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Foster AA, Hoffmann JA, Douglas MD, Monuteaux MC, Douglas KE, Benevides TW, Hudgins JD, Stewart AM. Comprehensiveness of State Insurance Laws and Perceived Access to Pediatric Mental Health Care. JAMA Netw Open 2024; 7:e2426402. [PMID: 39133489 DOI: 10.1001/jamanetworkopen.2024.26402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/13/2024] Open
Abstract
Importance Many US children and adolescents with mental and behavioral health (MBH) conditions do not access MBH services. One contributing factor is limited insurance coverage, which is influenced by state MBH insurance parity legislation. Objective To investigate the association of patient-level factors and the comprehensiveness of state MBH insurance legislation with perceived poor access to MBH care and perceived inadequate MBH insurance coverage for US children and adolescents. Design, Setting, and Participants This retrospective cross-sectional study was conducted using responses by caregivers of children and adolescents aged 6 to 17 years with MBH conditions in the National Survey of Children's Health and State Mental Health Insurance Laws Dataset from 2016 to 2019. Data analyses were conducted from May 2022 to January 2024. Exposure MBH insurance legislation comprehensiveness defined by State Mental Health Insurance Laws Dataset (SMHILD) scores (range, 0-7). Main Outcomes and Measures Perceived poor access to MBH care and perceived inadequacy of MBH insurance were assessed. Multivariable regression models adjusted for individual-level characteristics. Results There were 29 876 caregivers of children and adolescents with MBH conditions during the study period representing 14 292 300 youths nationally (7 816 727 aged 12-17 years [54.7%]; 8 455 171 male [59.2%]; 292 543 Asian [2.0%], 2 076 442 Black [14.5%], and 9 942 088 White [69.6%%]; 3 202 525 Hispanic [22.4%]). A total of 3193 caregivers representing 1 770 492 children and adolescents (12.4%) perceived poor access to MBH care, and 3517 caregivers representing 1 643 260 of 13 175 295 children and adolescents (12.5%) perceived inadequate MBH insurance coverage. In multivariable models, there were higher odds of perceived poor access to MBH care among caregivers of Black (adjusted odds ratio [aOR], 1.35; 95% CI, 1.04-1.75) and Asian (aOR, 1.69; 95% CI, 1.01-2.84) compared with White children and adolescents. As exposures to adverse childhood experiences (ACEs) increased, the odds of perceived poor access to MBH care increased (aORs ranged from 1.68; 95%, CI 1.32-2.13 for 1 ACE to 4.28; 95% CI, 3.17-5.77 for ≥4 ACEs compared with no ACEs). Compared with living in states with the least comprehensive MBH insurance legislation (SMHILD score, 0-2), living in states with the most comprehensive legislation (SMHILD score, 5-7) was associated with lower odds of perceived poor access to MBH care (aOR, 0.79; 95% CI, 0.63-0.99), while living in states with moderately comprehensive legislation (score, 4) was associated with higher odds of perceived inadequate MBH insurance coverage (aOR, 1.23; 95% CI, 1.01-1.49). Conclusions and Relevance In this study, living in states with the most comprehensive MBH insurance legislation was associated with lower odds of perceived poor access to MBH care among caregivers for children and adolescents with MBH conditions. This finding suggests that advocacy for comprehensive mental health parity legislation may promote improved child and adolescent access to MBH services.
