Affiliation(s)
- Martin Andersen
- Department of Economics, Bryan School, University of North Carolina at Greensboro, PO Box 26170, Greensboro, NC 27402, United States.
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Garnick DW, Horgan CM, Merrick EL, Hodgkin D, Reif S, Quinn AE, Stewart M, Creedon TB. Private Health Plans' Contracts with Managed Behavioral Healthcare Organizations. J Behav Health Serv Res 2015; 44:149-157. [PMID: 26276421 DOI: 10.1007/s11414-015-9474-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Deborah W Garnick
- Institute for Behavioral Health, Schneider Institutes for Health Policy, Heller School for Social Policy and Management, Brandeis University, 415 South Street, 02454, Waltham, MA, USA.
| | - Constance M Horgan
- Institute for Behavioral Health, Schneider Institutes for Health Policy, Heller School for Social Policy and Management, Brandeis University, 415 South Street, 02454, Waltham, MA, USA
| | - Elizabeth L Merrick
- Institute for Behavioral Health, Schneider Institutes for Health Policy, Heller School for Social Policy and Management, Brandeis University, 415 South Street, 02454, Waltham, MA, USA
| | - Dominic Hodgkin
- Institute for Behavioral Health, Schneider Institutes for Health Policy, Heller School for Social Policy and Management, Brandeis University, 415 South Street, 02454, Waltham, MA, USA
| | - Sharon Reif
- Institute for Behavioral Health, Schneider Institutes for Health Policy, Heller School for Social Policy and Management, Brandeis University, 415 South Street, 02454, Waltham, MA, USA
| | - Amity E Quinn
- Institute for Behavioral Health, Schneider Institutes for Health Policy, Heller School for Social Policy and Management, Brandeis University, 415 South Street, 02454, Waltham, MA, USA
| | - Maureen Stewart
- Institute for Behavioral Health, Schneider Institutes for Health Policy, Heller School for Social Policy and Management, Brandeis University, 415 South Street, 02454, Waltham, MA, USA
| | - Timothy B Creedon
- Institute for Behavioral Health, Schneider Institutes for Health Policy, Heller School for Social Policy and Management, Brandeis University, 415 South Street, 02454, Waltham, MA, USA
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Golberstein E, Busch SH, Zaha R, Greenfield SF, Beardslee WR, Meara E. Effect of the Affordable Care Act's young adult insurance expansions on hospital-based mental health care. Am J Psychiatry 2015; 172:182-9. [PMID: 25263817 PMCID: PMC4314328 DOI: 10.1176/appi.ajp.2014.14030375] [Citation(s) in RCA: 77] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Insurance coverage for young adults has increased since 2010, when the Affordable Care Act (ACA) required insurers to permit children to remain on parental policies until age 26 as dependents. This study estimated the association between the dependent coverage provision and changes in young adults' use of hospital-based services for substance use disorders and non-substance use psychiatric disorders. METHOD The authors conducted a quasi-experimental comparison of a national sample of non-childbirth-related inpatient admissions to general hospitals (a total of 2,670,463 admissions, 430,583 of which had primary psychiatric diagnoses) and California emergency department visits with psychiatric diagnoses (N=11,139,689), using data spanning 2005 to 2011. Analyses compared young adults who were targeted by the ACA dependent coverage provision (19- to 25-year-olds) and those who were not (26- to 29-year-olds), estimating changes in utilization before and after implementation of the dependent coverage provision. Primary outcome measures included quarterly inpatient admissions for primary diagnoses of any psychiatric disorder per 1,000 population; emergency department visits with any psychiatric diagnosis per 1,000 population; and payer source. RESULTS Dependent coverage expansion was associated with 0.14 more inpatient admissions for psychiatric diagnoses per 1,000 for 19- to 25-year-olds (targeted by the ACA) than for 26- to 29-year-olds (not targeted by the ACA). The coverage expansion was associated with 0.45 fewer psychiatric emergency department visits per 1,000 in California. The probability that inpatient admissions nationally and emergency department visits in California were uninsured decreased significantly. CONCLUSIONS ACA dependent coverage provisions produced modest increases in general hospital psychiatric inpatient admissions and higher rates of insurance coverage for young adults nationally. Lower rates of emergency department visits were observed in California.
