Medicaid Reimbursement For Psychiatric Services: Comparisons Across States And With Medicare

Trends in Outpatient Psychotherapy Among Adults in the US

Importance

While access to psychotherapy has recently increased in the US, concern exists that recent gains may be unevenly distributed despite teletherapy expansion.

Objective

To characterize recent trends and patterns in outpatient psychotherapy by US adults.

Design, Setting, and Participants

This is a repeated cross-sectional study of psychotherapy use among adults (ages ≥18 years) in the 2018 to 2021 Medical Expenditure Panel Surveys, which are nationally representative surveys of the civilian noninstitutionalized population. Data were analyzed from March to August 2024.

Main Outcomes and Measures

Age-, sex-, and distress-adjusted differences between 2018 and 2021 in use of any psychotherapy and video-based psychotherapy (teletherapy) in 2021 with tests for trend differences (interactions) across levels of sociodemographic characteristics and distress were assessed. Psychological distress was measured using the Kessler-6 scale, with scores of 13 or higher defining serious psychological distress, 1 to 12 defining mild to moderate distress, and 0 defining no distress.

Results

The analysis involved 89 619 participants (47 838 female [51.5%] and 41 781 male [48.5%]; 22 510 aged 18-34 years [29.0%], 43 371 aged 35-64 years [48.8%], and 23 738 aged ≥65 years [22.2%]). Between 2018 and 2021, psychotherapy use increased significantly faster for females (931/12 270 females [7.7%] to 1207/12 237 females [10.5%]) than males (547/10 741 males [5.2%] to 655/10 544 males [6.3%]), younger (455/6149 individuals [8.0%] to 602/5296 individuals [11.9%] aged 18-34 years) than older (217/5550 individuals [3.6%] to 304/6708 individuals [4.6%] aged ≥65 years) adults, college graduates (503/6456 adults [7.6%] to 810/7277 adults [11.4%]) than those without a high school diploma (193/3824 adults [5.5%] to 200/3593 adults [7.0%]), privately insured (881/14 387 adults [6.1%] to 1154/13 414 adults [8.9%]) than publicly insured (558/6511 adults [8.8%] to 659/7453 adults [8.8%]) individuals, adults at 2 to 4 times the poverty level (370/6670 adults [5.7%] to 488/6370 adults [8.2%]) than those below the poverty level (384/4495 adults [9.7%] to 428/4760 adults [10.0%]), employed persons overall (733/13 358 adults [5.7%] to 1082/12 365 adults [8.9%]) than unemployed persons aged 65 years and younger (547/5138 adults [10.8%] to 519/4905 adults [10.5%]), and urban (1335/20 682 adults [6.5%] to 1729/20 590 adults [8.7%]) than rural (143/2329 adults [6.4%] to 133/2191 adults [5.9%]) residents. In 2021, after controlling for distress level, teletherapy use was significantly higher among younger than middle-aged (aged 35-64 years: difference, -3.7 percentage points; 95% CI, -5.1 to -2.3) or older (aged ≥65 years: difference, -6.5 percentage points (95% CI, -8.0 to -5.0 percentage points) adults, females (difference, 1.9 percentage points; 95% CI, 0.9 to 2.9 percentage points) than males, not married (difference, 2.9 percentage points; 95% CI, 1.6 to 4.2 percentage points) than married persons, college educated adults (difference, 4.9 percentage points; 95% CI, 3.3 to 6.4 percentage points) than those without a high school diploma, people with higher (eg, 400% vs <100% of the federal poverty level: difference, 2.3 percentage points; 95% CI, 1.2 to 3.5 percentage points) than lower incomes, privately than publicly (difference, -2.5 percentage points; 95% CI, -3.4 to -1.5 percentage points) insured persons, and urban (difference, 2.7 percentage points; 95% CI, 1.5 to 3.8 percentage points) than rural residents.

Conclusions

This study found that psychotherapy use increased significantly faster among several socioeconomically advantaged groups and that inequalities were evident in teletherapy access. These trends and patterns highlight a need for clinical interventions and health care policies to broaden access to psychotherapy including teletherapy.

Trends in Emergency Department, Primary Care, and Behavioral Health Use for Pediatric Mental Health Conditions in Virginia before and during the COVID-19 pandemic

BACKGROUND

Pediatric emergency department (ED) visits for mental health are costly and often preventable. Access to primary care and behavioral health providers can improve mental health and reduce unnecessary ED visits.

METHODS

Quantitative analysis of the Virginia All-Payers Claims Database to assess mental health ED and outpatient care for children and adolescents up to age 21 years between 2016 and 2021. We determined the proportion of children and adolescents seen by primary care or behavioral health one week and one year before an ED visit, and how many had follow-up care within one and two months after.

