Medicare Advantage And Commercial Prices For Mental Health Services

Association of Medicare Advantage Enrollment With Financial Burden of Care : A Retrospective Cohort Study

BACKGROUND

Compared with traditional Medicare (TM), Medicare Advantage (MA) plans typically offer supplemental benefits and lower copayments for in-network services and must include an out-of-pocket spending limit.

OBJECTIVE

To examine whether the financial burden of care decreased for persons switching from TM to MA (TM-to-MA switchers) relative to those remaining in TM (TM stayers).

DESIGN

Retrospective longitudinal cohort study comparing changes in financial outcomes between TM-to-MA switchers and TM stayers.

SETTING

Population-based.

PARTICIPANTS

7054 TM stayers and 1544 TM-to-MA switchers from the Medical Expenditure Panel Survey, 2014 to 2021.

MEASUREMENTS

Individual health care costs (out-of-pocket spending and cost sharing), financial burden (high and catastrophic), and subjective financial hardship (difficulty paying medical bills, paying medical bills over time, and inability to pay medical bills).

RESULTS

Compared with TM stayers, TM-to-MA switchers had small differences in out-of-pocket spending ($168 [95% CI, -$133 to $469]) and proportions of total health expenses paid out of pocket (cost sharing) (0.2 percentage point [CI, -1.3 to 1.7 percentage points]), families with out-of-pocket spending greater than 20% of their income (high financial burden) (0.3 percentage point [CI, -2.5 to 3.0 percentage points]), families reporting out-of-pocket spending greater than 40% of their income (catastrophic financial burden) (0.7 percentage point [CI, -0.1 to 1.6 percentage points]), families reporting paying medical bills over time (-0.2 percentage point [CI, -1.7 to 1.4 percentage points]), families having problems paying medical bills (-0.4 percentage point [CI, -2.7 to 1.8 percentage points]), and families reporting being unable to pay medical bills (0.4 percentage point [CI, -1.3 to 2.0 percentage points]).

LIMITATION

Inability to account for all medical care and cost needs and variations across MA plans, small baseline differences in out-of-pocket spending, and potential residual confounding.

CONCLUSION

Differences in financial outcomes between beneficiaries who switched from TM to MA and those who stayed with TM were small. Differences in financial burden ranged across outcomes and did not have a consistent pattern.

PRIMARY FUNDING SOURCE

The National Research Foundation of Korea.

Financial Hardship Among Traditional Medicare and Medicare Advantage Enrollees With and Without Food Insecurity

BACKGROUND

Compared to traditional Medicare (TM), Medicare Advantage (MA) plans impose out-of-pocket cost limits and offer extra benefits, potentially providing financial relief for MA enrollees, especially for those with food insecurity.

OBJECTIVE

To examine whether the prevalence of food insecurity differs between TM and MA enrollees at baseline and then examine whether MA enrollment in a baseline year is associated with less financial hardships in the following year, relative to TM enrollment, especially for those experiencing food insecurity.

DESIGN

We conducted a retrospective longitudinal cohort study.

PARTICIPANTS

Our analysis included 2807 Medicare beneficiaries (weighted sample size, 23,963,947) who maintained continuous enrollment in either TM or MA in both 2020 and 2021 from the Medical Expenditure Panel Survey.

MAIN MEASURES

We assessed outcomes related to financial hardships in health care and non-health care domains (measured in 2021). Our primary independent variables were food insecurity and MA enrollment (measured in 2020).

RESULTS

The point estimate of food insecurity prevalence was greater among MA enrollees than TM enrollees, but the difference was not statistically significant (1.1 percentage points [95% CI, - 1.0, 3.4]). Furthermore, there is evidence that compared to TM enrollment, MA enrollment did not mitigate the risk of financial hardship, particularly for food-insecure enrollees. Rather, food-secure MA enrollees faced greater financial hardship in the following year than food-secure TM enrollees (11.2% [8.9-13.6] and 7.6% [6.9-8.3] for problems paying medical bills and 5.5% [4.6-6.4] and 2.8% [2.1-3.6] for paying medical bills over time). Moreover, the point estimate of financial hardship was higher among food-insecure MA enrollees than food-insecure TM enrollees (21.5% [5.4-37.5] and 11.2% [4.1-18.4] and 23.7% [9.6-37.9] and 6.9% [0.5-13.3]) despite the lack of statistical significance.