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Affiliation(s)
- Ezra Golberstein
- Division of Health Policy and Management, University of Minnesota School of Public Health
| | - Susan H. Busch
- Department of Health Policy and Management Yale School of Public Health
| | - Rebecca Zaha
- The Dartmouth Institute for Health Policy and Clinical Practice Geisel School of Medicine
| | | | - William R. Beardslee
- Baer Prevention Initiatives, Department of Psychiatry Boston Children's Hospital AND Gardner-Monks Professor of Child Psychiatry Harvard Medical School
| | - Ellen Meara
- The Dartmouth Institute for Health Policy and Clinical Practice Geisel School of Medicine AND National Bureau of Economic Research, Cambridge, MA
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Saloner B, Matone M, Kreider AR, Budeir MS, Miller D, Huang YS, Raghavan R, French B, Rubin D. Second-generation antipsychotic use among stimulant-using children, by organization of medicaid mental health. Psychiatr Serv 2014; 65:1458-64. [PMID: 25179737 PMCID: PMC4757898 DOI: 10.1176/appi.ps.201300574] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Reducing overuse of second-generation antipsychotics among Medicaid-enrolled children is a national priority, yet little is known about how service organization affects use. This study compared differences in second-generation antipsychotic utilization among Medicaid-enrolled children across fee-for-service, integrated managed care, and managed behavioral health carve-out organizational structures. METHODS Organizational structures of Medicaid programs in 82 diverse counties in 34 states were categorized and linked to child-level cross-sectional claims data from the Medicaid Analytic Extract covering fiscal years 2004, 2006, and 2008. To approximate the population at risk of antipsychotic treatment, the sample was restricted to stimulant-using children ages three to 18 (N=419,226). The sample was stratified by Medicaid eligibility group, and logistic regression models were estimated for probability of second-generation antipsychotic use. Models included indicators of county-level organizational structure as main predictors, with sequential adjustment for personal and county-level covariates. RESULTS With adjustment for person-level covariates, second-generation antipsychotic use was 31% higher among youths in foster care in fee-for-service counties than for youths in counties with carve-outs (odds ratio [OR]=1.69, 95% confidence interval [CI]=1.26-2.27). Foster care youths in integrated counties had the second highest adjusted odds (OR=1.31, CI=1.08-1.58). Similar patterns of use also were found for youths eligible for Supplemental Security Income but not for those eligible for Temporary Assistance for Needy Families. Differences persisted after adjustment for county-level characteristics. CONCLUSIONS Carve-outs, versus other arrangements, were associated with lower second-generation antipsychotic use. Future research should explore carve-out features (for example, tighter management of inpatient or restricted access, as well as care coordination) contributing to lower second-generation antipsychotic use.
