Medicaid Acceptance by Psychiatrists Before and After Medicaid Expansion

Medicaid Acceptance Varies by Physician Seniority and Specialty in California

Given varied insurance acceptances and differing pay between insurances, our objective was to examine the number of California physicians enrolled in Medicare and Medicaid (Medi-Cal), stratified by specialty and graduation year. Medi-Cal and Medicare providers were extracted from publicly available databases (Centers for Medicare & Medicaid Services and California Health and Human Services) and were subsequently merged into one dataset using National Provider Identifier. From there, we stratified physicians by specialty and graduation year. We found that emergency medicine, radiology, pathology, anesthesiology, general surgery, and internal medicine had the highest percent of Medi-Cal-accepting physicians, whereas dermatology, psychiatry, physical medicine & rehabilitation, and plastic & reconstructive surgery physicians had the lowest. There also appears to be an inverse relationship between acceptance of Medi-Cal and earlier year of graduation (P < 0.05). This study demonstrated striking variability in Medi-Cal acceptance based upon physician years in practice and specialty. Older, experienced physicians, as well as physicians of certain specialties, are less likely to accept Medi-Cal.

State paid sick leave mandates associated with increased mental health disorder prescriptions among Medicaid enrollees

The United States does not have a federal paid sick leave policy. As a result, many workers, in particular lower wage workers, cannot take time off work to attend to health and family responsibilities. Fifteen states have adopted or announced paid sick leave mandates that offer employees approximately 7 days of financially protected work time each year. This time can facilitate health care use, including treatment related to mental health disorders, conditions for which treatment is time-consuming. We studied the effect of state paid sick leave mandates on prescription medications dispensed for mental health disorders using the Medicaid State Drug Utilization Database 2011-2022. We found that medications dispensed for mental health disorders increased 6% per year following adoption of a state paid sick leave mandate.

The 988 suicide hotline-Lifeline or letdown? A pre-post policy analysis

Suicide has emerged as an urgent threat in recent years as COVID-19 impaired the health and economic wellbeing of millions of Americans. According to the Centers for Disease Control and Prevention, the impact of COVID-19 and the ongoing opioid epidemic has "taken a mental, emotional, physical, and economic toll on individuals, families, and communities," increasing the need for innovative solutions to prevent suicide on a national scale. The National Suicide Hotline Designation Act of 2020 established 988 as the universal telephone number for suicide prevention and represents a key federal intervention to address this crisis. However, research on 9-8-8's effectiveness is limited, given the Act's recent enactment and implementation at the federal and state levels. This policy analysis investigates how and to what extent the mental health crisis system in Georgia has improved since the implementation of the 2020 Act as well as the implications of state law on population-level mental health outcomes. Georgia is used as a nationally representative case study for two reasons: (1) Georgia had a robust statewide suicide hotline prior to 2020, providing solid infrastructure on which federal expansion of a suicide hotline number could be built, and (2) the conflicting characteristics of Georgia's mental health system represent several different pockets of the U.S., allowing this analysis to apply to a broad range of states and locales. The paper draws on takeaways from Georgia to propose state and national policy recommendations for equitable interventions to prevent and respond to this form of violence.

Self-Pay Outpatient Mental Health Care for Children and Adolescents, by Socioeconomic Status

OBJECTIVE

Many parents struggle to find mental health care for their children, and many mental health clinicians do not accept insurance payments. The authors aimed to estimate the frequency and cost of self-pay psychotherapy and psychotropic medication management visits for youths and to determine how service use varies by family income.

METHODS

A descriptive cross-sectional analysis was performed among youths ages 5-17 years in the 2018-2020 Medical Expenditure Panel Survey. Specialist visits included those with psychiatrists, psychologists, social workers, and mental health counselors or family therapists.

