Predictors of cancer screening among Black and White Maryland Medicaid enrollees with serious mental illness.

BACKGROUND: Cancer is the second leading cause of death for people with serious mental illness (SMI), such as schizophrenia and bipolar disorder. People with SMI receive cancer screenings at lower rates than the general population. AIMS: We sought to identify factors associated with cancer screening in a publicly insured population with SMI and stratified by race, a factor itself linked with differential rates of cancer screening. MATERIALS AND METHODS: We used Maryland Medicaid administrative claims data (2010-2018) to examine screening rates for cervical cancer (N = 40,622), breast cancer (N = 9818), colorectal cancer (N = 19,306), and prostate cancer (N = 4887) among eligible Black and white enrollees with SMI. We examined individual-level socio-demographic and clinical factors, including co-occurring substance use disorder, medical comorbidities, psychiatric diagnosis, obstetric-gynecologic and primary care utilization, as well as county-level characteristics, including metropolitan status, mean household income, and primary care workforce capacity. Generalized estimating equations with a logit link were used to examine the characteristics associated with cancer screening. RESULTS: Compared with white enrollees, Black enrollees were more likely to receive screening for cervical cancer (AOR: 1.18; 95% CI: 1.15-1.22), breast cancer (AOR: 1.27; 95% CI: 1.19-1.36), and colorectal cancer (AOR: 1.07; 95% CI: 1.02-1.13), while similar rates were observed for prostate cancer screening (AOR: 1.06; 95% CI: 0.96-1.18). Primary care utilization and longer Medicaid enrollment were positively associated with cancer screening while co-occurring substance use disorder was negatively associated with cancer screening. CONCLUSION: Improving cancer screening rates among populations with SMI should focus on facilitating continuous insurance coverage and access to primary care.

Cancer Screening Among Adults With and Without Serious Mental Illness: A Mixed Methods Study.

BACKGROUND: Persons with serious mental illness (SMI) die 10-20 years earlier than the general population; cancer is the second leading cause of death. Differences in cancer screening between SMI and the general population are not well understood. OBJECTIVES: To describe receipt of cancer screening among individuals with versus without SMI and to explore clinicians' perceptions around cancer screening for people with SMI. METHODS: Mixed-methods study using 2010-2017 MarketScan commercial insurance administrative claims data and semi-structured clinician interviews. In the quantitative analyses, we used multivariate logistic regression analyses to calculate the likelihood of receiving cervical, breast, colorectal, or prostate cancer screening among people with versus without SMI, defined as schizophrenia or bipolar disorder. We conducted semi-structured interviews with 17 primary care physicians and 15 psychiatrists. Interview transcripts were coded using a hybrid deductive/inductive approach. RESULTS: Relative to those without SMI, individuals with SMI were less likely to receive screening for cervical cancer [adjusted odds ratio (aOR): 0.80; 95% confidence interval (CI): 0.80-0.81], breast cancer (aOR: 0.79; 95% CI: 0.78-0.80), colorectal cancer (aOR: 0.90; 95% CI: 0.89-0.91), and prostate cancer (aOR: 0.85; 95% CI: 0.84-0.87). Clinicians identified 5 themes that may help explain the lower rates of cancer screening in persons with SMI: access to care, available support, prioritization of other issues, communication, and patient concerns. CONCLUSIONS: People with SMI were less likely to receive 4 common types of cancer screening. Improving cancer screening rates in the SMI population will likely require a multidisciplinary approach to overcome barriers to screening.

Behavioral health home impact on transitional care and readmissions among adults with serious mental illness.

OBJECTIVE: To evaluate the impact of Maryland's behavioral health homes (BHHs) on receipt of follow-up care and readmissions following hospitalization among Medicaid enrollees with serious mental illness (SMI). DATA SOURCES: Maryland Medicaid administrative claims for 12 232 individuals. STUDY DESIGN: Weighted marginal structural models were estimated to account for time-varying exposure to BHH enrollment and time-varying confounders. These models compared changes over time in outcomes among BHH and comparison participants. Outcome measures included readmissions and follow-up care within 7 and 30 days following hospitalization. DATA COLLECTION/EXTRACTION METHODS: Eligibility criteria included continuous enrollment in Medicaid for the first two years of the study period; 21-64 years; and use of psychiatric rehabilitation services. PRINCIPAL FINDINGS: Over three years, BHH enrollment was associated with 3.8 percentage point (95% CI: 1.5, 6.1) increased probability of having a mental health follow-up service within 7 days of discharge from a mental illness-related hospitalization and 1.9 percentage point (95% CI: 0.0, 3.9) increased probability of having a general medical follow-up within 7 days of discharge from a somatic hospitalization. BHHs had no effect on probability of readmission. CONCLUSIONS: BHHs may improve follow-up care for Medicaid enrollees with SMI, but effects do not translate into reduced risk of readmission.

