Care Coordination in Emergency Departments for Children and Adolescents With Behavioral Health Conditions: Assessing the Degree of Regular Follow-up After Psychiatric Emergency Department Visits.

BACKGROUND: Increasing numbers of children are receiving care for behavioral health conditions in emergency departments (EDs). However, studies of mental health-related care coordination between EDs and primary and/or specialty care settings are limited. Such coordination is important because ED care alone may be insufficient for patients' behavioral health needs. METHODS: We analyzed claims during the year 2014 from Truven Health Analytics MarketScan Medicaid and Commercial databases for outpatient services and prescription drugs for youth 2 to 18 years old with continuous enrollment. We applied a standard care coordination measure to insurance claims data in order to examine whether youth received a primary care or specialty follow-up visit within 7 days following an ED visit with a psychiatric diagnosis. We calculated descriptive statistics to evaluate differences in care coordination by enrollees' demographic, insurance, and health-related characteristics. In addition, we constructed a multivariate logistic regression model to detect the factors associated with the receipt of care coordination. RESULTS: The total percentages of children who received care coordination were 45.8% (Medicaid) and 46.6% (private insurance). Regardless of insurance coverage type, children aged 10 to 14 years had increased odds of care coordination compared with youth aged 15 to 18 years. Children aged 2 to 5 years and males had decreased odds of care coordination. CONCLUSIONS: It is of concern that fewer than half of patients received care coordination following an ED visit. Factors such as behavioral health workforce shortages, wait times for an appointment with a provider, and lack of reimbursement for care coordination may help explain these results.

Characterizing behavioral health-related emergency department utilization among children with Medicaid: Comparing high and low frequency utilizers.

While the frequency of children's behavioral health (BH)-related visits to the emergency department (ED) is rising nationwide, few studies have examined predictors of high rates of ED use. This study examines Florida Medicaid claims (2011-2012) for children age 0-18 who were seen in an emergency department (ED) for behavioral health (BH) conditions. A logistic regression model was used to explore factors associated with frequent ED use and patterns of psychotropic medication utilization. The majority (95%) of patients with at least one BH-related ED visit had three or fewer of these visits, but 5% had four or more. Seventy-four percent of ED visits were not associated with psychotropic medication, including over half (54%) of visits for attention deficit hyperactivity disorder (ADHD). Frequent ED use was higher among older children and those with substance use disorders. The implementation of interventions that reduce non-emergent ED visits through the provision of care coordination, social work services, and/or the use of community health workers as care navigators may address these findings.

Pediatric integrated behavioral health service delivery models: Using a federal framework to assess levels of integration.

OBJECTIVE: To assess the level of integration of pediatric integrated behavioral health service delivery models (IBHSDM) since it has not been well established. DATA SOURCES: A systematic review of journal databases (e.g., PubMed) and Google searches was used to identify publications. STUDY SELECTION: Studies were included if they examined children who were treated in an IBHSDM. DATA EXTRACTION: The authors extracted data from studies and assessed them for level of integration using a federal conceptual framework. DATA SYNTHESIS: Guided by PRISMA standards, the authors identified 40 journal articles that described 32 integrated delivery models. Five models (15.6%) were rated at integration level 1 or 2 (coordinated care), eight models (25%) were rated level 3 and five models (15.6%) were rated level 4 (co-located care), and fourteen models (43.8%) were rated level 5 or 6 (integrated care). CONCLUSIONS: In general, it is assumed that more completely integrated care will result in higher quality care and reduced costs. Thirteen of the models described (40.6%) had levels of integration of 3 or lower that may be too low to produce desired effects on quality and cost. Future research should address potential barriers that impede the development of models with higher degrees of integration.

Utilization of Mental Health Services in Educational Setting by Adolescents in the United States.

BACKGROUND: Schools play an important role as providers of mental health services for adolescents; however, information on the broader picture of utilization of mental health services in educational versus other settings is limited because of the lack of national-level data. METHODS: Using multinomial logistic regression models based on national-level data from the 2012-2015 National Survey on Drug Use and Health, we explore the characteristics of adolescents who received mental health treatment in educational and other settings. In addition, the study examines the reasons for seeking services in various treatment settings. RESULTS: The analysis finds that while the majority of adolescents who access mental health services receive care at noneducational settings, slightly more than one-third of them received services only in an educational setting. Adolescents who had public insurance, were from low-income households, and were from racial/ethnic minority groups were more likely to access services in an educational setting only. Common reasons for accessing services in educational settings included problems with schools, friends, and family members. CONCLUSIONS: Despite increased access to treatment in outpatient settings in the last decade, schools play an important role in providing access to mental health services for disadvantaged populations.

