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Abstract
OBJECTIVE The authors aimed to analyze psychiatrists' and other physicians' acceptance of insurance and the associations between insurance acceptance and specific physician- and practice-level characteristics. METHODS Using the restricted version of the National Ambulatory Medical Care Survey, January 2007-December 2016, the authors analyzed acceptance of private insurance, public insurance, and any insurance among psychiatrists compared with nonpsychiatrist physicians. Because data were considered restricted, all analyses were conducted at federal Research Data Center facilities. RESULTS The unweighted sample included an average of 4,725 physicians per 2-year time grouping between 2007 and 2016, with an average of 7% being psychiatrists. Nonpsychiatrists participated in all insurance networks at higher rates than did psychiatrists, and the acceptance gap was wider for public (Medicare and Medicaid) than private (noncapitated and capitated) insurance. Among psychiatrists, those practicing in metropolitan statistical areas and those in solo practices were significantly less likely than their peers in other locations and treatment settings to accept private, public, or any insurance. These findings were also observed among nonpsychiatrists, although to a lesser extent. CONCLUSIONS In addition to general policy interventions to improve insurance network adequacy for psychiatric care, additional measures or incentives to promote insurance network participation should be considered for psychiatrists in solo practices and those in metropolitan areas.
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Affiliation(s)
- Andrew D Carlo
- Meadows Mental Health Policy Institute, Dallas (Carlo); Department of Psychiatry and Behavioral Sciences (Carlo, Jordan) and Center for Health Services and Outcomes Research, Institute for Public Health and Medicine (Jordan), Northwestern University Feinberg School of Medicine, Chicago; Departments of Pharmacy, Health Services, and Economics (Basu) and Department of Psychiatry and Behavioral Sciences (Unützer), University of Washington, Seattle
| | - Anirban Basu
- Meadows Mental Health Policy Institute, Dallas (Carlo); Department of Psychiatry and Behavioral Sciences (Carlo, Jordan) and Center for Health Services and Outcomes Research, Institute for Public Health and Medicine (Jordan), Northwestern University Feinberg School of Medicine, Chicago; Departments of Pharmacy, Health Services, and Economics (Basu) and Department of Psychiatry and Behavioral Sciences (Unützer), University of Washington, Seattle
| | - Jürgen Unützer
- Meadows Mental Health Policy Institute, Dallas (Carlo); Department of Psychiatry and Behavioral Sciences (Carlo, Jordan) and Center for Health Services and Outcomes Research, Institute for Public Health and Medicine (Jordan), Northwestern University Feinberg School of Medicine, Chicago; Departments of Pharmacy, Health Services, and Economics (Basu) and Department of Psychiatry and Behavioral Sciences (Unützer), University of Washington, Seattle
| | - Neil Jordan
- Meadows Mental Health Policy Institute, Dallas (Carlo); Department of Psychiatry and Behavioral Sciences (Carlo, Jordan) and Center for Health Services and Outcomes Research, Institute for Public Health and Medicine (Jordan), Northwestern University Feinberg School of Medicine, Chicago; Departments of Pharmacy, Health Services, and Economics (Basu) and Department of Psychiatry and Behavioral Sciences (Unützer), University of Washington, Seattle
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2
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Goldman HH. How Phantom Networks And Other Barriers Impede Progress On Mental Health Insurance Reform. HEALTH AFFAIRS (PROJECT HOPE) 2022; 41:1023-1025. [PMID: 35787083 DOI: 10.1377/hlthaff.2022.00541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Phantom networks are but one of many barriers to realizing access to mental health services. The term phantom networks refers to the misleading practice of listing providers as members of a network when they are not actually accepting patients. Inaccurate information on provider availability impedes the implementation of reforms that are designed to improve health insurance coverage of mental health treatment. Some other barriers to improving access to mental health services include low reimbursement rates from Medicaid, hesitancy of psychiatrists and psychologists to participate in networks, and practices of some managed care networks that require prior approval of mental health services such as psychiatric hospitalization. Phantom networks and these other barriers stand in the way of patients finding providers to help them at a time of need for treatment and support.
