Benefits, Challenges, and Opportunities in Addressing Medicaid Beneficiaries' Non-Medical Risks to Health: A Qualitative Analysis.

CONTEXT: North Carolina's Healthy Opportunities Pilots (HOP) is a Medicaid 1115 Waiver program that seeks to address nonmedical risks to health for Medicaid beneficiaries through multisector collaboration. Among other stakeholders, HOP involves collaboration between human services organizations that deliver interventions, network leads, which establish and oversee the human services organizations within a region of the state. OBJECTIVE: To understand how employees at human services organizations and network leads prepared to deliver HOP services. DESIGN: Qualitative analysis of semistructured interviews. Interviews were conducted between April and June 2022. Interviews were recorded, transcribed verbatim, coded thematically, and analyzed using a conceptual model derived from the consolidated framework for implementation research. SETTING: Organizations within North Carolina counties participating in HOP. PARTICIPANTS: Employees of human services and network lead organizations across all 3 HOP regions of North Carolina. RESULTS: The researchers interviewed 37 participants. Overall, organizations experienced benefits from HOP participation, including capacity-building resources, flexibility in allocating resources, and creating community-wide enthusiasm for addressing nonmedical risks to health. There were also key challenges. These included the time needed to build capacity, adjustments to the work processes and regulations inherent to multisector collaboration, geographic variation in availability of services to offer, and the difficulty of addressing different needs. Finally, participants recognized substantial opportunities that HOP presented, including membership in a more extensive network, exposure to a learning community, and a more sustainable funding source. CONCLUSIONS: The perspectives of individuals preparing to deliver HOP services offer important lessons for those developing and implementing large-scale programs that can address nonmedical threats to health.

North Carolina Medicaid System Perspectives on Substance Use Disorder Treatment Policy Changes During the COVID-19 Pandemic.

OBJECTIVE: This study aimed to describe perspectives from stakeholders involved in the Medicaid system in North Carolina regarding substance use disorder (SUD) treatment policy changes during the coronavirus disease 2019 pandemic. METHODS: We conducted semistructured interviews in early 2022 with state agency representatives, Medicaid managed care organizations, and Medicaid providers (n = 22) as well as 3 focus groups of Medicaid beneficiaries with SUD (n = 14). Interviews and focus groups focused on 4 topics: policies, meeting needs during COVID, demand for SUD services, and staffing. RESULTS: Overall, policy changes, such as telehealth and take-home methadone, were considered beneficial, with participants displaying substantial support for both policies. Shifting demand for services, staffing shortages, and technology barriers presented significant challenges. Innovative benefits and services were used to adapt to these challenges, including the provision of digital devices and data plans to improve access to telehealth. CONCLUSIONS: Perspectives from Medicaid stakeholders, including state organizations to beneficiaries, support the continuation of SUD policy changes that occurred. Staffing shortages remain a substantial barrier. Based on the participants' positive responses to the SUD policy changes made during the coronavirus disease 2019 pandemic, such as take-home methadone and telehealth initiation of buprenorphine, these changes should be continued. Additional steps are needed to ensure payment parity for telehealth services.

The Economics of Treatment for Depression.

The global prevalence of depression has risen over the past three decades across all socioeconomic groups and geographic regions, with a particularly rapid increase in prevalence among adolescents (aged 12-17 years) in the United States. Depression imposes large health, economic, and societal costs, including reduced life span and quality of life, medical costs, and reduced educational attainment and workplace productivity. A wide range of treatment modalities for depression are available, but socioeconomic disparities in treatment access are driven by treatment costs, lack of culturally tailored options, stigma, and provider shortages, among other barriers. This review highlights the need for comparative research to better understand treatments' relative efficacy, cost-effectiveness, scalability, and potential heterogeneity in efficacy across socioeconomic groups and country and cultural contexts. To address the growing burden of depression, mental health policy could consider reducing restrictions on the supply of providers, implementing digital interventions, reducing stigma, and promoting healthy lifestyles.

Permanent Supportive Housing Receipt and Health Care Use Among Adults With Disabilities.