CONCLUSION

These findings suggest that the promise of financial protection offered by MA plans has not been fully realized, particularly for those with food insecurity.

The Economics of Treatment for Depression

The global prevalence of depression has risen over the past three decades across all socioeconomic groups and geographic regions, with a particularly rapid increase in prevalence among adolescents (aged 12-17 years) in the United States. Depression imposes large health, economic, and societal costs, including reduced life span and quality of life, medical costs, and reduced educational attainment and workplace productivity. A wide range of treatment modalities for depression are available, but socioeconomic disparities in treatment access are driven by treatment costs, lack of culturally tailored options, stigma, and provider shortages, among other barriers. This review highlights the need for comparative research to better understand treatments' relative efficacy, cost-effectiveness, scalability, and potential heterogeneity in efficacy across socioeconomic groups and country and cultural contexts. To address the growing burden of depression, mental health policy could consider reducing restrictions on the supply of providers, implementing digital interventions, reducing stigma, and promoting healthy lifestyles.

Commercial Insurer Market Power and Medicaid Managed Care Networks

Over 70% of Medicaid beneficiaries are enrolled in Medicaid managed care (MMC). MMC provider networks therefore represent a critical determinant of access to the Medicaid program. Many MMC insurers also participate in commercial insurance markets where prices are high, and some insurers exercise considerable market power. In this paper, we examined the relationship between commercial insurer market power and MMC physician network breadth using linked national enrollment data and provider directory data. Insurers with more commercial market power had broader Medicaid physician networks. Insurers with over 30% market share had 37.3% broader Medicaid networks than insurers in the same county that had no commercial market share. These differences were driven by greater breadth among primary care providers, as well as other specialists including OB/GYNs, surgeons, neurologists, and cardiologists. Commercial insurance market power may have spillovers on access to care for MMC beneficiaries.

Administrative Frictions and the Mental Health Workforce

This Viewpoint describes the administrative barriers experienced by mental health professionals and recommends strategies to address these barriers.

Unmet need for mental health care is common across insurance market segments in the United States

A substantial proportion of individuals with depression in the United States do not receive treatment. While access challenges for mental health care have been documented, few recent estimates of unmet mental health needs across insurance market segments exist. Using nationally representative survey data with participant-reported depression symptom severity and mental health care use collected in Spring 2023, we assessed access to mental health care among individuals with similar levels of depression symptom severity with commercial, Medicare, Medicaid, and no insurance. Among individuals who reported symptoms consistent with moderately severe to severe depression, 37.8% did not have a diagnosis for depression (41.0%, 28.1%, 33.6%, and 56.3% with commercial, Medicare, Medicaid, and no insurance), 51.9% did not see a mental health specialist (49.7%, 51.7%, 44.9%, and 91.8%), and 32.4% avoided mental health care due to affordability in the past 12 months (30.2%, 34.0%, 21.1%, and 54.8%). There was substantial unmet need for mental health treatment in all insurance market segments, but especially among individuals without insurance.

Health Care Spending, Use, and Financial Hardship Among Traditional Medicare and Medicare Advantage Enrollees With Mental Health Symptoms

OBJECTIVE

We examined the differences in health care spending and utilization, and financial hardship between Traditional Medicare (TM) and Medicare Advantage (MA) enrollees with mental health symptoms.

DESIGN

Cross-sectional study.

PARTICIPANTS

We identified Medicare beneficiaries with mental health symptoms using the Patient Health Questionnaire-2 and the Kessler-6 Psychological Distress Scale in the 2015-2021 Medical Expenditure Panel Survey.

MEASUREMENTS

Outcomes included health care spending and utilization (both general and mental health services), and financial hardship. The primary independent variable was MA enrollment.

