Evidence-Based Practices for Medicaid Beneficiaries with Schizophrenia and Bipolar Disorder. D. Psychosocial EBPs

04/09/2012

We measured the receipt of specific psychosocial EBPs and any psychosocial services (not exclusively EBPs). Table A.7 summarizes the approach used to measure psychosocial services.

1. National Codes Used to Identify Psychosocial EBPs

We identified psychosocial EBPs using HCPCS, ICD-9, CPT, and state-specific billing codes in states that deliver mental health services under FFS arrangements (Table A.8). We did not attempt to measure the receipt of psychosocial EBPs among beneficiaries who receive mental health services through managed care arrangements because we have no way of knowing what codes (if any) managed care entities use for psychosocial EBPs.

TABLE A.7. Measurement of Psychosocial EBPs for Schizophrenia and Bipolar Disorder

EBP for Bipolar Disorder

Numerator

Denominator

Psychotherapy Beneficiaries with at least one psychotherapy claim during the study period Beneficiaries diagnosed with schizophrenia or bipolar disorder
Family therapy/ psychoeducation Beneficiaries with at least one family therapy claim during the study period Beneficiaries diagnosed with schizophrenia or bipolar disorder
Supported employment Beneficiaries with at least one supported employment claim during the study period Beneficiaries diagnosed with schizophrenia or bipolar disorder
Assertive Community Treatment Beneficiaries with at least one ACT claim during the study period Beneficiaries diagnosed with schizophrenia or bipolar disorder
Any psychosocial EBP Beneficiaries with at least one claim for psychotherapy, family therapy, supported employment, or ACT during the study period Beneficiaries diagnosed with schizophrenia or bipolar disorder
Any psychosocial services Beneficiaries with at least one claim for an ambulatory mental health service other than evaluation, testing, or medication management during the study period Beneficiaries diagnosed with schizophrenia or bipolar disorder
TABLE A.8. National Procedure Codes Used to Identify Psychosocial EBPs
 

HCPCS

ICD-9

CPT

Assertive community treatment H0039, H0040 None None
Cognitive behavioral therapy None None 97532, 97633
Family therapy H1011 94.42 96154, 96155, 90846, 90847, 90849, 90887, 99510
Psychotherapy H0002, H2027, G0410, G0411 93.81, 94.3, 94.31 94.36–94.39, 94.4, 94.51 90804–90819, 90821–90824, 90826–90829, 90845, 90853, 90857, 90875, 90876, 90880, 97532, 97634, 4060F
Supported employment H2023–H2026 None None
Skills training H2014 None 97535, 97537

2. Identification of State Codes for Psychosocial Services

Because some states have developed their own Medicaid billing codes for psychosocial services, we attempted to identify those codes that are used for specific psychosocial EBPs to include in the numerator of our measures. When states submit Medicaid claims data to CMS, they classify each claim into one of 30 types of service (TOS) codes that generally correspond to the basis for coverage under the Medicaid state plan. During the process of creating the MAX files, claims are classified according to four TOS codes--durable medical equipment, residential care, adult day care, and psychiatric services. This re-classification of claims uses national HCPCs, CPT, and ICD-9 procedure codes as well as state-specific procedure codes that the MAX team has identified through research and consultation with each state’s Medicaid agency.

TABLE A.9. Criteria for Classifying State-Specific Procedure Codes

Classification

Inclusions

Exclusions

NOTE: Only the state-specific procedure codes that are mapped to the psychiatric service TOS were evaluated using these criteria.
Any psychosocial treatment All services provided to beneficiaries with mental illness, including all services identified as EBPs below as well as crisis services, case management, behavioral interventions or management, intensive day treatment programs, residential or day habilitation programs, partial hospitalization, collateral contacts or collateral therapy, psychiatric outpatient or clinic visits, and other unspecified services provided by mental health clinics, psychiatrists, psychologists, or other mental health providers Any substance abuse treatment; services aimed at the MR/DD or autistic population; medication administration or medication management; “evaluation” or “assessment” services that are not clearly described as one of our EBPs
Assertive community treatment Procedure codes labeled as “ACT” or “Assertive Community Treatment” Case management, crisis services
Cognitive behavioral therapy Procedure codes labeled as “CBT” or “cognitive behavioral therapy” only None
Family therapy Family therapy, family support, family education, or family counseling Collateral therapy, collateral contacts
Psychotherapy Individual, group, or unspecified psychotherapy, therapy, or counseling None
Supported employment Supportive employment habilitation Prevocational habilitation, vocational rehabilitation
Skills training Functional therapy, group or individual skill development, daily living skills, social skills, or coping support skills  
TABLE A.10. Odds of High Medication Continuity for Beneficiaries with Schizophrenia or Bipolar Disorder