This study assessed whether permanent supportive housing (PSH) participation is associated with health service use among a population of adults with disabilities, including people transitioning into PSH from community and institutional settings. Our primary data sources were 2014 to 2018 secondary data from a PSH program in North Carolina linked to Medicaid claims. We used propensity score weighting to estimate the average treatment effect on the treated of PSH participation. All models were stratified by whether individuals were in institutional or community settings prior to PSH. In weighted analyses, among individuals who were institutionalized prior to PSH, PSH participation was associated with greater hospitalizations and emergency department (ED) visits and fewer primary care visits during the follow-up period, compared with similar individuals who largely remained institutionalized. Individuals who entered PSH from community settings did not have significantly different health service use from similar comparison group members during the 12-month follow-up period.

Comparing Medicaid Expenditures for Standard and Enhanced Therapeutic Foster Care.

Therapeutic foster care (TFC) is a service for children with high behavioral health needs that has shown promise to prevent entry into more restrictive and expensive care settings. The purpose of this study was to compare Medicaid expenditures associated with TFC with Medicaid expenditures associated with an enhanced higher-rate service called Intensive Alternative Family Treatment (IAFT). We conducted a secondary analysis of Medicaid claims in North Carolina among children entering care in 2018-2019. Using propensity score analysis with difference-in-difference estimation, we compared monthly Medicaid expenditures before and after initiating TFC and IAFT (N = 5472 person-months). Youth entering IAFT had higher expenditures prior to treatment than those entering TFC. Both standard TFC and IAFT were associated with a downward trend in expenditures following treatment initiation. Both TFC and IAFT reverse a trend of increasing Medicaid costs prior to care among children with high behavioral health needs.

Are North Carolina clinicians delivering opioid use disorder treatment to Medicaid beneficiaries?

BACKGROUND AND AIMS: Medicaid is a public health insurance program in the United States that serves low-income individuals. Medicaid beneficiaries have elevated risk of opioid use disorder (OUD), yet face barriers to receiving medications for OUD (MOUD). To inform efforts to increase MOUD receipt among Medicaid beneficiaries, this study: (1) estimated Medicaid participation prevalence among clinicians authorized to prescribe buprenorphine and (2) estimated the association between clinician characteristics and OUD care delivery to Medicaid beneficiaries. DESIGN, SETTING AND PARTICIPANTS: Retrospective study of North Carolina, USA licensed physicians, physician assistants and nurse practitioners. Licensure data from 2018 were merged with 2019 US Drug Enforcement Administration (DEA) data to identify clinicians who received the DEA waiver required to prescribe buprenorphine (n = 1714). Medicaid claims data were used to characterize clinician engagement in OUD care delivery. MEASUREMENTS: Outcomes were indicators of any Medicaid professional claims and any Medicaid prescription claims for buprenorphine and/or naltrexone. Predictors included clinician characteristics (e.g. gender and race) and characteristics of clinicians' practice location (e.g. area opioid overdose death rate). FINDINGS: Most waivered clinicians delivered services to Medicaid beneficiaries, ranging from 67.0% of behavioral health clinicians to 82.9% of specialist physicians. Among waivered clinicians with Medicaid professional claims, prevalence of prescribing buprenorphine to Medicaid beneficiaries ranged from 30.3% among specialist physicians to 51.6% among behavioral health clinicians. The probability of prescribing MOUD to Medicaid beneficiaries was higher among waivered clinicians identifying as male compared with female (8.5 percentage points, P = 0.004) or black compared with white (9.9 percentage points, P = 0.007), older clinicians (0.5 percentage point increase per year, P < 0.001) and clinicians in counties with a higher opioid overdose death rate (5.0 percentage point increase per additional death per 10 000 residents, P = 0.010). CONCLUSIONS: Among clinicians in North Carolina, USA who are authorized to prescribe buprenorphine, 67-83% (depending on type of specialist) deliver services to Medicaid beneficiaries, but only 30-52% of those prescribe medications for opioid use disorder (OUD) to Medicaid beneficiaries. Engagement in OUD care delivery to Medicaid beneficiaries varies by clinician demographic and area characteristics.