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Alegría M, Falgas-Bague I, Fukuda M, Zhen-Duan J, Weaver C, O’Malley I, Layton T, Wallace J, Zhang L, Markle S, Neighbors C, Lincourt P, Hussain S, Manseau M, Stein BD, Rigotti N, Wakeman S, Kane M, Evins AE, McGuire T. Performance Metrics of Substance Use Disorder Care Among Medicaid Enrollees in New York, New York. JAMA HEALTH FORUM 2022; 3:e221771. [PMID: 35977217 PMCID: PMC9250047 DOI: 10.1001/jamahealthforum.2022.1771] [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: 02/02/2022] [Accepted: 04/28/2022] [Indexed: 11/14/2022] Open
Abstract
Importance There is limited evaluation of the performance of Medicaid managed care (MMC) private plans in covering substance use disorder (SUD) treatment. Objective To compare the performance of MMC plans across 19 indicators of access, quality, and outcomes of SUD treatment. Design Setting and Participants This cross-sectional study used administrative claims and mandatory assignment to plans of up to 159 016 adult Medicaid recipients residing in 1 of the 5 counties (boroughs) of New York, New York, from January 2009 to December 2017 to identify differences in SUD treatment access, patterns, and outcomes among different types of MMC plans. Data from the latest years were received from the New York State Department of Health in October 2019, and analysis began soon thereafter. Approximately 17% did not make an active choice of plan, and a subset of these (approximately 4%) can be regarded as randomly assigned. Exposures Plan assignment. Main Outcomes and Measures Percentage of the enrollees achieving performance measures across 19 indicators of access, process, and outcomes of SUD treatment. Results Medicaid claims data from 159 016 adults (mean [SD] age, 35.9 [12.7] years; 74 261 women [46.7%]; 8746 [5.5%] Asian, 73 783 [46.4%] Black, and 40 549 [25.5%] White individuals) who were auto assigned to an MMC plan were analyzed. Consistent with national patterns, all plans achieved less than 50% (range, 0%-62.1%) on most performance measures. Across all plans, there were low levels of treatment engagement for alcohol (range, 0%-0.4%) and tobacco treatment (range, 0.8%-7.2%), except for engagement for opioid disorder treatment (range, 41.5%-61.4%). For access measures, 4 of the 9 plans performed significantly higher than the mean on recognition of an SUD diagnosis, any service use for the first time, and tobacco use screening. Of the process measures, total monthly expenditures on SUD treatment was the only measure for which plans differed significantly from the mean. Outcome measures differed little across plans. Conclusions and Relevance The results of this cross-sectional study suggest the need for progress in engaging patients in SUD treatment and improvement in the low performance of SUD care and limited variation in MMC plans in New York, New York. Improvement in the overall performance of SUD treatment in Medicaid potentially depends on general program improvements, not moving recipients among plans.
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Affiliation(s)
- Margarita Alegría
- Disparities Research Unit, Massachusetts General Hospital, Boston
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
| | - Irene Falgas-Bague
- Disparities Research Unit, Massachusetts General Hospital, Boston
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Marie Fukuda
- Disparities Research Unit, Massachusetts General Hospital, Boston
| | - Jenny Zhen-Duan
- Disparities Research Unit, Massachusetts General Hospital, Boston
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Cole Weaver
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Isabel O’Malley
- Disparities Research Unit, Massachusetts General Hospital, Boston
| | - Timothy Layton
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Jacob Wallace
- Yale School of Public Health, New Haven, Connecticut
| | - Lulu Zhang
- Disparities Research Unit, Massachusetts General Hospital, Boston
| | - Sheri Markle
- Disparities Research Unit, Massachusetts General Hospital, Boston
| | - Charles Neighbors
- Grossman School of Medicine, New York University, New York
- Wagner School of Public Service, New York University, New York
| | - Pat Lincourt
- New York State Office of Alcoholism and Substance Abuse Services, Albany, New York
| | - Shazia Hussain
- New York State Office of Alcoholism and Substance Abuse Services, Albany, New York
| | - Marc Manseau
- Grossman School of Medicine, New York University, New York
- New York State Office of Mental Health, New York
| | | | - Nancy Rigotti
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
- Division of General Internal Medicine, Massachusetts General Hospital, Boston
- Tobacco Research and Treatment Center, Massachusetts General Hospital, Boston
| | - Sarah Wakeman
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
- Substance Use Disorder Initiative, Massachusetts General Hospital, Boston
| | - Martha Kane
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
- Addictions Services Unit, Massachusetts General Hospital, Boston
| | - A. Eden Evins
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
- Center for Addiction Medicine, Massachusetts General Hospital, Boston
| | - Thomas McGuire
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
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4
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Zhu JM, Charlesworth CJ, Polsky D, McConnell KJ. Phantom Networks: Discrepancies Between Reported And Realized Mental Health Care Access In Oregon Medicaid. Health Aff (Millwood) 2022; 41:1013-1022. [PMID: 35787079 PMCID: PMC9876384 DOI: 10.1377/hlthaff.2022.00052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Understanding the extent to which beneficiaries can "realize" access to reported provider networks is imperative in mental health care, where there are significant unmet needs. We compared listings of providers in network directories against provider networks empirically constructed from administrative claims among members who were ages sixty-four and younger and enrolled in Oregon's Medicaid managed care organizations between January 1 and December 31, 2018. "In-network" providers were those with any medical claims filed for at least five unique Medicaid beneficiaries enrolled in a given health plan. They included primary care providers, specialty mental health prescribers, and nonprescribing mental health clinicians. Overall, 58.2 percent of network directory listings were "phantom" providers who did not see Medicaid patients, including 67.4 percent of mental health prescribers, 59.0 percent of mental health nonprescribers, and 54.0 percent of primary care providers. Significant discrepancies between the providers listed in directories and those whom enrollees can access suggest that provider network monitoring and enforcement may fall short if based on directory information.
