Federal Parity and Access to Behavioral Health Care in Private Health Plans

Medicaid managed care restrictions on medications for the treatment of opioid use disorder

OBJECTIVE

To examine whether Medicaid managed care plan (MCP) utilization management policies for buprenorphine-naloxone and injectable naltrexone are related to key state Medicaid program policy decisions.

DATA SOURCES AND STUDY SETTING

We abstracted data on state Medicaid regulatory and policy information from publicly available sources and publicly available insurance benefit documentation from all 241 Medicaid MCPs operating in 2021.

STUDY DESIGN

In this cross-sectional study, we used bivariate and multivariate analyses to examine whether Medicaid MCP prior authorization and quantity limits on receipt of buprenorphine and injectable naltrexone were associated with key state Medicaid choices to leverage federal funds to expand coverage and eligibility (Medicaid expansion, 1115 waivers) and to regulate Medicaid MCPs (uniform preferred drug lists, medical loss ratio remittance). Models were adjusted for MCP characteristics, including profit status, behavioral health contracting arrangement, National Committee for Quality Assurance accreditation, size, market share, and state opioid overdose death rates. Average marginal effects (AME) were reported.

PRINCIPAL FINDINGS

Utilization management was common among MCPs, and restrictions were more commonly applied to buprenorphine than injectable naltrexone, despite its higher cost. States that required MCPs to comply with utilization management policies stipulated in a uniform preferred drug list were more likely to require prior authorization for buprenorphine (AME: 0.29, 95% CI: 0.15-0.42) and injectable naltrexone (AME: 0.25, 95% CI: 0.12-0.38). MCPs in states that required plans to pay back earnings above a certain threshold were less likely to require prior authorization for buprenorphine (AME: -0.30, 95% CI: -0.43 to -0.18).

CONCLUSIONS

Restrictions on medications for opioid use disorder are widespread among MCPs and vary by medication. State Medicaid regulatory and policy characteristics were strongly linked to MCPs' utilization management approaches. State Medicaid policy and contracting approaches may be levers to eliminate utilization management restrictions on medications for opioid use disorder.

PERSPECTIVE: Health Economic Interests at NIMH and NIDA to Improve Delivery of Behavioral Health Services

BACKGROUND

Effective financing mechanisms are essential to ensuring that people can access and utilize effective treatments and services. Financing mechanisms are needed not only to pay for the delivery of those treatments and services, but also ancillary costs, while also keeping care affordable.

AIMS

This article highlights key areas of the interest of the National Institute of Mental Health (NIMH) and the National Institute on Drug Abuse (NIDA) in supporting applied health economics and health care financing research. Specifically, this article discusses the long-range impact of NIH's earlier investments in applied health economics research, and NIH's ongoing efforts to communicate its interests in health economics research. We discuss the 2023 NIMH-NIDA-sponsored health economics conference, and the ideas presented there for developing and assessing innovative behavioral health care financing models; three of the presented papers were recently published in the Journal of Mental Health Policy and Economics.

METHODS

We describe the history and impact of NIMH- and NIDA-sponsored economic research and identify current research interests as identified in the NIMH and NIDA Strategic Plans and recent funding announcements. We examine themes presented at the NIMH-NIDA Health Economics conference. The conference included over 300 participants from 20 countries, from six continents.

RESULTS

The topics highlighted at the conference highlight the ways in which NIH-funded research has promoted the development of innovative health care financing methods, both from the supply side (e.g., providers and payers) and demand side (e.g., service users and families). Invited speakers discussed the findings from NIH-supported research in the topic areas of payment and financing, behavioral economics and social determinants of health. Keynote speakers highlighted emerging topics in the field, including the economics of health equity, biases in mental health models in health care, and value-based insurance design.

DISCUSSION

We demonstrate a resurgence of and explicit interest in health economics and policy research at NIMH and NIDA. However, more work is needed in order to design funding mechanisms that fully provide access to and facilitate use of effective evidence-based practices to improve mental health outcomes. For example, it is important that policy and health economic research projects include decision makers who will be the end users of data and study results, to ensure that results can be meaningfully put into practice.