The Role of Primary Care in the Initiation of Opioid Use Disorder Treatment in Statewide Public and Private Insurance.

OBJECTIVE: To determine if individuals newly diagnosed with opioid use disorder (OUD) who saw a primary care provider (PCP) before or on the date of diagnosis had higher rates of medication treatment for OUD (MOUD). METHODS: Observational study using logistic regression with claims data from Medicaid and a large private insurer in North Carolina from January 2014 to July 2017. KEY RESULTS: Between 2014 and 2017, the prevalence of diagnosed OUD increased by 47% among Medicaid enrollees and by 76% among the privately insured. Over the same time period, the percent of people with an OUD who received MOUD fell among both groups, while PCP involvement in treatment increased. Of Medicaid enrollees receiving buprenorphine, the percent receiving buprenorphine from a PCP increased from 32% in 2014 to 39% in 2017. Approximately 82% of people newly diagnosed with OUD had a PCP visit in the 12 months before diagnosis in Medicaid and private insurance. Those with a prior PCP visit were not more likely to receive MOUD. Seeing a PCP at diagnosis was associated with a higher probability of receiving MOUD than seeing an emergency provider but a lower probability than seeing a behavioral health specialist or other provider type. CONCLUSIONS: People newly diagnosed with OUD had high rates of contact with PCPs before diagnosis, supporting the importance of PCPs in diagnosing OUD and connecting people to MOUD. Policies and programs to increase access to MOUD and improve PCPs' ability to connect people to evidence-based treatment are needed.

Duration of medical home participation and quality of care for patients with chronic conditions.

OBJECTIVE: To examine whether the length of participation in a patient-centered medical home (PCMH), an evidence-based practice, leads to higher quality care for Medicaid enrollees with multiple co-morbid chronic conditions and major depressive disorder (MDD). DATA SOURCES: This analysis uses a unique data source that links North Carolina Medicaid claims and enrollment data with other administrative data including electronic records of state-funded mental health services, a state psychiatric hospital utilization database, and electronic records from a five-county behavioral health carve-out program. STUDY DESIGN: This retrospective cohort study uses generalized estimating equations (GEEs) on person-year-level observations to examine the association between the duration of PCMH participation and measures of guideline-concordant care, including the receipt of minimally adequate care for MDD, defined as 6 months of antidepressant use or eight psychotherapy visits each year. DATA COLLECTION/EXTRACTION METHODS: Adults with two or more chronic conditions reflected in administrative data, including MDD. PRINCIPAL FINDINGS: We found a 1.7 percentage point increase in the likelihood of receiving guideline-concordant care at 4 months of PCMH participation, as compared to newly enrolled individuals with a single month of participation (p < 0.05). This effect increased with each additional month of PCMH participation; 12 months of participation was associated with a 19.1 percentage point increase in the likelihood of receiving guideline-concordant care over a single month of participation (p < 0.01). CONCLUSIONS: The PCMH model is associated with higher quality of care for patients with multiple chronic conditions and MDD over time, and these benefits increase the longer a patient is enrolled. Providers and policy makers should consider the positive effect of increased contact with PCMHs when designing and evaluating initiatives to improve care for this population.

Effect of Enhanced Primary Care for People with Serious Mental Illness on Service Use and Screening.

BACKGROUND: Strategies are needed to better address the physical health needs of people with serious mental illness (SMI). Enhanced primary care for people with SMI has the potential to improve care of people with SMI, but evidence is lacking. OBJECTIVE: To examine the effect of a novel enhanced primary care model for people with SMI on service use and screening. DESIGN: Using North Carolina Medicaid claims data, we performed a retrospective cohort analysis comparing healthcare use and screening receipt of people with SMI newly receiving enhanced primary care to people with SMI newly receiving usual primary care. We used inverse probability of treatment weighting to estimate average differences in outcomes between the treatment and comparison groups adjusting for observed baseline characteristics. PARTICIPANTS: People with SMI newly receiving primary care in North Carolina. INTERVENTIONS: Enhanced primary care that includes features tailored for individuals with SMI. MAIN MEASURES: Outcome measures included outpatient visits, emergency department (ED) visits, inpatient stays and days, and recommended screenings 18 months after the initial primary care visit. KEY RESULTS: Compared to usual primary care, enhanced primary care was associated with an increase of 1.2 primary care visits (95% confidence interval [CI]: 0.31 to 2.1) in the 18 months after the initial visit and decreases of 0.33 non-psychiatric inpatient stays (CI: - 0.49 to - 0.16) and 3.0 non-psychiatric inpatient days (CI: - 5.3 to - 0.60). Enhanced primary care had no significant effect on psychiatric service and ED use. Enhanced primary care increased the probability of glucose and HIV screening, decreased the probability of lipid screening, and had no effect on hemoglobin A1c and colorectal cancer screening. CONCLUSIONS: Enhanced primary care for people with SMI can increase receipt of some preventive screening and decrease use of non-psychiatric inpatient care compared to usual primary care.

