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.

Policy Levers to Promote Access to and Utilization of Children's Mental Health Services: A Systematic Review.

Policies have potential to help families obtain behavioral healthcare for their children, but little is known about evidence for specific policy approaches. We reviewed evaluations of select policy levers to promote accessibility, affordability, acceptability, availability, or utilization of children's mental and behavioral health services. Twenty articles met inclusion criteria. Location-based policy levers (school-based services and integrated care models) were associated with higher utilization and acceptability, with mixed evidence on accessibility. Studies of insurance-based levers (mental health parity and public insurance) provided some evidence for affordability outcomes. We found no eligible studies of workforce development or telehealth policy levers, or of availability outcomes.

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.

Mental Health Insurance Parity and Provider Wages.

BACKGROUND: Policymakers frequently mandate that employers or insurers provide insurance benefits deemed to be critical to individuals' well-being. However, in the presence of private market imperfections, mandates that increase demand for a service can lead to price increases for that service, without necessarily affecting the quantity being supplied. We test this idea empirically by looking at mental health parity mandates. OBJECTIVE: This study evaluated whether implementation of parity laws was associated with changes in mental health provider wages. METHOD: Quasi-experimental analysis of average wages by state and year for six mental health care-related occupations were considered: Clinical, Counseling, and School Psychologists; Substance Abuse and Behavioral Disorder Counselors; Marriage and Family Therapists; Mental Health Counselors; Mental Health and Substance Abuse Social Workers; and Psychiatrists. Data from 1999-2013 were used to estimate the association between the implementation of state mental health parity laws and the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act and average mental health provider wages. RESULTS: Mental health parity laws were associated with a significant increase in mental health care provider wages controlling for changes in mental health provider wages in states not exposed to parity (3.5 percent [95% CI: 0.3%, 6.6%]; p<.05). DISCUSSION: Mental health parity laws were associated with statistically significant but modest increases in mental health provider wages. IMPLICATIONS: Health insurance benefit expansions may lead to increased prices for health services when the private market that supplies the service is imperfect or constrained. In the context of mental health parity, this work suggests that part of the value of expanding insurance benefits for mental health coverage was captured by providers. Given historically low wage levels of mental health providers, this increase may be a first step in bringing mental health provider wages in line with parallel health professions, potentially reducing turnover rates and improving treatment quality.

Effects of the mental health parity and addictions equality act on depression treatment choice in primary care facilities.

Objective The Mental Health Parity and Addictions Equality Act (MHPAEA) of 2010 in the United States sought to expand mental health insurance benefits on par with medical benefits. As primary care facilities are often the first step in identifying mental health concerns, it is essential to examine the association of this policy with primary care physicians' choice on depression treatment. Method A retrospective cross-sectional study was conducted using data from the 2007-2012 National Ambulatory Medical Care Survey, including a weighted total of 162,699,930 depression patients. Using the Heckman two-step selection procedure, a logistic and a multinomial regression were conducted to examine the association of the MHPAEA with physicians' two-step process of deciding whether and which type of treatment was prescribed. Sociological factors were controlled. Results Treatment was significantly more likely to be provided after the MHPAEA. Psychotherapy was used for treatment for 10.0% of the sample while medication was used for 75.0% of the sample. Patient race/ethnicity, practice setting, physician specialty, and primary source of payment were associated with diverging likelihood of being prescribed depression treatment. Non-Hispanic White patients were more likely to be provided treatment than non-Hispanic Black patients. Patients were less likely to be prescribed only medication than only psychotherapy after the MHPAEA enactment. Conclusions The MHPAEA was associated with primary care providers' decision and choice on depression treatment. Educational and policy interventions aimed at improving physician's understanding of their own treatment tendencies and decreasing barriers to depression treatment may impact the disparities in underserved, minority, and older populations.

Baseline Insurance Status and Risk of Common Mental Disorders: A Propensity-Based Analysis of a Longitudinal U.S. Sample.

