The cost of access to mental health services in managed care

Supporting Physical-Behavioral Health Integration Using Medicaid Managed Care Organizations

This paper describes key findings of two states that sought to integrate physical and behavioral health services by delivering them through one Medicaid managed care contract. The purpose was to explore how managed care organizations (MCOs) could improve physical and behavioral health integration. Promising practices include leveraging data accumulated by MCOs about beneficiaries to support providers and enhanced case management, encouraging MCOs to pay providers for care coordination and care collocation, and offering protections to providers and beneficiaries. Finally, in the absence of a shared vision among key stakeholders regarding how to best promote integrated care, a state can make progress by promoting stakeholder innovation.

The Impact Of Medicare's Mental Health Cost-Sharing Parity On Use Of Mental Health Care Services

Before the implementation of cost-sharing parity in Medicare, beneficiaries faced higher cost sharing for mental health services than for other medical services. The Medicare Improvements for Patients and Providers Act of 2008 phased in cost-sharing reductions in Medicare for outpatient mental health services in the period 2010-14. Using data for 2006-15 from the Medical Expenditure Panel Survey and difference-in-differences analyses, we assessed whether this reduction in mental health cost sharing was associated with changes in specialty and primary care outpatient mental health visits and psychotropic medication fills. We compared people with Medicare and with private insurance before and after parity implementation. Medicare beneficiaries' use of psychotropic medication increased after the implementation of cost-sharing parity, but we did not detect a change in visits. Changes in the use of psychotropic medications were greater among people with probable serious mental illness and among Medicare beneficiaries who did not report having supplemental coverage. The increased medication use could signal improvements in mental health care access among Medicare beneficiaries, especially among the subgroups most likely to benefit from the policy change.

National Trends In Specialty Outpatient Mental Health Care Among Adults

We examined national trends in the receipt of specialty outpatient mental health care, using data for 2008-15 from the National Survey on Drug Use and Health. Between 2008-09 and 2014-15 the number of US adults who received outpatient mental health care in the specialty sector rose from 11.3 million to 13.7 million per year, representing an increase from 5.0 percent to 5.7 percent of the adult population. Among those recipients, however, the annual weighted mean number of visits to the specialty sector remained unchanged. We found increases in both numbers and percentages of adults who received care within the specialty sector across age and sex groups and among non-Hispanic whites, people with Medicare, people with private health insurance, and people with family incomes of $20,000-$49,999. Increases in receipt of specialty mental health care during 2012-15 may be related to recent policy initiatives aimed at reducing financial barriers to care.

The role of provider supply and organization in reducing racial/ethnic disparities in mental health care in the U.S

Racial and ethnic disparities in mental health care access in the United States are well documented. Prior studies highlight the importance of individual and community factors such as health insurance coverage, language and cultural barriers, and socioeconomic differences, though these factors fail to explain the extent of measured disparities. A critical factor in mental health care access is a local area's organization and supply of mental health care providers. However, it is unclear how geographic differences in provider organization and supply impact racial/ethnic disparities. The present study is the first analysis of a nationally representative U.S. sample to identify contextual factors (county-level provider organization and supply, as well as socioeconomic characteristics) associated with use of mental health care services and how these factors differ across racial/ethnic groups. Hierarchical logistic models were used to examine racial/ethnic differences in the association of county-level provider organization (health maintenance organization (HMO) penetration) and supply (density of specialty mental health providers and existence of a community mental health center) with any use of mental health services and specialty mental health services. Models controlled for individual- and county-level socio-demographic and mental health characteristics. Increased county-level supply of mental health care providers was significantly associated with greater use of any mental health services and any specialty care, and these positive associations were greater for Latinos and African-Americans compared to non-Latino Whites. Expanding the mental health care workforce holds promise for reducing racial/ethnic disparities in mental health care access. Policymakers should consider that increasing the management of mental health care may not only decrease expenditures, but also provide a potential lever for reducing mental health care disparities between social groups.

Development and process evaluation of a primary care internet-based intervention to prevent depression in emerging adults

BACKGROUND

Primary care is a potential setting for implementation of depression prevention interventions using cognitive behavioral therapy (CBT) and interpersonal psychotherapy (IPT). The purpose of this study was to develop and conduct a process evaluation of a primary care/ Internet-based intervention that addresses key dissemination barriers in a community setting.

METHOD

We used an interdisciplinary team of investigators in a multistep intervention development process among a sample of primary care patients (aged 18 to 24 years). The intervention included an initial primary care motivational interview to engage the participant, 11 Internet-based modules based on CBT (to counter pessimistic thinking) and IPT (to activate social networks and strengthen relationship skills), and a follow-up motivational interview in primary care to enhance behavior change. Each component of the intervention was rated with regard to dissemination barriers of (1) fidelity, (2) motivation, (3) dose, (4) perceived helpfulness (rated on a Likert scale), and (5) potential costs. The study was conducted from April through June of 2004.