RESULTS

MA enrollees with mental health symptoms were 2.3 percentage points (95% CI: -3.4, -1.2; relative difference: 16.1%) less likely to have specialty mental health visits than TM enrollees with mental health symptoms. There were no significant differences in total health care spending, but annual out-of-pocket spending was $292 (95% CI: 152-432; 18.2%) higher among MA enrollees with mental health symptoms than TM enrollees with mental health symptoms. Additionally, MA enrollees with mental health symptoms were 5.0 (95% CI: 2.9-7.2; 22.3%) and 2.5 percentage points (95% CI: 0.8-4.2; 20.9%) more likely to have difficulty paying medical bills over time and to experience high financial burden than TM enrollees with mental health symptoms.

CONCLUSION

Our findings suggest that MA enrollees with mental health symptoms were more likely to experience limited access to mental health services and high financial hardship compared to TM enrollees with mental health symptoms. There is a need to develop policies aimed at improving access to mental health services while reducing financial burden for MA enrollees.

Psychiatrist and Nonpsychiatrist Physician Network Breadth in Dual Eligible Special Needs Plans

OBJECTIVE

Dual Eligible Special Needs Plans (D-SNPs) are a type of Medicare Advantage (MA) plan for individuals who have both Medicare and Medicaid coverage. The authors compared the breadths of psychiatrist and nonpsychiatrist provider networks in D-SNPs and other MA plans.

METHODS

MA plan provider network data were merged with plan service areas and a nationwide provider database to form a data set with 843 observations on networks subclassified by state and network type (D-SNP or other MA) covering 42 U.S. states and Washington, D.C. Network breadth measured the in-network fraction of clinically active Medicare-accepting psychiatrists and other physician providers in the plans' service areas in each state. Regression analyses were used to compare psychiatrist and nonpsychiatrist network breadth and psychiatrist-nonpsychiatrist breadth differences between D-SNPs and other MA plans, after adjustment for state-level differences.

RESULTS

Mean psychiatrist network breadth was 0.319 in D-SNPs and 0.299 in other MA plans, and nonpsychiatrist network breadth was 0.346 in D-SNPs and 0.358 in other MA plans. Psychiatrist networks were narrower than nonpsychiatrist networks (0.303 vs. 0.355, p<0.001), but mean psychiatrist network breadth did not differ between D-SNPs and other MA plans. In regression analyses, the psychiatrist-nonpsychiatrist breadth difference was smaller in D-SNPs (-0.031) than in other MA plans (-0.060) (p=0.002).

CONCLUSIONS

Psychiatrist provider networks in a nationwide sample of D-SNPs had similar breadth as psychiatrist networks used in other MA plans. Special provider network adequacy requirements for psychiatrists in D-SNP networks may be worthy of further consideration given D-SNPs' disproportionate enrollment of adults with serious mental illness who have dual Medicare-Medicaid insurance coverage.

Psychiatrist Networks In Medicare Advantage Plans Are Substantially Narrower Than In Medicaid And ACA Markets

Medicare Advantage now covers twenty-eight million older adults, many of whom have mental health needs. Enrollees are often restricted to providers who participate in a health plan's network, which may present a barrier to care. We used a novel data set linking network service areas, plans, and providers to compare psychiatrist network breadth-the percentage of providers in a given area that are considered "in network" for a plan-across Medicare Advantage, Medicaid managed care, and Affordable Care Act plan markets. We found that nearly two-thirds of psychiatrist networks in Medicare Advantage were narrow (that is, they contained fewer than 25 percent of providers in a network's service area) compared with approximately 40 percent in Medicaid managed care and Affordable Care Act plan markets. We did not observe similar differences in network breadth for primary care physicians or other physician specialists across markets. Amid efforts to strengthen network adequacy, our findings suggest that psychiatrist networks in Medicare Advantage are particularly narrow, which may disadvantage enrollees as they attempt to obtain mental health services.

Experiences that matter in bipolar disorder: a qualitative study using the capability, comfort and calm framework

BACKGROUND

When assessing the value of an intervention in bipolar disorder, researchers and clinicians often focus on metrics that quantify improvements to core diagnostic symptoms (e.g., mania). Providers often overlook or misunderstand the impact of treatment on life quality and function. We wanted to better characterize the shared experiences and obstacles of bipolar disorder within the United States from the patient's perspective.