OBJECTIVE: Because of pervasive poor general medical and mental health status among patients receiving Medicaid, there has been substantial debate about whether Medicaid, as currently financed and delivered, is better than no insurance. The study aimed to address whether insurance status is associated with the subsequent incidence and persistence of common mental disorders. METHODS: Data came from a nationally representative U.S. population-based longitudinal survey that assessed mental disorders at two time points three years apart. Propensity score methods were used to adjust for potential confounding and to assess the association between three mutually exclusive insurance status groups (no insurance, private insurance only, and Medicaid only) and the subsequent incidence and persistence of mood, anxiety, and substance use disorders for persons ages 18-65 (N=26,410). RESULTS: Compared with private insurance, lack of insurance was associated with higher odds of both the incidence and persistence of substance use disorders and with higher odds of persistence of any mood or anxiety disorder. Compared with having private insurance, having Medicaid insurance was associated with increased odds of persistent mood and anxiety disorders during follow-up. Overall, findings did not significantly differ between the uninsured and Medicaid groups. CONCLUSIONS: The findings do not support prior reports that U.S. adults with Medicaid have worse mental health outcomes than uninsured adults. Lacking insurance may put individuals at higher risk of developing substance use disorders, and uninsured individuals with preexisting mental conditions were more likely to have mood, anxiety, and substance use problems that persist over time.

A roadmap to parity in mental health financing: the case of Lebanon.

BACKGROUND: Inadequate access to mental health (MH) services in Lebanon, where prevalence is noteworthy, is a concern. Although a multitude of factors affects access to services, lack of financial coverage of MH services is one that merits further investigation. AIM OF THE STUDY: This study aims at providing a systematic description of MH financing systems with a special focus on Lebanon, presenting stakeholder viewpoints on best MH financing alternatives/strategies and recommending options for enhancing financial coverage. METHODS: A comprehensive review of existing literature on MH financing systems was conducted, with a focus on the system in Lebanon. In addition, key stakeholders were interviewed to assess MH organizational and financing arrangements. Finally, a national round table was organized with the aim of discussing findings (from the review and interviews) and developing an action roadmap. RESULTS: Taxation and out-of-pocket payments are the most common MH financing sources worldwide and in the Eastern Mediterranean Region. In Lebanon, all funding entities, except private insurance and mutual funds, cover inpatient and outpatient MH services, albeit with inconsistencies in levels of coverage. The national roundtable recommended two main MH financing enhancements: (i) creating a knowledge-sharing committee between insurers and MH specialists, and (ii) convincing labor unions/representatives to lobby for MH coverage as part of the negotiated benefit package. DISCUSSION: There are concerns regarding the equity, effectiveness and efficiency of the MH financing system in Lebanon. The fragmented system in Lebanon leads to differences in MH coverage across different financing intermediaries, which is inequitable. The fact that one out of four Lebanese suffer a mental disorder throughout their lives and very low percentages of those obtain treatment signals a problem in effectiveness. As for efficiency, the inefficient fragmentation of MH financing among seven intermediaries is a problematic characteristic of the healthcare financing system as a whole. Moreover, the orientation of the general healthcare system towards curative rather than preventive care is reflected in MH financing as well. Limitations of the study include the lack of access to data about the MH expenditure of every financing intermediary in Lebanon; therefore it was not possible to calculate a total annual MH spending on a country level. Another limitation was the inability to map the sources of funding with the MH service provision sector, as more extensive data about the MH services provided by each of the public, private, voluntary and informal sectors is needed. IMPLICATIONS FOR HEALTH POLICIES: Providing a clear description of the current MH financing system helps policymakers recognize the disparities present in the coverage of MH, guiding them into making informed decisions on allocation of funds. This study therefore constitutes the first step towards achieving more equitable and socially just coverage, advances knowledge and provides well-needed locally relevant research. Findings are expected to inform policymaking and have already contributed to influencing a change in the policy of the Internal Security Forces Health Fund. As a result of the roundtable discussion and follow up that ensued, the fund has removed the suicide attempt exclusion from its insurance policy.

Health insurance in China: variation in co-payments and psychiatric hospital utilization.

