Evidence-Based Practices for Medicaid Beneficiaries with Schizophrenia and Bipolar Disorder. Introduction and Rationale for the Project


Medicaid provides critical access to health and behavioral health care for individuals with serious and persistent mental illnesses (SPMI). More than half of Medicaid beneficiaries who are eligible on the basis of a disability are diagnosed with a mental illness--including schizophrenia and bipolar disorder (Kronick et al. 2009). Those beneficiaries with SPMI have a particularly high risk of disabling comorbid physical health conditions, substance abuse, frequent hospitalizations, and premature death.

Evidence-based practices (EBPs)--including medications, psychosocial services, and physical health care--help individuals with SPMI live successfully in the community and avoid negative health outcomes. A range of factors are likely to interact in a complex and dynamic manner to influence the receipt of EBPs. These factors include the demographic characteristics and treatment preferences of beneficiaries, providers’ awareness of and attitudes toward EBPs, and the organization and financing of service systems.

Because Medicaid pays for more mental health services than any other public or private payer in the nation, the program has a tremendous impact on the quality and outcomes of mental health services for a large and vulnerable population. Medicaid policies and practices have the potential to influence the receipt of EBPs. Despite the important role of Medicaid in paying for mental health services, little is known about the extent to which Medicaid beneficiaries with SPMI receive EBPs. There is also a need for information about the features of Medicaid programs and mental health systems that may facilitate or impede the receipt of EBPs. Such information would be useful in developing Medicaid policies and services systems to improve the quality of care for this population.

This project, conducted by Mathematica Policy Research for the Office of the Assistant Secretary for Planning and Evaluation (ASPE), U.S. Department of Health and Human Services, sought to answer the following three questions:

  • To what extent do Medicaid beneficiaries with schizophrenia and bipolar disorder receive medications, psychosocial services, and physical health care consistent with the latest evidence-based and recommended standards of care?

  • Is the receipt of EBPs associated with beneficiary demographic and health characteristics, including race/ethnicity, gender, age, and the presence of comorbid conditions?

  • What features of state mental health systems or Medicaid programs are associated with the receipt of EBPs for beneficiaries with schizophrenia and bipolar disorder?

Key program features noted in the third question include Medicaid policies and payment practices that may limit the circumstances under which a treatment is eligible for reimbursement, as well as broader delivery system characteristics, such as the financing and coordination of services. This project examined whether the receipt of certain EBPs was associated with the amount of funding controlled by state mental health agencies (SMHAs) and dedicated to community-based services, the managed care arrangements in states, and Medicaid practices that may restrict access to medications.

This project focused on beneficiaries with schizophrenia and bipolar disorder--a segment of the SPMI population for which there are several well-researched pharmacologic and psychosocial EBPs. The project began with a review of EBPs for schizophrenia and bipolar disorder. We then measured the extent to which beneficiaries received EBPs, using Medicaid claims data from 22 states. A technical advisory panel of clinicians, researchers, and policy experts guided the identification of EBPs and specification of measures and provided feedback on the analysis plan and the findings in this report.

This report summarizes key findings from the study. After providing a brief description of the data used for the study, we report the extent to which beneficiaries received EBPs and then describe state-to-state variation in the receipt of EBPs. We then report whether the receipt of EBPs was associated with beneficiary or state characteristics. In the final chapter, we discuss the implications of the findings and offer recommendations and resources states and others can use to improve the delivery of EBPs. A technical appendix to this report provides further detail on the methodology used for the study.

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