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Affiliation(s)
- Jane M. Zhu
- Oregon Health & Science University, Portland, Oregon
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5
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Busch SH, Kyanko K. Assessment of Perceptions of Mental Health vs Medical Health Plan Networks Among US Adults With Private Insurance. JAMA Netw Open 2021; 4:e2130770. [PMID: 34677592 PMCID: PMC8536951 DOI: 10.1001/jamanetworkopen.2021.30770] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Ten years after the Mental Health Parity and Addiction Equity Act, patients continue to report insurance-related barriers to specialty mental health care. OBJECTIVES To assess privately insured patients' perceptions of the adequacy of their health plan's provider network (provider network includes physicians, clinicians, other health care professionals, and their institutions that constitute the network), whether practitioners frequently leave plans, and whether practitioner plan participation affected patients' plan choice. DESIGN, SETTING, AND PARTICIPANTS A nationally representative, population-based internet survey study of English-speaking US adults participating in KnowledgePanel, an online research panel, was conducted from August to September 2018. Data analysis was performed from November 12, 2020, to May 12, 2021. From a sample of 29 854 panelists aged 18 to 64 years, 19 602 initiated the screener (completion rate of 66%), and 728 met study criteria: adults with private insurance receiving both specialty mental health and medical care in the past year. EXPOSURE Health plan's provider network. MAIN OUTCOMES AND MEASURES Self-report of plan inadequacy, whether a practitioner left the plan and the participant's responses (stopped treatment, switched practitioner, or continued treatment), and whether participation of a specific practitioner was considered when a health plan was chosen. Experiences with both mental health and medical provider networks were assessed. Analyses were weighted to match the sample to the US population. Weights provided by KnowledgePanel were also adjusted for panel recruitment, attrition, oversampling, and survey nonresponse. RESULTS Of a total of 728 study participants, 204 (39%) were aged 18 to 34 years, 504 (61%) were women, 82 (17%) were Hispanic, and 551 (66%) were non-Hispanic White individuals. Serious psychological distress was reported by 262 participants (36%), and 214 participants (29%) also received mental health treatment from a primary care practitioner. Participants rated their mental health provider network as inadequate more frequently than their medical provider network (163 [21%] vs 70 [10%]; odds ratio [OR], 2.69; 95% CI, 1.64-4.40; P < .001). However, among the 193 participants also receiving mental health treatment from a primary care practitioner, there was no significant difference in the ratings of mental health and medical provider networks (44 [14%] vs 18 [9%]; OR, 1.55; 95% CI, 0.65-3.67; P = .32). Sixty participants (8%) reported that a mental health practitioner had left their plan's insurance network in the past 3 years. Of the 523 participants with a choice of plan, 98 (20%) considered whether a specific mental health practitioner was in network before choosing a plan. CONCLUSIONS AND RELEVANCE This study's findings suggest that more participants perceived their mental health networks to be inadequate compared with their medical networks. Increasing the availability of mental health treatment in primary care practices may aid plans in constructing adequate mental health provider networks and improve patient access to mental health care.