RESULTS

From 2016 to 2021, pediatric ED visits dropped 14%, but mental health visits rose 10.6%, and suicidality visits tripled (301 to 929, p < 0.001). Only 5% of youth with suicidality ED visits had a primary care visit within 7 days prior, and 18% saw a mental health provider. During the pandemic, prior-year primary care visits for mental health ED cases declined (68.1-61.8%, p < 0.0001). Follow-ups within 60 days dropped for primary care (mental health: 40.0-34.2%; suicidality: 37.5-33.5%), slightly improved for behavioral health (32.2-37.1%), and stayed stable for suicidality (64.1-63.0%).

CONCLUSIONS

The pediatric mental health crisis has worsened since the pandemic. There were substantial missed opportunities for prevention and intervention for children and adolescents prior to and following an ED visit for mental health or suicidality.

Changes in Mental Health Services Use Under the ACA in One State: Role of Mental Health Provider Shortages

OBJECTIVE

This study aimed to examine whether changes in mental health services use under the Patient Protection and Affordable Care Act (ACA) differed in Mental Health Professional Shortage Areas (MHPSAs) versus non-MHPSAs.

METHODS

Multiple waves of data from the California Health Interview Survey (2011-2018) were analyzed. The sample (N=10,497) was restricted to adults (ages 18-64) who reported experiencing serious psychological distress (SPD) during the past 12 months. MHPSAs were identified by using scores from the Health Resources and Services Administration and were matched to respondents' zip codes. Weighted logistic regression and generalized linear models were used to identify adjusted changes in the rates of four measures of mental health services use (any primary care visit for mental health reasons, any specialty mental health care visit, any prescription psychiatric medication, and total number of outpatient visits for mental health) before and after implementation of the ACA.

RESULTS

Rates of uninsured nonelderly adults with SPD in MHPSAs and non-MHPSAs decreased under the ACA. Changes in rates of specialty mental health services use under the ACA were statistically significant only in non-MHPSAs. Changes in mental health services use did not differ significantly between MHPSAs and non-MHPSAs for any of the four measures.

CONCLUSIONS

Changes in the four measures of mental health use under the ACA did not differ in MHPSAs versus non-MHPSAs. Future research into the ACA's long-term effects should examine systemic and structural barriers to mental health care and to having sufficient numbers of mental health professionals.

Impact of an Oregon health policy aimed at strengthening adolescent linkage to outpatient mental health care from the emergency department

BACKGROUND

Oregon introduced a state policy, HB 3090, on October 6, 2017, which increased requirements on emergency departments (EDs) to improve transitions to outpatient mental health care. The objective of this study was to examine the policy's impact among low-income adolescent patients who face severe barriers to follow-up.

METHODS

This was a retrospective cohort study of visits by Medicaid enrollees ages 14-18 presenting to any Oregon ED for a mental health concern between January 1, 2016, and December 31, 2019. We calculated standardized mean differences and used interrupted time series models to evaluate the association of HB 3090 with 14-day mental health follow-up, in-ED services, and inpatient admissions, adjusting for gender, race/ethnicity, primary language, and calendar months.

RESULTS

Among 26,071 adolescent mental health-related ED visits, we found an estimated increase of 3.63 percentage points (pp; 95% confidence interval [CI] 0.27 to 6.99) in the adjusted probability of a 14-day outpatient mental health claim postpolicy. However, this effect was attenuated over time, with a slope change of -0.25 pp (95% CI -0.5 to 0) for each month thereafter. The probability of receiving mental health services in the ED or inpatient admission did not change in association with the policy.

CONCLUSIONS

There was a small increase in short-term outpatient mental health visits after the policy, but the association weakened over time, and other key outcomes did not change. Putting pressure on EDs to perform better in this area is likely to be a minimally effective strategy without accompanying strengthening of mental health resources.

Moving psychedelic-assisted therapies from promising research into routine clinical practice: Lessons from the field of implementation science

Psychedelics (e.g., 3,4-Methylenedioxymethamphetamine [MDMA], lysergic acid diethylamide [LSD], psilocybin) are molecules that have the potential to produce rapid therapeutic effects when paired with psychotherapy. Randomized clinical trials of psychedelic-assisted psychotherapy (PAT) have shown promising results for post-traumatic stress disorder (PTSD), depression, and substance use disorders. The U.S. Food and Drug Administration has acknowledged the promise of PAT, signaling potential approval of psilocybin-assisted therapy for depression by 2026. Given this timeline, implementation scientists must engage with PAT researchers, policymakers, and practitioners to think critically about bringing these promising new treatments into routine practice settings while maintaining quality and safety. This commentary aims to initiate a dialogue between implementation scientists and PAT researchers and practitioners on addressing these questions with a lens toward equity. Specifically, we discuss how the field of implementation science can support PAT stakeholders to accelerate the translational process from research into practice, focusing specifically on safety-net settings (i.e., Federally Qualified Health Centers and Veterans Affairs health systems) that serve historically marginalized populations. We use the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) Framework to illustrate five critical areas where implementation science can help move PAT from research into real-world practice. For each RE-AIM dimension, we highlight ways the field of implementation science can contribute tools (e.g., implementation strategies), methodologies (e.g., pragmatic hybrid implementation-effectiveness trials), and approaches (community-based participatory research) for establishing the safety, effectiveness, and accessibility of PAT for historically underserved communities.

