Does Primary Care Fill the Gap in Access to Specialty Mental Health Care? A Mixed Methods Study.

BACKGROUND: Broad consensus supports the use of primary care to address unmet need for mental health treatment. OBJECTIVE: To better understand whether primary care filled the gap when individuals were unable to access specialty mental health care. DESIGN: 2018 mixed methods study with a national US internet survey (completion rate 66%) and follow-up interviews. PARTICIPANTS: Privately insured English-speaking adults ages 18-64 reporting serious psychological distress that used an outpatient mental health provider in the last year or attempted to use a mental health provider but did not ultimately use specialty services (N = 428). Follow-up interviews were conducted with 30 survey respondents. MAIN MEASURES: Whether survey respondents obtained mental health care from their primary care provider (PCP), and if so, the rating of that care on a 1 to 10 scale, with ratings of 9 or 10 considered highly rated. Interviews explored patient-reported barriers and facilitators to engagement and satisfaction with care provided by PCPs. KEY RESULTS: Of the 22% that reported they tried to but did not access specialty mental health care, 53% reported receiving mental health care from a PCP. Respondents receiving care only from their PCP were less likely to rate their PCP care highly (21% versus 48%; p = 0.01). Interviewees reported experiences with PCP-provided mental health care related to three major themes: PCP engagement, relationship with the PCP, and PCP role. CONCLUSIONS: Primary care is partially filling the gap for mental health treatment when specialty care is not available. Patient experiences reinforce the need for screening and follow-up in primary care, clinician training, and referral to a trusted specialty consultant when needed.

Comparative Effectiveness of Digital Breast Tomosynthesis and Mammography in Older Women.

BACKGROUND: Digital breast tomosynthesis (DBT) has become a prevalent mode of breast cancer screening in recent years. Although older women are commonly screened for breast cancer, little is known about screening outcomes using DBT among older women. OBJECTIVE: To assess proximal screening outcomes with DBT compared to traditional two-dimensional(2-D) mammography among women 67-74 and women 75 and older. DESIGN: Cohort study. PARTICIPANTS: Medicare fee-for-service beneficiaries aged 67 years and older with no history of prior cancer who received a screening mammogram in 2015. MAIN MEASURES: Use of subsequent imaging (ultrasound and diagnostic mammography) as an indication of recall, breast cancer detection, and characteristics of breast cancer at the time of diagnosis. Analyses used weighted logistic regression to adjust for potential confounders. KEY RESULTS: Our study included 26,406 women aged 67-74 and 17,001 women 75 and older who were screened for breast cancer. Among women 75 and older, the rate of subsequent imaging among women screened with DBT did not differ significantly from 2-D mammography (91.8 versus 97.0 per 1,000 screening mammograms, p=0.37). In this age group, DBT was associated with 2.1 additional cancers detected per 1,000 screening mammograms compared to 2D (11.5 versus 9.4, p=0.003), though these additional cancers were almost exclusively in situ and stage I invasive cancers. For women 67-74 years old, DBT was associated with a higher rate of subsequent imaging than 2-D mammography (113.9 versus 100.3, p=0.004) and a higher rate of stage I invasive cancer detection (4.7 versus 3.7, p=0.002), but not other stages. CONCLUSIONS: Breast cancer screening with DBT was not associated with lower rates of subsequent imaging among older women. Most additional cancers detected with DBT were early stage. Whether detecting these additional early-stage cancers among older women improves health outcomes remains uncertain.

What Explains Changes in Availability of Specialty Mental Health Services in Organized Settings?