METHODS

We recruited 24 individuals diagnosed with bipolar disorder and six caretakers supporting someone with the condition. Participants were involved in treatment or support services for bipolar disorder in central Texas. As part of this qualitative study, participants discussed their everyday successes and obstacles related to living with bipolar disorder during personalized, open-ended interviews. Audio files were transcribed, and Nvivo software processed an initial thematic analysis. We then categorized themes into bipolar disorder-related obstacles that limit the patient's capability (i.e., function), comfort (i.e., relief from suffering) and calm (i.e., life disruption) (Liu et al., FebClin Orthop 475:315-317, 2017; Teisberg et al., MayAcad Med 95:682-685, 2020). We then discuss themes and suggest practical strategies that might improve the value of care for patients and their families.

RESULTS

Issues regarding capability included the struggle to maintain identity, disruptions to meaningful employment, relationship loss and the unpredictable nature of bipolar disorder. Comfort related themes included the personal perception of diagnosis, social stigma and medication issues. Calm themes included managing dismissive doctors, finding the right psychotherapist and navigating financial burdens.

CONCLUSIONS

Qualitative data from patients with bipolar disorder helps identify gaps in care or practical limitations to treatment. When we listen to these individuals, it is clear that treatments must also address the unmet psychosocial impacts of the condition to improve patient care, capability and calm.

Excess healthcare resource utilization and healthcare costs among privately and publicly insured patients with major depressive disorder and acute suicidal ideation or behavior in the United States

BACKGROUND

This study assessed the healthcare resource utilization (HRU) and cost burden of patients with major depressive disorder (MDD) and acute suicidal ideation or behavior (SIB; MDSI) versus those with MDD without SIB and those without MDD.

METHODS

Adults were selected from the MarketScan® Databases (10/2015-02/2020). The MDSI cohort received an MDD diagnosis within 6 months of a claim for acute SIB (index date). The index date was a random MDD claim in the MDD without SIB cohort and a random date in the non-MDD cohort. Patients had continuous eligibility ≥12 months pre- and ≥1 month post-index. HRU and costs were compared during 1- and 12-month post-index periods between MDSI and control cohorts matched 1:1 on demographics.

RESULTS

The MDSI cohort included 73,242 patients (mean age 35 years, 60.6% female, 37.2% Medicaid coverage). At 1 month post-index, the MDSI cohort versus the MDD without SIB/non-MDD cohorts had 12.8/67.2 times more inpatient admissions and 3.3/8.9 times more emergency department visits; they had 2.9 times more outpatient visits versus the non-MDD cohort (all p < 0.001). The MDSI cohort had incremental mean healthcare costs of $5255 and $6674 per-patient-month versus the MDD without SIB and non-MDD cohorts (all p < 0.001); inpatient costs drove up to 89.5% of incremental costs. At 12 months post-index, HRU and costs remained higher in MDSI versus control cohorts.

LIMITATIONS

SIB are underreported in claims; unobserved confounders may cause bias.

CONCLUSIONS

MDSI is associated with substantial excess healthcare costs driven by inpatient costs, concentrated in the first month post-index, and persisting during the following year.

Effect of Medicare Advantage on health care use and care dissatisfaction in mental illness

OBJECTIVE

To examine the effects of Medicare Advantage (MA) enrollment on health care use and dissatisfaction with care received among Medicare beneficiaries with mental illness.

DATA SOURCES

I identified traditional Medicare (TM) and MA beneficiaries with mental illness using the Medicare Current Beneficiary Survey for 2012-2016.

STUDY DESIGN

I included two types of outcomes: four measures of health care use and 10 measures of care dissatisfaction. My primary independent variable was enrollment in TM versus MA. To address selective enrollment into MA, I used an instrumental variable (IV) approach. Following prior research, I decomposed the MA benchmark into exogenous and endogenous components and then used the exogenous component as my instrument.

DATA COLLECTION/EXTRACTION METHODS

Not Applicable.