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Affiliation(s)
- Susan H. Busch
- Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut
| | - Kelly Kyanko
- Department of Population Health, New York University School of Medicine, New York
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6
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Busch SH, Kyanko KA. Incorrect Provider Directories Associated With Out-Of-Network Mental Health Care And Outpatient Surprise Bills. Health Aff (Millwood) 2021; 39:975-983. [PMID: 32479225 DOI: 10.1377/hlthaff.2019.01501] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Mental health services are up to six times more likely than general medical services to be delivered by an out-of-network provider, in part because many psychiatrists do not accept commercial insurance. Provider directories help patients identify in-network providers, although directory information is often not accurate. We conducted a national survey of privately insured patients who received specialty mental health treatment. We found that 44 percent had used a mental health provider directory and that 53 percent of these patients had encountered directory inaccuracies. Those who encountered inaccuracies were more likely (40 percent versus 20 percent) to be treated by an out-of-network provider and four times more likely (16 percent versus 4 percent) to receive a surprise outpatient out-of-network bill (that is, they did not initially know that a provider was out of network). A federal standard for directory accuracy, stronger enforcement of existing laws with insurers liable for directory errors, and additional monitoring by regulators may be needed.
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Affiliation(s)
- Susan H Busch
- Susan H. Busch is a professor in the Department of Health Policy and Management, Yale School of Public Health, in New Haven, Connecticut
| | - Kelly A Kyanko
- Kelly A. Kyanko is an assistant professor in the Department of Population Health, New York University Langone Health, in New York City
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7
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Abstract
The COVID-19 pandemic presents a crisis of mental health in the United States (U.S.) alongside a crisis of infectious disease. Racial inequities in COVID-19 morbidity and mortality have brought health equity to the forefront of public health policy, exacerbating prior inequities in mental health care access and outcomes. This Commentary asserts that policymakers and advocates must prioritize mental health when responding to the pandemic. While the pandemic is an emergency of unprecedented scale, the authors argue that it also is an opportunity to implement broad-based mental health policy reforms in the U.S. that build on the successes of the Affordable Care Act and the Mental Health Parity and Addiction Equity Act. Guided by innovative state and local policies to promote population-level mental health, we outline a series of empirically grounded strategies for federal and state policymakers to promote mental health equity in the wake of COVID-19.
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8
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SCHOR EDWARDL. Developing a Structure of Essential Services for a Child and Adolescent Mental Health System. Milbank Q 2021; 99:62-90. [PMID: 33463772 PMCID: PMC7984671 DOI: 10.1111/1468-0009.12490] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Policy Points That child and adolescent mental health services needs are frequently unmet has been known for many decades, yet few systemic solutions have been sought and fewer have been implemented at scale. Key among the barriers to improving child and adolescent mental health services has been the lack of well-organized primary mental health care. Such care is a mutual but uncoordinated responsibility of multiple disciplines and agencies. Achieving consensus on the essential structures and processes of mental health services is a feasible first step toward creating an organized system.
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9
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Rose S. Intersections of machine learning and epidemiological methods for health services research. Int J Epidemiol 2021; 49:1763-1770. [PMID: 32236476 PMCID: PMC7825941 DOI: 10.1093/ije/dyaa035] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/17/2020] [Indexed: 12/15/2022] Open
Abstract
The field of health services research is broad and seeks to answer questions about the health care system. It is inherently interdisciplinary, and epidemiologists have made crucial contributions. Parametric regression techniques remain standard practice in health services research with machine learning techniques currently having low penetrance in comparison. However, studies in several prominent areas, including health care spending, outcomes and quality, have begun deploying machine learning tools for these applications. Nevertheless, major advances in epidemiological methods are also as yet underleveraged in health services research. This article summarizes the current state of machine learning in key areas of health services research, and discusses important future directions at the intersection of machine learning and epidemiological methods for health services research.
