The findings from this project can inform states efforts to design policies and interventions to improve the quality of care for beneficiaries with SPMI. While these beneficiaries make up a relatively small proportion of each states Medicaid population, their complex needs are costly: total Medicaid spending on the population in this study averaged $26,119 per year, compared with $5,337 for the Medicaid population as a whole.11 This project found that, although most beneficiaries received an evidence-based medication, continuity of medications was poor in many states, and few beneficiaries received medication monitoring and preventive physical health services. Further, in some states, nearly half of beneficiaries did not receive any psychosocial services and the extent to which these psychosocial services are evidence-based is unclear using claims data. Several characteristics of beneficiaries, state mental health systems, and Medicaid programs were associated with the receipt of EBPs, and with medication continuity in particular.
Using MAX data--which are standardized and suitable for making comparisons across states--this study was able to measure the receipt of EBPs systematically across 22 states and a large population of beneficiaries. Thus, with the exception of psychosocial EBPs, as previously noted, differences across states in the receipt of services do not reflect limitations of the data or missing data for a particular state. We should, however, note several limitations of our study. Several states are missing from this study due to concerns about the completeness and reliability of their data in MAX in 2007. Most notably, two states with large populations, New York and Texas were omitted from the analysis. In addition, several states that have made efforts to implement psychosocial EBPs (New York, Vermont, Oregon, and Ohio) or medication management practices (Arkansas, Kentucky, Texas, and New York) were excluded due to concerns about their MAX data in 2007. Further work might investigate how the rates of EBPs in the states excluded from these analyses compare with those included. We used only one calendar year of Medicaid claims, from 2007. It is possible that the receipt of some EBPs has improved since 2007. It is also possible that some beneficiaries received a physical health examination, cancer screening, or medication monitoring outside of the calendar year of the data, but within a reasonable timeframe. Nonetheless, even if some beneficiaries received these services outside of the calendar year, the rates of physical health services and medication monitoring would likely still be quite poor. Due to data limitations, the study included mostly FFS Medicaid claims, so it was not possible to measure features of managed care organizations that may be associated with the receipt of EBPs. Finally, there was insufficient variation in states use of different types of Medicaid waivers or optional coverage categories to draw conclusions about their relationship to the receipt of EBPs. This study could not measure all of the beneficiary, state, or Medicaid program characteristics that may influence the receipt of EBPs. There may be unmeasured variables that confound our bivarite or multivariate findings. State Medicaid agencies or SMHAs may wish to conduct additional analyses to identify state-specific factors associated with the receipt of EBPs. These exploratory findings can provide a foundation for future research and monitoring.
Based on the findings from this project, Medicaid agencies, SMHAs, state and federal policymakers, and other stakeholders may wish to consider the following opportunities to improve the quality of care for Medicaid beneficiaries with SPMI:
Continue to foster efforts to integrate mental health, physical health, and substance abuse services for Medicaid beneficiaries with SPMI. The findings from this project underscore the importance of overcoming longstanding deficits in the delivery of coordinated physical and behavioral health services for Medicaid beneficiaries with SPMI. While all adults should receive basic preventive health services, those with SPMI are in particular need of regular medication monitoring and health screening for the side effects of medications. The well-documented difficulties involved in addressing the physical health conditions of Medicaid beneficiaries with SPMI include the fragmentation of physical and behavioral health care providers and restrictions on same-day Medicaid billing for behavioral and physical health services imposed by some state Medicaid programs. However, some state Medicaid agencies already have taken steps to overcome these difficulties by removing same-day billing restrictions and/or creating billing codes specifically designed to support integrated physical behavioral health care (the Substance Abuse and Mental Health Services Administration [SAMHSA] and Health Resources and Services Administration [HRSA] Center for Integrated Health Solutions 2011). In addition, some state Medicaid agencies have adopted Health and Behavior Assessment and Intervention Codes, which provide a mechanism to bill for services that address the psychological, emotional, behavioral, and cognitive factors that affect physical health conditions (MaineHealth 2009). At the same time, state Medicaid agencies and managed care organizations have developed promising strategies for coordinating and integrating physical and behavioral health care (Hamblin et al. 2011). As state Medicaid agencies and mental health systems look to adopt these models of care and reimbursement mechanisms to support integrated services, they can draw upon the resources of the Center for Integrated Health Solutions, sponsored by SAMHSA and HRSA (National Council for Community Behavioral Healthcare 2011), as well as the Integrated Care Resource Center (2011), sponsored by CMS, for technical assistance and guidance. Finally, the inverse relationship between substance abuse disorders and medication continuity speaks to the need to strengthen the delivery of care for individuals with co-occurring disorders. Resources to help states and providers better integrate services and implement EBPs, including EBPs for co-occurring disorders, medication management, ACT, supported employment, family psychoeducation, and other services, are available from SAMHSAs EBP toolkit (SAMHSA 2011).