The Impact of Single Mothers' Health Insurance Coverage on Behavioral Health Services Utilization by Their Adolescent Children.

Adolescents living in single-mother households are more likely to have behavioral health conditions, but are less likely to utilize any behavioral health services. Using nationally representative mother-child pair data pooled over 6 years from the National Survey on Drug Use and Health, the study finds that when single mothers were uninsured, their adolescent children were less likely to utilize any behavioral health services, even when the children themselves were covered by insurance. The extension of health coverage under the Affordable Care Act (ACA) to uninsured single mothers could improve the behavioral health of the adolescent population.

Differential Reimbursement of Psychiatric Services by Psychiatrists and Other Medical Providers.

OBJECTIVE: Given low psychiatrist participation in insurance networks, this study examines how psychiatrists are reimbursed in network and out of network under commercial insurance relative to other providers for the same diagnoses and services. METHODS: Paid private insurance claims from the 2014 Truven Health Analytics MarketScan Commercial Claims and Encounters Database were analyzed. The sample included all services billed for 3.8 million individuals with a mental disorder as the primary diagnosis by psychiatrists, nonpsychiatrist medical doctors, psychologists, social workers, or psychiatric nurses. The authors determined the most common services provided by each provider type, the median reimbursement and median out-of-pocket payment for the services by provider type and by network status (in or out of network), and the proportion of bills for services delivered out of network. RESULTS: "Evaluation and management" services for presenting problems of low to moderate and moderate to high severity were the two procedures most frequently billed by psychiatrists and nonpsychiatrist medical doctors. The median reimbursement for services for presenting problems of low to moderate and moderate to high severity was 13% less ($66 versus $76) and 20% less ($91 versus $114), respectively, for psychiatrists versus nonpsychiatrist medical doctors if the services were provided in network but 28% higher ($100 versus $78) and 6% higher ($122 versus $115), respectively, for psychiatrists versus nonpsychiatrist medical doctors for services provided out of network. CONCLUSIONS: Psychiatrists receive lower in-network reimbursement than nonpsychiatrist medical doctors for many of the same services. This may contribute to psychiatrists' lower participation in insurance networks relative to other providers and has implications for patient cost sharing and access to psychiatrists.

Use of Inpatient Behavioral Health Services by Children and Adolescents With Private Insurance Coverage.

OBJECTIVE: This study examined trends in hospitalizations of youths for behavioral health conditions in acute care hospital nonpsychiatric beds, acute care hospital psychiatric and detoxification beds, and specialty psychiatric hospitals. METHODS: Using data on hospitalizations for behavioral health conditions in 2009 (N=21,805) and 2014 (N=27,550) from the MarketScan Commercial Claims and Encounters database, this study examined the percentage of youths (ages two to 18) with one or more hospitalizations, by demographic characteristic and bed type, and the behavioral health diagnoses for which patients were hospitalized. RESULTS: The greatest increase in hospitalizations of youths occurred in acute care hospital psychiatric and detoxification beds. The percentage of hospitalizations for suicidal ideation or self-harm injuries increased by 17.8 (N=526) to 30.0 (N=1,249) percentage points, depending on bed type. CONCLUSIONS: The continued trend of rising hospitalizations of youths is consistent with recent studies showing a doubling of hospitalizations of youths for suicide and self-harm.

A national survey of state licensing, regulating, and monitoring of residential facilities for children with mental illness.