PRINCIPAL FINDINGS

IV analyses showed that compared with TM enrollment, MA enrollment significantly decreased outpatient hospital visits and medical provider visits by 6.73 (95% CI: -12.10 to -1.36) and 36.48 (95% CI: -52.67 to -20.28). However, there were no significant changes in inpatient hospital admissions and prescription drug purchases. Compared with TM enrollment, MA enrollment significantly increased dissatisfaction with out-of-pocket expenses by 25.51 percentage points (95% CI: 0.43 to 50.60). However, there were no significant changes in other measures of care dissatisfaction in terms of access to care, quality of care, and prescription medication.

CONCLUSIONS

These findings suggest that MA enrollment may lead to low health care use among those with mental illness, indicating efficient care delivery. Also, MA enrollment may not preclude those with mental illness from accessing needed care. However, high dissatisfaction with out-of-pocket expenses among MA beneficiaries may imply the use of out-of-network providers. Further research is warranted to investigate whether high dissatisfaction with out-of-pocket expenses may be attributable to MA's narrow networks for mental services.

Phantom Networks: Discrepancies Between Reported And Realized Mental Health Care Access In Oregon Medicaid

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.

Comparison of Performance of Psychiatrists vs Other Outpatient Physicians in the 2020 US Medicare Merit-Based Incentive Payment System

Question

How did psychiatrists perform in the 2020 Medicare Merit-Based Incentive Payment System (MIPS) compared with other outpatient physicians?

Findings

In this cross-sectional study of 9356 psychiatrists and 196 306 other outpatient physicians participating in the 2020 MIPS, psychiatrists had significantly lower performance scores, were significantly more likely to be assessed a performance penalty, and were less likely to be assessed a bonus than other physicians.

Meaning

Psychiatrists performed worse than other physicians in Medicare’s new mandatory outpatient value-based payment system; therefore, more research is needed to evaluate the appropriateness of MIPS measures for psychiatrists.

Importance

Medicare’s Merit-Based Incentive Payment System (MIPS) is a new, mandatory, outpatient value-based payment program that ties reimbursement to performance on cost and quality measures for many US clinicians. However, it is currently unknown how the program measures the performance of psychiatrists, who often treat a different patient case mix with different clinical considerations than do other outpatient clinicians.

Objective

To compare performance scores and value-based reimbursement for psychiatrists vs other outpatient physicians in the 2020 MIPS.

Design, Setting, and Participants

In this cross-sectional study, the Centers for Medicare & Medicaid Services Provider Data Catalog was used to identify outpatient Medicare physicians listed in the National Downloadable File between January 1, 2018, and December 31, 2020, who participated in the 2020 MIPS and received a publicly reported final performance score. Data from the 593 863 clinicians participating in the 2020 MIPS were used to compare differences in the 2020 MIPS performance scores and value-based reimbursement (based on performance in 2018) for psychiatrists vs other physicians, adjusting for physician, patient, and practice area characteristics.

Exposures

Participation in MIPS.

Main Outcomes and Measures

Primary outcomes were final MIPS performance score and negative (penalty), positive, and exceptional performance bonus payment adjustments. Secondary outcomes were scores in the MIPS performance domains: quality, promoting interoperability, improvement activities, and cost.

Results

This study included 9356 psychiatrists (3407 [36.4%] female and 5 949 [63.6%] male) and 196 306 other outpatient physicians (69 221 [35.3%] female and 127 085 [64.7%] male) (data on age and race are not available). Compared with other physicians, psychiatrists were less likely to be affiliated with a safety-net hospital (2119 [22.6%] vs 64 997 [33.1%]) or a major teaching hospital (2148 [23.0%] vs 53 321 [27.2%]) and had lower annual Medicare patient volume (181 vs 437 patients) and mean patient risk scores (1.65 vs 1.78) (P < .001 for all). The mean final MIPS performance score for psychiatrists was 84.0 vs 89.7 for other physicians (absolute difference, −5.7; 95% CI, −6.2 to −5.2). A total of 573 psychiatrists (6.1%) received a penalty vs 5739 (2.9%) of other physicians (absolute difference, 3.2%; 95% CI, 2.8%-3.6%); 8664 psychiatrists (92.6%) vs 189 037 other physicians (96.3%) received a positive payment adjustment (absolute difference, −3.7%; 95% CI, −3.3% to −4.1%), and 7672 psychiatrists (82.0%) vs 174 040 other physicians (88.7%) received a bonus payment adjustment (absolute difference, −6.7%; 95% CI, −6.0% to −7.3%). These differences remained significant after adjustment.

