Evidence-Based Practices for Medicaid Beneficiaries with Schizophrenia and Bipolar Disorder. C. State Variation in Receipt of Psychosocial Services

04/09/2012

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.

TABLE 7. Proportion of Beneficiaries with Schizophrenia or Bipolar Disorder who Received Psychosocial Services in 2007, by State

  State  

Any  Psychosocial  Service

Specific Psychosocial EBPs

  Psychotherapy  

Family  Therapy  

Skills  Training  

  ACTa  

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.

  1. ACT is an evidence-based treatment for individuals who experience difficulty living independently in the community or a sentinel event such as frequent hospitalization. The study initially measured the receipt of ACT among the entire study population. Given the low number of claims for ACT and limitations in capturing psychiatric hospitalization in Medicaid claims, we did not calculate the proportion of beneficiaries with a hospitalization who received ACT. States are not supposed to submit claims for services funded by state-only dollars in the data files used to create the MAX data files. The Institutions for Mental Disease (IMD) exclusion prohibits federal Medicaid matching funds for services delivered to working-age adults in IMD, which generally include psychiatric hospitals. As a result, stays in a psychiatric hospital among working-age adults generally cannot be observed in the MAX data.
ND 45.4 44.0 0.7 1.7 ---
CT 48.6 45.8 0.9 0.8 ---
WV 50.9 40.9 1.1 0.8 2.0
LA 53.9 51.7 2.5 7.1 ---
IA 62.3 49.4 3.6 2.4 2.1
MS 68.3 59.2 5.0 0.3 3.9
MO 71.3 45.1 0.6 0.0 ---
AK 71.8 43.3 2.5 49.8 ---
SD 73.7 26.3 1.3 --- 9.0
IL 73.9 58.8 0.5 5.2 5.1
OK 75.0 45.1 6.1 --- 4.4
NV 77.6 70.7 1.7 19.4 ---
IN 78.6 64.5 3.1 34.2 8.9
NC 79.2 47.1 3.2 0.4 8.5
MD 81.3 71.5 10.7 2.9 6.5
GA 82.2 61.3 0.8 6.8 4.0
CA 82.5 n.a. n.a. n.a. n.a.
AL 84.5 67.1 5.4 0.1 5.0
WY 84.6 62.6 3.1 18.9 ---
NH 85.6 59.9 2.9 1.1 ---
DC 87.2 23.0 0.8 3.1 7.9
ID 87.7 62.5 4.6 0.4 ---

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

Figure 6 is a scatter plot where each dot represents a state and is labeled with a state name. The placement of the dot horizontally represents the proportion of total state mental health agency funding that is used for community-based services, and the placement of the dot vertically represents the proportion of Medicaid beneficiaries in the study receiving an identifiable psychosocial EBP. There is an observable linear relationship in the figure, with states that have a low proportion of mental health agency funding used for community-based services also having a lower proportion of beneficiaries receiving a psychosocial EBP. Moving from left to right across the figure, or from lowest to highest proportion of mental health agency funding used for community based services, the figure shows that 27 percent of mental health agency funding in Louisiana is spent on community services, and 53 percent of beneficiaries in that state received a psychosocial EBP. In South Dakota, 36 percent of funding is used for community based services and 35 percent of beneficiaries received a psychosocial EBP. In Mississippi, 45 percent of funding is used for community based services and 61 percent of beneficiaries received a psychosocial EBP. In Missouri, 48 percent of funding is used for community based services and 45 percent of beneficiaries received a psychosocial EBP. In Alabama, 52 percent of funding is used for community based services and 71 percent of beneficiaries received a psychosocial EBP. In the District of Columbia, 52 percent of funding is used for community based services and 32 percent of beneficiaries received a psychosocial EBP. In Georgia, 52 percent of funding is used for community based services and 66 percent of beneficiaries received a psychosocial EBP. In Idaho, 55 percent of funding is used for community based services and 63 percent of beneficiaries received a psychosocial EBP. In Connecticut, 60 percent of funding is used for community based services and 46 percent of beneficiaries received a psychosocial EBP. In Wyoming, 61 percent of funding is used for community based services and 69 percent of beneficiaries received a psychosocial EBP. In West Virginia, 63 percent of funding is used for community based services and 43 percent of beneficiaries received a psychosocial EBP. In Nevada, 65 percent of funding is used for community based services and 76 percent of beneficiaries received a psychosocial EBP. In Indiana, 66 percent of funding is used for community based services and 74 percent of beneficiaries received a psychosocial EBP. In North Dakota, 66 percent of funding is used for community based services and 45 percent of beneficiaries received a psychosocial EBP. In New Hampshire, 67 percent of funding is used for community based services and 61 percent of beneficiaries received a psychosocial EBP. In Oklahoma, 67 percent of funding is used for community based services and 49 percent of beneficiaries received a psychosocial EBP. In Maryland, 68 percent of funding is used for community based services and 77 percent of beneficiaries received a psychosocial EBP. In Illinois, 71 percent of funding is used for community based services and 62 percent of beneficiaries received a psychosocial EBP. In North Carolina, 82 percent of funding is used for community based services and 55 percent of beneficiaries received a psychosocial EBP. In Alaska, 85 percent of funding is used for community based services and 70 percent of beneficiaries received a psychosocial EBP. In Iowa, 87 percent of funding is used for community based services and 53 percent of beneficiaries received a psychosocial EBP.

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.

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