RESULTS

Approximately one in five of 13,639 outpatient mental health specialist visits were self-pay, with psychologists (23% of visits) and social workers (24% of visits) most likely to see youths on a self-pay basis. Use of self-pay care was strongly associated with higher income, but even families earning <$28,000 per year utilized some self-pay care, at a median cost of $95 per visit. Self-pay visits were associated with slightly lower clinical need than insurance-covered visits, although this measure varied by income.

CONCLUSIONS

The self-pay market for child mental health care potentially exacerbates inequities in access to care by burdening low-income families with high costs. Incentivizing mental health providers to participate in insurance for larger portions of their patient panels, for example, by increasing reimbursement rates and reducing paperwork, may help improve equitable access to mental health care. To the extent that reimbursement rates drive insurance acceptance, the frequency of self-pay mental health visits suggests that mental health services are underreimbursed relative to their benefit to patients and families.

National and State-Level Trends in Mental Health and Substance Use Disorder Services at Federally Qualified Health Centers, 2012-2019

INTRODUCTION

A disproportionate share of Federally Qualified Health Center (FQHC) users have a behavioral health condition, but there exists limited research examining changes in behavioral health provision in FQHCs. The objectives of this study were to describe how the provision of behavioral health services by FQHCs to the population of people with behavioral health conditions has changed over time in the US, how these trends varied across states, and whether the proportion of total delivered services that are behavioral health services has changed within FQHCs over time.

METHODS

Descriptive analysis using the Uniform Data System and Global Burden of Disease Datasets from years 2012 to 2019.

RESULTS

From 2012 to 2019, FQHC behavioral health visits per 1,000 population with any behavioral health condition grew 103%, with a 26-fold difference in average rates across states during the study period. Annual behavioral health visits per patient increased from 3.2 to 2012 to 3.4 in 2019. From 2012 to 2019, the number of behavioral health visits per 1,000 FQHC patients grew by 51%, whereas the rate of asthma visits declined by 14%, heart disease visits declined by 4%, and hypertension and diabetes related visits remained stable (changing < 1% for both).

DISCUSSION/CONCLUSION

Behavioral health visit growth at FQHCs outpaced national prevalence of behavioral health conditions. This growth was driven by FQHCs serving an increasing number of patients with behavioral health conditions, without sacrificing the frequency of visits for individual patients with behavioral health conditions.

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.

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.

Rural and frontier access to mental health prescribers and nonprescribers: A geospatial analysis in Oregon Medicaid

OBJECTIVE

Medicaid enrollees in rural and frontier areas face inadequate access to mental health services, but the extent to which access varies for different provider types is unknown. We assessed access to Medicaid-participating prescribing and nonprescribing mental health clinicians, focusing on Oregon, which has a substantial rural population.

METHODS

Using 2018 Medicaid claims data, we identified enrollees aged 18-64 with psychiatric diagnoses and specialty mental health providers who billed Medicaid at least once during the study period. We measured both 30- and 60-minute drive time to a mental health provider, and a spatial access score derived from the enhanced 2-step floating catchment area (E2SFCA) approach at the level of Zip Code Tabulation Areas (ZCTAs). Results were stratified for prescribers and nonprescribers, across urban, rural, and frontier areas.

RESULTS

Overall, a majority of ZCTAs (68.6%) had at least 1 mental health prescriber and nonprescriber within a 30-minute drive. E2SFCA measures demonstrated that while frontier ZCTAs had the lowest access to prescribers (84.3% in the lowest quintile of access) compared to other regions, some frontier ZCTAs had relatively high access to nonprescribers (34.3% in the third and fourth quartiles of access).

CONCLUSIONS

Some frontier areas with relatively poor access to Medicaid-participating mental health prescribers demonstrated relatively high access to nonprescribers, suggesting reliance on nonprescribing clinicians for mental health care delivery amid rural workforce constraints. Efforts to monitor network adequacy should consider differential access to different provider types, and incorporate methods, such as E2SFCA, to better account for service demand and supply.

Acceptance of Insurance by Psychiatrists and Other Physicians, 2007-2016

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.