Health insurance coverage and self-employment.

BACKGROUND: Self-employed workers are 10% of the US labor force, with growth projected over the next decade. Whether existing policy mechanisms are sufficient to ensure health insurance coverage for self-employed workers, who do not have access to employer-sponsored coverage, is unclear. OBJECTIVE: To determine whether self-employment is associated with lack of health insurance coverage. DATA SOURCES: Secondary analysis of Medical Expenditure Panel Survey (MEPS) data collected 2014-2017. STUDY DESIGN: Participants were working age (18-64 years), employed, civilian noninstitutionalized US adults with two years of Medical Expenditure Panel Survey (MEPS) participation in 2014-2017. We compared those who were employees vs those who were self-employed. Key outcomes were self-report of health insurance coverage, and of delaying needed medical care. DATA EXTRACTION METHODS: Longitudinal design among individuals who were employees during study year 1, comparing health insurance coverage among those who did vs did not transition to self-employment in year 2. PRINCIPAL FINDINGS: 16 335 individuals, representing 121 473 345 working-age adults, met inclusion criteria; of these, 147, representing 1 097 582 individuals, transitioned to self-employment. In unadjusted analyses, 25.7% of those who became self-employed were uninsured in year 2, vs 8.1% of those who remained employees (P < .0001). In adjusted models, self-employment was associated with greater risk of being uninsured (26.1% vs 8.0%, risk difference 18.0%, 95% confidence interval [CI] 9.2% to 26.9%, P = .0001). A time-by-employment type product term suggests that 10.0 percentage points (95%CI 0.3 to 19.7 percentage points, P = .04) of the risk difference may be attributable to the change to self-employment. Self-employment was also associated with delaying needed medical care (12.0% vs 3.1%, risk difference: 8.9%, 95% CI 3.1% to 14.6%, P = .003). CONCLUSIONS: One in four self-employed workers lack health insurance coverage. Given the rise in self-employment, it is imperative to identify ways to improve health care insurance access for self-employed working-age US adults.

Are There Performance Advantages Favoring Federally Qualified Health Centers in Medical Home Care for Persons with Severe Mental Illness?

To identify whether medical homes in FQHCs have advantages over other group and individual medical practices in caring for people with severe mental illness. Models estimated the effect of the type of medical home on monthly service utilization, medication adherence, and total Medicaid spending over a 4-year period for adults aged 18 or older with a major depressive disorder (N = 65,755), bipolar disorder (N = 19,925), or schizophrenia (N = 8501) enrolled in North Carolina's Medicaid program. Inverse probability of treatment weights (IPTW) were used to adjust for nonrandom assignment of patients to practices. Generalized estimating equations for repeated measures were used with gamma distributions and log links for the continuous measures of medication adherence and spending, and binomial distributions with logit links for binary measures of any outpatient or any emergency department visits. Adults with major depression or bipolar disorders in FQHC medical homes had a lower probability of outpatient service use than their counterparts in individual and group practices. The probability of emergency department use, medication adherence, and total Medicaid spending were relatively similar across the three settings. This study suggests that no one type of medical practice setting-whether FQHC, other group, or individual-consistently outperforms the others in providing medical home services to people with severe mental illness.

Are Certain Health Centers Better Patient-Centered Medical Homes for People with Severe Mental Illness?