IMPLICATIONS FOR HEALTH CARE

Designing effective and efficient funding mechanisms can help ensure that service users have access to effective treatments and that clinicians and provider organizations are adequately compensated for their work.

IMPLICATIONS FOR HEALTH POLICIES

Federal, state, and local policies, as well as policies of payers and health care organizations, can influence the type of care that is supported and incentivized.

IMPLICATIONS FOR FURTHER RESEARCH

As demonstrated by the research interests as outlined in their respective Strategic Plans and funding announcements, NIMH and NIDA continue to fund health economic and policy research that aims to improve health care access, quality and outcomes for people with or at risk of developing behavioral health conditions in the US and around the world.

How policymakers innovate around behavioral health: adoption of the New Mexico "No Behavioral Health Cost-Sharing" law

State policymakers have long sought to improve access to mental health and substance use disorder (MH/SUD) treatment through insurance market reforms. Examining decisions made by innovative policymakers ("policy entrepreneurs") can inform the potential scope and limits of legislative reform. Beginning in 2022, New Mexico became the first state to eliminate cost-sharing for MH/SUD treatment in private insurance plans subject to state regulation. Based on key informant interviews (n = 30), this study recounts the law's passage and intended impact. Key facilitators to the law's passage included receptive leadership, legislative champions with medical and insurance backgrounds, the use of local research evidence, advocate testimony, support from health industry figures, the severity of MH/SUD, and increased attention to MH/SUD during the COVID-19 pandemic. Findings have important implications for states considering similar laws to improve access to MH/SUD treatment.

Cost Burden Impacts Cancer Patient Service Utilization Behavior in a US Commercial Plan

Objectives: The burden of affording high-cost medical treatment (eg, cancer therapy) may impact whether some patients choose to access other needed health services within US commercial plans. However, deferring needed care for a mental or behavioral health (M/BH) condition could result in preventable hospital utilization. This research investigates how income level and total out-of-pocket costs (OOPC) interact to influence the service utilization behavior of insured adult cancer patients with a comorbid M/BH diagnosis. Methods: A cross-sectional, retrospective analysis was performed using medical service claims (July 2017-June 2018) and administrative data from eligible members of a large US commercial health benefits plan ( N =5,054). Nonparametric tests were used to examine variation in mean utilization by patient income level and OOPC decile. Negative binomial regression modeling was performed to analyze independent variable effects on count outcomes for outpatient behavioral visits and emergency department (ED) visits. Results: There was significant variation in patient service utilization by income level and total OOPC. Overall, as OOPC increased patients used less outpatient behavioral care ( p <.000). Compared to average and higher incomes, those with lower incomes (<$50,000/year) utilized significantly fewer outpatient visits ( p <.000) and significantly more ED visits ( p <.001) relative to increasing OOPC. Conclusions: The interaction of income level and OOPC (ie, cost burden) could inhibit patients' decision to access supportive behavioral care in the commercial plan. The cumulative cost burden from cancer treatment may promote underutilization of outpatient services and greater ED reliance, particularly among lower income plan members.

Access to Mental Healthcare in the 21st Century: An Evolutionary Concept Analysis

BACKGROUND

One of the most important aspects of receiving medical care is access to that care. For people with mental illness who have greater healthcare needs and are at risk for poor health outcomes, reduced access to care constitutes a crisis. While the COVID-19 (coronavirus disease 2019) pandemic continues to affect the United States, specifying what it means to have access to mental healthcare is more critical than ever.

AIMS

The aims of this concept analysis are to review definitions and descriptions of access to mental healthcare in the literature and to synthesize the relevance of these findings to inform future research, theory development, policy, and practice.

METHODS

The concept of access to mental healthcare was analyzed using Rodgers's evolutionary concept analysis method. CINAHL, PsycINFO, and MEDLINE were queried for peer-reviewed articles about access to mental healthcare published from January 2010 to April 2020 (n = 72). Data were reviewed for concept antecedents, attributes, consequences, surrogate, and related terms.