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Affiliation(s)
- Sherri Rose
- Department of Health Care Policy, Harvard Medical School, 180 Longwood Ave, Boston, MA, 02115, USA
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10
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Bunger AC, Choi MS, MacDowell H, Gregoire T. Competition Among Mental Health Organizations: Environmental Drivers and Strategic Responses. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2020; 48:393-407. [PMID: 32918644 PMCID: PMC8038990 DOI: 10.1007/s10488-020-01079-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
While mental health system reforms have sought to leverage competition in the private sector to improve service quality and costs, competition among mental health organizations is poorly understood. To inform future studies about the impact of policy and system reforms on mental health organizations and service delivery, this qualitative study explores (1) resources for which organizations compete most intensively, (2) drivers of competition, and (3) leaders’ strategic organizational responses. Semi-structured phone interviews were conducted with 15 organizational leaders (CEO’s, executive directors) representing about 22% of organizations in the regional mental health market. Interviews covered leaders’ perceptions about competition, and their strategic responses. Porter’s seminal framework on competition was used to interpret codes and themes. Intensive competition for personnel was driven by workforce shortages, new for-profit organizations, and alternative employment opportunities. In response, organizations have attended to wages/benefits, recruitment, and retention. However, strong community need, expanded insurance coverage, and a history of local strategic responses that created service niches appeared to have minimized competition for financial resources in the region. Competition for funding and clients was expected to intensify under systems reform, and in anticipation, organizations were expanding services. Leaders also feared for the viability of smaller organizations in highly competitive environments. Consistent with theory on competition, mental health organizations compete and respond in ways that might improve services. However, the goals of privatization may have been unrealized because of minimal competition for funding and clients, and intense competition may undermine quality.
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Affiliation(s)
- Alicia C Bunger
- College of Social Work, Ohio State University, 1947 College Road, Columbus, OH, 43210, USA.
| | - Mi Sun Choi
- College of Social Work, Ohio State University, 1947 College Road, Columbus, OH, 43210, USA.,Department of Social Welfare, Silla University, Busan, South Korea
| | - Hannah MacDowell
- Community Naloxone Distribution Consultant, Ohio Department of Health, Columbus, Ohio, USA
| | - Thomas Gregoire
- College of Social Work, Ohio State University, 1947 College Road, Columbus, OH, 43210, USA
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11
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McGuire TG, van Kleef RC, van Veen SHCM. Paying for Mental Health Care in Private Health Insurance in the Netherlands: Some Lessons for the United States. Psychiatr Serv 2020; 71:538-539. [PMID: 32290808 DOI: 10.1176/appi.ps.202000104] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Thomas G McGuire
- Department of Health Care Policy, Harvard Medical School, and the National Bureau of Economic Research, Boston (McGuire); Erasmus School of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands (van Kleef); PricewaterhouseCoopers, Amsterdam (van Veen)
| | - Richard C van Kleef
- Department of Health Care Policy, Harvard Medical School, and the National Bureau of Economic Research, Boston (McGuire); Erasmus School of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands (van Kleef); PricewaterhouseCoopers, Amsterdam (van Veen)
| | - Suzanne H C M van Veen
- Department of Health Care Policy, Harvard Medical School, and the National Bureau of Economic Research, Boston (McGuire); Erasmus School of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands (van Kleef); PricewaterhouseCoopers, Amsterdam (van Veen)
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12
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Changes in Medicaid Acceptance by Substance Abuse Treatment Facilities After Implementation of Federal Parity. Med Care 2020; 58:101-107. [PMID: 31688556 DOI: 10.1097/mlr.0000000000001242] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Adequate access for mental illness and substance use disorder (SUD) treatment, particularly for Medicaid enrollees, is challenging. Policy efforts, including the Mental Health Parity and Addiction Equity Act (MHPAEA), have targeted expanded access to care. With MHPAEA, more Medicaid plans were required to increase their coverage of SUD treatment, which may impact provider acceptance of Medicaid. OBJECTIVES To identify changes in Medicaid acceptance by SUD treatment facilities after the implementation of MHPAEA (parity). RESEARCH DESIGN Observational study using an interrupted time series design. SUBJECTS 2002-2013 data from the National Survey of Substance Abuse Treatment Services (N-SSATS) for all SUD treatment facilities was combined with state-level characteristics. MEASURES Primary outcome is whether a SUD treatment facility reported accepting Medicaid insurance. RESULTS Implementation of MHPAEA was associated with a 4.6 percentage point increase in the probability of an SUD treatment facility accepting Medicaid (P<0.001), independent of facility and state characteristics, time trends, and key characteristics of state Medicaid programs. CONCLUSIONS After parity, more SUD treatment facilities accepted Medicaid payments, which may ultimately increase access to care for individuals with SUD. The findings underscore how parity laws are critical policy tools for creating contexts that enable historically vulnerable and underserved populations with SUD to access needed health care.