Independent Variables

Beneficiaries with Schizophrenia

Beneficiaries with Bipolar Disorder

Odds Ratio

95% Confidence Interval

Odds Ratio

95% Confidence Interval

* p < 0.05 ** p < 0.01 *** p < 0.001

NOTES: Nevada was dropped from both regressions because the majority of its beneficiaries are missing information on county residence (used to identify those living in mental health shortage areas) in the MAX data files. Additionally, Alaska, North Dakota, South Dakota, and Wyoming were dropped from the regression of medication continuity for bipolar disorder because each state had fewer than 100 beneficiaries with valid values for the medication continuity measure. The regression for medication continuity for schizophrenia included 91,338 beneficiaries in 21 states who had schizophrenia and had filled at least one prescription for an antipsychotic during the year.

The regression for medication continuity for bipolar disorder included 33,124 beneficiaries across 17 states who had bipolar disorder and had filled at least one prescription for an evidence-based medication during the year. The regression for high medication continuity for schizophrenia included a variable for whether or not the state Medicaid program required prior authorization for antipsychotics since antipsychotics were considered the only evidence-based medications for schizophrenia. The regression of high medication continuity for bipolar disorder included a variable for the number of prior authorization policies in a state as opposed to modeling each prior authorization policy separately because we had few states that required prior authorization for anticonvulsants, and thus, a lack of statistical variation to generate a useful estimate.

Residence in a mental health provider shortage area signifies that the beneficiary resided in a county where the whole county was designated as Mental Health Care Health Professional Shortage Area (HPSA) by HRSA. Data from the Area Resource File 2007 Release was used to identify HPSA counties.

 

Prior authorization required for antipsychotics 0.72** 0.57-0.91 n.a. n.a.
Number of prior authorization policies n.a. n.a. 0.90 0.83-1.003
Generic copayment amount
   $0.50 – $1 0.98 0.73-1.31 1.06 0.72-1.55
   $2 0.45** 0.27-0.76 0.74 0.39-1.39
   $3 0.73** 0.57-0.94 0.88 0.61-1.28
Branded copayment amount
   $1 0.62* 0.41-0.95 0.52* 0.31-0.92
   $2 1.36 0.79-2.33 0.89 0.47-1.67
   $3 0.84 0.62-1.15 0.78 0.51-1.20
Percent of SMHA funding spent on community-based services 1.06* 1.01-1.11 1.01 0.95-1.07
Male beneficiary 1.13*** 1.09-1.16 1.15*** 1.09-1.21
Age 1.02*** 1.01-1.02 1.02*** 1.01-1.03
Beneficiary race
   African American 0.45*** 0.44-0.47 0.52*** 0.49-0.57
   Hispanic 0.69*** 0.66-0.74 0.75*** 0.68-0.83
   Other/Unknown 0.87*** 0.83-0.91 0.98 0.89-1.06
Lived in county designated as mental health provider shortage area 0.94** 0.92-0.98 1.00 0.95-1.05
Enrolled in HMO 0.72*** 0.67-.076 0.79*** 0.73-0.86
Comorbid substance abuse disorder 0.53*** 0.50-0.55 0.49*** 0.46-0.53
Comorbid cardiovascular disease 0.80*** 0.75-0.86 0.86** 0.77-0.96
Comorbid diabetes 1.47*** 1.40-1.53 1.37*** 1.28-1.46
Received any psychosocial services 1.07*** 1.04-1.11 1.13*** 1.07-1.20

We examined state-specific codes that were mapped to the MAX TOS code for “psychiatric services” to identify codes that could identify specific psychosocial EBPs and those that identified other psychosocial services that may or may be evidence-based. Table A.9 summarizes the decision rules used to classify state-specific procedure codes as being a psychosocial EBP or as being for some other psychosocial treatment.

 

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