Despite enormous expenditures and innovations in treatment, the United States health care system does not consistently deliver effective treatment to individuals with serious mental illnesses. Health care reform promises to make insurance benefits newly available to many, eliminate inequitable treatment limits and financial requirements, and promote integrated primary and behavioral health care. Quality measures can help achieve the full promise of these reforms by providing feedback to payors and providers and enabling greater transparency and accountability.
The purpose of this project was to identify, specify, and test at least three measures that address pharmacological treatment, psychosocial treatment, and physical health needs for individuals with schizophrenia that can be calculated solely from Medicaid claims data. The psychosocial treatment measure was dropped because procedure codes used in claims data are ambiguous, lacking sufficient detail to reflect the actual service provided and these codes are not used consistently in different states and programs. Ten measures were pilot tested using MAX data. They address the following concepts: use of antipsychotic medications, antipsychotic medication possession ratio, diabetes screening, diabetes monitoring cardiovascular health screening, cardiovascular health monitoring cervical cancer screening, emergency department utilization for mental health conditions, and follow-up after mental health hospitalization within seven days and within 30 days. [149 PDF pages]