Patient-centered medical homes based at federally-qualified health centers (FQHCs) can benefit patients with complex health needs, such as severe mental illness (SMI). However, little is known about FQHC characteristics associated with changes in health care expenditures and utilization for individuals with SMI. Using North Carolina Medicaid claims and FQHC data from the Uniform Data System, multivariate regression identified FQHC characteristics associated with total expenditures, medication adherence and emergency department utilization among adults with SMI, controlling for time-invariant differences by health center. Few of the FQHC-level factors affected the outcomes-not even offering on-site behavioral health services. Although the FQHCs in the analysis sample exhibited considerable variation in the provision of specialty behavioral services and in staffing configurations, it may be the case that the examination of average effects across a heterogeneous group of adults with SMI mask benefits of FQHCs to certain subgroups. These findings support the conclusion that there is no "one-size-fits-all" model that works best for this diverse patient population. Study results are relevant for practices embarking on expanded medical home services for people with SMI.

Putting Providers At-Risk through Capitation or Shared Savings: How Strong are Incentives for Upcoding and Treatment Changes?

BACKGROUND: Alternative payment models, including Accountable Care Organizations and fully capitated models, change incentives for treatment over fee-for-service models and are widely used in a variety of settings. The level of payment may affect the assignment to a payment category, but to date the upcoding literature has been motivated largely incorporating financial penalties for upcoding rather than by a theoretical model that incorporates the downstream effects of upcoding on service provision requirements. AIMS OF THE STUDY: In this paper, we contribute to the literature on upcoding by developing a new theoretical model that is applicable to capitated, case-rate and shared savings payment systems. This model incorporates the downstream effects of upcoding on service provision requirements rather than just the avoidance of penalties. This difference is important especially for shared-savings models with quality benchmarks. METHODS: We test implications of our theoretical model on changes in severity determination and service use associated with changes in case-rate payments in a publicly-funded mental health care system. We model provider-assigned severity categories as a function of risk-adjusted capitated payments using conditional logit regressions and counts of service days per month using negative binomial models. RESULTS: We find that severity determination is only weakly associated with the payment rate, with relatively small upcoding effects, but that level of use shows a greater degree of association. DISCUSSION: These results are consistent with our theoretical predictions where the marginal utility of savings or profit is small, as would be expected from public sector agencies. Upcoding did seem to occur, but at very small levels and may have been mitigated after the county and providers had some experience with the new system. The association between the payment levels and the number of service days in a month, however, was significant in the first period, and potentially at a clinically important level. Limitations include data from a single county/multiple provider system and potential unmeasured confounding during the post-implementation period. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: Providers in our data were not at risk for inpatient services but decreases in use of outpatient services associated with rate decreases may lead to further increases in inpatient use and therefore expenditures over time. IMPLICATIONS FOR HEALTH POLICIES: Health program directors and policy makers need to be acutely aware of the interplay between provider payments and patient care and eventual health and mental health outcomes. IMPLICATIONS FOR FURTHER RESEARCH: Further research could examine the implications of the theoretical model of upcoding in other payment systems, estimate the power of the tiered-risk systems, and examine their influence on clinical outcomes.

The effect of an accountable care organization on dental care for children with disabilities.

OBJECTIVES: Accountable care organizations (ACOs) are a new model of health-care delivery that aim to improve care through increased provider collaboration and financial rewards for meeting cost and quality targets for a defined patient population. In this study, we examined a state policy change that effectively moved some children with disabilities into a Medicaid-serving pediatric ACO on dental service use. We hypothesize that ACOs' emphasis on prevention, care coordination, and reduction in emergency department use will extend to dental services. STUDY DESIGN/METHODS: We used Ohio Medicaid administrative claims data for year 2011-2016 to examine changes in patterns of dental service use by Medicaid-eligible children with disabilities before and after enrolling in an ACO compared with similar children enrolled in non-ACO managed care plans. RESULTS: Dental utilization is relatively low among Medicaid-eligible children with disabilities. We find that preventive dental visits increased 3.1% points (P < 0.05) from a baseline in the control group of 33.9 percent among ACO-enrolled children, especially among adolescent children, compared to similar children that were not in the ACO, representing an 11 percent increase in the rate of preventive dental visits relative to the comparison group. However, overall dental utilization did not increase for children with disabilities who were part of the ACO compared to similar children who were not in the ACO. CONCLUSIONS: Access to dental care is a continuing challenge for children covered by Medicaid. ACOs that serve Medicaid children are well positioned to include dental services and could play an important role in improving access to dental care and increasing dental utilization.