Evictions and psychiatric treatment

Stable housing is critical for health, employment, education, and other social outcomes. Evictions reflect a form of housing instability that is experienced by millions of Americans each year. Inadequately treated psychiatric disorders have the potential to influence evictions in several ways. For example, these disorders may impede labor market performance and thus the ability to pay rent, or increase the likelihood of risky and/or nuisance behaviors that can lead to a lease violation. We estimate the effect of local access to psychiatric treatment on eviction rates. We combine data on the number of psychiatric treatment centers that offer outpatient and residential care within a county with eviction rates in a two-way fixed-effects framework. Our findings imply that 10 additional psychiatric treatment centers in a county lead to a reduction of 2.1% in the eviction rate.

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.

Does use of primary care-based behavioral health programs differ by race and ethnicity? Evidence from a multi-site collaborative care model

BACKGROUND

Collaborative care models (CoCM) that integrate mental health and primary care improve outcomes and could help address racial and ethnic mental health disparities. We examined whether use of these programs differs by race/ethnicity.

METHODS

This retrospective study examined two CoCM interventions implemented across primary care clinics in a large health system in Massachusetts: 1) a primary care-based behavioral health program for depression or anxiety (IMPACT model) and 2) referral to community-based specialty care services (Resource-finding). Outcomes included enrollment, non-completion, and symptom screening rates, and discharge status for Black, Hispanic and White patients referred for CoCM, 2017-2019.

RESULTS

Black and Hispanic vs. White patients referred to CoCM (n = 17,280) were more likely to live in high poverty ZIP codes (34% and 40% vs. 9%). Rates of program enrollment, non-completion, and symptom screening were similar across groups (e.g., 76%, 77%, and 75% of Black, Hispanic, and White patients enrolled). Hispanic vs. White patients were more likely to be enrolled in IMPACT (56%) vs. Resource-finding (43%). Among those completing IMPACT, Hispanic vs. White patients were more likely to be stepped to psychiatry vs. discharged to their primary care provider (51% vs. 20%, aOR = 1.55, 95% CI: 1.02-2.35).

CONCLUSIONS

Black and Hispanic patients referred to CoCM were similarly likely to use the program as White patients. Hispanic patients completing IMPACT were more frequently referred to psychiatry.

IMPLICATIONS

These results highlight the promise of CoCMs for engaging minority populations in mental healthcare. Hispanic patients may benefit from additional intervention or earlier linkage to specialty care.

Buprenorphine Utilization and Prescribing Among New Jersey Medicaid Beneficiaries After Adoption of Initiatives Designed to Improve Treatment Access

Importance

Buprenorphine is underutilized as a treatment for opioid use disorder (OUD); state policies may improve buprenorphine access and utilization.

Objective

To assess buprenorphine prescribing trends following New Jersey Medicaid initiatives designed to improve access.

Design, Setting, and Participants

This cross-sectional interrupted time series analysis included New Jersey Medicaid beneficiaries who were prescribed buprenorphine and had 12 months continuous Medicaid enrollment, OUD diagnosis, and no Medicare dual eligibility, as well as physician or advanced practitioners who prescribed buprenorphine to Medicaid beneficiaries. The study used Medicaid claims data from 2017 to 2021.

Exposure

Implementation of New Jersey Medicaid initiatives in 2019 that removed prior authorizations, increased reimbursement for office-based OUD treatment, and established regional Centers of Excellence.

Main Outcomes and Measures

Rate of buprenorphine receipt per 1000 beneficiaries with OUD; percentage of new buprenorphine episodes lasting at least 180 days; buprenorphine prescribing rate per 1000 Medicaid prescribers, overall and by specialty.