Conclusions and Relevance

In this cross-sectional study that compared US psychiatrists with other outpatient physicians, psychiatrists had significantly lower 2020 MIPS performance scores, were penalized more frequently, and received fewer bonuses. Policy makers should evaluate whether current MIPS performance measures appropriately assess the performance of psychiatrists.

Organizational Best Practices Supporting Mental Health in the Workplace

OBJECTIVE

To provide a narrative review of best and promising practices for achieving exemplary mental health in the workplace as the foundation for the inaugural Carolyn C. Mattingly Award for Mental Health in the Workplace.

METHODS

Research was drawn from peer-reviewed articles using the search terms associated with workplace mental health.

RESULTS

Eight categories of best practices were identified: (1) culture, (2) robust mental health benefits, (3) mental health resources, (4) workplace policies and practices, (5) healthy work environment, (6) leadership support, (7) outcomes measurement, and (8) innovation.

CONCLUSION

The review provided the scientific backing to support criteria developed for the Carolyn C. Mattingly Award for Mental Health in the Workplace. By recognizing organizations that apply evidence-based practices in their health and well-being programs, the Mattingly Award may inspire employers to adopt best practices.

Assessment of Perceptions of Mental Health vs Medical Health Plan Networks Among US Adults With Private Insurance

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.

Driving Access and Quality: A Shift to Value-Based Behavioral Health Care

Multiple barriers exist to accessing behavioral health care, and several are related to payment. The national shortage of behavioral health providers is exacerbated by their not joining health insurance networks, often shifting the cost of treatment to patients. In the face of high out-of-network expenses, deductibles, and copays, many insured patients forgo behavioral health treatment altogether. However, even when patients access care, health outcomes are not routinely measured, and there is reason to suspect that the quality of care is poor. To address these issues, value-based reimbursement for behavioral health care offers a sustainable pathway to increase payment for providers in return for improved population health outcomes and costs. This article describes a comprehensive collaborative effort between a payer and a health care technology and services organization to support behavioral health providers to enter into value-based care. This approach changes financial incentives to drive improvements in behavioral health care access and quality.

Cluster Analysis of Care Pathways in Adults with Major Depressive Disorder with Acute Suicidal Ideation or Behavior in the USA

BACKGROUND AND OBJECTIVE

Suicidal ideation or behavior are core symptoms of major depressive disorder (MDD). This study aimed to understand heterogeneity among patients with MDD and acute suicidal ideation or behavior.

METHODS

Adults with a diagnosis of MDD on the same day or 6 months before a claim for suicidal ideation or behavior (index date) were identified in the MarketScan^® Databases (10/01/2014-04/30/2019). A mathematical algorithm was used to cluster patients on characteristics of care measured pre-index. Patient care pathways were described by cluster during the 12-month pre-index period and up to 12 months post-index.

RESULTS

Among 38,876 patients with MDD and acute suicidal ideation or behavior, three clusters were identified. Across clusters, pre-index exposure to mental healthcare was revealed as a key differentiator: Cluster 1 (N = 16,025) was least exposed, Cluster 2 (N = 5640) moderately exposed, and Cluster 3 (N = 17,211) most exposed. Patients whose MDD diagnosis was first observed during their index event comprised 86.0% and 72.8% of Clusters 1 and 2, respectively; in Cluster 3, all patients had an MDD diagnosis pre-index. Within 30 days post-index, in Clusters 1, 2, and 3, respectively, 79.3%, 85.2%, and 88.2% used mental health services, including outpatient visits for MDD. Within 12 months post-index, 61.5%, 91.5%, and 84.6% had one or more antidepressant claim, respectively. Per-patient index event costs averaged $5614, $6645, and $5853, respectively.