Effects of Maryland's Affordable Care Act Medicaid Health Home Waiver on Quality of Cardiovascular Care Among People with Serious Mental Illness.

BACKGROUND: Nineteen US states and D.C. have used the Affordable Care Act Medicaid health home waiver to create behavioral health home (BHH) programs for Medicaid beneficiaries with serious mental illness (SMI). BHH programs integrate physical healthcare management and coordination into specialty mental health programs. No studies have evaluated the effects of a BHH program created through the Affordable Care Act waiver on cardiovascular care quality among people with SMI. OBJECTIVE: To study the effects of Maryland's Medicaid health home waiver BHH program, implemented October 1, 2013, on quality of cardiovascular care among individuals with SMI. DESIGN: Retrospective cohort analysis using Maryland Medicaid administrative claims data from July 1, 2010, to September 30, 2016. We used marginal structural modeling with inverse probability of treatment weighting to account for censoring and potential time-dependent confounding. PARTICIPANTS: Maryland Medicaid beneficiaries with diabetes or cardiovascular disease (CVD) participating in psychiatric rehabilitation programs, the setting in which BHHs were implemented. To qualify for psychiatric rehabilitation programs, individuals must have SMI. The analytic sample included BHH and non-BHH participants, N = 2605 with diabetes and N = 1899 with CVD. MAIN MEASURES: Healthcare Effectiveness Data and Information Set (HEDIS) measures of cardiovascular care quality including annual receipt of diabetic eye and foot exams; HbA1c, diabetic nephropathy, and cholesterol testing; and statin therapy receipt and adherence among individuals with diabetes, as well as HEDIS measures of annual receipt of cholesterol testing and statin therapy and adherence among individuals with CVD. KEY RESULTS: Relative to non-enrollment, enrollment in Maryland's BHH program was associated with increased likelihood of eye exam receipt among individuals with SMI and co-morbid diabetes, but no changes in other care quality measures. CONCLUSIONS: Additional financing, infrastructure, and implementation supports may be needed to realize the full potential of Maryland's BHH to improve cardiovascular care for people with SMI.

Association Between the Maryland Medicaid Behavioral Health Home Program and Cancer Screening in People With Serious Mental Illness.

OBJECTIVE: This study evaluated the association of the Maryland Medicaid behavioral health home (BHH) integrated care program with cancer screening. METHODS: Using administrative claims data from October 2012 to September 2016, the authors measured cancer screening among 12,176 adults in Maryland's psychiatric rehabilitation program who were eligible for cervical (N=6,811), breast (N=1,658), and colorectal (N=3,430) cancer screening. Marginal structural modeling was used to examine the association between receipt of annual cancer screening and whether participants had ever enrolled in a BHH (enrolled: N=3,298, 27%; not enrolled: N=8,878, 73%). RESULTS: Relative to nonenrollment, BHH enrollment was associated with increased screening for cervical and breast cancer but not for colorectal cancer. Predicted annual rates remained low, even in BHHs. CONCLUSIONS: Despite estimates of improvements in cervical and breast cancer screening after BHH implementation, cancer screening rates remained suboptimal. Broader cancer screening interventions are needed to improve cancer screening for people with mental illness.

The Clinical Examination and Socially At-Risk Populations: The Examination Matters for Health Disparities.

Data from the United States show that persons from low socioeconomic backgrounds, those who are socially isolated, belong to racial or ethnic minority groups, or identify as lesbian, gay, bisexual, or transgender experience health disparities at a higher rate. Clinicians must transition from a biomedical to a biopsychosocial framework within the clinical examination to better address social determinants of health that contribute to health disparities. We review the characteristics of successful patient-clinician interactions. We describe strategies for relationship-centered care within routine encounters. Our goal is to train clinicians to mitigate differences and reduce disparities in health care delivery.

Physical health outcomes and implementation of behavioural health homes: a comprehensive review.

People with serious mental illness (SMI) have mortality rates 2-3-times higher than the general population, mostly driven by physical health conditions. Behavioural health homes (BHHs) integrate primary care into specialty mental healthcare settings with the goal of improving management of physical health conditions among people with SMI. Implementation and evaluation of BHH models is increasing in the US. This comprehensive review summarized the available evidence on the effects of BHHs on physical healthcare delivery and outcomes and identified perceived barriers and facilitators that have arisen during implementation to-date. This review found 11 studies reporting outcomes data on utilization, screening/monitoring, health promotion, patient-reported outcomes, physical health and/or costs of BHHs. The results of the review suggest that BHHs have resulted in improved primary care access and screening and monitoring for cardiovascular-related conditions among consumers with SMI. No significant effect of BHHs was reported for outcomes on diabetes control, weight management, or smoking cessation. Overall, the physical health outcomes data is limited and mixed, and implementation of BHHs is variable.