Differences between states in the receipt of EBPs could be attributable to underlying differences in the demographic characteristics of state Medicaid populations, differences in structures or orientation of service systems, or specific Medicaid policies and practices that could limit reimbursement of a particular EBP. In this chapter, we describe state-to-state variation in the receipt of EBPs. We used descriptive and multivariate statistics to identify the features of state mental health service systems and Medicaid programs associated with this variation, and the likelihood that an individual beneficiary received services.
Our analysis of state Medicaid program or mental health system characteristics focused on state features that could be directly measured using MAX data or reliably constructed using secondary data sources. Thus, we focused on three main state features: (1) enrollment in managed care, (2) Medicaid prescription drug (RX) policies, and (3) funding for community-based mental health services. Table 4 summarizes the features of states and the size of the study population affected by a particular state feature.
Managed Care. Enrollment in managed care was measured directly using MAX data. As shown in Table 4, 13 percent of the study population located in three states was enrolled in an HMO for part or all of the year. Over 60 percent of beneficiaries in our study who were enrolled in an HMO lived in California, 37 percent lived in Maryland, and 2 percent lived in Indiana. Eight percent of the study population was enrolled in another form of managed care, such as a behavioral health organization (BHO), prepaid IP hospital plan, or primary care case management (PCCM) program. However, in these states, nearly the entire study population was enrolled in managed care, preventing an in-state comparison of managed care enrollees to beneficiaries in the FFS system. In sum, a relatively small proportion of the study population was enrolled in managed care in a few states, so readers should be cautious when drawing conclusions about managed care. The findings may differ if the data included a larger population of beneficiaries enrolled in managed care across many states.
Medicaid RX Policies. Medicaid RX policies were measured using data from the National Pharmaceutical Council. These policies included the state’s use of prior authorization policies for antipsychotics, anticonvulsants, or antidepressants; limits on medication quantity supplies and refills; and copayment requirements for RXs. Most beneficiaries lived in a state without prior authorization requirements or restrictive medication supply or refill limits (Table 4). Nearly one-quarter of the study population (24 percent) lived in a state with a three-dollar copayment for preferred or generic drugs, while 49 percent of the population lived in a state with a three-dollar copayment for nonpreferred or branded medications.
State Policy or Characteristic
Number of States with Policy or Characteristics
Beneficiaries with Schizophrenia or Bipolar Disorder Affected byPolicy or Characteristic
|SOURCES: The National Pharmaceutical Council, for Medicaid medication management and copayment information. National Research Institute (NRI), for data on the proportion of SMHA funding used for community-based services. MAX provided managed care enrollment data for each beneficiary.|
|Managed Care Arrangements|
|No managed care (FFS system)||16||113,761||79|
|Enrolled in HMO||3||18,243||13|
|Enrolled in BHO||1||2,164||2|
|Enrolled in PCCM||1||4,023||3|
|Enrolled in prepaid IP hospital program||1||5,519||4|
|Prior Authorization for Mental Health Medications|
|No prior authorization required||14||113,111||79|
|Required for antipsychotics||4||13,513||9|
|Required for antidepressants||8||30,599||21|
|Required for anticonvulsants||3||5,989||4|
|Monthly Medication Supply Limit|
|Limited to 31 days or less||5||16,776||12|
|Supply limit greater than 31 days||17||126,934||88|
|Limit on Refills per Prescription|
|Six or fewer||2||9,763||7|
|More than six||20||133,947||93|
|Beneficiary Copayment for Generic or Preferred Medications|
|Beneficiary Copayment for Branded or Nonpreferred Medications|
|Proportion of SMHA Funding Used for Community-Based Services|
Funding for Community-Based Mental Health Services. The orientation of the state mental health system toward community-based versus institutional or hospital-based services (as indicated by financing levels), as well as the relationship between Medicaid and SMHAs, was measured using data from a 2007 survey of state mental health directors conducted by the National Association of State Mental Health Program Directors, NRI. As shown in Table 4, 43 percent of beneficiaries in the study lived in one of the four states where more than three-quarters of state mental health system funding was used to provide community-based services.
There are several features of states that could influence the receipt of EBPs but for which we did not have a reliable or authoritative source in 2007. These features include detailed information on the type and scope of mental health benefits covered for adults in each state, limitations on the number or duration of mental health services, and the qualifications required for individuals or organizations to enroll in the program as mental health providers. While information is available on whether states covered certain mental health services in 2007, in general it tended to lack sufficient detail to allow for adequate differentiation between states in the generosity and accessibility of their mental health benefit. Finally, the characteristics of Medicaid providers could not be measured using MAX data. These unmeasured variables could confound the findings and thus these findings should be interpreted cautiously.
We conducted state-level analyses to examine the relationship between certain state features and the proportion of beneficiaries who received an EBP. When there was sufficient variation and reliably collected explanatory variables, we conducted person-level random effects multivariate analyses to further examine whether any beneficiary, SMHA, or Medicaid program characteristics were associated with the receipt of EBPs.