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13
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Progovac AM, Mullin BO, Creedon TB, McDowell A, Sanchez-Roman MJ, Hatfield LA, Schuster MA, Cook BL. Trends in Mental Health Care Use in Medicare from 2009 to 2014 by Gender Minority and Disability Status. LGBT Health 2019; 6:297-305. [PMID: 31436481 DOI: 10.1089/lgbt.2018.0221] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Purpose: This study examines trends in Medicare beneficiaries' mental health care use from 2009 to 2014 by gender minority and disability status. Methods: Using 2009 to 2014 Medicare claims, we modeled mental health care use (outpatient mental health care, inpatient mental health care, and psychotropic drugs) over time, adjusting for age and behavioral health diagnoses. We compared trends for gender minority beneficiaries (identified using diagnosis codes) to trends for a 5% random sample of other beneficiaries, stratified by original entitlement reason (age vs. disability). Results: Adjusted outpatient and inpatient mental health care use decreased and differences generally narrowed between gender minority and other beneficiaries over the study period. Among beneficiaries qualifying through disability, the gap in the number of outpatient and inpatient visits (among those with at least one visit in a given year) widened. Psychotropic drug use rose for all beneficiaries, but the proportion of gender minority beneficiaries in the aged cohort who had a psychotropic medication prescription rose faster than for other aged beneficiaries. Conclusions: Mental health care needs for Medicare beneficiaries may be met increasingly by using psychotropic medications rather than outpatient visits, and this pattern is more pronounced for identified gender minority (especially aged) beneficiaries. These trends may indicate a growing need for research and provider training in safe and effective psychotropic medication prescribing alongside gender-affirming treatments such as hormone therapy, especially for aged gender minority individuals who likely already experience polypharmacy.
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Affiliation(s)
- Ana M Progovac
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts.,Health Equity Research Lab, Department of Psychiatry, Cambridge Health Alliance, Cambridge, Massachusetts
| | - Brian O Mullin
- Health Equity Research Lab, Department of Psychiatry, Cambridge Health Alliance, Cambridge, Massachusetts
| | - Timothy B Creedon
- Health Equity Research Lab, Department of Psychiatry, Cambridge Health Alliance, Cambridge, Massachusetts
| | - Alex McDowell
- PhD Program in Health Policy, Harvard University, Cambridge, Massachusetts.,Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Maria Jose Sanchez-Roman
- Health Equity Research Lab, Department of Psychiatry, Cambridge Health Alliance, Cambridge, Massachusetts.,Department of Prevention and Community Health, Milken Institute School of Public Health, George Washington University, Washington, DC
| | - Laura A Hatfield
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | | | - Benjamin Lê Cook
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts.,Health Equity Research Lab, Department of Psychiatry, Cambridge Health Alliance, Cambridge, Massachusetts
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14
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Mulvaney-Day N, Gibbons BJ, Alikhan S, Karakus M. Mental Health Parity and Addiction Equity Act and the Use of Outpatient Behavioral Health Services in the United States, 2005-2016. Am J Public Health 2019; 109:S190-S196. [PMID: 31242013 DOI: 10.2105/ajph.2019.305023] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
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.
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Affiliation(s)
- Norah Mulvaney-Day
- Norah Mulvaney-Day and Mustafa Karakus are with Behavioral Health Research and Policy, Government Health and Human Services, IBM Watson Health, Cambridge, MA. Brent J. Gibbons is with the Centre for Health Services and Policy Research, Saw Swee Hock School of Public Health, National University of Singapore, Singapore. At the time of the study, Shums Alikhan was with Government Health and Human Services, IBM Watson Health
| | - Brent J Gibbons
- Norah Mulvaney-Day and Mustafa Karakus are with Behavioral Health Research and Policy, Government Health and Human Services, IBM Watson Health, Cambridge, MA. Brent J. Gibbons is with the Centre for Health Services and Policy Research, Saw Swee Hock School of Public Health, National University of Singapore, Singapore. At the time of the study, Shums Alikhan was with Government Health and Human Services, IBM Watson Health
| | - Shums Alikhan
- Norah Mulvaney-Day and Mustafa Karakus are with Behavioral Health Research and Policy, Government Health and Human Services, IBM Watson Health, Cambridge, MA. Brent J. Gibbons is with the Centre for Health Services and Policy Research, Saw Swee Hock School of Public Health, National University of Singapore, Singapore. At the time of the study, Shums Alikhan was with Government Health and Human Services, IBM Watson Health
| | - Mustafa Karakus
- Norah Mulvaney-Day and Mustafa Karakus are with Behavioral Health Research and Policy, Government Health and Human Services, IBM Watson Health, Cambridge, MA. Brent J. Gibbons is with the Centre for Health Services and Policy Research, Saw Swee Hock School of Public Health, National University of Singapore, Singapore. At the time of the study, Shums Alikhan was with Government Health and Human Services, IBM Watson Health
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15
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Rose S, McGuire TG. Limitations of P-Values and R-squared for Stepwise Regression Building: A Fairness Demonstration in Health Policy Risk Adjustment. AM STAT 2019; 73:152-156. [PMID: 31263291 DOI: 10.1080/00031305.2018.1518269] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Stepwise regression building procedures are commonly used applied statistical tools, despite their well-known drawbacks. While many of their limitations have been widely discussed in the literature, other aspects of the use of individual statistical fit measures, especially in high-dimensional stepwise regression settings, have not. Giving primacy to individual fit, as is done with p-values and R2, when group fit may be the larger concern, can lead to misguided decision making. One of the most consequential uses of stepwise regression is in health care, where these tools allocate hundreds of billions of dollars to health plans enrolling individuals with different predicted health care costs. The main goal of this "risk adjustment" system is to convey incentives to health plans such that they provide health care services fairly, a component of which is not to discriminate in access or care for persons or groups likely to be expensive. We address some specific limitations of p-values and R2 for high-dimensional stepwise regression in this policy problem through an illustrated example by additionally considering a group-level fairness metric.