OBJECTIVE: Little national information is available to help policy makers understand the methods that states use to regulate residential facilities for children with mental illness. This article describes the results of a government-sponsored survey of state officials that examined how states license, regulate, and monitor such facilities. METHODS: Questionnaires were mailed to selected officials in each of the 50 states and the District of Columbia, followed by extensive telephone and e-mail contacts. Questionnaire items covered program characteristics, licensing and accreditation, mandated services, monitoring and oversight methods, and payment sources. RESULTS: Information was gathered on 71 types of residential facilities in 38 states, accounting for 3,628 separate residential facilities with 50,507 beds as of September 30, 2003. States differed widely in the types of residential facilities that they regulate and their mix of regulatory methods, which included requirements for announced and unannounced visits, mandated staff-to-client ratios, minimum levels of education for facility directors, specifications for licensing practices and critical incident reporting, mandated complaint review procedures, and accreditation from designated organizations. Welfare, mental health, and health departments all participated in regulating facilities. CONCLUSIONS: States relied on at least several regulatory methods, but no state used all of the possible methods. The regulatory environment is complex in most states because several agencies are involved in licensing, regulating, and reviewing complaints. To ensure that residential facilities effectively address the needs of children with mental illness and their families, policy makers should review and improve their state's data on methods for regulating residential facilities.

Mental health benefits in Employer-sponsored Health Plans, 1997-2003.

Data drawn from the Mercer National Survey of Employer-sponsored Health Plans in 1997 and 2003 indicate that a large majority of employers continue to provide some level of coverage for mental health (MH) services in their primary plans. However, a majority of plans continue to impose different benefit limitations for MH than for other medical treatment. Among plans with limitations on MH coverage, there was a sharp increase in the use of limits on inpatient days and outpatient visits between 1997 and 2003. The proportion of employers providing coverage for some MH services decreased; e.g., among small employers, 88% provided coverage for inpatient MH care in 2003, compared with 94% in 1997. These results suggest that parity legislation has had a noticeable but limited effect, but that, at least in the short-term, it is unlikely that universal parity in employer-based plans will be achieved through a legislative strategy.

National estimates of mental health insurance benefits.

This article presents estimates of the proportion of the U.S. population that had mental health benefits in 1999, of the extent of their coverage, and of the proportion that were enrolled in health plans subject to the Mental Health Parity Act of 1996 (MHPA). Findings indicate that over three-quarters (76%) of the U.S. population had mental health benefits as part of their health insurance. Approximately 18% of the population had no mental health benefits, and for the remaining 6%, mental health benefits could not be determined. Of the 18% with no mental health benefits, most (84%) had no health insurance whatsoever, while the remainder (16%) had health insurance that did not cover mental health benefits. Estimates of the generosity of coverage indicate that 44% of the population had benefits that included prescription drugs, and that provided at least 30 inpatient days and 20 outpatient visits for psychiatric care. For 12% of the population, benefit generosity could not be determined. Finally, study results suggest that the MHPA affected only 42% of the U.S. population.

Mental health services for children in large, employer-based health plans, 1999.

This study examines 1999 data from Medstat's MarketScan database of privately insured employees of US firms and their dependents. Of enrolled children and adolescents ages 2-18, 6.6% had claims for mental health services. Average outpatient expenditures per user were $651. Of children/adolescents with claims for mental health services (MH claimants), 3.4% had inpatient MH services, with an average length of stay of 8.9 days and average MH-related inpatient expenditure per user of $7,048. One half of MH claimants who had pharmacy benefit data had claims for psychotropic medications, with average expenditures per user of $328. Whereas children/adolescent mental health users comprised 8.3% of all service users, expenditures for their care were 20.5% of all service expenditures for children/adolescents in private health plans. Results also highlight the importance of including data on psychotropic medication in analysis of children's MH services utilization, as well as the need to consider the use of psychotropic medications among children/adolescents who do not utilize other MH services.

Characteristics of Individuals With Behavioral Health Conditions Who Remain Uninsured After Full Implementation of the ACA.