Policy Points Community mental health facilities often do not offer the full range of evidence-based clinical and support services for individuals with serious mental illness. Facilities were no more likely to offer six of seven services studied in 2019 compared with 2010 in both Medicaid expansion and nonexpansion states. For-profit facilities generally experienced the largest declines in service availability, while public facilities experienced the smallest declines with small increases in availability of select services. New payment models that incentivize the offer of specialty support services may be needed to encourage adoption of clinical and support services by specialty mental health organizations. CONTEXT: Community mental health facilities often do not offer the full range of evidence-based clinical and support services for individuals with serious mental illness. This creates equity issues, particularly when low-income and minority communities have access to fewer facilities. Medicaid expansion might encourage facilities to offer these services. However, this decision may also be affected by facility ownership type or mediated by service cost structure, particularly in the absence of innovative payment mechanisms. In this study, we determine whether and how Medicaid expansion and facility ownership are associated with changes in specialty mental health service availability in organized settings over time. METHODS: We estimated two-way fixed effects models using six cross-sections of the National Mental Health Services Survey and compared changes in facility-reported offering of seven services from 2010 to 2019 (54,885 facility years): psychotropic medication, case management, family psychoeducation, psychiatric emergency walk-in services, supported employment, assertive community treatment, illness management, and recovery services. We tested whether Medicaid expansion and facility ownership (private for-profit, private not-for-profit, public) were associated with differential changes in service availability from 2010 to 2019. FINDINGS: Overall, facilities were no more likely to offer nearly all services in 2019 than 2010. We found smaller declines for psychotropic medication and psychiatric emergency walk-in services among facilities in Medicaid expansion states compared to declines in non-Medicaid expansion states (6.3 (95% CI 95% CI = 1.8-10.7) and 5.5 (95% CI = 0.2-10.8) percentage points respectively). For-profit facilities experienced the largest declines in availability from 2010 to 2019, while public facilities experienced the smallest declines and some increases in availability of select services. CONCLUSIONS: Specialty mental health services are still not widely offered in community outpatient settings despite significant investments in Medicaid, although Medicaid expansion was associated with slower declines in availability. New payment models that incentivize outpatient facilities to offer clinical and support services may be needed.

Cost savings of a primary care program for individuals recently released from prison: a propensity-matched study.

BACKGROUND: Criminal justice system costs in the United States have exponentially increased over the last decades, and providing health care to individuals released from incarceration is costly. To better understand how to manage costs to state budgets for those who have been incarcerated, we aimed to assess state-level costs of an enhanced primary care program, Transitions Clinic Network (TCN), for chronically-ill and older individuals recently released from prison. METHODS: We linked administrative data from Connecticut Department of Correction, Medicaid, and Department of Mental Health and Addiction Services to identify a propensity matched comparison group and estimate costs of a primary care program serving chronically-ill and older individuals released from incarceration between 2013 and 2016. We matched 94 people released from incarceration who received care at a TCN program to 94 people released from incarceration who did not receive care at TCN program on numerous characteristics. People eligible for TCN program participation were released from incarceration within the prior 6 months and had a chronic health condition or were over the age of 50. We estimated 1) costs associated with the TCN program and 2) costs accrued by Medicaid and the criminal justice system. We evaluated associations between program participation and Medicaid and criminal justice system costs over a 12-month period using bivariate analyses with nonparametric bootstrapping method. RESULTS: The 12-month TCN program operating cost was estimated at $54,394 ($146 per participant per month). Average monthly Medicaid costs per participant were not statistically different between the TCN ($1737 ± $3449) and comparison ($1356 ± $2530) groups. Average monthly criminal justice system costs per participant were significantly lower among TCN group ($733 ± $1130) compared with the matched group ($1276 ± $1738, p < 0.05). We estimate every dollar invested in the TCN program yielded a 12-month return of $2.55 to the state. CONCLUSIONS: Medicaid investments in an enhanced primary care program for individuals returning from incarceration are cost neutral and positively impact state budgets by reducing criminal justice system costs.

Understanding Regional Variation in the Cost of Breast Cancer Screening Among Privately Insured Women in the United States.