CONCLUSIONS

Patients with MDD and acute suicidal ideation or behavior least exposed to the healthcare system pre-index similarly received the least care post-index. An opportunity exists to optimize treatment and follow-up with mental health services.

Incorrect Provider Directories Associated With Out-Of-Network Mental Health Care And Outpatient Surprise Bills

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.

A sequence analysis of hospitalization patterns and service utilization in patients with major psychiatric disorders in China

BACKGROUND

Understanding the long-term inpatient service cost and utilization of psychiatric patients may provide insight into service demand for these patients and guide the design of targeted mental health programs. This study assesses 3-year hospitalization patterns and quantifies service utilization intensity of psychiatric patients in Beijing, China.

METHODS

We identified patients admitted for one of three major psychiatric disorders (schizophrenia, bipolar and depressive disorders) between January 1 and December 31, 2013 in Beijing, China. Inpatient admissions during the following 3 years were extracted and analyzed using sequence analysis. Clinical characteristics, psychiatric and non-psychiatric service use of included patients were analyzed.

RESULTS

The study included 3443 patients (7657 hospitalizations). The patient hospitalization sequences were grouped into 4 clusters: short stay (N = 2741 (79.61% of patients), who had 126,911 or 26.82% of the hospital days within the sample), repeated long stay (N = 404 (11.73%), 76,915 (16.26%) days), long-term stay (N = 101 (2.93%), 59,909 (12.66%) days) and permanent stay (N = 197 (5.72%), 209,402 (44.26%) days). Length and frequency of hospitalization, as well as readmission rates were significantly different across the 4 clusters. Over the 3-year period, hospitalization days per year decreased for patients in the short stay and repeated long stay clusters. Patients with schizophrenia (1705 (49.52%)) had 78.4% of cumulative psychiatric stays, with 11.14% of them in the permanent stay cluster. Among patients with depression, 23.11% had non-psychiatric hospitalizations, and on average 46.65% of their total inpatient expenses were for non-psychiatric care, the highest among three diagnostic groups.

CONCLUSION

Hospitalization patterns varied significantly among psychiatric patients and across diagnostic categories. The high psychiatric care service use of the long-term and permanent stay patients underlines the need for evidence-based interventions to reduce cost and improve care quality.

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.

Randomized trial shows healthcare payment reform has equal-sized spillover effects on patients not targeted by reform

Changes in the way health insurers pay healthcare providers may not only directly affect the insurer's patients but may also affect patients covered by other insurers. We provide evidence of such spillovers in the context of a nationwide Medicare bundled payment reform that was implemented in some areas of the country but not in others, via random assignment. We estimate that the payment reform-which targeted traditional Medicare patients-had effects of similar magnitude on the healthcare experience of nontargeted, privately insured Medicare Advantage patients. We discuss the implications of these findings for estimates of the impact of healthcare payment reforms and more generally for the design of healthcare policy.

Prices And Cost Sharing For Psychotherapy In Network Versus Out Of Network In The United States

Patients in the US are more likely to receive out-of-network behavioral health care, including treatment for mental health or substance use disorders, than they are to receive other medical and surgical services out of network. To date, out-of-network and in-network trends in the prices and use of ambulatory behavioral health care have been seldom described. Here we compare levels and growth of insurer-negotiated prices (allowed amounts), patient cost sharing, and use of psychotherapy services in network and out of network in a large, commercially insured US population during 2007-17. For both adult and child psychotherapy, prices and cost sharing were substantially higher out of network than they were in network. These gaps widened during the eleven-year period. Prices and cost sharing for in-network psychotherapy decreased during this period, whereas prices and cost sharing for out-of-network psychotherapy increased. Use of adult and child psychotherapy increased during this period, driven by growth of in-network rather than out-of-network use. The increasing gap in prices and cost sharing between out-of-network and in-network psychotherapy, viewed in the context of a shortage of behavioral health providers who accept insurance, may limit access to ambulatory behavioral health care.