Medical home effects on enrollees with mental and physical illness.

OBJECTIVES: To assess the effect of medical home enrollment on acute care use and healthcare spending among Medicaid beneficiaries with mental and physical illness. STUDY DESIGN: Retrospective cohort analysis of administrative data. METHODS: We used 2007-2010 Medicaid claims and state psychiatric hospital data from a sample of 83,819 individuals diagnosed with schizophrenia or depression and at least 1 comorbid physical condition. We performed fixed-effects regression analysis at the person-month level to examine the effect of medical home enrollment on the probabilities of emergency department (ED) use, inpatient admission, and outpatient care use and on amount of Medicaid spending. RESULTS: Medical home enrollment had no effect on ED use in either cohort and was associated with a lower probability of inpatient admission in the depression cohort (P <.05). Medical home enrollees in both cohorts experienced an increase in the probability of having any outpatient visits (P <.05). Medical home enrollment was associated with an increase in mean monthly spending among those with schizophrenia ($65.8; P <.05) and a decrease among those with depression (-$66.4; P <.05). CONCLUSIONS: Among Medicaid beneficiaries with comorbid mental and physical illness, medical home enrollment appears to increase outpatient healthcare use and has mixed effects on acute care use. For individuals in this population who previously had no engagement with the healthcare system, use of the medical home model may represent an investment in providing improved access to needed outpatient services with cost savings potential for beneficiaries with depression.

Effect of the Patient-Centered Medical Home on Racial Disparities in Quality of Care.

BACKGROUND: Research demonstrates that the patient-centered medical home (PCMH) is associated with improved clinical outcomes and quality of care, and the populations that can most benefit from this model require long-term management, e.g., persons with chronic illness and behavioral health conditions. However, different populations may not benefit equally from the PCMH, and empirical evidence about the effects of this model on racial disparities is limited. OBJECTIVE: Estimate the association between enrollment in National Committee for Quality Assurance (NCQA)-recognized PCMHs and racial disparities in quality of care for adults with major depressive disorder (MDD) and comorbid medical conditions. DESIGN: Applying a quasi-experimental instrumental variable design to account for differential selection into the PCMH, we used generalized estimating equations to determine the probability of receiving eight disease-specific quality measures. SUBJECTS: Medicaid enrollees in three states not dually enrolled in Medicare, ages 18-64 with MDD and > 1 other chronic condition. A subgroup analysis was conducted for enrollees with comorbid diabetes. INTERVENTIONS: Enrollment in an NCQA-recognized PCMH. MAIN MEASURES: Disease-specific quality indicators for MDD (e.g., antidepressant use, receipt of psychotherapy), and for diabetes, (e.g. A1c testing, LDL-C testing, retinal exams, and medical attention for nephropathy). KEY RESULTS: PCMH enrollment was associated with an increase in the overall likelihood of receiving six of eight recommended services and a decrease in the likelihood of receiving any psychotherapy (4.94 percentage points, p < 0.01) and retinal exams (5.51 percentage points, p < 0.05). Although both groups improved, PCMH enrollment was associated with an exacerbation of the Black-white disparity in adequate antidepressant use by 4.20 percentage points (p < 0.01). CONCLUSIONS: While PCMH enrollment may improve the overall quality of care, the effect is inconsistent across racial groups and not always associated with reductions in racial disparities in quality.

How does being part of a pediatric accountable care organization impact health service use for children with disabilities?

