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.

Follow-Up Care After Behavioral Health-Related Hospitalization for Children and Adolescents.

Although the coordination of follow-up behavioral health-related care between hospitals and outpatient behavioral health care settings is important, studies on this topic are few. Claims were selected from Truven Health Analytics' Marketscan databases during 2014 for youth aged 2-18 years who had an inpatient stay with a behavioral health diagnosis. Analyses identified whether youth received a behavioral health follow-up visit within 30 days following a hospitalization. The percentage of children who received post-hospitalization follow-up care was 59.1% (Medicaid) and 59.4% (private insurance). While children less than 15 years old (Medicaid) had increased odds of follow-up care compared with youth aged 15-18 years, children 2-9 years old with commercial insurance had decreased odds of follow-up care. Variations in follow-up care by patient characteristics provide an opportunity to target efforts to increase coordinated care to those who are least likely to receive it.

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.

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.

Differences in Utilization of Mental Health Treatment Among Children and Adolescents With Medicaid or Private Insurance.

OBJECTIVE: Children and adolescents with diagnosed mental disorders may require developmentally tailored interventions. However, little is known about the difference in mental health treatment utilization among children by age group and health insurance coverage. METHODS: Using the 2016 MarketScan database, the study examined treatment utilization patterns by health insurance coverage (private and Medicaid) and developmental age group (preschool-age children, ages 3-5; young children, ages 6-11; and adolescents, ages 12-17). RESULTS: Psychiatric medication only was the most common form of treatment utilization among all children, regardless of developmental age group or insurance coverage. Specifically, psychiatric medication only was received by 38% of preschool-aged children with Medicaid and 42% of those with private insurance, 43% of young children with Medicaid and 39% of those with private insurance, and 55% of adolescents with Medicaid and 49% of those with private insurance. CONCLUSIONS: Given that evidence-based practices suggest that combined treatment with psychiatric medications and psychotherapy may be the recommended treatment, the study's findings raise potential concerns about the high use of medication-only treatment.

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.

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.

Perceived Unmet Mental Health Treatment Need Among Adults with Criminal Justice System Involvement.

Research shows criminal justice system involved individuals are more likely to have behavioral health needs. This study analyzes nationally representative data on non-incarcerated individuals with mental disorders. It examines whether having past year criminal justice system involvement was associated with perceiving an unmet need for mental health treatment and the reasons for that unmet need. Results show criminal justice system involved individuals were more likely to report perceived unmet need for mental health treatment (OR = 1.20, p <.001). Among those not receiving mental health treatment, criminal justice system involvement yielded a higher relative risk of identifying affordability as the primary reason for having unmet mental health treatment need (RRR = 1.92, p <.001). Among those receiving mental health treatment, having criminal justice system involvement yielded a higher relative risk of identifying stigma as the primary reason for having unmet need (RRR = 1.99, p <.001).

Utilization of Mental Health Services by Preschool-Aged Children with Private Insurance Coverage.

There is increasing recognition that some preschool-aged children suffer from mental health conditions, but little is known about the treatment they receive. Using the 2014 MarketScan Commercial Claims and Encounters database (N = 1,987,759) the study finds that only a small proportion of preschool-aged children receive any behavioral interventions, including psychotherapy, in conjunction with having a filled psychiatric prescription. Nearly all of the preschool-aged children who had psychotropic prescriptions filled had no other claims for treatment, and among those children who had prescriptions for psychotropic medication filled, the vast majority did not have a mental health diagnosis on a claim.

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.

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.

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.

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.

Trends in cigarette use, by serious psychological distress status in the United States, 1998-2013.

OBJECTIVES: The study compared trends in current and heavy cigarette smoking between adults with and without serious psychological distress (SPD). METHODS: This study examined data from 480,024 adults aged 18years or older in the 1998-2013 National Health Interview Survey (NHIS) public use files. SPD is defined as having a Kessler-6 score of 13 or higher in the past month. Trends in the prevalence of current smoking and heavy smoking for 2-year time periods were assessed among those with versus those without SPD using logistic regression; tests of interaction terms determined whether smoking trends differed by SPD status. RESULTS: The prevalence of current smoking decreased over time among adults without SPD (adjusted odds ratio [AOR]=0.97, 95% CI=0.97-0.98), but remained stable among adults with SPD (AOR=1.01, 95% CI=0.99-1.03). Both groups had significant declines in heavy smoking over time; however, the rates of decline were greater among adults without versus with SPD (AOR=0.87, 95% CI=0.86-0.88 and AOR=0.91, 95% CI=0.88-0.94, respectively). CONCLUSIONS: The prevalence of current smoking is not declining among adults with SPD, and the prevalence of heavy smoking is not declining as quickly among adults with SPD as compared with those without SPD. Smoking cessation efforts may need to target these populations and tailor programs accordingly.