Improve the delivery of evidence-based psychosocial services. In some states, 25-50 percent of beneficiaries did not receive any psychosocial services during the year. In other states, the majority of beneficiaries received psychosocial services, but the degree to which those services were consistent with EBPs was unclear. There were few claims for specific psychosocial EBPs, including ACT, CBT, family therapy, skills training, or supported employment. As previously mentioned, the lack of claims for these EBPs could be due, in part, to the lack of specificity in billing codes. States may wish to examine the extent to which the psychosocial services being reimbursed are consistent with the evidence base. They also may want to seek ways to incentivize the delivery of EBPs and maintain their fidelity through provider certification or other mechanisms. Finally, there may be a need for some states to develop state-specific billing codes or adopt national CPT and HCPCS codes for psychosocial EPBs to facilitate the accurate tracking and monitoring of these services.
Consider whether certain Medicaid policies and practices impede care. As states refine their Medicaid benefit packages in light of continuing budget pressures and federal and state health care reforms, they should give further consideration to practices and policies that may facilitate or impede with the receipt of EBPs. Although this study could not measure every factor associated with the delivery of EBPs, the exploratory findings from this study provided some evidence that copayments and prior authorization requirement were inversely associated with medication continuity. Other studies have found that prior authorization policies may prevent Medicaid beneficiaries with bipolar disorder from filling prescriptions for antipsychotics and anticonvulsants (Lu et al. 2010). Given that poor medication continuity is associated with relapses and costly hospitalizations among individuals with SPMI (West et al. 2010), states may consider exempting these beneficiaries or certain medications from prior authorization and copayment requirements. In addition, while this study did not include many states with managed care arrangements, we found some evidence that HMO enrollment was associated with better receipt of preventive physical health services but worse medication continuity and monitoring. Although readers should be cautious in interpreting these findings from a small group of managed care plans, the findings suggest that states should carefully consider the potential benefits and harms associated with enrolling this population into HMOs and must monitor their quality of care.
Bolster efforts to reduce racial differences in medication use and monitoring. The findings from this project are consistent with well-documented racial and ethnic differences in the receipt of mental health services (Samnaliev et al. 2009). Previous research has found that African Americans in particular receive suboptimal medication therapy. We found that African Americans had the lowest rates of medication continuity, medication monitoring, and screening for cardiovascular disease and diabetes. Conversely, African Americans were more likely to receive depot antipsychotics. The causes of these differences are complex and may include beneficiary attitudes or beliefs about certain medications or services, providers biases in treatment or prescribing practices, and other barriers to care experienced by racial or ethnic minorities--which we could not explore in this study using claims data alone. Reducing these differences likely necessitates a multipronged approach of provider and beneficiary outreach and education to encourage appropriate prescribing practices, medication monitoring, and health screening. States could use Medicaid claims to monitor racial and ethnic differences in prescribing patterns and the receipt of services to identify geographic areas, providers, or subpopulations that may benefit from targeted interventions.
Target the needs of transition-age youth. Younger Medicaid beneficiaries with schizophrenia and bipolar disorder had worse medication continuity compared with their older counterparts. The symptoms and impairment associated with schizophrenia and bipolar disorder typically begin during young adulthood. If untreated, these disorders can disrupt the educational and employment trajectories of youth, leading to lifelong disability and economic hardship. In the coming years, the number of youth enrolled in Medicaid with SPMI may increase, due to guaranteed Medicaid eligibility for youth aging out of foster and other Medicaid eligibility expansions as a result of the Affordable Care Act. State Medicaid agencies and mental health systems will need to identify best practices for engaging transition-age youth in care and improving the delivery of services to this population. States may benefit from drawing on the resources of the Pathways to Positive Futures Center, sponsored by SAMHSA and the National Institute of Disability and Rehabilitation Research (Pathways to Positive Futures 2011). In addition, findings from the RAISE intervention, an initiative supported by the National Institute of Mental Health to identify promising strategies to help individuals in the early stages of schizophrenia and other mental illnesses, may help to inform best practices.
Use claims and enrollment data to monitor quality of care. State and federal agencies should continue to monitor the quality of care for Medicaid beneficiaries with SPMI. The National Behavioral Health Quality Framework, developed by SAMHSA, establishes priorities for improving the accessibility, quality, and outcomes of behavioral health services. Medicaid claims data are a valuable resource for tracking progress toward reaching the goals of the Quality Framework. However, the completeness and reliability of Medicaid data vary across states. Some states lack billing codes to track specific services, particularly psychosocial EBPs. These states may need to enhance the data to make them sufficient for quality monitoring. States may be able to use the findings from this project as a baseline from which to assess future progress.
Too few Medicaid beneficiaries with SPMI receive the medications, psychosocial services, and physical health care needed to support their ability to live independently, maintain employment, and prevent a relapse. For Medicaid programs and SMHAs, the findings from this study can be a starting point for a closer look at the factors within their state that are associated with the receipt of EBPs. For federal and state policymakers, the findings can serve as a baseline from which they can assess progress towards the broader use of EBPs.