OBJECTIVE: To examine the impact of a Medicaid-serving pediatric accountable care organization (ACO) on health service use by children who qualify for Medicaid by virtue of a disability under the "aged, blind, and disabled" (ABD) eligibility criteria. DATA SOURCES/STUDY SETTING: We evaluated a 2013 Ohio policy change that effectively moved ABD Medicaid children into an ACO model of care using Ohio Medicaid administrative claims data for years 2011-2016. STUDY DESIGN: We used a difference-in-difference design to examine changes in patterns of health care service use by ABD-enrolled children before and after enrolling in an ACO compared with ABD-enrolled children enrolled in non-ACO managed care plans. DATA COLLECTION/EXTRACTION METHODS: We identified 17 356 children who resided in 34 of 88 counties as the ACO "intervention" group and 47 026 ABD-enrolled children who resided outside of the ACO region as non-ACO controls. PRINCIPAL FINDINGS: Being part of the ACO increased adolescent preventative service and decreased use of ADHD medications as compared to similar children in non-ACO capitated managed care plans. Relative home health service use decreased for children in the ACO. CONCLUSIONS: Our overall results indicate that being part of an ACO may improve quality in certain areas, such as adolescent well-child visits, though there may be room for improvement in other areas considered important by patients and their families such as home health service.

Do timely mental health services reduce re-incarceration among prison releasees with severe mental illness?

OBJECTIVE: To examine whether the receipt of timely mental health services is associated with changes in criminal justice interactions. DATA SOURCES: We used linked administrative data from Medicaid, mental health, and criminal justice settings in Washington State for persons with severe mental illness released from prison (n = 3086). STUDY DESIGN: We estimate local and average treatment effects to examine measures of criminal justice use in the year following release as a function of timely mental health services. DATA EXTRACTION METHODS: Measures of timely service and criminal justice use within 12 months postrelease were created from administrative data. PRINCIPAL FINDINGS: Individuals receiving timely mental health services are more likely to experience prison re-incarceration overall and specifically for technical violations 12 months postrelease. The effect of service receipt on incarceration for new charges was negative but not significant. CONCLUSIONS: The finding that mental health services receipt is associated with increased risk of re-incarceration due to technical violations speaks to the complexity of the relationship between mental health and criminal justice services for justice-involved persons with severe mental illness. Further research should examine strategies at the interface of criminal justice and mental health that can improve mental health and criminal justice outcomes for this vulnerable population.

The effect of referral to expedited Medicaid on substance use treatment utilization among people with serious mental illness released from prison.

Adults released from incarceration are at high risk of death from drug-related causes, pointing to the importance of connecting individuals to healthcare services after release from prison. Though Medicaid plays an important role in financing behavioral health treatments for vulnerable groups, many states terminate individuals' Medicaid coverage during incarceration. A significant risk factor for substance use disorders (SUD) among incarcerated individuals is serious mental illness (SMI). In January 2006, Washington State began a program of expedited Medicaid enrollment for individuals with mental illnesses being discharged from state prisons, jails, and psychiatric hospitals. Prior literature has shown this program to be effective in increasing Medicaid enrollment and use of mental health services for people with SMI. The current paper examined the effect of referral to expedited Medicaid on use of SUD treatment for people with SMI released from prison. Our sample consisted of 3086 individuals with a diagnosis of SMI who were released from prison from January 1, 2006 to December 31, 2007. Of the sample we identified, 871 individuals received referrals for expedited Medicaid and 2215 did not. To control for selection bias on observed characteristics for referral, we used inverse probability weights (IPW) to balance the referred and not-referred groups on more than 50 baseline covariates. We used doubly-robust IPW models to estimate the effect of referral to expedited Medicaid on use of SUD treatments following prison release. Approximately 12% of our sample used any SUD treatment by 3 months after release, with this percentage rising to 28% at 12 months. When controlling for baseline differences, referral to expedited Medicaid enrollment was associated on average with a 6.7 (SE 2.9, p < .05) percentage point increase in the predicted probability of using any SUD treatment in the 3 months following release as compared to those not referred to the program. This effect size represents a 61% increase in the probability of using any treatment by 3 months. The result was similar for the 6-month follow-up period and persisted at the 12-month follow-up though the magnitude of the effect decreased somewhat. Overall, our results suggest that expedited Medicaid enrollment for people with SMI released from prison can increase use of SUD services.