Mental health and substance abuse services in ten state Medicaid programs.

Program data for 1993 on Medicaid mental health and substance abuse (MH/SA) services and expenditures were developed from Health Care Financing Administration (HCFA) research files for 10 states. These data show that MH/SA service users are 7 to 13% of Medicaid enrollees. The percentage of Medicaid enrollees accounted for by MH/SA users increases with age, reaching a fifth of the 45-64 age group. Across the 10 states, MH/SA spending represents 11% of total Medicaid expenditures. When their expenditures for non-MH/SA services are also considered, MH/SA users account for 28% of total Medicaid expenditures.

Spending on mental health and substance abuse treatment, 1987-1997.

This paper is the result of an ongoing effort to track spending on mental health and substance abuse (MH/SA) treatment nationwide. Spending for MH/SA treatment was $85.3 billion in 1997: $73.4 billion for mental illness and $11.9 billion for substance abuse. MH/SA spending growth averaged 6.8 percent a year between 1987 and 1997, while national health expenditures grew by 8.2 percent.

Transform-limited spectral compression due to self-phase modulation in fibers.

We demonstrate near-transform-limited pulse generation through spectral compression arising from nonlinear propagation of negatively chirped pulses in optical fiber. The output pulse intensity and phase were quantified by use of second-harmonic generation frequency-resolved optical gating. Spectral compression from 8.4 to 2.4 nm was obtained. Furthermore, the phase of the spectrally compressed pulse was found to be constant over the spectral and temporal envelopes, which is indicative of a transform-limited pulse. Good agreement was found between the experimental results and numerical pulse-propagation studies.

Behavioral health benefits in employer-sponsored health plans, 1997.

Data for 1997 show that three-quarters or more of employer-sponsored health plans continue to place greater restrictions on behavioral health coverage than on general medical coverage. The nature of these restrictions varies by plan type. Some improvement in the treatment of mental health/substance abuse (MH/SA) benefits in employer plans may be occurring, however. Comparisons with data from 1996 show that the proportion of plans with benefits for "alternative" types of MH/SA services, such as nonhospital residential care, has increased. Further, the proportion with special limitations on these benefits shows a modest decrease.

Utilization of Medicaid mental health services by nondisabled children and adolescents.

OBJECTIVE: Mental health service use and costs for nondisabled children and adolescents in the Medicaid programs of Michigan and Tennessee were examined to improve understanding of patterns of service use in this population. METHODS: Data from the Medicaid Analysis Project for States, sponsored by the Health Care Financing Administration, were examined for nondisabled children and adolescents under 19 years of age who were continuously enrolled in Medicaid in 1990 and who received Medicaid mental services, including treatment for alcohol and drug abuse. Recipients of mental health services constituted 5 and 7 percent of the nondisabled children and adolescents in the Medicaid programs in Michigan and Tennessee, respectively. RESULTS: Total expenditures for mental health care recipients were three or more times higher than the level suggested by their proportion in the general Medicaid nondisabled population. Their psychiatric hospitalizations were much longer, with mean lengths of stay of 44 days in Tennessee and 60 in Michigan. Although inpatient utilization rates were similar in the two states, outpatient utilization differed by type of problem treated, provider, and type of treatment. About a third of mental health recipients received psychotropic drugs; cerebral stimulants were the most commonly prescribed type. CONCLUSIONS: Results illustrate the need to learn more about Medicaid mental health services for younger children and the use of psychotropic drugs. They also suggest that states reforming their Medicaid programs to contain costs should pay particular attention to the use of mental health services by children and adolescents.

Use of utilization management methods in State Medicaid programs.

This article describes the use of utilization management (UM) methods by State Medicaid programs. The use of optional UM methods range from zero in one State to eight in four States, with a median of five. A majority of States have programs for ambulatory surgery, preadmission certification, lock-in, primary-care case management, and targeted case management. Overall, no UM method was judged by States to have an adverse effect on access of quality of care. For UM methods mandated by the Medicaid program, more than one-third of the States rated physician certification as minimally effective.

The Medicaid program and the Clinton plan: implications for mental health services.

This paper reviews problems that the Medicaid program poses for health care reformers and how the Clinton plan would deal with them. The Clinton plan represents a compromise between preserving or expanding the Medicaid program and eliminating. The plan would seek to extend services to those without insurance and reduce health care costs, partly by limiting services and increasing out-of-pocket costs for Medicaid beneficiaries. All Medicaid beneficiaries would be included in the same basic system of health care that the plan proposes for other Americans. All current beneficiaries would remain eligible for Medicaid, but services would be reduced for many of them. However, services that are important for persons with severe mental illness would be maintained. The plan also would increase out-of-pocket costs for premiums and services, and these increases could be significant for some beneficiaries.

Problems with expanding Medicaid for the uninsured.