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Affiliation(s)
- Sherri Rose
- Department of Health Care Policy, Harvard Medical School, Boston, MA, 01201
| | - Thomas G McGuire
- Department of Health Care Policy, Harvard Medical School, Boston, MA 01201 and Research Associate at NBER, Cambridge, MA, 02138
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16
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Rose S. Robust Machine Learning Variable Importance Analyses of Medical Conditions for Health Care Spending. Health Serv Res 2018. [PMID: 29527659 DOI: 10.1111/1475-6773.12848] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To propose nonparametric double robust machine learning in variable importance analyses of medical conditions for health spending. DATA SOURCES 2011-2012 Truven MarketScan database. STUDY DESIGN I evaluate how much more, on average, commercially insured enrollees with each of 26 of the most prevalent medical conditions cost per year after controlling for demographics and other medical conditions. This is accomplished within the nonparametric targeted learning framework, which incorporates ensemble machine learning. Previous literature studying the impact of medical conditions on health care spending has almost exclusively focused on parametric risk adjustment; thus, I compare my approach to parametric regression. PRINCIPAL FINDINGS My results demonstrate that multiple sclerosis, congestive heart failure, severe cancers, major depression and bipolar disorders, and chronic hepatitis are the most costly medical conditions on average per individual. These findings differed from those obtained using parametric regression. CONCLUSIONS The literature may be underestimating the spending contributions of several medical conditions, which is a potentially critical oversight. If current methods are not capturing the true incremental effect of medical conditions, undesirable incentives related to care may remain. Further work is needed to directly study these issues in the context of federal formulas.
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Affiliation(s)
- Sherri Rose
- Department of Health Care Policy, Harvard Medical School, Boston, MA
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Stewart MT, Horgan CM, Hodgkin D, Creedon TB, Quinn A, Garito L, Reif S, Garnick DW. Behavioral Health Coverage Under the Affordable Care Act: What Can We Learn From Marketplace Products? Psychiatr Serv 2018; 69:315-321. [PMID: 29241429 PMCID: PMC5832546 DOI: 10.1176/appi.ps.201700098] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE The 2008 federal parity law and the 2010 Affordable Care Act (ACA) sought to expand access to behavioral health services. There was concern that health plans might discourage enrollment by individuals with behavioral health conditions who tend to be higher cost. This study compared behavioral health benefits available in the group insurance market (nonmarketplace) to those sold through the ACA marketplaces to check for evidence of less generous behavioral health coverage in marketplace plans. METHODS Data were from a 2014 nationally representative survey of commercial health plans regarding behavioral health services (80% response rate). The sample included the most common silver marketplace product and, as a comparison, the most common nonmarketplace product of the same type (for example, health maintenance organization or preferred provider organization) from each health plan (N=106 marketplace and nonmarketplace pairs, or 212 products). RESULTS Marketplace and nonmarketplace products were similar in terms of coverage, prior authorization, and continuing review requirements. Marketplace products were more likely to employ narrow and tiered behavioral health provider networks. Narrow and tiered networks were more common in state than in federal marketplaces. CONCLUSIONS Provider network design is a tool that health plans may use to control cost and possibly discourage enrollment by high-cost users, including those with behavioral health conditions. The ACA was successful in ensuring robust behavioral health coverage in marketplace plans. As the marketplaces evolve or are replaced, these data provide an important baseline to which future systems can be compared.
