Because of the aforementioned limitations in completely identifying specific psychosocial EBPs in each state, it is difficult to make direct state-to-state comparisons of the receipt of psychosocial EBPs. However, it is possible to make cautious state-to-state comparisons of the proportion of beneficiaries who received any psychosocial services, since this was measured consistently across states.
There was state-to-state variation in the proportion of beneficiaries who received any psychosocial services in 2007 (Table 7). Fewer than half received any psychosocial services in North Dakota and Connecticut, while in 12 states, more than three-quarters of beneficiaries received a psychosocial service.
Any Psychosocial Service
Specific Psychosocial EBPs
SOURCE: MAX data, calendar year 2007.
NOTE: Any EBP includes claims for psychotherapy, family therapy, skills training, ACT, supported employment, and CBT. --- indicates that no claims for that service were identified. The absence of claims may be due to the lack of specific billing codes used in a state. Due to limitations in the claims data, specific psychosocial services could not be measured in California, so rates of psychosocial EBPs are not available in that state.
States for which we identified claims for psychosocial EBPs used several Medicaid coverage options to reimburse these services. The clinic and rehabilitation options were used most commonly to reimburse psychosocial EBPs. In 11 of the 21 states (excluding California), more than half of the psychotherapy claims were reimbursed under the clinic option. One state (Wyoming) covered the majority of psychotherapy claims using the rehabilitation option, while two states (Illinois and Maryland) covered most psychotherapy under the physician benefit, and three states (South Dakota, Iowa, and Wyoming) covered most psychotherapy under the other practitioner benefit. However, even in states where most psychotherapy was covered using one benefit category, some psychotherapy claims were covered under the other benefit categories as well. In contrast, the other psychosocial EBPs were concentrated almost exclusively in a single benefit category. For example, in the 12 states with identifiable claims for ACT services, five used the clinic option exclusively to cover the service, four used the rehab option exclusively, and one used a mix of the clinic and rehab options. A similar pattern occurred with skills training, with states choosing either the clinic or rehab option to deliver the service. However, the benefit category under which the service was covered did not appear related to the proportion of beneficiaries in a state who received the service.
FIGURE 6. Proportion of Medicaid Beneficiaries in Each State Receiving an Identifiable Psychosocial EBP, by Proportion of SMHA Funding Used for Community-Based Services
SOURCE: MAX data, calendar year 2007. NRI is source for data on the proportion of SMHA funding used for community-based services.
The relationship between managed care enrollment and the receipt of any psychosocial services was unclear. In one of the three states with comprehensive managed care (California), beneficiaries enrolled in the HMO were slightly more likely to receive any psychosocial service than those not enrolled. In Maryland, HMO enrollees were significantly more likely to receive a psychosocial service (82 percent compared with 55 percent). In contrast, in Indiana only 68 percent of HMO enrollees received a psychosocial service, compared with 79 percent of beneficiaries in the FFS system. In the only other state with comprehensive managed care (Indiana), beneficiaries enrolled in the HMO were much less likely to receive a psychosocial service than those not enrolled.
Unlike medication continuity, the receipt of any psychosocial service was not strongly associated with region or the proportion of the mental health system funding dedicated to community-based services. However, the receipt of an identifiable psychosocial EBP (mostly psychotherapy) was positively related to the proportion of mental health system funding dedicated to community-based services (Figure 6).
It is unclear whether states where a higher proportion of mental health system funding goes to community-based services offer more psychosocial EBPs or whether it is more likely that psychosocial EBPs are billed in a way that allows for their identification in those states.