BACKGROUND: Economic reform in China 30 years ago virtually eliminated all public health insurance. In the last 10 years, diverse government insurance programs have been implemented, now covering 95% of the population, primarily for inpatient care. While the development of health care in China is an incomplete work in progress and highly variable, it is unclear whether the depth of insurance coverage affects the accessibility, length of stay (LOS) of inpatient mental health services or not. AIM OF THE STUDY: This study aims to examine the relationship between variation in insurance coverage, accessibility to inpatient mental health care and intensity of care as measured by length of stay (LOS). METHODS: Using administrative data from the Guangzhou Psychiatric Hospital (GPH), we used regression models to determine the relationship between the depth of insurance coverage and the likelihood of hospital utilization and LOS net of sociodemographic characteristics and diagnosis. RESULTS: Between April 1, 2010 and March 31, 2013, 8,478 patients were discharged with ICD-10 psychiatric diagnoses with an average LOS of 75.1 (sd=244.3) days, among which 4,727 (55.8%) patients were first admissions. Logistic regression analysis showed that insurance plans with lower co-payments were significant predictors of multiple psychiatric admissions and longer LOS. IMPLICATIONS FOR HEALTH POLICY: These data point to significant variability in the health insurance coverage in China and indicate a clear need for greater equalization in future years. Although the Chinese government has provided at least shallow coverage to virtually all of its citizens at this stage, further efforts are needed to expand and equalize coverage as economic development proceeds, especially in rural areas. IMPLICATIONS FOR FURTHER RESEARCH: Although variation in health insurance plans in China are extensive and impact the accessibility and duration of psychiatric hospital care, their impact on outcomes and use of post-discharge outpatient care is unknown and requires further study.

Use of hospital-based services among young adults with behavioral health diagnoses before and after health insurance expansions.

IMPORTANCE: Young adults have high levels of behavioral health needs but often lack health insurance. Recent health reforms have increased coverage, but it is unclear how use of hospital-based care changed after expanding insurance. OBJECTIVE To evaluate the association between health insurance coverage expansions and use of hospital-based care among young adults with behavioral health diagnoses. DESIGN, SETTING, AND PARTICIPANTS: Quasi-experimental analyses of community hospital inpatient and emergency department use from 2003-2009 based on hospital discharge data, comparing differential changes in service use among young adults with behavioral health diagnoses in Massachusetts vs other states before and after Massachusetts' 2006 health reform. This population-based sample included inpatient admissions (n = 2,533,307, representing 12,821,746 weighted admissions across 7 years) nationwide and emergency department visits (n = 6,817,855 across 7 years) from Maryland and Massachusetts for 12- to 25-year-old patients. MAIN OUTCOMES AND MEASURES: Inpatient admission rates per 1000 population for primary diagnosis of any behavioral health disorder by diagnosis; emergency department visit rates per 1000 population by behavioral health diagnosis; and insurance coverage for hospital discharges. RESULTS: After 2006, uninsurance among 19- to 25-year-old individuals in Massachusetts decreased from 26% to 10% (16 percentage points; 95% CI, 13-20). Young adults experienced relative declines in inpatient admission rates of 2.0 per 1000 for primary diagnoses of any behavioral health disorder (95% CI, 0.95-3.2), 0.38 for depression (95% CI, 0.18-0.58), and 1.3 for substance use disorder (95% CI, 0.68-1.8). The increase in emergency department visits with any behavioral health diagnosis after 2006 was lower among young adults in Massachusetts compared with Maryland (16.5 per 1000; 95% CI, 11.4-21.6). Among young adults in Massachusetts, the percentage of behavioral health discharges that were uninsured decreased by 5.0 (95% CI, 3.0-7.2) percentage points in inpatient settings and 5.0 (95% CI, 1.7-7.8) percentage points in emergency departments relative to other states. CONCLUSIONS AND RELEVANCE: Expanded health insurance coverage for young adults was not associated with large increases in hospital-based care for behavioral health, but it increased financial protection for young adults with behavioral health diagnoses and for the hospitals that care for them.

Health insurance and treatment of adolescents with co-occurring major depression and substance use disorders.