BACKGROUND: Breast cancer screening for women aged 40-49 years is prevalent and costly, with costs varying substantially across US regions. Newer approaches to mammography may improve cancer detection but also increase screening costs. We assessed factors associated with regional variation in screening costs. METHODS: We used Blue Cross Blue Shield Axis, a large US commercial claims database accessed through secure portal, to assess regional variation in screening utilization and costs. We included screening mammography±digital breast tomosynthesis (DBT), screening ultrasound, diagnostic mammography±DBT, diagnostic ultrasound, magnetic resonance imaging and biopsy, and evaluated their utilization and costs. We assessed regional variation in annual per-screened-beneficiary costs and examined potential savings from reducing regional variation. RESULTS: Of the 2,257,393 privately insured women, 41.2% received screening mammography in 2017 (range: 26.6%-54.2% across regions). Wide regional variation was found in the DBT proportion (0.7%-91.1%) and mean costs of DBT ($299; range: $113-714) and 2-dimensional (D) mammograms ($213; range: $107-471). In one-fourth of the regions, the mean DBT cost was lower than the mean 2D mammography cost in the full sample. Regional variation in the per-screened-beneficiary cost (mean: $353; range: $151-751) was mainly attributable to variation in the cost of DBT (accounting for 23.4% of regional variation) and 2D mammography (23.0%). Reducing regional variation by decreasing the highest values to the national mean was projected to save $79-335 million annually. CONCLUSIONS: The mean mammogram cost for privately insured women ages 40-49 varies 7-fold across regions, driving substantial variation in breast cancer screening costs. Reducing this regional variation would substantially decrease the screening costs.

Has depression surpassed HIV as a burden to gay and bisexual men's health in the United States? A comparative modeling study.

BACKGROUND: While advances in HIV prevention and treatment have changed the epidemic for gay and bisexual men, another epidemic faces this population. Gay and bisexual men represent one of the highest risk groups for depression, which potentially poses quality-of-life and public health challenges comparable to those of HIV. The present study seeks to inform comprehensive care for sexual minority men by estimating and comparing the morbidity of HIV and depression for US gay and bisexual men. METHODS: In 2018, weighted counts of gay and bisexual men living with HIV and depression were derived from the CDC's Medical Monitoring Project and the National Survey on Drug Use and Health, respectively. Years lived with disability for HIV and depression were calculated using the Global Burden of Disease Study's disability weights. FINDINGS: Among gay and bisexual adult men in the US, the prevalence of past-year major depressive episodes is 14.17%, while the prevalence of HIV is 11.52%. We estimate that in calendar year 2015, major depressive episodes imposed 85,361 (95% CI 58,293-112,212) years lived with disability among US adult gay and bisexual men, whereas HIV posed 42,981 (95% CI 36,221-49,722) years lived with disability. INTERPRETATION: This analysis shows that depression morbidity currently exceeds that for HIV among US adult gay and bisexual men. While gay and bisexual men are frequently understood to be a high-risk population for HIV, including in guidelines for HIV prevention and treatment, the present analysis suggests that this population should also be considered high-risk for depression.

Dense Breast Notification Laws, Education, and Women's Awareness and Knowledge of Breast Density: a Nationally Representative Survey.

BACKGROUND: To date, 38 states have enacted dense breast notification (DBN) laws mandating that mammogram reports include language informing women of risks related to dense breast tissue. OBJECTIVE: Nationally representative survey to assess the association between residing in a state with a DBN law and women's awareness and knowledge about breast density, and breast cancer anxiety. DESIGN: Internet survey conducted in 2018 with participants in KnowledgePanel®, an online research panel. PARTICIPANTS: English-speaking US women ages 40-59 years without a personal history of breast cancer who had received at least one screening mammogram (N = 1928; survey completion rate 68.2%). MAIN MEASURES: (1) Reported history of increased breast density, (2) knowledge of the increased risk of breast cancer with dense breasts, (3) knowledge of the masking effect of dense breasts on mammography, and (4) breast cancer anxiety. KEY RESULTS: Women residing in DBN states were more likely to report increased breast density (43.6%) compared with women residing in non-DBN states (32.7%, p < 0.01, adjusted odds ratio, 1.70, 95% CI,1.34-2.17). Interaction effect between DBN states and education status showed that the impact of DBN on women's reporting of dense breasts was significant for women with greater than high school education, but not among women with a high school education or less (p value = 0.01 for interaction). Only 23.0% of women overall knew that increased breast density was associated with a higher risk of breast cancer, and 68.0% of women understood that dense breasts decreased the sensitivity of mammography. There were no significant differences between women in DBN states and non-DBN states for these outcomes, or for breast cancer-related anxiety. CONCLUSIONS: State DBN laws were not associated with increased understanding of the clinical implications of breast density. DBN laws were associated with a higher likelihood of women reporting increased breast density, though not among women with lower education.

Changes in community mental health services availability and suicide mortality in the US: a retrospective study.

