Medicaid coverage for mental illness: balancing access and costs

Medicaid provisions and the US mental health industry composition

BACKGROUND

Medicaid is the largest payer for mental health (MH) services.

AIMS

This study examines associations between Medicaid provisions and the MH industry composition.

METHODS

Medicaid data derived from the Centers for Medicare and Medicaid Services. MH facility gross payroll and occupational employment data derived from the Bureau of Labor Statistics. State fixed-effects regression models are performed to examine associations.

RESULTS

In the 1999-2009 period, per-capita gross payroll gains are largest for residential MH and substance abuse (SA) facilities and MH practitioner offices, followed by MH clinics and physician offices. Likewise, occupational employment gains per 100 000 people are largest for MH and SA social workers and MH counselors, followed by psychiatrists and psychologists. The Medicaid beneficiary rate is related with gross payroll gains at residential MH and SA facilities (p < 0.001) and MH clinics (p < 0.001), and with employment gains for MH and SA social workers (p < 0.001) and MH counselors (p < 0.001). Smaller effect sizes exist with MH physician offices (p < 0.05) and psychiatric hospitals' (p < 0.01) gross payroll. No statistically significant relationship exists between the Medicaid beneficiary rate and psychiatrist and psychologist employment.

CONCLUSION

Medicaid provisions are related with the MH industry composition. An imbalanced MH industry may lead to inadequate management of MH disorders.

A proposal for comprehensive and specific essential mental health and substance use disorder benefits

This Article analyzes the initial efforts of the Federal Department of Health and Human Services (HHS) to implement the essential mental health and substance use disorder services benefit required by section 1302(b)(1)(E) of the Affordable Care Act (ACA) and proposes the adoption of a comprehensive and specific essential mental health and substance use disorder benefit set. At a minimum, the benefit set should cover medically necessary and evidence-based inpatient and outpatient mental healthcare services, inpatient substance abuse detoxification services, inpatient and outpatient substance abuse rehabilitation services, emergency mental healthcare services, prescription drugs for mental health conditions, participation in psychiatric disease management programs, and community-based mental healthcare services.

This Article builds on three previous articles that have proposed reforms of federal and state mental health parity laws and mandatory mental health and substance use disorder benefit laws.

Psychiatric inpatient expenditures and public health insurance programmes: analysis of a national database covering the entire South Korean population

BACKGROUND

Medical spending on psychiatric hospitalization has been reported to impose a tremendous socio-economic burden on many developed countries with public health insurance programmes. However, there has been no in-depth study of the factors affecting psychiatric inpatient medical expenditures and differentiated these factors across different types of public health insurance programmes. In view of this, this study attempted to explore factors affecting medical expenditures for psychiatric inpatients between two public health insurance programmes covering the entire South Korean population: National Health Insurance (NHI) and National Medical Care Aid (AID).

METHODS

This retrospective, cross-sectional study used a nationwide, population-based reimbursement claims dataset consisting of 1,131,346 claims of all 160,465 citizens institutionalized due to psychiatric diagnosis between January 2005 and June 2006 in South Korea. To adjust for possible correlation of patients characteristics within the same medical institution and a non-linearity structure, a Box-Cox transformed, multilevel regression analysis was performed.

RESULTS

Compared with inpatients 19 years old or younger, the medical expenditures of inpatients between 50 and 64 years old were 10% higher among NHI beneficiaries but 40% higher among AID beneficiaries. Males showed higher medical expenditures than did females. Expenditures on inpatients with schizophrenia as compared to expenditures on those with neurotic disorders were 120% higher among NHI beneficiaries but 83% higher among AID beneficiaries. Expenditures on inpatients of psychiatric hospitals were greater on average than expenditures on inpatients of general hospitals. Among AID beneficiaries, institutions owned by private groups treated inpatients with 32% higher costs than did government institutions. Among NHI beneficiaries, inpatients medical expenditures were positively associated with the proportion of patients diagnosed into dementia or schizophrenia categories. However, for AID beneficiaries, inpatient medical expenditures were positively associated with the proportion of all patients with a psychiatric diagnosis that were AID beneficiaries in a medical institution.

CONCLUSIONS

This study provides evidence that patient and institutional factors are associated with psychiatric inpatient medical expenditures, and that they may have different effects for beneficiaries of different public health insurance programmes. Policy efforts to reduce psychiatric inpatient medical expenditures should be made differently across the different types of public health insurance programmes.

Substance use, dependence, and service utilization among the US uninsured nonelderly population

OBJECTIVES

We examined the prevalence and correlates of substance use, dependence, and service utilization among uninsured persons aged 12 to 64 years.

METHODS

We drew study data from the 1998 National Household Survey on Drug Abuse.

RESULTS

An estimated 80% of uninsured nonelderly persons reported being uninsured for more than 6 months in the prior year. Only 9% of these uninsured persons who were dependent on alcohol or drugs had received any substance abuse service in the past year. Non-Hispanic Whites were an estimated 3 times more likely than Blacks to receive substance abuse services.

CONCLUSIONS

Compared with the privately insured, uninsured persons had increased odds of having alcohol/drug dependence and appeared to face substantial barriers to health services for substance use problems.

Medicaid and mental health: be careful what you ask for

Medicaid has had an enormous impact on the shape and impact of public mental health care. Medicaid mental health policy has expanded access, fostered consumerism, and created incentives for expansion of community-based providers. It also has dramatically changed the economic rules governing public mental health care, leading state governments to alter their behavior. The result has been a tilting of public mental health care toward Medicaid-covered people and services.