OBJECTIVE: The goals of this study were to identify treatment rates among adolescents with co-occurring major depressive episode (MDE) and substance use disorder (SUD), and to examine the role of health insurance in the treatment of these disorders. METHOD: Seven years of cross-sectional data (2004-2010) were pooled from the National Survey on Drug Use and Health to derive a nationally representative sample of 2,111 adolescents who had both a past-year MDE and SUD and whose insurance status was known. The associations of public and private insurance with MDE and SUD treatment were examined using multinomial logistic regressions that controlled for health status and sociodemographic variables. RESULTS: Less than one-half (48%) of adolescents received any form of MDE treatment in the past year, and only 10% received any form of SUD treatment. Only 16% of adolescents who received MDE treatment also received SUD treatment. Relative to no insurance, public insurance was associated with an increased likelihood of receiving MDE treatment alone, but not with an increased likelihood of receiving both MDE and SUD treatment. Involvement in the criminal justice system was the major factor affecting the likelihood that an adolescent would receive both MDE and SUD treatment, as opposed to either no treatment or treatment for MDE alone. CONCLUSIONS: Exceptionally low rates of SUD treatment were observed in this high-risk sample. Study findings highlight a missed opportunity to assess and to treat SUD among adolescents with co-occurring MDE and SUD who have received some form of MDE treatment in the past year.

Psychiatric inpatient expenditures and public health insurance programmes: analysis of a national database covering the entire South Korean population.

BACKGROUND: Medical spending on psychiatric hospitalization has been reported to impose a tremendous socio-economic burden on many developed countries with public health insurance programmes. However, there has been no in-depth study of the factors affecting psychiatric inpatient medical expenditures and differentiated these factors across different types of public health insurance programmes. In view of this, this study attempted to explore factors affecting medical expenditures for psychiatric inpatients between two public health insurance programmes covering the entire South Korean population: National Health Insurance (NHI) and National Medical Care Aid (AID). METHODS: This retrospective, cross-sectional study used a nationwide, population-based reimbursement claims dataset consisting of 1,131,346 claims of all 160,465 citizens institutionalized due to psychiatric diagnosis between January 2005 and June 2006 in South Korea. To adjust for possible correlation of patients characteristics within the same medical institution and a non-linearity structure, a Box-Cox transformed, multilevel regression analysis was performed. RESULTS: Compared with inpatients 19 years old or younger, the medical expenditures of inpatients between 50 and 64 years old were 10% higher among NHI beneficiaries but 40% higher among AID beneficiaries. Males showed higher medical expenditures than did females. Expenditures on inpatients with schizophrenia as compared to expenditures on those with neurotic disorders were 120% higher among NHI beneficiaries but 83% higher among AID beneficiaries. Expenditures on inpatients of psychiatric hospitals were greater on average than expenditures on inpatients of general hospitals. Among AID beneficiaries, institutions owned by private groups treated inpatients with 32% higher costs than did government institutions. Among NHI beneficiaries, inpatients medical expenditures were positively associated with the proportion of patients diagnosed into dementia or schizophrenia categories. However, for AID beneficiaries, inpatient medical expenditures were positively associated with the proportion of all patients with a psychiatric diagnosis that were AID beneficiaries in a medical institution. CONCLUSIONS: This study provides evidence that patient and institutional factors are associated with psychiatric inpatient medical expenditures, and that they may have different effects for beneficiaries of different public health insurance programmes. Policy efforts to reduce psychiatric inpatient medical expenditures should be made differently across the different types of public health insurance programmes.

Interstate variations in psychotropic medication use among a national sample of children in the child welfare system.

Geographic variations in service utilization have emerged as sentinels of quality of care. We used data from the National Survey of Child and Adolescent Well-Being (NSCAW), the Kaiser Family Foundation, and the Area Resource File to examine interstate variations in psychotropic medication use among children coming into contact with child welfare agencies. Mean probabilities of medication use differed by 13% between California (7.1%) and Texas (20.1%). On regression analyses, children in California had a fifth of the odds of medication use compared to children in Texas, principally, because child characteristics of age, gender, foster care placement, and mental health need seem to be evaluated differently in Texas compared to in other states. These findings suggest that interstate variations in psychotropic medication use are driven by child characteristics, rather than by mental health need. Understanding the clinical contexts of psychotropic medication use is necessary to assure high-quality care for these children.

Multiple psychiatric diagnoses common in privately insured children on atypical antipsychotics.