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Affiliation(s)
- Brendan Saloner
- Dr. Saloner is with the Department of Health Care Policy, Johns Hopkins University, Baltimore (e-mail: ). Ms. Matone, Ms. Kreider, Mr. Budeir, Ms. Miller, and Dr. Rubin are with PolicyLab, Children's Hospital of Philadelphia, Philadelphia. Dr. Rubin is also with the Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia. Ms. Huang is with Division of General Pediatrics and Healthcare Analytics Unit, Children's Hospital of Philadelphia. Dr. Raghavan is with the George Warren Brown School of Social Work, Washington University in St. Louis, St. Louis, Missouri. Dr. French is with the Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia
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Meara E, Golberstein E, Zaha R, Greenfield SF, Beardslee WR, Busch SH. Use of hospital-based services among young adults with behavioral health diagnoses before and after health insurance expansions. JAMA Psychiatry 2014; 71:404-11. [PMID: 24554245 PMCID: PMC4140186 DOI: 10.1001/jamapsychiatry.2013.3972] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Young adults have high levels of behavioral health needs but often lack health insurance. Recent health reforms have increased coverage, but it is unclear how use of hospital-based care changed after expanding insurance. OBJECTIVE To evaluate the association between health insurance coverage expansions and use of hospital-based care among young adults with behavioral health diagnoses. DESIGN, SETTING, AND PARTICIPANTS Quasi-experimental analyses of community hospital inpatient and emergency department use from 2003-2009 based on hospital discharge data, comparing differential changes in service use among young adults with behavioral health diagnoses in Massachusetts vs other states before and after Massachusetts' 2006 health reform. This population-based sample included inpatient admissions (n = 2,533,307, representing 12,821,746 weighted admissions across 7 years) nationwide and emergency department visits (n = 6,817,855 across 7 years) from Maryland and Massachusetts for 12- to 25-year-old patients. MAIN OUTCOMES AND MEASURES Inpatient admission rates per 1000 population for primary diagnosis of any behavioral health disorder by diagnosis; emergency department visit rates per 1000 population by behavioral health diagnosis; and insurance coverage for hospital discharges. RESULTS After 2006, uninsurance among 19- to 25-year-old individuals in Massachusetts decreased from 26% to 10% (16 percentage points; 95% CI, 13-20). Young adults experienced relative declines in inpatient admission rates of 2.0 per 1000 for primary diagnoses of any behavioral health disorder (95% CI, 0.95-3.2), 0.38 for depression (95% CI, 0.18-0.58), and 1.3 for substance use disorder (95% CI, 0.68-1.8). The increase in emergency department visits with any behavioral health diagnosis after 2006 was lower among young adults in Massachusetts compared with Maryland (16.5 per 1000; 95% CI, 11.4-21.6). Among young adults in Massachusetts, the percentage of behavioral health discharges that were uninsured decreased by 5.0 (95% CI, 3.0-7.2) percentage points in inpatient settings and 5.0 (95% CI, 1.7-7.8) percentage points in emergency departments relative to other states. CONCLUSIONS AND RELEVANCE Expanded health insurance coverage for young adults was not associated with large increases in hospital-based care for behavioral health, but it increased financial protection for young adults with behavioral health diagnoses and for the hospitals that care for them.
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Affiliation(s)
- Ellen Meara
- Associate Professor, The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, 35 Centerra Parkway, Lebanon, NH 03766, Phone: 603-653-0899 Fax: 603-653-0820,National Bureau of Economic Research, Cambridge, MA
| | - Ezra Golberstein
- Assistant Professor of Health Policy and Management, University of Minnesota School of Public Health
| | - Rebecca Zaha
- Epidemiologic Research Analyst, The Dartmouth Institute for Health Policy and Clinical Practice Geisel School of Medicine
| | - Shelly F. Greenfield
- Chief Academic Officer, McLean Hospital,Professor of Psychiatry, Harvard Medical School
| | - William R. Beardslee
- Director, Baer Prevention Initiatives, Department of Psychiatry, Boston Children's Hospital,Gardner-Monks Professor of Child Psychiatry, Harvard Medical School
| | - Susan H. Busch
- Associate Professor, Department of Health Policy and Management, Yale School of Public Health
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Taylor-Brown S, Rosenberg T, McDaniel SH. Chronic Illness and Primary Care: Integrating Mental Health and Primary Care. THE CHALLENGES OF MENTAL HEALTH CAREGIVING 2014. [DOI: 10.1007/978-1-4614-8791-3_4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