Out-Of-Network Spending Mostly Declined In Privately Insured Populations With A Few Notable Exceptions From 2008 To 2016

While out-of-network or potential "surprise" billing has garnered increasing attention, particularly in emergency department and inpatient settings, few national studies have examined out-of-network care overall or in other settings. We examined out-of-network spending and use among two large nationwide populations with employer-sponsored insurance. In a primary sample of 27,883,040 people in data for 2008-16 from the Truven MarketScan Commercial Claims and Encounters Database, we found that the unadjusted share of total spending that occurred out of network decreased from 7.0 percent in 2008-10 to 6.1 percent in 2014-16, an adjusted average decline of 0.10 percentage points per year. Using a secondary sample of 13,093,209 people in the Health Care Cost Institute database provided qualitatively similar results, including when provider charges (upper bound for balance billing) were used in place of observed out-of-network prices. In subgroup analyses of the primary sample, the share of out-of-network spending was stable or declined among all segments of care except hospitalist services, pathologist services, and laboratory tests across the study period. Out-of-network use demonstrated comparable patterns. Prices were higher out of network than in network. Policy makers should focus their efforts on protecting consumers from balance billing or potential surprise billing in clinical scenarios where patients often have little choice over their provider.

Mental health and chemical dependency services at US transplant centers

The purpose of this study was to assess the availability of mental health (MH) and chemical dependency (CD) services at US transplant centers, because appropriate psychosocial assessment and care is associated with better transplant outcomes. We used the 2017-2018 American Hospital Association survey, Area Health Resource File, and Centers for Medicare & Medicaid Services Hospital Compare databases to quantify availability of services and examined associations of hospital- and health services area-level characteristics with odds of offering services with generalized linear mixed models. We found that 15% of transplant centers did not offer MH services and 62% did not offer CD services. Hospitals were more likely to offer MH services if they were larger (OR [95% CI]: 1.03 [1.01, 1.06]) and had a lower rate of uninsured patients in the health services area (OR [95% CI]: 0.89 [0.80, 0.99]) and were more likely to offer CD services if they were larger (OR [95% CI]: 1.02 [1.01, 1.03]) or were members of a system (OR [95% CI]: 2.31 [1.26, 4.24]). Additional research is needed to understand whether lack of MH or CD services at transplant centers affects patients' ability to access comprehensive psychosocial care and whether this affects patient outcomes.

Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents

Attention-deficit/hyperactivity disorder (ADHD) is 1 of the most common neurobehavioral disorders of childhood and can profoundly affect children's academic achievement, well-being, and social interactions. The American Academy of Pediatrics first published clinical recommendations for evaluation and diagnosis of pediatric ADHD in 2000; recommendations for treatment followed in 2001. The guidelines were revised in 2011 and published with an accompanying process of care algorithm (PoCA) providing discrete and manageable steps by which clinicians could fulfill the clinical guideline's recommendations. Since the release of the 2011 guideline, the Diagnostic and Statistical Manual of Mental Disorders has been revised to the fifth edition, and new ADHD-related research has been published. These publications do not support dramatic changes to the previous recommendations. Therefore, only incremental updates have been made in this guideline revision, including the addition of a key action statement related to diagnosis and treatment of comorbid conditions in children and adolescents with ADHD. The accompanying process of care algorithm has also been updated to assist in implementing the guideline recommendations. Throughout the process of revising the guideline and algorithm, numerous systemic barriers were identified that restrict and/or hamper pediatric clinicians' ability to adopt their recommendations. Therefore, the subcommittee created a companion article (available in the Supplemental Information) on systemic barriers to the care of children and adolescents with ADHD, which identifies the major systemic-level barriers and presents recommendations to address those barriers; in this article, we support the recommendations of the clinical practice guideline and accompanying process of care algorithm.

Health Care Crisis by the Numbers

We summarize recent data on health and health care in the United States. Many millions suffer financial distress due to medical bills and forego needed care because of costs. Pay-for-performance programs have failed to achieve the results promised and in some cases have backfired. Health care firms expend huge amounts on marketing that provides no benefit to patients. Millions of health care workers, particularly women of color, are so poorly paid that they live in poverty, and gender-based pay inequities remain common in the health sector. Polls continue to show strong popular support for a single-payer reform, but politicians continue to resist it.