RESULTS

Five models of access to mental healthcare were identified, with several antecedents and consequences: utilization, economic loss/gain, incarceration, and patient/provider satisfaction. Cross-sectional and predictive studies highlighted three interrelated attributes: clinical management, healthcare delivery, and connectedness.

CONCLUSIONS

The concept of access to mental healthcare is often used stagnantly across disciplines to create health policies, yet the concept is transformative. Future research requires up-to-date operational definitions of access to mental healthcare to target interdisciplinary approaches.

Insurance expansions and adolescent use of substance use disorder treatment

OBJECTIVE

To provide evidence on the effects of expansions to private and public insurance programs on adolescent specialty substance use disorder (SUD) treatment use.

DATA SOURCE/STUDY SETTING

The Treatment Episodes Data Set (TEDS), 1996 to 2017.

STUDY DESIGN

A quasi-experimental difference-in-differences design using observational data.

DATA COLLECTION

The TEDS provides administrative data on admissions to specialty SUD treatment.

PRINCIPAL FINDINGS

Expansions of laws that compel private insurers to cover SUD treatment services at parity with general health care increase adolescent admissions by 26% (P < .05). These increases are driven by nonintensive outpatient admissions, the most common treatment episodes, which rise by 30% (P < .05) postparity law. In contrast, increases in income eligibility for public insurance targeting those 6-18 years old are not statistically associated with SUD treatment.

CONCLUSIONS

Private insurance expansions allow more adolescents to receive SUD treatment, while public insurance income eligibility expansions do not appear to influence adolescent SUD treatment.

Psychiatrist Participation in Private Health Insurance Markets: Paucity in the Land of Plenty

OBJECTIVE

Access to specialty mental health care may be poor because many psychiatrists do not accept health insurance reimbursement, whereas many patients rely on insurance to help pay for care. The objective of this study was to examine the extent of participation in private insurance by licensed psychiatrists.

METHODS

Using 2013 Massachusetts licensing data and the All-Payer Claims Database (APCD), the authors performed a cross-sectional analysis of licensed psychiatrists in Massachusetts. The fraction of psychiatrists who filed insurance claims, number of unique patients with insurance claims per psychiatrist, and physician characteristics associated with insurance participation were evaluated.

RESULTS

In 2013, Massachusetts had 2,348 licensed psychiatrists. Overall, 79% (N=1,843) had at least one paid claim for an outpatient visit in the APCD, but only 6% (N=151) had claims for at least 300 patients per year (a full caseload). Psychiatrists had a median of 18 patients with claims (mean=73). Compared with psychiatrists 30-39 years since medical school graduation, those within 19 years since graduation were less likely to bill for an outpatient (7-19 years, odds ratio [OR]=0.67, 95% confidence interval [CI]=0.47-0.94) and less likely to have claims for ≥300 patients per year (7-19 years, OR=0.49, 95% CI=0.29-0.83). Participation varied across insurance types (93% for group commercial plans versus 33% for Medicaid managed care plans).

CONCLUSIONS

Among Massachusetts psychiatrists, participation in the private insurance market appears to be limited. Older psychiatrists are more likely to participate, and patients' access to psychiatrists who accept insurance could worsen as these psychiatrists retire.

Impact of the Young Adult Dependent Coverage Expansion on Opioid Overdoses and Deaths: a Quasi-Experimental Study

BACKGROUND

Several policymakers have suggested that the Affordable Care Act (ACA) has fueled the opioid epidemic by subsidizing opioid pain medications. These claims have supported numerous efforts to repeal the ACA.

OBJECTIVE

To determine the effect of the ACA's young adult dependent coverage insurance expansion on emergency department (ED) encounters and out-of-hospital deaths from opioid overdose.

DESIGN

Difference-in-differences analyses comparing ED encounters and out-of-hospital deaths before (2009) and after (2011-2013) the ACA young adult dependent coverage expansion. We further stratified by prescription opioid, non-prescription opioid, and methadone overdoses.