Results

Of 101 423 Medicaid beneficiaries (mean [SD] age, 41.0 [11.6] years; 54 726 [54.0%] male; 30 071 [29.6%] Black, 10 143 [10.0%] Hispanic, and 51 238 [50.5%] White), 20 090 filled at least 1 prescription for buprenorphine from 1788 prescribers. Policy implementation was associated with an inflection point in buprenorphine prescribing trend; after implementation, the trend increased by 36%, from 1.29 (95% CI, 1.02-1.56) prescriptions per 1000 beneficiaries with OUD to 1.76 (95% CI, 1.46-2.06) prescriptions per 1000 beneficiaries with OUD. Among beneficiaries with new buprenorphine episodes, the percentage retained for at least 180 days was stable before and after initiatives were implemented. The initiatives were associated with an increase in the growth rate of buprenorphine prescribers (0.43 per 1000 prescribers; 95% CI, 0.34 to 0.51 per 1000 prescribers). Trends were similar across specialties, but increases were most pronounced among primary care and emergency medicine physicians (eg, primary care: 0.42 per 1000 prescribers; 95% CI, 0.32-0.53 per 1000 prescribers). Advanced practitioners accounted for a growing percentage of buprenorphine prescribers, with a monthly increase of 0.42 per 1000 prescribers (95% CI, 0.32-0.52 per 1000 prescribers). A secondary analysis to test for changes associated with non-state-specific secular trends in prescribing found that quarterly trends in buprenorphine prescriptions increased in New Jersey relative to all other states following initiative implementation.

Conclusions and Relevance

In this cross-sectional study of state-level New Jersey Medicaid initiatives designed to expand buprenorphine access, implementation was associated with an upward trend in buprenorphine prescribing and receipt. No change was observed in the percentage of new buprenorphine treatment episodes lasting 180 or more days, indicating that retention remains a challenge. Findings support implementation of similar initiatives but highlight the need for efforts to support long-term retention.

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

Medicaid is characterized by low rates of provider participation, often attributed to reimbursement rates below those of commercial insurance or Medicare. Understanding the extent to which Medicaid reimbursement for mental health services varies across states may help illuminate one lever for increasing Medicaid participation among psychiatrists. We used publicly available Medicaid fee-for-service schedules from state Medicaid agency websites in 2022 to construct two indices for a common set of mental health services provided by psychiatrists: a Medicaid-to-Medicare index to benchmark each state's Medicaid reimbursement with that of Medicare for the same set of services, and a state-to-national Medicaid index comparing each state's Medicaid reimbursement with an enrollment-weighted national average. On average, Medicaid paid psychiatrists at 81.0 percent of Medicare rates, and a majority of states had a Medicaid-to-Medicare index that was less than 1.0 (median, 0.76). State-to-national Medicaid indices for psychiatrists' mental health services ranged from 0.46 (Pennsylvania) to 2.34 (Nebraska) but did not correlate with the supply of Medicaid-participating psychiatrists. As policy makers look to reimbursement rates as one strategy to address ongoing mental health workforce shortages, comparing Medicaid payment across states may help benchmark ongoing state and federal proposals.

The association of state-level drug and opioid overdose deaths with the capacity of behavioural health professionals in the United States

As behavioural health occupations have diversified, more specialists such as social workers and counsellors are involved in providing substance use disorder treatment services. This study examined the association between changes in the number of different types of behavioural health professionals and changes in drug and opioid overdose deaths in the United States. Using publicly available state-level data from 2008 to 2017, we constructed multivariate linear regression models with state- and year fixed-effects to examine the effect of changes in the number of different types of behavioural health professionals (i.e. psychiatrists, psychologists, social workers and counsellors) on changes in drug and opioid overdose deaths at the state level, controlling for state population characteristics and other state-level factors. After controlling for confounding factors, a 1% increase in the number of social workers and counsellors at the state level was significantly associated with a 0.215% reduction in drug overdose deaths per 100,000 state population and with a 0.358% reduction in opioid overdose deaths per 100,000 state population. We did not find statistically significant associations between changes in drug overdose death rates and increases in the number of psychiatrists or psychologists alone. Our findings suggest efforts to facilitate a prepared and skilled workforce, such as expanding the capacity of social workers and counsellors, to maximise access to substance use disorder treatment services.