Utilization of Mental Health Services by Veterans Living in Rural Areas.

PURPOSE: There is concern that veterans living in rural areas may not be receiving the mental health (MH) treatment they need. This study uses recent national survey data to examine the utilization of MH treatment among military veterans with a MH condition living in rural areas, providing comparisons with estimates of veterans living in urban areas. METHODS: Multivariable logistic regression is utilized to examine differences in MH service use by urban/rural residence, controlling for other factors. Rates of utilization of inpatient and outpatient treatment, psychotropic medication, any MH treatment, and perceived unmet need for MH care are examined. FINDINGS: There were significant differences in MH treatment utilization among veterans by rural/urban residence. Multivariate estimates indicate that compared to veterans with a MH condition living in urban areas, veterans in rural areas had 70% lower odds of receiving any MH treatment. Veterans with a MH condition in rural areas have approximately 52% and 64% lower odds of receiving outpatient treatment and prescription medications, respectively, compared to those living in urban areas. Differences in perceived unmet need for mental health treatment were not statistically significant. CONCLUSIONS: While research indicates that recent efforts to improve MH service delivery have resulted in improved access to services, this study found that veterans' rates of MH treatment are lower in rural areas, compared to urban areas. Continued efforts to support the provision of behavioral health services to rural veterans are needed. Telemedicine, using rural providers to their maximum potential, and engagement with community stakeholder groups are promising approaches.

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.

Opportunities for social work under the Affordable Care Act: A call for action.

The Affordable Care Act (ACA) has profoundly restructured American health care. Numerous social work authors have commented on the importance of the ACA's reforms to social work practice, education, and research. This article summarizes the literature, adds relevant information, and makes recommendations for future actions. The policy, opinion, and peer-reviewed literatures were systematically reviewed. Sixty-three publications appeared between 2010 and 2015 are included. Five themes emerged, as follows: 1) the crucial provisions of the ACA, 2) the natural affinity of social work and the ACA reforms, 3) curricular adaptations needed to address changing workforce needs, 4) areas for continued social work advocacy, and 5) opportunities for high-impact social work research. This article provides a comprehensive introduction to the ACA, its reforms, and opportunities for social work to assume a high visibility leadership role in implementing the reforms, with particular emphasis on needed curricular changes and opportunities for research.

The Implications of the Affordable Care Act for Behavioral Health Services Utilization.

This analysis estimates the number of currently uninsured adults who may gain coverage and access behavioral health (BH) services under the ACA. Data on BH status, socio-demographic characteristics, insurance coverage, and services utilization were drawn from the 2008-2012 National Survey on Drug Use and Health. Multivariate logistic regression modeling was used to estimate changes in services utilization under the ACA. Estimates indicate that 2.8 million adults may receive BH treatment through Medicaid expansions, and 3.1 million through participation in health insurance exchanges. This represents a 40% increase in BH services utilization, primarily for mental health services.

Medicaid Expansion Under the Affordable Care Act: Potential Changes in Receipt of Mental Health Treatment Among Low-Income Nonelderly Adults With Serious Mental Illness.

OBJECTIVES: We designed this study to examine differences in receipt of mental health treatment between low-income uninsured nonelderly adults with serious mental illness (SMI) who were eligible for Medicaid under the Affordable Care Act (ACA) and their existing Medicaid counterparts. Assessing these differences might estimate the impact of the Medicaid expansion efforts under the ACA on receipt of mental health treatment among uninsured nonelderly adults with SMI. METHODS: We examined data from 2000 persons aged 18 to 64 years who participated in the 2008 to 2013 National Survey on Drug Use and Health, had income below 138% of the federal poverty level, met SMI criteria, and either were uninsured (n = 1000) or had Medicaid-only coverage (n = 1000). We defined SMI according to the Alcohol, Drug Abuse, and Mental Health Administration Reorganization Act. We used descriptive analyses and logistic regression modeling. RESULTS: In the 28 states currently expanding Medicaid, the model-adjusted prevalence (MAP) of receiving mental health treatment among Medicaid-only enrollees with SMI (MAP = 71.3%; 95% confidence interval [CI] = 65.74%, 76.29%) was 30.1% greater than their uninsured counterparts (MAP = 54.8%; 95% CI = 48.16%, 61.33%). In the United States, the MAP of receiving mental health treatment among Medicaid-only enrollees with SMI (MAP = 70.4%; 95% CI = 65.67%, 74.70%) was 35.9% higher than their uninsured counterparts (MAP = 51.8%; 95% CI = 46.98%, 56.65%). CONCLUSIONS: Estimated increases in receipt of mental health treatment because of enrolling in Medicaid among low-income uninsured adults with SMI might help inform planning and implementation efforts for the Medicaid expansion under the ACA.

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.