PARTICIPANTS

Adults aged 23-25 years old and 27-29 years old who presented to the ED or died prior to reaching the hospital from opioid overdose.

MAIN MEASURES

Rate of ED encounters and deaths for opioid overdose per 100,000 U.S. adults.

KEY RESULTS

There were 108,253 ED encounters from opioid overdose in total. The expansion was not associated with a significant change in the ED encounter rates for opioid overdoses of all types (2.04 per 100,000 adults [95% CI - 0.75 to 4.82]), prescription opioids (0.60 per 100,000 adults [95% CI - 1.98 to 0.77]), or methadone (0.29 per 100,000 adults [95% CI - 0.78 to 0.21]). There was a slight increase in the rate of non-prescription opioid overdoses (1.91 per 100,000 adults [95% CI 0.13-3.71]). The expansion was not associated with a significant change in the out-of-hospital mortality rates for opioid overdoses of all types (0.49 per 100,000 adults [95% CI - 0.80 to 1.78]).

CONCLUSIONS

Our findings do not support claims that the ACA has fueled the prescription opioid epidemic. However, the expansion was associated with an increase in the rate of ED encounters for non-prescription opioid overdoses such as heroin, although almost all were non-fatal. Future research is warranted to understand the role of private insurance in providing access to treatment in this population.

Mental Health Parity and Addiction Equity Act and the Use of Outpatient Behavioral Health Services in the United States, 2005-2016

Objectives. To assess the impact of the 2008 Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act (MHPAEA) on mental and substance use disorder services in the private, large group employer-sponsored insurance market in the United States. Methods. We analyzed data from the IBM MarketScan Commercial Database from January 2005 through September 2015 by using population-level interrupted time series regressions to determine whether parity implementation was associated with utilization and spending outcomes. Results. MHPAEA had significant positive associations with utilization of mental and substance use disorder outpatient services. A spending decomposition analysis indicated that increases in utilization were the primary drivers of increases in spending associated with MHPAEA. Analyses of opioid use disorder and nonopioid substance use disorder services found that associations with utilization and spending were not attributable only to increases in treatment of opioid use disorder. Conclusions. MHPAEA is positively associated with utilization of outpatient mental and substance use disorder services for Americans covered by large group employer-sponsored insurance. Public Health Implications. These trends continued over the 5-year post-MHPAEA period, underscoring the long-term relationship between this policy change and utilization of behavioral health services.

Suicide in the Elderly: A Multidisciplinary Approach to Prevention

Suicide in the elderly is a growing problem. The elderly population is increasing, and elderly patients have multiple issues that place them at higher risk of suicidality. These issues include physical illnesses, mental illness, loss of functional status, isolation, and family, financial, and social factors. Access to firearms is another significant risk factor, because elderly patients are more likely to use firearms in suicide attempts; interventions to reduce firearms mortality may save lives. Tackling the difficult problem of suicide in the elderly may require a multidisciplinary, community-based series of interventions.

Racial-ethnic and neighborhood inequities in age of treatment receipt among a national sample of children with autism spectrum disorder

The aim of this study is to examine the impact of child race-ethnicity and neighborhood characteristics on age of treatment receipt among children with autism spectrum disorder. Here, we included 1309 children diagnosed with autism spectrum disorder in the National Survey of Children's Health, 2011-2012. Controlling for key covariates, we used a weighted generalized logit model to analyze differences in age of treatment receipt (<2 years, 2 years, 3 years, and ⩾4 years). Compared to non-Hispanic White children, the relative probability (odds) of entering treatment at 3 years and ⩾4 years rather than <2 years was 326% and 367% higher, respectively, for non-Hispanic Black children. Compared to children whose parents perceived their neighborhood to be cohesive, the relative probability of entering treatment at 2 years and 3 years rather than <2 years was 59% and 61% lower, respectively, for children whose parents did not. Significant racial-ethnic and neighborhood inequities exist in age of treatment receipt, suggesting a need for research that explores the underlying causal mechanisms of inequities.