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Green CA, Estroff SE, Yarborough BJH, Spofford M, Solloway MR, Kitson RS, Perrin NA. Directions for future patient-centered and comparative effectiveness research for people with serious mental illness in a learning mental health care system. Schizophr Bull 2014; 40 Suppl 1:S1-S94. [PMID: 24489078 PMCID: PMC3911266 DOI: 10.1093/schbul/sbt170] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Cook BL, Doksum T, Chen CN, Carle A, Alegría M. The role of provider supply and organization in reducing racial/ethnic disparities in mental health care in the U.S. Soc Sci Med 2013; 84:102-9. [PMID: 23466259 PMCID: PMC3659418 DOI: 10.1016/j.socscimed.2013.02.006] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2012] [Revised: 01/01/2013] [Accepted: 02/03/2013] [Indexed: 11/21/2022]
Abstract
Racial and ethnic disparities in mental health care access in the United States are well documented. Prior studies highlight the importance of individual and community factors such as health insurance coverage, language and cultural barriers, and socioeconomic differences, though these factors fail to explain the extent of measured disparities. A critical factor in mental health care access is a local area's organization and supply of mental health care providers. However, it is unclear how geographic differences in provider organization and supply impact racial/ethnic disparities. The present study is the first analysis of a nationally representative U.S. sample to identify contextual factors (county-level provider organization and supply, as well as socioeconomic characteristics) associated with use of mental health care services and how these factors differ across racial/ethnic groups. Hierarchical logistic models were used to examine racial/ethnic differences in the association of county-level provider organization (health maintenance organization (HMO) penetration) and supply (density of specialty mental health providers and existence of a community mental health center) with any use of mental health services and specialty mental health services. Models controlled for individual- and county-level socio-demographic and mental health characteristics. Increased county-level supply of mental health care providers was significantly associated with greater use of any mental health services and any specialty care, and these positive associations were greater for Latinos and African-Americans compared to non-Latino Whites. Expanding the mental health care workforce holds promise for reducing racial/ethnic disparities in mental health care access. Policymakers should consider that increasing the management of mental health care may not only decrease expenditures, but also provide a potential lever for reducing mental health care disparities between social groups.
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Affiliation(s)
- Benjamin Lê Cook
- Department of Psychiatry, Harvard Medical School, Center for Multicultural Mental Health Research, Somerville, MA 02478, USA.
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21
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Adams SH, Newacheck PW, Park MJ, Brindis CD, Irwin CE. Medical home for adolescents: low attainment rates for those with mental health problems and other vulnerable groups. Acad Pediatr 2013; 13:113-21. [PMID: 23375459 DOI: 10.1016/j.acap.2012.11.004] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2012] [Revised: 11/16/2012] [Accepted: 11/20/2012] [Indexed: 01/23/2023]
Abstract
BACKGROUND The importance of the medical home for children has been demonstrated but has not been examined comprehensively for adolescents. Adolescence is a unique period of physical, cognitive, and psychosocial changes when many mental disorders first emerge; thus, receiving care within a medical home could improve well-being. This study examines rates of medical home attainment and its components for adolescents and subgroups, including those with mental health conditions. METHODS Utilizing the 2007 National Survey of Children's Health, we determined the following for adolescents aged 10 to 17 years (n = 45 897): 1) rates of medical home attainment and its 5 components (usual source of care, having a personal doctor, and receiving needed referrals, effective care coordination, and family-centered care); and 2) subgroup differences; gender, race/ethnicity, income, insurance, region, language spoken at home, respondent education, and the presence of mental health conditions. RESULTS Fifty-four percent of adolescents had a past-year medical home. Rates were lower for minority youth compared to whites; lower-income and uninsured youth; those in households that are non-English speaking in which the respondent did not have some college; and those with mental health as opposed to physical health conditions (all P < .01). Patterns of disparities in the medical home components were similar, and rates were lowest for effective care coordination and family-centered care components. CONCLUSIONS Nearly half of adolescents lacked a medical home in the past year. Even lower rates for subgroups highlight the need to increase access to comprehensive quality health care. Efforts to improve effective care coordination and family-centered care could result in higher quality of care for all children and adolescents, and specifically for disadvantaged adolescents and those with mental health conditions.
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Affiliation(s)
- Sally H Adams
- Department of Pediatrics, University of California, San Francisco, CA 94143, USA.