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Affiliation(s)
- Ashley A Foster
- Department of Emergency Medicine, University of California, San Francisco
| | - Jennifer A Hoffmann
- Division of Emergency Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Megan D Douglas
- Department of Community Health and Preventive Medicine, National Center for Primary Care, Morehouse School of Medicine, Atlanta, Georgia
| | - Michael C Monuteaux
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Katherine E Douglas
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Teal W Benevides
- Institute of Public and Preventive Health, Augusta University, Augusta, Georgia
| | - Joel D Hudgins
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Amanda M Stewart
- Division of Emergency Medicine, Children's National Hospital, Washington, District of Columbia
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Su HI, Kaiser BN, Crable EL, Ortega RF, Yoeun SW, Economou MA, Fernandez E, Romero SAD, Aarons GA, McMenamin SB. Implementation of state health insurance benefit mandates for cancer-related fertility preservation: following policy through a complex system. Implement Sci 2024; 19:14. [PMID: 38365808 PMCID: PMC10870606 DOI: 10.1186/s13012-024-01343-1] [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] [Received: 09/12/2023] [Accepted: 01/20/2024] [Indexed: 02/18/2024] Open
Abstract
BACKGROUND A myriad of federal, state, and organizational policies are designed to improve access to evidence-based healthcare, but the impact of these policies likely varies due to contextual determinants of, reinterpretations of, and poor compliance with policy requirements throughout implementation. Strategies enhancing implementation and compliance with policy intent can improve population health. Critically assessing the multi-level environments where health policies and their related health services are implemented is essential to designing effective policy-level implementation strategies. California passed a 2019 health insurance benefit mandate requiring coverage of fertility preservation services for individuals at risk of infertility due to medical treatments, in order to improve access to services that are otherwise cost prohibitive. Our objective was to document and understand the multi-level environment, relationships, and activities involved in using state benefit mandates to facilitate patient access to fertility preservation services. METHODS We conducted a mixed-methods study and used the policy-optimized exploration, preparation, implementation, and sustainment (EPIS) framework to analyze the implementation of California's fertility preservation benefit mandate (SB 600) at and between the state insurance regulator, insurer, and clinic levels. RESULTS Seventeen publicly available fertility preservation benefit mandate-relevant documents were reviewed. Interviews were conducted with four insurers; 25 financial, administrative, and provider participants from 16 oncology and fertility clinics; three fertility pharmaceutical representatives; and two patient advocates. The mandate and insurance regulator guidance represented two "Big P" (system level) policies that gave rise to a host of "little p" (organizational) policies by and between the regulator, insurers, clinics, and patients. Many little p policies were bridging factors to support implementation across levels and fertility preservation service access. Characterizing the mandate's functions (i.e., policy goals) and forms (i.e., ways that policies were enacted) led to identification of (1) intended and unintended implementation, service, and patient outcomes, (2) implementation processes by level and EPIS phase, (3) actor-delineated key processes and heterogeneity among them, and (4) inner and outer context determinants that drove adaptations. CONCLUSIONS Following the midstream and downstream implementation of a state health insurance benefit mandate, data generated will enable development of policy-level implementation strategies, evaluation of determinants and important outcomes of effective implementation, and design of future mandates to improve fit and fidelity.
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Affiliation(s)
- H Irene Su
- Moores Cancer Center and Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Diego, La Jolla, San Diego, CA, 92093, USA.
| | - Bonnie N Kaiser
- Department of Anthropology and Global Health Program, University of California San Diego, La Jolla, San Diego, CA, 92093, USA
| | - Erika L Crable
- Department of Psychiatry, Altman Clinical and Translational Research Institute Dissemination and Implementation Science Center, Herbert Wertheim School of Public Health and Human Longevity Science, University of California, La Jolla, Los Angeles, CA, 92093, USA
- Child and Adolescent Services Research Center, San Diego, CA, USA
| | - Ricardo Flores Ortega
- Moores Cancer Center and Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Diego, La Jolla, San Diego, CA, 92093, USA
| | - Sara W Yoeun
- Herbert Wertheim School of Public Health and Human Longevity Science, University of California, La Jolla, Loss Angeles, CA, 92093, USA
| | - Melina A Economou
- Department of Anthropology and Global Health Program, University of California San Diego, La Jolla, San Diego, CA, 92093, USA
| | - Estefania Fernandez
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Diego, La Jolla, San Diego, CA, 92093, USA
| | - Sally A D Romero
- Department of Obstetrics, Gynecology and Reproductive Sciences and Herbert Wertheim School of Public Health and Human Longevity Science, University of California San Diego, La Jolla, San Diego, CA, 92093, USA
| | - Gregory A Aarons
- Child and Adolescent Services Research Center, San Diego, CA, USA
- Department of Psychiatry and Altman Clinical and Translational Research Institute Dissemination and Implementation Science Center, University of California San Diego, La Jolla, San Diego, CA, 92093, USA
| | - Sara B McMenamin
- Herbert Wertheim School of Public Health and Human Longevity Science, University of California, La Jolla, Loss Angeles, CA, 92093, USA.
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Moon KJ, Stephenson S, Hasenstab KA, Sridhar S, Seiber EE, Breitborde NJK, Nawaz S. Policy Complexities in Financing First Episode Psychosis Services: Implementation Realities from a Home Rule State. J Behav Health Serv Res 2024; 51:132-145. [PMID: 38017296 DOI: 10.1007/s11414-023-09865-0] [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] [Accepted: 10/04/2023] [Indexed: 11/30/2023]
Abstract
Over the past decade, significant investments have been made in coordinated specialty care (CSC) models for first episode psychosis (FEP), with the goal of promoting recovery and preventing disability. CSC programs have proliferated as a result, but financing challenges imperil their growth and sustainability. In this commentary, the authors discuss (1) entrenched and emergent challenges in behavioral health policy of consequence for CSC financing; (2) implementation realities in the home rule context of Ohio, where significant variability exists across counties; and (3) recommendations to improve both care quality and access for individuals with FEP. The authors aim to provoke careful thought about policy interventions to bridge science-to-service gaps, and in this way, advance behavioral health equity.