BACKGROUND: Despite the fact that the overwhelming majority of mental health services are delivered in outpatient settings, the effect of changes in non-hospital-based mental health care on increased suicide rates is largely unknown. This study examines the association between changes in community mental health center (CMHC) supply and suicide mortality in the United States. METHODS: Retrospective analysis was performed using data from National Mental Health Services Survey (N-MHSS) and the Centers for Disease Control and Prevention (CDC) Wide-Ranging Online Data for Epidemiologic Research (WONDER) (2014-2017). Population-weighted multiple linear regressions were used to examine within-state associations between CMHCs per capita and suicide mortality. Models controlled for state-level characteristics (i.e., number of hospital psychiatric units per capita, number of mental health professionals per capita, age, race, and percent low-income), year and state. RESULTS: From 2014 to 2017, the number of CMHCs decreased by 14% nationally (from 3406 to 2920). Suicide increased by 9.7% (from 15.4 to 16.9 per 100,000) in the same time period. We find a small but negative association between the number of CMHCs and suicide deaths (- 0.52, 95% CI - 1.08 to 0.03; p = 0.066). Declines in the number of CMHCs from 2014 to 2017 may be associated with approximately 6% of the national increase in suicide, representing 263 additional suicide deaths. CONCLUSIONS: State governments should avoid the declining number of CMHCs and the services these facilities provide, which may be an important component of suicide prevention efforts.

National Referral and Treatment Patterns Among Mental Health Pediatric Primary Care Visits.

The current study explored factors that predict referral from pediatric primary care to mental health specialty care among a nationally representative sample of visits (N = 2056). Results of a logistic regression indicated that patient visits that included rarer/serious diagnoses (e.g., bipolar disorder) were more likely to receive a referral in comparison to those with ADHD (OR = 4.75, SE = 1.37). Other characteristics associated with increased likelihood of referral were those with comorbid mental health conditions (OR = 2.20, SE = 0.84) and those from a metropolitan area (OR = 2.23, SE = 0.75). Implications are discussed.

Assessing the Relative Contribution of Resident Versus Facility Characteristics Associated With Antipsychotic Medication Receipt Among Nursing Facility Residents.

OBJECTIVE: In 2012 Centers for Medicare and Medicaid Services (CMS) launched a multifaceted initiative aimed at reducing the unnecessary use of antipsychotic medications in nursing facilities due to evidence these medications are associated with little or uncertain benefit and substantial risk. Yet, little is known about whether efforts to reduce antipsychotic medication should be focused on residents with targeted characteristics, or on nursing facility regulation (eg, staffing levels). Our objective was to identify the relative contribution of resident and facility characteristics to potentially inappropriate antipsychotic use. METHODS: We examined 1,156,875 long stay residents in 14,699 US nursing facilities in 2014 and predicted resident antipsychotic use controlling sequentially for resident and facility characteristics and calculated the incremental variation explained. RESULTS: We found significant variability in unadjusted rates of potentially inappropriate antipsychotic use among nursing facilities (mean=18.0%; interquartile range: 11.3%-23.7%; SD: 11.1). Regression results indicated that 93% of the explained variation in antipsychotic use was attributed to resident characteristics and 7% was attributed to facility-level factors. At the facility level, worker hours per resident day was not significantly associated with antipsychotic use. Simulations indicated that applying the effect sizes achieved by the best performing facilities to the existing case mix across all nursing facilities would result in no more than a 1 percentage point change in population-level antipsychotic use. CONCLUSIONS: Efforts to reduce antipsychotic use may have greater impact by developing new clinical strategies to address specific diagnoses rather than regulations related to facility-level attributes.

Association of State Dense Breast Notification Laws With Supplemental Testing and Cancer Detection After Screening Mammography.