OBJECTIVE: To evaluate the prevalence of atypical antipsychotic use in privately insured children and the diagnoses associated with treatment. STUDY DESIGN: Claims were used to conduct a retrospective cohort study of children aged 2 through 18 years in the Midwest, covered by private insurance between 2002 and 2005 (n = 172,766). The 1-year prevalence of children receiving atypical antipsychotics was determined along with associated diagnoses. RESULTS: The 1-year prevalence of atypical antipsychotics ranged from 7.9 per 1000 in 2002 to 9.0 in 2005. The leading diagnoses were disruptive behavior disorders (67%), mood disorders (65%), and anxiety disorders (43%).The authors found that 75% of children on atypical antipsychotics had more than one psychiatric diagnosis. CONCLUSIONS: Atypical antipsychotic use is primarily seen in children who have multiple psychiatric diagnoses. Studies are needed to assess the long-term safety and effectiveness in such patients with multiple diagnoses.

[Usage of inpatient treatments after reduction of inpatient capacities: Supply influences demand]. / Inanspruchnahme stationärer Behandlungen nach Abbau stationärer Kapazitäten: Das Angebot beeinflusst die Nachfrage.

OBJECTIVE: Next to socio-economic factors, subjective need, political and health economiaspects play an important role in the planning of psychiatric structures. The aim of this study was to assess the consequences of a reduction of inpatient capacities fort the usage of psychiatric inpatient care. METHODS: The admissions of inpatients from a region in which the inpatient service has been replaced by the inpatient service from another region in the canton of Zurich, Switzerland, has been analysed. RESULTS: Within the first two years after the omission of the service the admissions of patients with social health insurance policies from the relative sector decreased significantly as compared to the rest of the canton. In contrast to this, admissions of patients with private health insurances from the relative region and from the rest of the canton increased in a similar way. CONCLUSION: It can be stated that in the first time after a reduction of inpatient capacities patients with social health insurance policies do not use inpatient alternatives even when these are easily accessible. This finding is meaningful for the arrangement of alternative offers for this very large group of patients in psychiatric health care planning.

Viability of using employment rates from randomized trials as benchmarks for supported employment program performance.

Cumulative employment rates published by randomized trials are based on each enrollee's pre-planned 18-24-months of study participation. By contrast, community programs typically report employment rates for clients active in services during a calendar quarter. Using data from three supported employment programs in randomized trials, we show that trial cumulative employment rates are about twice as large as quarterly employment rates for the same program. Therefore, we recommend that administrators, service networks, and mental health authorities begin to publish quarterly employment rates, and quarterly median earnings, to allow policymakers to set realistic performance expectations for supported employment programs.

Dropout from outpatient mental health care in the United States.

OBJECTIVE: Although mental health treatment dropout is common, patterns and predictors of dropout are poorly understood. This study explored patterns and predictors of mental health treatment dropout in a nationally representative sample. METHODS: Data were from the National Comorbidity Survey Replication, a nationally representative household survey. Respondents who had received mental health treatment in the 12 months before the interview (N=1,664) were asked about dropout, which was defined as quitting treatment before the provider wanted them to stop. Cross-tabulation and discrete-time survival analyses were used to identify predictors. RESULTS: Approximately one-fifth (22%) of patients quit treatment prematurely. The highest dropout rate was from treatment received in the general medical sector (32%), and the lowest was from treatment received by psychiatrists (15%). Dropout rates were intermediate from treatment in the human services sector (20%) and among patients seen by nonpsychiatrist mental health professionals (19%). Over 70% of all dropout occurred after the first or second visits. Mental health insurance was associated with low odds of dropout (odds ratio=.6, 95% confidence interval=.4-.9). Psychiatric comorbidity was associated with a trend toward dropout. Several patient characteristics differentially predicted dropout across treatment sectors and in early and later phases of treatment. CONCLUSIONS: Roughly one-fifth of adults in mental health treatment dropped out before completing the recommended course of treatment. Dropout was most common in the general medical sector and varied by patient characteristics across treatment sectors. Interventions focused on high-risk patients and sectors that have higher dropout rates will likely be required to reduce the large proportion of patients who prematurely terminate treatment.