In Medicaid Managed Care Networks, Care Is Highly Concentrated Among A Small Percentage Of Physicians

States have increasingly outsourced the provision of Medicaid services to private managed care plans. To ensure that plans maintain access to care, many states set network adequacy standards that require plans to contract with a minimum number of physicians. In this study we used data from the period 2015-17 for four states to assess the level of Medicaid participation among physicians listed in the provider network directories of each managed care plan. We found that about one-third of outpatient primary care and specialist physicians contracted with Medicaid managed care plans in our sample saw fewer than ten Medicaid beneficiaries in a year. Care was highly concentrated: 25 percent of primary care physicians provided 86 percent of the care, and 25 percent of specialists, on average, provided 75 percent of the care. Our findings suggest that current network adequacy standards might not reflect actual access; new methods are needed that account for beneficiaries' preferences and physicians' willingness to serve Medicaid patients.

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.

Trends in Outpatient Psychotherapy Provision by U.S. Psychiatrists: 1996-2016

OBJECTIVE

Previous work has demonstrated significant declines in the provision of outpatient psychotherapy by U.S. psychiatrists. The objective of this study was to characterize patterns and trends of psychotherapy by U.S. psychiatrists from 1996 to 2016.

METHODS

A retrospective, nationally representative analysis of psychiatrist visits from 21 waves of the U.S. National Ambulatory Medical Care Survey between 1996 and 2016 (N=29,673) was conducted to assess rates of outpatient psychotherapy provision by U.S. psychiatrists. Provision was modeled as risk differences and adjusted by clinical, sociodemographic, geographic, and financial characteristics.

RESULTS

Between 1996 and 2016, the weighted percentage of visits involving psychotherapy declined significantly from 44.4% in 1996-1997 to 21.6% in 2015-2016. Declines were most marked among patients diagnosed with social phobia (29% to 8%), dysthymic disorder (65% to 30%), and personality disorders (68% to 17%). For patients diagnosed with schizophrenia, psychotherapy provision remained stable (10%-12%). In the 2010-2016 period, about half of psychiatrists (53%) no longer provided psychotherapy at all. Antidepressant, antipsychotic, and sedative-hypnotic prescriptions were negatively associated with psychotherapy provision. During the study period, sociodemographic disparities grew, with older, White patients residing in metropolitan areas in the Northeast or West increasingly becoming the most likely to receive psychotherapy. Self-pay predicted access to solo-practice psychiatrists, who saw fewer patients but more frequently, and were more likely to provide psychotherapy.

CONCLUSIONS

Previously reported declines in psychiatrist provision of psychotherapy continued through 2016, affecting nearly all clinical categories. In the 2010s, about half of psychiatrists practiced no psychotherapy at all, creating new challenges to the integration of neurobiological and psychosocial elements of clinical care.

Impacts of Early ACA Medicaid Expansions on Physician Participation

OBJECTIVE

To quantify impacts of early Affordable Care Act (ACA) Medicaid expansions on Medicaid participation for primary care physicians.

DATA SOURCES

The study uses secondary Medicaid Analytic eXtract (MAX) data from the United States for 2009-2012 as well as secondary National Plan and Provider Enumeration System (NPPES) data from the United States for 2015.

STUDY DESIGN

The study uses a quasi-experimental difference-in-differences study design where the policy change is Medicaid expansion in 6 states that adopted early ACA Medicaid expansions during 2010 and 2011: California, Connecticut, the District of Columbia, Minnesota, New Jersey, and Washington. The key outcome variables are five monthly measures of physician participation: the number of Medicaid visits, the number of Medicaid patients, seeing at least 1 Medicaid patient, seeing at least 25 Medicaid patients, and seeing at least 50 Medicaid patients.

DATA COLLECTION/EXTRACTION METHODS

The sample consists of all physicians who were active between 2005 and 2015 according to the NPPES.