OBJECTIVES: To evaluate the association of state dense breast notification (DBN) laws with use of supplemental tests and cancer diagnosis after screening mammography. METHODS: We examined screening mammograms (n = 1 441 544) performed in 2014 and 2015 among privately insured women aged 40 to 59 years living in 9 US states that enacted DBN laws in 2014 to 2015 and 25 US states with no DBN law in effect. DBN status at screening mammography was categorized as no DBN, generic DBN, and DBN that mandates notification of possible benefits of supplemental screening (DBN+SS). We used logistic regression to examine the change in rate of supplemental ultrasound, magnetic resonance imaging, breast biopsy, and breast cancer detection. RESULTS: DBN+SS laws were associated with 10.5 more ultrasounds per 1000 mammograms (95% CI = 3.0, 17.6 per 1000; P = .006) and 0.37 more breast cancers detected per 1000 mammograms (95% CI = 0.05, 0.69 per 1000; P = .02) compared with no DBN law. No significant differences were found for generic DBN laws in either ultrasound or cancer detection. CONCLUSIONS: DBN legislation is associated with increased use of ultrasound and cancer detection after implementation only when notification of the possible benefits of supplemental screening is required.

Emergency Department-Initiated Buprenorphine for Opioid Dependence with Continuation in Primary Care: Outcomes During and After Intervention.

BACKGROUND: Emergency department (ED)-initiated buprenorphine/naloxone with continuation in primary care was found to increase engagement in addiction treatment and reduce illicit opioid use at 30 days compared to referral only or a brief intervention with referral. OBJECTIVE: To evaluate the long-term outcomes at 2, 6 and 12 months following ED interventions. DESIGN: Evaluation of treatment engagement, drug use, and HIV risk among a cohort of patients from a randomized trial who completed at least one long-term follow-up assessment. PARTICIPANTS: A total of 290/329 patients (88% of the randomized sample) were included. The followed cohort did not differ significantly from the randomized sample. INTERVENTIONS: ED-initiated buprenorphine with 10-week continuation in primary care, referral, or brief intervention were provided in the ED at study entry. MAIN MEASURES: Self-reported engagement in formal addiction treatment, days of illicit opioid use, and HIV risk (2, 6, 12 months); urine toxicology (2, 6 months). KEY RESULTS: A greater number of patients in the buprenorphine group were engaged in addiction treatment at 2 months [68/92 (74%), 95% CI 65-83] compared with referral [42/79 (53%), 95% CI 42-64] and brief intervention [39/83 (47%), 95% CI 37-58; p < 0.001]. The differences were not significant at 6 months [51/92 (55%), 95% CI 45-65; 46/70 (66%) 95% CI 54-76; 43/76 (57%) 95% CI 45-67; p = 0.37] or 12 months [42/86 (49%) 95% CI 39-59; 37/73 (51%) 95% CI 39-62; 49/78 (63%) 95% CI 52-73; p = 0.16]. At 2 months, the buprenorphine group reported fewer days of illicit opioid use [1.1 (95% CI 0.6-1.6)] versus referral [1.8 (95% CI 1.2-2.3)] and brief intervention [2.0 (95% CI 1.5-2.6), p = 0.04]. No significant differences in illicit opioid use were observed at 6 or 12 months. There were no significant differences in HIV risk or rates of opioid-negative urine results at any time. CONCLUSIONS: ED-initiated buprenorphine was associated with increased engagement in addiction treatment and reduced illicit opioid use during the 2-month interval when buprenorphine was continued in primary care. Outcomes at 6 and 12 months were comparable across all groups.

Knowledge of Density and Screening Ultrasound.

To determine breast density awareness and attitudes regarding supplemental breast ultrasound screening since implementation of the nation's first breast density notification law, Connecticut Public Act 09-41. A self-administered survey was distributed at a Connecticut academic breast imaging center between February 2013 and February 2014. Women with prior mammography reports describing heterogeneous or extremely dense breast tissue were invited to participate when presenting for screening mammography, screening ultrasound, or both. Data were collected on breast density awareness, history of prior ultrasounds, attitudes toward ultrasound and breast-cancer risk, and demographics. Data were collected from 950 completed surveys. The majority of surveyed women (92%) were aware of their breast density, and 77% had undergone a prior screening ultrasound. Forty-three percent of participants who were aware of their breast density also expressed increased anxiety about developing breast cancer due to having dense breast tissue. Caucasian race and higher education were significantly associated (p < 0.05) with knowledge of personal breast density (93% and 95%, respectively) and having a prior screening breast ultrasound (79% and 80%, respectively). Patients with less than a college degree (82%) were significantly more likely to rely exclusively on their provider's recommendation regarding obtaining screening ultrasound (p < 0.05). Breast density awareness is strongly associated with higher education, higher income, and Caucasian race. Non-Caucasian patients and those with less than a college education rely more heavily on their physicians' recommendations regarding screening ultrasound. Among women aware of their increased breast density, nearly half reported associated increased anxiety regarding the possibility of developing breast cancer.