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22
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Ajmera M, Wilkins TL, Findley PA, Sambamoorthi U. Multimorbidity, Mental Illness, and Quality of Care: Preventable Hospitalizations among Medicare Beneficiaries. INTERNATIONAL JOURNAL OF FAMILY MEDICINE 2012; 2012:823294. [PMID: 23320168 PMCID: PMC3539324 DOI: 10.1155/2012/823294] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/11/2012] [Revised: 10/06/2012] [Accepted: 10/21/2012] [Indexed: 06/01/2023]
Abstract
Background. Individuals with multimorbidity are vulnerable to poor quality of care due to issues related to care coordination. Ambulatory care sensitive hospitalizations (ACSHs) are widely accepted quality indicators because they can be avoided by timely, appropriate, and high-quality outpatient care. Objective. To examine the association between multimorbidity, mental illness, and ACSH. Study Design. We used a longitudinal panel design with data from multiple years (2000-2005) of Medicare Current Beneficiary Survey. Individuals were categorized into three groups: (1) multimorbidity with mental illness (MM/MI); (2) MM/no MI; (3) no MM. Multivariable logistic regressions were used to analyze the association between multimorbidity and ACSH. Results. Any ACSH rates varied from 10.8% in MM/MI group to 8.8% in MM/No MI group. Likelihood of any ACSH was higher among beneficiaries with MM/MI (AOR = 1.62; 95% CI = 1.14, 2.30) and MM (AOR = 1.54; 95% CI = 1.12, 2.11) compared to beneficiaries without multimorbidity. There was no statistically significant difference in likelihood of ACSH between MM/MI and MM/No MI groups. Conclusion. Multimorbidity (with or without MI) had an independent and significant association with any ACSH. However, presence of mental illness alone was not associated with poor quality of care as measured by ACSH.
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Affiliation(s)
- Mayank Ajmera
- Department of Pharmaceutical Systems and Policy, School of Pharmacy, West Virginia University, Morgantown, WV 26506, USA
| | - Tricia Lee Wilkins
- Department of Pharmaceutical Systems and Policy, School of Pharmacy, West Virginia University, Morgantown, WV 26506, USA
| | | | - Usha Sambamoorthi
- Department of Pharmaceutical Systems and Policy, School of Pharmacy, West Virginia University, Morgantown, WV 26506, USA
- HSR&D Center for Healthcare Knowledge Management, Veterans Administration New Jersey Healthcare System East Orange, NJ 07018, USA
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Chuang E, Wells R, Alexander JA. Public managed care and service access in outpatient substance abuse treatment units. J Behav Health Serv Res 2012; 38:444-63. [PMID: 21184286 DOI: 10.1007/s11414-010-9230-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The continued growth of public managed behavioral health care has raised concerns about possible effects on services provided. This study uses a national sample of outpatient substance abuse treatment units surveyed in 2005 to examine associations between public managed care and service access, measured as both the types of services provided and the amount of treatment received by clients. The percentage of clients funded through public managed care versus other types of public funding was positively associated with treatment units' odds of providing some types of resource-intensive services and with the odds of providing transportation to clients, but was negatively associated with the average number of individual therapy sessions clients received over the course of treatment. In general, public managed care does not appear to restrict access to outpatient substance abuse treatment, although states should monitor these contracts to ensure clients receive adequate courses of individual treatment.
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Affiliation(s)
- Emmeline Chuang
- Department of Mental Health Law and Policy, Department of Child and Family Studies, College of Behavioral and Community Studies, 13301 Bruce B Downs Blvd, Tampa, FL 33612-3807, USA.
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Reay WE. Organizational adaptation: bridging the research to practice gap. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2010; 37:95-9. [PMID: 20143149 DOI: 10.1007/s10488-010-0275-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Currently, the children's mental health system appears dysfunctional and in need of serious attention. A possible remedy for this disarray would be for researchers and providers to establish integrated management systems which include mutual, cross organizational learning, and reciprocal feedback mechanisms. This type of adaptive co-management to organizational governance would fully integrate research and practice at the community level. Using a public health service model, this organizational management approach to research and practice would harvest diverse scientific knowledge and disseminate that knowledge through the natural occurring culture and practice of each community. Organizational and clinical knowledge acquisition, as well as practice improvements would necessarily occur over time and across institutions.