PRINCIPAL FINDINGS

For primary care physicians, Medicaid expansion led to a 29% increase in Medicaid visits (5.88 per month; 95% CI: 2.49 to 9.27), a 29% increase in Medicaid patients (4.59 per month; 95% CI: 2.16 to 7.02), and did not affect the probability of any Medicaid participation. Medicaid expansion also led to a 22% increase in the probability of seeing at least 25 Medicaid patients per month (4.58 percentage points; 95% CI: 1.27 to 7.89) and a 31% increase in the probability of seeing at least 50 Medicaid patients per month (2.99 percentage points; 95% CI: 0.99 to 4.99).

CONCLUSIONS

Early ACA Medicaid expansions led to increased Medicaid visits for primary care physicians but did not affect the probability of any Medicaid participation. Primary care physicians who had previously served Medicaid patients responded to early ACA Medicaid expansions by serving substantially more Medicaid patients.

A Qualitative Study of Barriers and Facilitators to Transitions From the Emergency Department to Outpatient Mental Health Care

OBJECTIVE

People with psychiatric disorders are among the most frequent users of emergency departments (EDs). The transition of care from the ED to outpatient mental health treatment may be important for continuity of care; however, little is known about the barriers and facilitators that patients experience in transitions to and engagement in outpatient mental health care. In this qualitative study, the authors examined the perspectives of patients and providers on these barriers and facilitators at the patient, provider, and health care system levels.

METHODS

The authors (trained interviewers) conducted 30 semistructured interviews with patients and 15 interviews with 13 mental health providers. Data were analyzed by using thematic analysis.

RESULTS

Patients and providers discussed similar barriers and facilitators to patient transitions and engagement in care. Patients with psychiatric disorders experienced barriers and facilitators at multiple levels when engaging in mental health care after discharge from the ED. Patient-level themes included openness to treatment and logistical challenges. Provider-level themes focused on the connection between patients and providers and on establishing and maintaining contact. Themes at the health care system level were coordination between the ED and outpatient clinics, managing appointments, and health care resources.

CONCLUSIONS

Key factors that influence transitions of care from the ED to outpatient treatment include patients' complex health and life circumstances, the establishment of a relationship with providers built on trust and compassion, and the level of coordination between care settings.

Medicaid participation among practitioners authorized to prescribe buprenorphine

INTRODUCTION

This study examines Medicaid participation among buprenorphine waivered providers in Virginia in 2019, with a particular focus on the prescribing differences between different physician specialties, nurse practitioners and physicians assistants (NP and PA).

METHODS

Secondary data sources include the 2019 DEA list of buprenorphine waivered prescribers, Virginia Medicaid claims for buprenorphine, physician characteristics from the Virginia Department of Health Professions, SAMHSA Behavioral Treatment Services Locator, and area level characteristics. This cross-sectional study is based on a linkage of Medicaid claims data to a list of Virginia practitioners authorized to prescribe buprenorphine in 2019. Using a two-part logistic regression, we assess prescriber license type and local area factors that are associated with: (1) the probability of prescribing buprenorphine to any Medicaid patients in 2019; (2) the number of Medicaid patients treated by each prescriber in 2019.

RESULTS

Adjusted odds ratios show that nurse practitioners with buprenorphine waivers are more likely to treat any Medicaid patients compared to physicians (odds ratio (OR), 2.016; p = 0.000). Among prescribers who treated any Medicaid patients, the probability of treating a large number of Medicaid patients was higher among nurse practitioners relative to physicians (OR, 2.869, p = 0.002). Medicaid participation was much higher among prescribers with patient limits of 100 and 275 compared to prescribers with patient limits of 30 (OR, 6.66, p = 0.000 and 29.40, p = 0.000, respectively).

CONCLUSIONS

State Medicaid programs have been at the forefront of addressing their state's opioid epidemic, including expanding access to buprenorphine treatment. This study provides evidence that targeted outreach efforts should include NP license types as well as physicians, and is consistent with prior studies showing that NP are especially important in filling treatment gaps for underserved areas and populations.

