Medicaid and Mental Health Services: Research Challenges

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Medicaid and Mental Health Services Research
Challenges

• Jeffrey A. Buck, Ph.D.
• Jeff.buck_at_samhsa.hhs.gov

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Medicaid is the largest MH Payer
MH100 billion (2003)
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Medicaid is nearly half of all public MH spending
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MH Public Payer Shares, 1993-2003
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Some characteristics 1999 data

• MH users are 10 of total beneficiaries
• Depression most frequent dx for adults
  hyperkinetic syndrome most frequent for children
• 35 of Medicaid MH users have ER visits,
  averaging 3 visits/yr, compared to 18 and 2
  visits/yr for overall Medicaid pop.
• Most MH user ER visits are not for psychiatric
  reasons

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Characteristics (contd)

• 9 of Medicaid MH users have inpatient psych care
  with an avg of 23 days annually
• 19 of total beneficiaries have psychotropic drug
  use 69 of MH service users
• Highest rates for 45 64 age group
• Stimulants most common for children
  antidepressants for adults
• Source 1999 Medicaid data

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Medicaid is the only provider of care for many
adults with serious mental illness
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Source of Support Adults w/SMI
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MH service users make up a major portion of high
cost Medicaid enrollees
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MH Users as a Percentage of High Cost Medicaid
Enrollees
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for MH Users as a of for All High Cost
Medicaid Enrollees
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Some major research issues

• Managed Care
• Nonspecialty providers
• Comorbid conditions
• Effects of recent policy changes

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Managed Care

• Nearly all states have a Medicaid managed care
  program
• Over half of these enroll aged/disabled
  eligibility groups
• Effects of the 1997 BBA
• Lock in extension
• Actuarially sound rates

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Nonspecialty MH providers in Medicaid

• ERs and general hospitals w/o psychiatric units
• Nursing homes
• Nonpsychiatric physicians
• Psychotropic drugs

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AHA Behavioral Health Task Force

• The 24/7 availability of the hospital emergency
  department makes hospitals the safety net or
  provider of last resort for behavioral
  healthcare.
• Many patients with severe behavioral health
  disorders seek care in general hospitals that are
  designed for short-stay medical-surgical
  patients.

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News item

• Janet Wells, public policy director for the
  National Citizens' Coalition for Nursing Home
  Reform, said nursing homes had become the new
  dumping ground for psychiatric patients. "These
  people should not be in nursing homes," she said.
  "They should be somewhere where they're getting
  treatment. Instead, they're just being cast
  aside."
• NY Times, 12/03

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Nonpsychiatric Physicians(Wang et al., 2006)

• General medical-only service sector experienced
  the greatest increase over the 90s and is now
  the most common
• MH specialty (other than psychiatrists) decreased
  along w/human services
• General medical w/ and w/o other MH specialty was
  also most frequent for the most serious disorders

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Medicaid Users of Psychotropic Drugs

• 19 of all Medicaid beneficiaries have at least
  one psychotropic prescription in a year
• Of these, nearly two-thirds (63) have no other
  evidence of MH service
• Source Medicaid Tables for 1999

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Comorbid conditions

• Jones et al. (2004) - 74 of SMI in Medicaid had
  at least one chronic health problem 50 had two
  or more
• Another Medicaid study found that of different
  pairings of chronic co-morbid conditions,
  psychosis was a factor in 5 of the 7 highest cost
  pairs
• 1/3 of Medicaid high cost enrollees are MH
  service users this is primarily due to
  nonpsychiatric care

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Effects of recent policy changes

• Medicare Part D
• Payer of last resort
• Institutional restrictions/comm svcs promotion
• Case management changes
• Increased scrutiny of spec. providers
• Consumer empowerment

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Some barriers

• Problems with Medicaid data
• Problems with data interoperability

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Quality/completeness of Medicaid MH Data

• Assessment of 1999 data rated each states
  Medicaid data from 1 (poor) to 4 (good)
• 27 states had data rated less than a 3
• 7 states had data with almost no info at all, or
  info not showing MH pop or MH svcs
• Some reasons for poor data managed care, uneven
  enrollment data, missing dx codes

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MH and Medicaid data incompatibility

• SMHA and Medicaid data are limited in their
  compatibility - differences in data elements and
  coding mean that identical service events cannot
  be identified with confidence
• Consequences
• Ltd ability to construct a comprehensive picture
• Failure to capture legitimate FFP
• Ltd ability to identify fraud/abuse
• Potential costs/problems for providers

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Conclusion

• Public MH services, particularly for those with
  disabilities, is becoming a Medicaid-centric
  system
• Despite this, many important research issues for
  those with serious MI have received little
  attention
• Although administrative data problems create
  barriers, much can still be done

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