Insurance acceptance and cash pay rates for psychotherapy in the US

Cost and insurance coverage remain important barriers to mental health care, including psychotherapy and mental health counseling services ("psychotherapy"). While data are scant, psychotherapy services are often delivered in private practice settings, where providers frequently do not take insurance and instead rely on direct pay. In this cross-sectional analysis, we use a large national online directory of 175 083 psychotherapy providers to describe characteristics of private practice psychotherapy providers who accept and do not accept insurance, and assess self-reported private pay rates. Overall, about one-third of private practice psychotherapists did not accept insurance, with insurance acceptance varying substantially across states. We also found significant session rate differentials, with Medicaid rates being on average 40% lower than reported cash pay rates, which averaged $143.26 a session. Taken together, low insurance acceptance across a broad swath of mental health provider types means that access to care is disproportionately reliant on patients' ability to afford out-of-pocket payments-even when covered by insurance. While our findings are descriptive and may not be representative of all US psychotherapists, they add to scant existing knowledge about the cash pay market for an important mental health service that has experienced increased use and demand over time.

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.

Factors Influencing Turnover and Attrition in the Public Behavioral Health System Workforce: Qualitative Study

Many states are experiencing a behavioral health workforce crisis, particularly in the public behavioral health system. An understanding of the factors influencing the workforce shortage is critical for informing public policies to improve workforce retention and access to care. The aim of this study was to assess factors contributing to behavioral health workforce turnover and attrition in Oregon. Semistructured qualitative interviews were conducted with 24 behavioral health providers, administrators, and policy experts with knowledge of Oregon's public behavioral health system. Interviews were transcribed and iteratively coded to reach consensus on emerging themes. Five key themes emerged that negatively affected the interviewees' workplace experience and longevity: low wages, documentation burden, poor physical and administrative infrastructure, lack of career development opportunities, and a chronically traumatic work environment. Large caseloads and patients' high symptom acuity contributed to worker stress. At the organizational and system levels, chronic underfunding and poor administrative infrastructure made frontline providers feel undervalued and unfulfilled, pushing them to leave the public behavioral health setting or behavioral health altogether. Behavioral health providers are negatively affected by systemic underinvestment. Policies to improve workforce shortages should target the effects of inadequate financial and workplace support on the daily work environment.

Epidemiology studies on effects of lithium salts in pregnancy are confounded by the inability to control for other potentially teratogenic factors

INTRODUCTION

In bipolar women who took lithium during pregnancy, several epidemiology studies have reported small increases in a rare fetal cardiac defect termed Ebstein's anomaly.

METHODS

Behavioral, environmental, and lifestyle-associated risk factors associated with bipolar disorder and health insurance status were determined from an Internet search. The search was conducted from October 1, 2023, through October 14, 2023. The search terms employed included the following: bipolar, bipolar disorder, mood disorders, pregnancy, congenital heart defects, Ebstein's anomaly, diabetes, hypertension, Medicaid, Medicaid patients, alcohol use, cigarette smoking, marijuana, cocaine, methamphetamine, narcotics, nutrition, diet, obesity, body mass index, environment, environmental exposures, poverty, socioeconomic status, divorce, unemployment, and income. No quotes, special fields, truncations, etc., were used in the searches. No filters of any kind were used in the searches.

RESULTS

Women who remain on lithium in the United States throughout their pregnancy are likely to be experiencing mania symptoms and/or suicidal ideation refractory to other drugs. Pregnant women administered the highest doses of lithium salts would be expected to have been insufficiently responsive to lower doses. Any small increases in the retrospectively determined risk of fetal cardiac anomalies in bipolar women taking lithium salts cannot be disentangled from potential developmental effects resulting from very high rates of cigarette smoking, poor diet, alcohol abuse, ingestion of illegal drugs like cocaine or opioids, marijuana smoking, obesity, and poverty.

CONCLUSIONS

The small risks in fetal cardiac abnormalities reported in the epidemiology literature do not establish a causal association for lithium salts and Ebstein's anomaly.

Policy Complexities in Financing First Episode Psychosis Services: Implementation Realities from a Home Rule State

Over the past decade, significant investments have been made in coordinated specialty care (CSC) models for first episode psychosis (FEP), with the goal of promoting recovery and preventing disability. CSC programs have proliferated as a result, but financing challenges imperil their growth and sustainability. In this commentary, the authors discuss (1) entrenched and emergent challenges in behavioral health policy of consequence for CSC financing; (2) implementation realities in the home rule context of Ohio, where significant variability exists across counties; and (3) recommendations to improve both care quality and access for individuals with FEP. The authors aim to provoke careful thought about policy interventions to bridge science-to-service gaps, and in this way, advance behavioral health equity.