Insurance expansions and adolescent use of substance use disorder treatment

OBJECTIVE

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

DATA SOURCE/STUDY SETTING

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

STUDY DESIGN

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

DATA COLLECTION

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

PRINCIPAL FINDINGS

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

CONCLUSIONS

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

Do expansions in adolescent access to public insurance affect the decisions of substance use disorder treatment providers?

We apply a mixed-payer economy model to study the effects of changes in the generosity of children's public health insurance programs - measured by Medicaid and Children's Health Insurance Program income thresholds - on substance use disorder (SUD) treatment provider behavior. Using government data on specialty SUD treatment providers over the period 1997-2011 combined with a two-way fixed-effects model and local event study, we show that increases in the generosity of children's public health insurance induce providers to participate in some, but not all, public markets. Our effects appear to be driven by non-profit and government providers. Non-profit providers also appear to increase treatment quantity slightly in response to coverage expansions.

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.

The Medicaid expansion did not crowd out access for medicaid recipients with disabilities in Oregon

BACKGROUND

The Affordable Care Act (ACA) substantially increased the number of Medicaid enrollees, which could have reduced access to health care services for those already on Medicaid before the expansion.

OBJECTIVE

To examine the association of the ACA expansion on health care access and utilization for adults ages 18-64 years who have qualified for Supplemental Security Income (SSI) in Oregon.

METHODS

We used Oregon Medicaid claims and enrollment data from 2012 to 2015 and information from the American Community Survey and the Local Area Unemployment Statistics. Multivariate regressions compared changes in health care access and utilization before and after the expansion among Medicaid recipients who qualified for SSI across counties in Oregon with higher and lower Medicaid enrollment increases due to the expansion. Health care access and utilization outcome measures included: primary care visits, non-behavioral health outpatient visits, behavioral health outpatient visits, emergency department (ED) visits and potentially avoidable ED visits.

RESULTS

The Medicaid expansion led to an uneven increase in Medicaid enrollment across Oregon's counties (mean increase from the first quarter of 2012 to the third quarter of 2015: 12.4% points; range: 7.3 to 18.6% points). Access and utilization outcomes for SSI Medicaid recipients were mostly unaffected by differential enrollment increases. ED visits increased more in counties with a larger Medicaid enrollment increase (estimate: 1.8, p < 0.05), but adjusting for pre-expansion trends eliminated this association.

CONCLUSIONS

We did not find evidence that an increase in Medicaid enrollment due to the ACA negatively impacted access and utilization for adult Medicaid recipients on SSI, who were eligible for Medicaid prior to expansion.

Impact of the Affordable Care Act Medicaid Expansion on Utilization of Mental Health Care

BACKGROUND

The Affordable Care Act's Medicaid expansions (ME) increased insurance coverage for low-income Americans, among whom unmet need for mental health care is high. Empirical evidence regarding the impact of expanding insurance coverage on use of mental health services among low income and minority populations is lacking.

METHODS

Data on mental health service use collected between 2007 and 2015 by the Medical Expenditures Panel Survey from nationally representative cross-sectional samples of low income (income<138% of the federal poverty line) adults were analyzed. Use trends among people in states that expanded Medicaid (ME states; n=29,827) were compared with concurrent trends among people in states that did not (non-ME states; n=22,873), with statistical adjustment for demographic characteristics and psychological distress.

RESULTS

Annual outpatient visits for mental health conditions increased by 0.513 (0.053-0.974) visits per person, from a baseline rate in ME states of 0.894 visits per person. However, no significant changes were observed in number of mental health related hospital stays, emergency department visits or prescription fills. The increase outpatient visits was limited to Hispanics and non-Hispanic Whites, with no increase in service use observed among non-Hispanic Blacks. There was no apparent increase in the number of users of outpatient mental health care (AOR=0.992, P=0.942) and a marginally significant (P=0.096) increase of 3.144 visits per user.

DISCUSSION

ME had a limited but positive impact on use of mental health services by low income Americans, although it may also have increased racial/ethnic disparities.