Managed behavioral health care: an instrument to characterize critical elements of public sector programs

OBJECTIVE

To develop an instrument to characterize public sector managed behavioral health care arrangements to capture key differences between managed and "unmanaged" care and among managed care arrangements.

STUDY DESIGN

The instrument was developed by a multi-institutional group of collaborators with participation of an expert panel. Included are six domains predicted to have an impact on access, service utilization, costs, and quality. The domains are: characteristics of the managed care plan, enrolled population, benefit design, payment and risk arrangements, composition of provider networks, and accountability. Data are collected at three levels: managed care organization, subcontractor, and network of service providers.

DATA COLLECTION METHODS

Data are collected through contract abstraction and key informant interviews. A multilevel coding scheme is used to organize the data into a matrix along key domains, which is then reviewed and verified by the key informants.

PRINCIPAL FINDINGS

This instrument can usefully differentiate between and among Medicaid fee-for-service programs and Medicaid managed care plans along key domains of interest. Beyond documenting basic features of the plans and providing contextual information, these data will support the refinement and testing of hypotheses about the impact of public sector managed care on access, quality, costs, and outcomes of care.

CONCLUSIONS

If managed behavioral health care research is to advance beyond simple case study comparisons, a well-conceptualized set of instruments is necessary.

Overview of Medicaid managed behavioral health care

The Oregon Health Plan is being implemented at a time when many states are revising their Medicaid mental health programs. A national overview places this state's efforts into context.

Psychometric properties of a decision-support tool for the era of managed care

This article reports psychometric properties of a decision-support scale designed to quantify the decision-making process for allocating psychiatric care. The authors developed a scale to evaluate the level of care needed for patients requiring psychiatric treatment in a health maintenance organization (HMO) setting. This study examines the reliability and validity of that scale by measuring interrater agreement among utilization reviewers from the HMO and between those reviewers and the clinicians who evaluated the patients directly. Agreement (kappa) among the five clinical raters acting in a utilization review capacity on dimensions of the scale ranged from .71 to .98. Kappas for agreement between the treatment intensity proposed by the reviewer/rater and used by the treating clinician were .41, .38, .40, .35, .36, and .39, respectively. The scale is reliable in the hands of trained personnel. Although there were important differences between clinicians' ratings and those of utilization review raters, these differences do not suggest that use of the scale would limit patient access to care.

Local factors affecting the tendency to bypass local hospitals for inpatient mental health care: an exploratory analysis

Using the records of 2,171 rural residents of Illinois who received inpatient treatment for mental illness or substance abuse, this paper examines factors that influence the tendency to seek service from a distant rather than a local hospital. Results indicate that the age and insurance coverage of the individual, the per capita income of the community area, surrogates for the service orientation of the local hospital and the proximity of the patient's residence to an urban center are significant influences. With the exceptions of drug abuse requiring detoxification or other symptomatic treatment, drug abuse accompanied by comorbidity and psychosocial disorders, psychosis, and childhood disorders, the primary diagnosis of the individual failed to have a significant effect on the propensity to bypass local sources of inpatient treatment.

The structure of economic incentives in the Robert Wood Johnson/HUD Program on Chronic Mental Illness 1988

This paper describes the financial arrangements put into place by cities participating in the Robert Wood Johnson Foundation's Program on Chronic Mental Illness. Descriptive information is given on the level of expenditure, the mix of revenues, and the terms under which local, federal, and Medicaid dollars are allocated to local programs. Data are presented on the use of state hospitals and the number of severely mentally ill individuals in treatment. These data are used to make observations on the initial stages of the demonstration.

Use of Medicaid for mental health care by clients of community support programs

The use of Medicaid for mental health services by the severely mentally ill is examined using paid Medicaid claims for clients of Community Support Programs in Wisconsin. The extent to which clients participate in Medicaid, the types and amounts of mental health services, and the costs of services are discussed. A narrow majority of CSP clients use Medicaid, which provides a substantial amount of case management service for program participants. Psychotropic medications are also used by a large percentage of clients. Other relatively common services covered by Medicaid are medication checks and psychotherapy. Average annual Medicaid payments for mental health services (including medications) are $2438.

Health maintenance organizations and persons with severe mental illness

Many if not most scenarios for reform of the U.S. health care system imply that health maintenance organizations (HMOs) will continue their rapid growth. Some advocates argue that a comprehensive health care system should offer services to the severely mentally ill on the same basis as the physically ill. Others note that severe mental illness has traditionally been addressed by a separate, social service system which, for all its deficiencies, has at least provided some level of care. Still others contend that allowing severely mentally ill persons "barrier free" access to health care would be prohibitively expensive. Inspired by this debate the author reviews our knowledge about HMOs and persons with severe mental illness. It is argued that workers in community mental health programs need to understand HMOs and their potential contribution to providing services for persons with severe mental illness.

The divergence of federal and state policies on the charitable tax exemption of nonprofit hospitals

Nonprofit hospitals have traditionally enjoyed charitable exemption from real estate taxes because they provide specific social benefits. However, in the past three decades, major health policy changes at the federal level--most significantly, implementation of the Medicare and Medicaid programs--have weakened this rationale. Federal tax regulations during this period have changed in ways that complement these federal health programs and the accompanying federal interests in encouraging efficiency and performance uniformity among hospitals. States and local governments, however, have different interests, and these may favor a strict set of tax exemption standards that disregard efficiency and elevate the importance of a measurable level of charitable service. Their divergent policies rest on a fundamental value judgment about whether nonprofit hospital care is intrinsically charitable or not. Increasingly, this judgment may be forced upon state courts and legislation by local governments seeking new tax revenues through the elimination of hospitals' exemption from real estate taxes.