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Affiliation(s)
- Maureen T Stewart
- Except for Dr. Quinn, the authors are with the Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts. Dr. Quinn is with the Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Constance M Horgan
- Except for Dr. Quinn, the authors are with the Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts. Dr. Quinn is with the Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Dominic Hodgkin
- Except for Dr. Quinn, the authors are with the Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts. Dr. Quinn is with the Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Timothy B Creedon
- Except for Dr. Quinn, the authors are with the Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts. Dr. Quinn is with the Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Amity Quinn
- Except for Dr. Quinn, the authors are with the Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts. Dr. Quinn is with the Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Lindsay Garito
- Except for Dr. Quinn, the authors are with the Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts. Dr. Quinn is with the Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Sharon Reif
- Except for Dr. Quinn, the authors are with the Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts. Dr. Quinn is with the Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Deborah W Garnick
- Except for Dr. Quinn, the authors are with the Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts. Dr. Quinn is with the Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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Peterson E, Busch S. Achieving Mental Health and Substance Use Disorder Treatment Parity: A Quarter Century of Policy Making and Research. Annu Rev Public Health 2018; 39:421-435. [PMID: 29328871 DOI: 10.1146/annurev-publhealth-040617-013603] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008 changed the landscape of mental health and substance use disorder coverage in the United States. The MHPAEA's comprehensiveness compared with past parity laws, including its extension of parity to plan management strategies, the so-called nonquantitative treatment limitations (NQTL), led to significant improvements in mental health care coverage. In this article, we review the history of this landmark legislation and its recent expansions to new populations, describe past research on the effects of this and other mental health/substance use disorder parity laws, and describe some directions for future research, including NQTL compliance issues, effects of parity on individuals with severe mental illness, and measurement of benefits other than mental health care use.
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Affiliation(s)
- Emma Peterson
- Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut 06520-8034, USA; ,
| | - Susan Busch
- Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut 06520-8034, USA; ,
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Zhu JM, Zhang Y, Polsky D. Networks In ACA Marketplaces Are Narrower For Mental Health Care Than For Primary Care. Health Aff (Millwood) 2017; 36:1624-1631. [DOI: 10.1377/hlthaff.2017.0325] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Jane M. Zhu
- Jane M. Zhu ( ) is a National Clinician Scholar and fellow in the Division of General Internal Medicine at the University of Pennsylvania Perelman School of Medicine, in Philadelphia
| | - Yuehan Zhang
- Yuehan Zhang is a statistical analyst in the Division of General Internal Medicine, University of Pennsylvania Perelman School of Medicine
| | - Daniel Polsky
- Daniel Polsky is the Robert D. Eilers Professor in Health Care Management and Economics and executive director of the Leonard Davis Institute of Health Economics, both at the University of Pennsylvania
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Ellis RP, Martins B, Zhu W. Health care demand elasticities by type of service. JOURNAL OF HEALTH ECONOMICS 2017; 55:232-243. [PMID: 28801131 PMCID: PMC5600717 DOI: 10.1016/j.jhealeco.2017.07.007] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Revised: 07/20/2017] [Accepted: 07/25/2017] [Indexed: 05/16/2023]
Abstract
We estimate within-year price elasticities of demand for detailed health care services using an instrumental variable strategy, in which individual monthly cost shares are instrumented by employer-year-plan-month average cost shares. A specification using backward myopic prices gives more plausible and stable results than using forward myopic prices. Using 171 million person-months spanning 73 employers from 2008 to 2014, we estimate that the overall demand elasticity by backward myopic consumers is -0.44, with higher elasticities of demand for pharmaceuticals (-0.44), specialists visits (-0.32), MRIs (-0.29) and mental health/substance abuse (-0.26), and lower elasticities for prevention visits (-0.02) and emergency rooms (-0.04). Demand response is lower for children, in larger firms, among hourly waged employees, and for sicker people. Overall the method appears promising for estimating elasticities for highly disaggregated services although the approach does not work well on services that are very expensive or persistent.
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Affiliation(s)
| | - Bruno Martins
- Boston University, Department of Economics, United States.
| | - Wenjia Zhu
- Harvard Medical School, Department of Health Care Policy, United States.
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