OBJECTIVE: Since full implementation of the Affordable Care Act (ACA) in 2014, the number of uninsured individuals in the United States has declined considerably; however, millions still lack health insurance. Although 29% of the remaining uninsured population (8.5 million individuals) have a mental or substance use disorder, little is known about this population. METHODS: This study used data from the 2014 National Survey on Drug Use and Health to describe demographic characteristics, socioeconomic status, and use of behavioral health services among adults (ages 18-64) with a behavioral disorder who remained uninsured (unweighted N=2,300; weighted N of approximately 8.5 million). RESULTS: Over half of individuals with a behavioral disorder who remained uninsured were non-Hispanic whites. The largest age group was 26- to 35-year-olds. Most worked in clerical or blue-collar occupations, and less than 20% were college graduates and above. More than 90% could qualify for insurance assistance under the ACA, either through Medicaid eligibility (income <138% of the federal poverty level [FPL]) or eligibility for cost-sharing subsidies or tax credits on the health insurance exchanges (income ≥138% but <400% of the FPL). Rates of behavioral health treatment were low; however, nearly half of Medicaid-eligible individuals (46%) reported a past-year emergency department visit. CONCLUSIONS: The high proportion of behavioral health conditions among the remaining uninsured population, and the fact that a significant portion of this population would be eligible for ACA insurance support, highlights the need for continued educational outreach efforts and steps to remove barriers to treatment access.

Reasons for Not Seeking Substance Use Disorder Treatment: Variations by Health Insurance Coverage.

A large number of adults with substance use disorder (SUD) do not receive treatment for their condition. Using data from the 2008-2013 National Survey of Drug Use and Health (NSDUH), this study analyzes why individuals with SUD report not receiving treatment even when they perceived a need for it. It further examines the variations in reported reasons for not receiving treatment by health insurance status and type. The results suggest that barriers such as stigma, lack of readiness to stop using substances, and not making treatment a priority are more common among the insured population, especially among those with private insurance. Financial barriers, such as not being able to afford the cost of treatment, are more prominent among the uninsured population. Efforts to improve utilization of treatment services will need to address financial as well as barriers related to stigma.

Effects of the 2013 Psychiatric Current Procedural Terminology Codes Revision on Psychotherapy in Psychiatric Billing.

OBJECTIVE: The purpose of this study was to determine whether the changes to the psychiatric Current Procedural Terminology (CPT) codes implemented in 2013 were associated with changes in types of services for which psychiatrists billed. METHODS: Analyses were conducted using paid private insurance claims from a large commercial database. The participant cohort comprised psychiatrists with at least one psychiatry visit reported in the database in each calendar year studied: 2012 (N of visits=778,445), 2013 (N=748,317), and 2014 (N=754,760). RESULTS: The percentage of visits in which psychiatrists billed for psychotherapy declined from 51.4% in 2012 to 42.1% in 2014. The decline held after the analyses adjusted for patient characteristics, plan type, and region. CONCLUSIONS: The update to CPT codes resulted in a decrease in visits for which psychiatrists billed for psychotherapy. Further research should explore whether the change in billing corresponds to changes in service delivery.

Epidemiologic studies of behavioral health following the Deepwater Horizon oil spill: limited impact or limited ability to measure?

Two large-scale epidemiologic federal surveys conducted in the Gulf Coast following the Deepwater Horizon oil spill and intended to measure its impact on mental disorders and substance use found less dramatic results than had been anticipated. However, several smaller-scale studies conducted shortly after the spill did find increases in the prevalence of certain psychological problems among individuals surveyed. Previous federal studies conducted following two disasters-the destruction of the World Trade Center (WTC) and Hurricanes Katrina and Rita-found few statistically significant changes in behavioral disorders in the wake of those events, except for individuals displaced from their homes by Katrina for 2 weeks or more. In this commentary, the authors discuss questions raised by these mixed results regarding the limitations of such studies, the behavioral health impact of the Deepwater Horizon spill compared to disasters causing more widespread loss of life and destruction of property, and the ways in which data collection following disasters might be improved to benefit public health planners.

The role of perceived need and health insurance in substance use treatment: implications for the Affordable Care Act.

The expansions in insurance coverage under the Patient Protection & Affordable Care Act (ACA) that took full effect in 2014 have been projected to increase the number of users of behavioral health services. By analyzing data from the 2008-2012 National Survey on Drug Use and Health, this paper examines whether health insurance expansion may result in an increase in substance use disorder (SUD) treatment utilization. The study sample includes 18,600 adults with SUD but no diagnosable mental health condition. The analysis finds that over 80% of that population receives no treatment and 97% do not perceive a need for treatment. When they do receive treatment, they are more likely to receive mental health treatment. Using multinomial logistic regression, the study finds that having Medicaid or private insurance is associated with higher likelihood of receiving SUD treatment, but only when individuals perceive a need for it, compared to being uninsured and not perceiving a need for treatment (the reference category). These results indicate that increased service utilization is associated with perceiving a need for substance abuse treatment, implying that outreach initiatives to raise awareness about SUD and the effective role of substance use treatment are needed to enhance the impact of the structural changes to the substance abuse treatment system resulting from the ACA.