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Affiliation(s)
- William E Reay
- OMNI Behavioral Health and Northcentral University, 5115 F Street, Omaha, NE 68117-2807, USA.
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Sterling S, Weisner C, Hinman A, Parthasarathy S. Access to treatment for adolescents with substance use and co-occurring disorders: challenges and opportunities. J Am Acad Child Adolesc Psychiatry 2010; 49:637-46; quiz 725-6. [PMID: 20610133 PMCID: PMC3045032 DOI: 10.1016/j.jaac.2010.03.019] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2010] [Revised: 03/23/2010] [Accepted: 03/31/2010] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To review the research on economic and systemic barriers faced by adolescents needing treatment for alcohol and drug problems, particularly those with co-occurring conditions. METHOD We reviewed the literature on adolescent access to alcohol and drug services, including early intervention, and integrated and specialty mental health treatment for those with co-occurring disorders, examining the role of health care systems, public policy (health reform), treatment financing and reimbursement systems (public and private), implementation of evidence-based practices, confidentiality practices, and treatment costs and cost/benefits. RESULTS Barriers to treatment, particularly integrated treatment, are largely rooted in our organizationally fragmented health care system, which encompasses public and private, carved-out and integrated systems, and different funding mechanisms (Medicaid versus block grants versus private insurance that include "high deductible" plans and other cost controls.) In both systems, carved-out programs de-link services from other mental health and general health care. Barriers are also rooted in disciplinary differences and weak clinical linkages between psychiatry, primary care and substance use, and in confidentiality policies that inhibit communication and coordination, while protecting patient privacy. CONCLUSION In this era of health care reform, we have the opportunity to increase access for adolescents and develop new models of integrated services for those with co-occurring conditions. We discuss opportunities for improving treatment access and implementation of evidence-based practices, examine implications of health reform and parity legislation for psychiatric and substance use treatment, and comment on key unanswered questions and future research opportunities.
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Affiliation(s)
- Stacy Sterling
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, 3rd Floor, Oakland, CA 94612-2403, USA.
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26
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Merrick EL, Hodgkin D, Hiatt D, Horgan CM, Azzone V, McCann B, Ritter G, Zolotusky G, McGuire TG, Reif S. Patterns of service use in two types of managed behavioral health care plans. Psychiatr Serv 2010; 61:86-9. [PMID: 20044425 PMCID: PMC2801078 DOI: 10.1176/appi.ps.61.1.86] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The study examined service use patterns by level of care in two managed care plans offered by a national managed behavioral health care organization (MBHO): an employee assistance program (EAP) combined with a standard behavioral health plan (integrated plan) and a standard behavioral health plan. METHODS The cross-sectional analysis used 2004 administrative data from the MBHO. Utilization of 11 specific service categories was compared. The weighted sample reflected exact matching on sociodemographic characteristics (unweighted N=710,014; weighted N=286,750). RESULTS A larger proportion of enrollees in the integrated plan than in the standard plan used outpatient mental health and substance abuse office visits (including EAP visits) (p<.01) and substance abuse intensive outpatient or day treatment (p<.05), and the proportion using residential substance abuse rehabilitation was lower (p<.05). CONCLUSIONS The integrated and standard products had distinct utilization patterns in this large MBHO. In particular, greater use of certain outpatient services was observed in the integrated plan.
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Affiliation(s)
- Elizabeth L Merrick
- Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, Waltham, MA 02454, USA.
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Affiliation(s)
- Kavita Patel
- Office of Public Engagement and Intergovernmental Affairs, the White House, Washington, DC, USA
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Levy Merrick ES, Hodgkin D, Horgan CM, Hiatt D, McCann B, Azzone V, Zolotusky G, Ritter G, Reif S, McGuire TG. Integrated employee assistance program/managed behavioral health care benefits: relationship with access and client characteristics. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2009; 36:416-23. [PMID: 19690952 DOI: 10.1007/s10488-009-0232-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2009] [Accepted: 07/22/2009] [Indexed: 11/27/2022]
Abstract
This study examined service user characteristics and determinants of access for enrollees in integrated EAP/behavioral health versus standard managed behavioral health care plans. A national managed behavioral health care organization's claims data from 2004 were used. Integrated plan service users were more likely to be employees rather than dependents, and to be diagnosed with adjustment disorder. Logistic regression analyses found greater likelihood in integrated plans of accessing behavioral health services (OR 1.20, CI 1.17-1.24), and substance abuse services specifically (OR 1.23, CI 1.06-1.43). Results are consistent with the concept that EAP benefits may increase access and address problems earlier.