Comparison of Medicaid Reimbursements for Psychiatrists and Primary Care Physicians

OBJECTIVE

This study aimed to investigate whether state Medicaid programs systematically reimburse psychiatrists less than they reimburse primary care physicians.

METHODS

This study used outpatient Medicaid claims data from 2014 for 11 U.S. states. Claims with a primary behavioral health diagnosis (i.e., mental or substance use disorder) and an evaluation and management procedure code of 99213 or 99214 were identified. These are the most frequently used procedure codes by both psychiatrists and primary care physicians when treating patients with mental and substance use disorders. Average reimbursements were compared for nonfacility claims submitted by psychiatrists and primary care physicians.

RESULTS

In 9 states, psychiatrists were reimbursed less on average than primary care physicians. In one state, reimbursements were nearly equivalent.

CONCLUSIONS

Disparities in reimbursements across specialties may reduce access to psychiatric specialty care through Medicaid and are inconsistent with the Mental Health Parity and Addiction Equity Act.

Public insurance expansions and mental health care availability

OBJECTIVE

To provide new evidence on the effects of large-scale public health insurance expansions, associated with the Affordable Care Act (ACA), on the availability of specialty mental health care treatment in the United States. We measure availability with the probability that a provider accepts Medicaid.

DATA SOURCE/STUDY SETTING

The National Mental Health Services Survey (N-MHSS) 2010-2018.

STUDY DESIGN

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

DATA COLLECTION

The N-MHSS provides administrative data on the universe of specialty mental health care providers in the United States. Response rates are above 90 percent in all years. Data cover 85 019 provider/year observations.

PRINCIPAL FINDINGS

ACA-Medicaid expansion increases the probability that a provider accepts Medicaid by 1.69 percentage points, 95 percent confidence interval: [0.0017,0.0321], which corresponds to an increase from 87.27 percent pre-expansion to 90.27 percent postexpansion in expansion states or a 1.94 percent increase. We observe spillovers to Medicare, although this finding is sensitive to specification.

CONCLUSIONS

This study provides evidence on the impact of ACA-Medicaid expansion on accepted forms of payment for specialty mental health care treatment. Findings suggest that expansion increases availability of providers who deliver valuable care for enrollees with severe mental illness. These findings may help policy makers reflecting on the future directions of the US health care delivery system.

Provider-Level Caseload of Psychosocial Services for Medicaid-Insured Children

OBJECTIVE

We estimated the caseload of providers, practices, and clinics for psychosocial services (including psychotherapy) to Medicaid-insured children to improve the understanding of the current supply of such services and to inform opportunities to increase their accessibility.

METHODS

We used 2012-2013 Medicaid claims data and data from the 2013 National Plan and Provider Enumeration System to identify and locate therapists, psychiatrists, and mental health centers along with primary, rehabilitative, and developmental care providers in the United States who provided psychosocial services to Medicaid-insured children. We estimated the per-provider, per-location, and state-level caseloads of providers offering these services to Medicaid-insured children in 34 states with sufficiently complete data to perform this analysis, by using the most recent year of Medicaid claims data available for each state. We measured caseload by calculating the number of psychosocial visits delivered by each provider in the selected year. We compared caseloads across states, urbanicity, provider specialty (eg, psychiatry, psychology, primary care), and practice setting (eg, mental health center, single practitioner).

RESULTS

We identified 63 314 providers, practices, or centers in the Medicaid claims data that provided psychosocial services to Medicaid-insured children in either 2012 or 2013. The median provider-level per-year caseload was <25 children and <250 visits across all provider types. Providers with a mental health center-related taxonomy accounted for >40% of visits for >30% of patients. Fewer than 10% of providers and locations accounted for >50% of patients and visits.

CONCLUSIONS

Psychosocial services are concentrated in a few locations, thereby reducing geographic accessibility of providers. Providers should be incentivized to offer care in more locations and to accept more Medicaid-insured patients.