RESULTS

Fidelity checklist and serial reviews were satisfactory (100% core concepts translated into intervention). Key motivations for participation included (1) risk reduction, (2) intervention effectiveness, (3) "resiliency," and (4) altruism. In terms of dose, 13 of 14 participants engaged the Internet-based components, completing a mean of 7.2 modules (SD = 3.9). The 2 primary care interviews and the self-assessment and resiliency modules received the highest helpfulness ratings. The duration of the 2 motivational interviews was approximately 17-18 minutes, which is similar to a typical primary care visit.

CONCLUSIONS

By using multidisciplinary teams and incorporating the opinions of potential users, complex preventive mental health interventions can be translated into primary care settings with adequate fidelity, motivation, dose, and perceived helpfulness, and at a reasonably low cost.

Transforming a traditional safety net into a coordinated care system: lessons from healthy San Francisco

Since 2007, San Francisco, California, has transformed its traditional safety-net health care "system"-in reality, an amalgam of a public hospital, private nonprofit hospitals, public and private clinics, and community health centers-into a comprehensive health care program called Healthy San Francisco. The experience offers lessons in how other local safety-net systems can prepare for profound changes under health reform. By July 2010, 53,546 adults had enrolled (70-89 percent of uninsured adults in San Francisco), and satisfaction is high (94 percent). Unnecessary emergency department visits were less common among enrollees (7.9 percent) than among Medicaid managed care recipients (15 percent). These findings indicate that other safety-net systems would do well to invest in information technology, establish primary care homes, increase coordination of care, and improve customer service as provisions of the national health care reform law phase in.

EMPLOYER CHOICES IN EAP DESIGN AND WORKSITE SERVICES

In today's complex private healthcare market, employers have varied preferences for particular features of behavioral health products such as Employee Assistance Programs (EAPs). Factors which may influence these preferences include: establishment size, type of organization, industry, workplace substance abuse regulations, and structure of health insurance benefits. This study of 103 large employer purchasers from a single managed behavioral healthcare organization investigated the impact of such variables on the EAP features that employers select to provide to workers and their families. Our findings indicate that for this group of employers, preferences for the type and delivery mode of EAP counseling services are fairly universal, while number of sessions provided and choices for EAP-provided worksite activities are much more varied, and may be more reflective of the diverse characteristics, organizational missions and workplace culture found among larger employers in the US.

The effects of health sector market factors and vulnerable group membership on access to alcohol, drug, and mental health care

OBJECTIVE

This study adapts Andersen's Behavioral Model to determine if health sector market conditions affect vulnerable subgroups' use of alcohol, drug, and mental health services (ADM) differently than the general population, focusing specifically on community-level predisposing and enabling characteristics.

DATA SOURCES

Wave 2 data (2000-2001) from the Health Care for Communities study, supplemented with cases from wave 1 (1997-1998), were merged with area characteristics taken from Census, Area Resource File (ARF), and other data sources.

STUDY DESIGN

The study used four-level hierarchical logistic regression to examine access to ADM care from any provider and specialty ADM access. Interactions between community-level predisposing and enabling vulnerability characteristics with individual race/ethnicity, age, income category, and insurance type were explored.

PRINCIPAL FINDINGS

Nonwhites, the poor, uninsured, and elderly had lower likelihoods of service use, but interactions between race/ethnicity, income, age and insurance status with community-level vulnerability factors were not statistically significant for any service use. For ADM specialty care, those with Medicare, Medicaid, private fully managed, and private partially managed insurance, the likelihood of utilization was higher in areas with higher HMO penetration. However, for those with other insurance or no insurance plan, the likelihood of utilization was lower in areas with higher HMO penetration.

CONCLUSIONS

Community-level enabling factors explain part of the effect of disadvantaged status but, with the exception of the effect of HMO penetration on the relationship between insurance and specialty care use, do not modify any of the residual individual-level effects of disadvantage. Interventions targeting both structural and individual levels may be necessary to address the problem of health disparities. More research with longitudinal data is necessary to sort out the causal direction of social context and ADM access outcomes, and whether policy interventions to change health sector market conditions can shift ADM treatment utilization.

Managed care organizational complexity and access to high-quality mental health services: perspective of U.S. primary care physicians

This analysis addresses the relationship between perceived access to high-quality specialty mental health and medical services and 2 aspects of managed care organizational complexity at the practice level: 1) gatekeeper requirements for specialty services, and 2) managing multiple contracts. Cross-sectional analysis of a national telephone survey of 7,197 primary care physicians (PCPs) was performed. Access was defined as high-quality specialty services being always or almost always available to the PCP's patients when medically necessary. PCPs rated access to high-quality outpatient specialty mental health services as much lower than that of specialty medical services (28%; 95% confidence interval [CI], 27-29 versus 81%; 95% CI, 80-82). After adjustment for physician, practice, and managed care factors (multiple logistic regression analysis), perceived access to high-quality outpatient mental health services was lowest for practices with the largest number of managed care contracts and when a physician's practice was a "mixed model" with regard to the gatekeeper function. Perceived access to high-quality specialty medical services was not as strongly associated with these practice characteristics. PCPs who interact with a large number of managed care plans and different administrative models may have the most difficulty in obtaining high-quality mental health services for their patients.