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Affiliation(s)
- Elizabeth S Levy Merrick
- Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, Waltham, MA 02454-9110, USA.
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Frank RG, Goldman HH, McGuire TG. Trends In Mental Health Cost Growth: An Expanded Role For Management? Health Aff (Millwood) 2009; 28:649-59. [DOI: 10.1377/hlthaff.28.3.649] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
| | | | - Thomas G. McGuire
- Department of Health Care Policy at Harvard Medical School in Boston, Massachusetts
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Affiliation(s)
- Dahlia K. Remler
- School of Public Affairs, Baruch College, City University of New York, New York, NY, 10010, and Economics Department, The Graduate Center of the City University of New York and National Bureau of Economic Research, New York, NY 10016;
| | - Jessica Greene
- Department of Planning, Public Policy, and Management, University of Oregon, Eugene, Oregon, 97403
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Azzone V, Frank RG, Pakes JR, Earle CC, Hassett MJ. Behavioral health services for women who have breast cancer. J Clin Oncol 2008; 27:706-12. [PMID: 19114705 DOI: 10.1200/jco.2008.16.3006] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To explore whether the use of behavioral health services (BHS) among women with breast cancer is influenced by how insurance plans administer these services, we compared utilization of psychotherapy and psychotherapeutic medications among women with breast cancer who received BHS coverage through a carve-out versus integrated arrangement. PATIENTS AND METHODS We analyzed insurance claims, enrollment data, and benefit design data from the MarketScan Commercial Claims & Encounters Research Database for the years 1998 to 2002 for women <or= 63 years old with newly diagnosed breast cancer. We compared the probability of receiving psychotherapy, the likelihood of receiving antidepressant/antianxiety/hypnotic medications, and the number of psychotherapy sessions used during the year after a breast cancer diagnosis among women whose behavioral health services were provided through carve-out versus integrated arrangements. RESULTS Women enrolled in carve-outs were significantly less likely to receive any psychotherapy visits compared with women in integrated arrangements (odds ratio, 0.68; P < .01). Conditional on having received psychotherapy, however, women in carve-out arrangements used more psychotherapy visits than women in integrated arrangements. The use of antianxiety/hypnotic drugs was significantly higher for women in carve-out arrangements versus women in integrated arrangements (36.1% v 32.6%, P < .05). Moreover, women who received psychotherapy were significantly more likely to received antidepressants and antianxiety/hypnotic medications (five and three times more likely, respectively). CONCLUSION The type of BHS arrangement was associated with the utilization of psychotherapy and psychotherapeutic medications among women with breast cancer.
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Affiliation(s)
- Vanessa Azzone
- Department of Health Care Policy, Harvard Medical School, Boston, MA 02115, USA.
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Abstract
This article examines the ways in which mental health services have been affected by managed care and describes how to address some of the ethical conflicts that have always existed, but have been transformed immeasurably. It outlines the ethical dilemmas between the competing values of mental health providers and managed care, as well as the practical ethical considerations related to confidentiality, billing, and coding. It suggests that there can be no real improvement for mental health providers in the ethical minefield of managed care until they stop focusing on how distressed they are about it and start dealing with the larger, systemic issues in psychiatry and American health care. The article concludes by noting that the only way to effect meaningful change in the health care system is to combine knowledge with advocacy and to proactively define the standards needed to make the necessary choices.
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Affiliation(s)
- Edie Rosenberg
- Department of Psychiatry, Children's Hospital Boston, 300 Longwood Avenue, Boston, MA 02115, USA
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