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Affiliation(s)
- Kyle J Moon
- Center for Health Outcomes and Policy Evaluation Studies, Ohio State University College of Public Health, Columbus, OH, USA
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Kathryn A Hasenstab
- Center for Health Outcomes and Policy Evaluation Studies, Ohio State University College of Public Health, Columbus, OH, USA
| | - Srinivasan Sridhar
- Center for Health Outcomes and Policy Evaluation Studies, Ohio State University College of Public Health, Columbus, OH, USA
| | - Eric E Seiber
- Center for Health Outcomes and Policy Evaluation Studies, Ohio State University College of Public Health, Columbus, OH, USA
- Division of Health Services Management and Policy, Ohio State University College of Public Health, Columbus, OH, USA
| | - Nicholas J K Breitborde
- Department of Psychiatry and Behavioral Health, Ohio State University College of Medicine, Columbus, OH, USA
- Department of Psychology, Ohio State University, Columbus, OH, USA
| | - Saira Nawaz
- Center for Health Outcomes and Policy Evaluation Studies, Ohio State University College of Public Health, Columbus, OH, USA.
- Division of Health Services Management and Policy, Ohio State University College of Public Health, Columbus, OH, USA.
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Harris SJ, Golberstein E, Maclean JC, Stein BD, Ettner SL, Saloner B. How policymakers innovate around behavioral health: adoption of the New Mexico "No Behavioral Health Cost-Sharing" law. HEALTH AFFAIRS SCHOLAR 2024; 2:qxad081. [PMID: 38756394 PMCID: PMC10986291 DOI: 10.1093/haschl/qxad081] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 11/16/2023] [Accepted: 12/04/2023] [Indexed: 05/18/2024]
Abstract
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.
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Affiliation(s)
- Samantha J Harris
- Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD 21205, United States
| | - Ezra Golberstein
- Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, MN 55455, United States
| | | | | | - Susan L Ettner
- Department of Medicine, Division of General Internal Medicine and Health Services Research, University of California Los Angeles, Los Angeles, CA 90095, United States
- Department of Health Policy and Management, University of California Los Angeles, Los Angeles, CA 90095, United States
| | - Brendan Saloner
- Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD 21205, United States
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Wortham WK, Rodwin AH, Purtle J, Munson MR, Raghavan R. Revisiting the policy ecology framework for implementation of evidence-based practices in mental health settings. Implement Sci 2023; 18:58. [PMID: 37936123 PMCID: PMC10629012 DOI: 10.1186/s13012-023-01309-9] [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] [Received: 03/03/2023] [Accepted: 10/01/2023] [Indexed: 11/09/2023] Open
Abstract
BACKGROUND Over the past three decades, policy actors and actions have been highly influential in supporting the implementation of evidence-based practices (EBPs) in mental health settings. An early examination of these actions resulted in the Policy Ecology Framework (PEF), which was originally developed as a tactical primer for state and local mental health regulators in the field of child mental health. However, the policy landscape for implementation has evolved significantly since the original PEF was published. An interrogation of the strategies originally proposed in the PEF is necessary to provide an updated menu of strategies to improve our understanding of the mechanisms of policy action and promote system improvement. OBJECTIVES This paper builds upon the original PEF to address changes in the policy landscape for the implementation of mental health EBPs between 2009 and 2022. We review the current state of policy strategies that support the implementation of EBPs in mental health care and outline key areas for policy-oriented implementation research. Our review identifies policy strategies at federal, state, agency, and organizational levels, and highlights developments in the social context in which EBPs are implemented. Furthermore, our review is organized around some key changes that occurred across each PEF domain that span organizational, agency, political, and social contexts along with subdomains within each area. DISCUSSION We present an updated menu of policy strategies to support the implementation of EBPs in mental health settings. This updated menu of strategies considers the broad range of conceptual developments and changes in the policy landscape. These developments have occurred across the organizational, agency, political, and social contexts and are important for policymakers to consider in the context of supporting the implementation of EBPs. The updated PEF expands and enhances the specification of policy levers currently available, and identifies policy targets that are underdeveloped (e.g., de-implementation and sustainment) but are becoming visible opportunities for policy to support system improvement. The updated PEF clarifies current policy efforts within the field of implementation science in health to conceptualize and better operationalize the role of policy in the implementation of EBPs.