Was federal parity associated with changes in Out-of-network mental health care use and spending?

BACKGROUND: The goal of the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act is to eliminate differences in insurance coverage between behavioral health and general medical care. The law requires out-of-network mental health benefits be equivalent to out-of-network medical/surgical benefits. Insurers were concerned this provision would lead to unsustainable increases in out-of-network related expenditures. We examined whether federal parity implementation was associated with significant increases in out-of-network mental health care use and spending. METHODS: We conducted an interrupted time series analysis using health insurance claims from self-insured employers (2007-2012). We examined changes in the probability of using out-of-network mental health services and, conditional on out-of-network mental health service use, changes in the number of outpatient out-of-network mental health visits and total out-of-network mental health spending associated with the implementation of federal parity in 2010. RESULTS: From 2007 to 2012, the proportion of individuals receiving any out-of-network mental health services each month declined dramatically from 18 to 12%, with a one-time drop of 3 percentage points at parity implementation (p < .01). Among out-of-network mental health service users, there was an increase in the number of visits per month (.12 visits; p < .01) and total spending per month ($49; p < .01) at parity implementation. Although there was a one-time increase in spending at parity implementation, this increase was accompanied by an attenuation of a trend toward increased spending growth, such that spending was back to original predictions by the end of our study period. CONCLUSIONS: Despite concerns expressed by the health insurance industry when federal parity was enacted, out-of-network mental health spending did not substantially increase after parity implementation. In addition, use of out-of-network mental health services appears to have contracted rather than expanded, suggesting insurers may have implemented other policies to curb out-of-network use, such as increasing access to in-network providers.

Mental Health Insurance Parity and Provider Wages.

BACKGROUND: Policymakers frequently mandate that employers or insurers provide insurance benefits deemed to be critical to individuals' well-being. However, in the presence of private market imperfections, mandates that increase demand for a service can lead to price increases for that service, without necessarily affecting the quantity being supplied. We test this idea empirically by looking at mental health parity mandates. OBJECTIVE: This study evaluated whether implementation of parity laws was associated with changes in mental health provider wages. METHOD: Quasi-experimental analysis of average wages by state and year for six mental health care-related occupations were considered: Clinical, Counseling, and School Psychologists; Substance Abuse and Behavioral Disorder Counselors; Marriage and Family Therapists; Mental Health Counselors; Mental Health and Substance Abuse Social Workers; and Psychiatrists. Data from 1999-2013 were used to estimate the association between the implementation of state mental health parity laws and the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act and average mental health provider wages. RESULTS: Mental health parity laws were associated with a significant increase in mental health care provider wages controlling for changes in mental health provider wages in states not exposed to parity (3.5 percent [95% CI: 0.3%, 6.6%]; p<.05). DISCUSSION: Mental health parity laws were associated with statistically significant but modest increases in mental health provider wages. IMPLICATIONS: Health insurance benefit expansions may lead to increased prices for health services when the private market that supplies the service is imperfect or constrained. In the context of mental health parity, this work suggests that part of the value of expanding insurance benefits for mental health coverage was captured by providers. Given historically low wage levels of mental health providers, this increase may be a first step in bringing mental health provider wages in line with parallel health professions, potentially reducing turnover rates and improving treatment quality.

Exploring Explanations for the Female-Male Earnings Difference Among Registered Nurses in the United States.

Research has shown male registered nurses (RNs) outearn their female colleagues by approximately $5,000 annually. The aim of this study was to explore differences in characteristics of female and male fulltime employed RNs, and to examine whether these differences help account for the female-male earnings gap in nursing. Specifically, the researchers tested whether the gender earnings gap could be explained by differences in career aspiration, workplace experience, time taken out of the labor force for child-rearing, and physical strength. While some evidence suggested motivational differences in career aspirations between female and male RNs exist, evidence supporting other hypotheses was not found. Given the expansion of nurses' roles in health care delivery, serious deliberations of how to respond to the earnings gap in nursing is warranted.