Many proposals for financing health care for the uninsured recommend expanding the Medicaid program. They often advocate extending Medicaid to all those under the poverty level and standardizing program benefits. However, the proposals have ignored important problems that must be resolved if the plans are to be successfully implemented, the most serious being the fiscal impacts that such proposals would have on states. The current Medicaid matching formula fails to reflect either the size of a state's Medicaid program or its ability to pay for it. As a result, the proportional fiscal effort that expansion proposals would require of states would greatly exceed that required of the federal government. Additionally, the fiscal impact would vary widely and have little relationship to a state's current Medicaid program generosity. Besides fiscal problems, significant differences exist between Medicaid and private plans in the areas of benefits, cost sharing, managed care, cost containment, and provider payment. Under a national system of health care, these differences would limit program economies, and create problems with perceived equity, continuity of care, and migration effects.

Recent trends in Medicaid expenditures.

Total net Medicaid expenditures exceeded $94 billion in FY 1991, with 5 states accounting for more than 40 percent--New York, California, Massachusetts, Pennsylvania, and Texas. Nationally, inpatient and institutional long-term care payments each comprise about one-third of Medicaid spending. Medicaid expenditures have grown rapidly. From 1987 to 1991 they nearly doubled, greatly exceeding the expenditure growth for Medicare and private health insurance. This growth has been unevenly distributed. Expenditures increased by 125 percent or more in 12 States during this period, but an equal number of States had increases below 75 percent. Although expenditures grew the most slowly in institutional long-term care, this still comprises the largest payment category. Spending for inpatient services, community long-term care, insurance payments, and services not otherwise classified had the fastest rate of growth. By 1995, projected Federal expenditures for Medicaid will exceed $100 billion, approximately equal to those for Medicare in 1991. Health care inflation, State program decisions, and Federal mandates all affect the growth in Medicaid expenditures. Legislative changes have expanded coverage of pregnant women, infants, and children, and also have increased Medicaid payments of Medicare premiums and cost sharing for the elderly and disabled. Other Federal mandates raised nursing home standards and expanded EPSDT services. Legislative requirements and court challenges caused some States to increase provider payment rates. Some States developed alternative financing arrangements to accommodate the fiscal demands of higher expenditure growth. Requirements for DSH payments allowed States to use Medicaid to offset State support of public hospitals. Provider taxes and donations permitted States to increase Medicaid payments without having to raise other revenues or place an economic burden on providers. These arrangements were significantly curtailed by legislation passed in 1991.

Medicaid support of alcohol, drug abuse, and mental health services.

Medicaid expenditures for alcohol, drug abuse, and mental health (ADM) services in 1984 were examined for the States of California and Michigan. Persons receiving such services constituted 9 to 10 percent of the total Medicaid population in the two States and accounted for 22 to 23 percent of total Medicaid expenditures. ADM expenditures were 11 to 12 percent of the total. Although the two States had similar proportions of overall expenditures for these services, Michigan appeared to emphasize inpatient psychiatric care, while California emphasized ambulatory and nursing home care. Based on the experience of the two States, national Medicaid expenditures for ADM services exclusive of long-term care were estimated to be $3.5 to $4.9 billion in 1984, two to three times the level suggested by earlier estimates.

Psychotropic medication of mentally retarded residents in community long-term care facilities.

Medicaid billing information was used to examine the administration of psychotropic medication to residents of community long-term care facilities providing mental retardation services. In 1984, 5,766 individuals receiving Medicaid in Illinois resided continuously in these facilities for the entire year. Of these, 1,667 (28.9%) received at least one psychotropic medication during the year, with thioridazine, haloperidol, and chlorpromazine being prescribed most frequently. Data for frequency, dose, and length of administration of individual psychotropic medications were reported for the total group and by level of mental retardation. Separate analyses indicated little or no influence of demographic and facility variables on either the probability of drug administration or amount administered.

Psychotropic drug practice in nursing homes.

This study examined the administration of psychotropic medication to Medicaid recipients who resided continuously in an Illinois nursing home during 1984. Of these residents, 20,037 (60%) received at least one such medication during the year, with administration most likely for those from the ages of 45 to 74 years. Haloperidol, thioridazine, and flurazepam were the most frequently prescribed drugs of those examined. The study also investigated the relationship of demographic and institutional variables to the probability of drug administration and the amount administered. These variables were most strongly related to the probability of antipsychotic, antiparkinson, and antimanic (lithium) administration. The association of these variables with the amount of drug administered was strongest for antimanic and antipsychotic medications, particularly the latter. In all analyses, the addition of institutional variables increased goodness of fit minimally over that produced by demographic variables alone. This finding supports the conclusion that the prescription of psychotropic medication is more influenced by individual patient characteristics than by the nature of the institutional setting in which the patient resides.