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Affiliation(s)
- Whitney K Wortham
- Silver School of Social Work, New York University, 1 Washington Square North, New York, NY, 10003, USA.
| | - Aaron H Rodwin
- Silver School of Social Work, New York University, 1 Washington Square North, New York, NY, 10003, USA
| | - Jonathan Purtle
- Department of Public Health Policy & Management, Global Center for Implementation Science, School of Global Public Health, New York University, 708 Broadway, New York, NY, 10003, USA
| | - Michelle R Munson
- Silver School of Social Work, New York University, 1 Washington Square North, New York, NY, 10003, USA
| | - Ramesh Raghavan
- Silver School of Social Work, New York University, 1 Washington Square North, New York, NY, 10003, USA
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Constantino JN. Bridging the Divide Between Health and Mental Health: New Opportunity for Parity in Childhood. J Am Acad Child Adolesc Psychiatry 2023; 62:1182-1184. [PMID: 37230286 DOI: 10.1016/j.jaac.2023.03.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Revised: 02/24/2023] [Accepted: 05/16/2023] [Indexed: 05/27/2023]
Abstract
The modern era for mental health parity in the US began in 1996, when Congress enacted the Mental Health Parity Act (MHPA), which required equivalence in aggregate lifetime and annual dollar limits for mental health benefits and medical/surgical benefits. Mental health parity generally refers to the equal treatment of mental health conditions and physical health conditions in insurance plans, the substance of which extends far beyond equivalence in the dollar limits of benefits. Mental health parity is a foundational aspiration that has not yet been fulfilled in the US; this article describes details of subsequent legislation that has created new opportunity to finish the work that was started by MHPA, to achieve actual mental health parity, with particular reference to the needs of children.
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Irene Su H, Kaiser B, Crable E, Ortega RF, Yoeun SW, Economou M, Fernandez E, Romero SA, Aarons GA, McMenamin SB. Implementation of state health insurance benefit mandates for cancer-related fertility preservation: Following policy through a complex system. RESEARCH SQUARE 2023:rs.3.rs-3340894. [PMID: 37886467 PMCID: PMC10602193 DOI: 10.21203/rs.3.rs-3340894/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/28/2023]
Abstract
Background A myriad of federal, state, and organizational policies are designed to improve access to evidence-based healthcare, but the impact of these policies likely varies due to contextual determinants, re-interpretations of and poor compliance with policy requirements throughout implementation. Strategies enhancing implementation and compliance with policy intent can improve population health. Critically assessing the multi-level environments where health policies and their related health services are implemented is essential to designing effective policy-level implementation strategies. California passed a 2019 health insurance benefit mandate requiring coverage of fertility preservation (FP) services for individuals at risk of infertility due to medical treatments to improve access to services that are otherwise cost-prohibitive. Our objective was to document and understand multi-level environment, relationships, and activities involved in using state benefit mandates to facilitate patient access to FP services. Methods We conducted a mixed-methods study and used the policy-optimized Exploration, Preparation, Implementation, Sustainment (EPIS) framework to analyze implementation of California's fertility preservation benefit mandate (SB 600) at and between the state insurance regulator, insurer and clinic levels. Results Seventeen publicly available FP benefit mandate-relevant documents were reviewed, and four insurers, 25 financial, administrative and provider participants from 16 oncology and fertility clinics, three fertility pharmaceutical representatives, and two patient advocates were interviewed. The mandate and insurance regulator guidance represented two "Big P" (system level) policies that gave rise to a host of "little p" (organizational) policies by and between the regulator, insurers, clinics, and patients. Many little p policies were bridging factors to support implementation across levels and FP service access. Characterizing the mandate's functions (i.e., policy goals) and forms (i.e., ways that policies were enacted) led to identification of (1) intended and unintended implementation, service, and patient outcomes; (2) implementation processes by level, EPIS phase; (3) actor-delineated key processes and heterogeneity among them; and (4) inner and outer context determinants that drove adaptations. Conclusions Following the mid- and down-stream implementation of a state health insurance benefit mandate, data generated will enable development of policy level implementation strategies, evaluation of determinants and important outcomes of effective implementation, and design of future mandates to improve fit and fidelity.
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Affiliation(s)
- H Irene Su
- University of California San Diego Moores Cancer Center
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