Behavioral health in the gulf coast region following the Deepwater Horizon oil spill: findings from two federal surveys.

This article summarizes findings from two large-scale, population-based surveys conducted by Substance Abuse and Mental Health Services Administration (SAMHSA) and Centers for Disease Control and Prevention (CDC) in the Gulf Coast region following the 2010 Deepwater Horizon oil spill, to measure the prevalence of mental and substance use disorders, chronic health conditions, and utilization of behavioral health services. Although many area residents undoubtedly experienced increased levels of anxiety and stress following the spill, findings suggest only modest or minimal changes in behavioral health at the aggregate level before and after the spill. The studies do not address potential long-term effects of the spill on physical and behavioral health nor did they target subpopulations that might have been most affected by the spill. Resources mobilized to reduce the economic and behavioral health impacts of the spill on coastal residents-including compensation for lost income from BP and increases in available mental health services-may have resulted in a reduction in potential mental health problems.

Effects of a discharge planning program on Medicaid coverage of state prisoners with serious mental illness.

OBJECTIVE: Many inmates with serious mental illness leave prisons without health insurance, which reduces their access to health care and therefore places them at risk of relapse and rearrest. This study assessed the effectiveness of a discharge planning program implemented in three Oklahoma state prisons to assist inmates with serious mental illness to enroll in Medicaid on the day of release or soon thereafter. METHODS: Administrative data containing demographic characteristics, Medicaid enrollment status, and mental health service use were collected for 686 inmates with serious mental illness released from Oklahoma state prisons between 2004 and 2008. Regression-adjusted difference-in-difference estimates were used to compare postrelease Medicaid enrollment and service use of 77 inmates eligible for program services with those of inmates with mental illness of similar severity in three comparison groups. RESULTS: In facilities implementing the program, the percentage of inmates with serious mental illness who enrolled in Medicaid on the day of release increased from 8% during the baseline period to 25% after program implementation. The difference-in-difference estimates, which adjusted for trends in Medicaid enrollment and inmate demographic and prison stay characteristics, indicated that the program increased Medicaid enrollment by 15 percentage points (p=.012) and increased Medicaid mental health service use by 16 percentage points (p=.009). CONCLUSIONS: Although additional research is needed to assess the program's long-term effects on health care utilization and rearrest, this study illustrated that with careful planning, interagency collaboration, and dedicated staff, states can successfully increase Medicaid coverage among inmates with serious mental illness on their release from prison.

Medicaid beneficiaries using mental health or substance abuse services in fee-for-service plans in 13 states, 2003.

OBJECTIVE: This study identified Medicaid beneficiaries using mental health or substance abuse services in fee-for-service plans in 13 states in 2003 (N=1,380,190) and examined their use of medical services. METHODS: Administrative and fee-for-service claims data from Medicaid Analytic eXtract files were analyzed to identify mutually exclusive groups of beneficiaries who used either mental health or substance abuse services and to describe patterns of medical service use. RESULTS: Overall, 11.7% of Medicaid beneficiaries were identified as using mental health or substance abuse services (10.9% and .7% used each of these services, respectively), with substantial variation across age and eligibility groups. Among beneficiaries using mental health services, 47.4% had visited an emergency room for any reason, 7.8% were treated for their disorder in inpatient settings, 13.8% received inpatient treatment for problems other than their mental or substance use disorders, and 70.4% received prescriptions for psychotropic medications. Among beneficiaries using substance abuse services, 60.7% had visited an emergency room, 12.6% were treated for their disorder in inpatient settings, 24.7% received other inpatient treatment, and 46.1% received prescriptions for psychotropic medications. Among beneficiaries not using either mental health or substance use services, 29.0% had visited an emergency room, 12.7% received inpatient treatment, and 10.1% received prescriptions for psychotropic medications. CONCLUSIONS: Beneficiaries who used mental health or substance abuse services entered general inpatient settings and visited emergency rooms more frequently than other beneficiaries.