Pennsylvania's Medical Home Initiative: Reductions in Healthcare Utilization and Cost Among Medicaid Patients with Medicaland Psychiatric Comorbidities.

BACKGROUND: The Chronic Care Initiative (CCI) was a large state-wide patient-centered medical home (PCMH) initiative in Pennsylvania in place from 2008-2011. OBJECTIVE: Determine whether the CCI impacted the utilization and costs for Medicaid patients with chronic medical conditions and comorbid psychiatric or substance use disorders. DESIGN: Analysis of Medicaid claims using difference-in-difference regression analyses to compare changes in utilization and costs for patients treated at CCI practices to propensity score-matched patients treated at comparison non-CCI practices. SETTING: Ninety-six CCI practices in Pennsylvania and 60 non-CCI practices during the same time period. PARTICIPANTS: A total of 11,105 comorbid Medicaid patients treated in CCI practices and an equal number of propensity-matched comparison patients treated in non-CCI practices. MEASUREMENTS: Changes in total per-patient costs from 1 year prior to 1 year following an index episode period. Secondary outcomes included utilization and costs for emergency department (ED), inpatient, and outpatient services. RESULTS: The CCI group experienced an average adjusted total cost savings of $4145.28 per patient per year (P = 0.023) for the CCI relative to the non-CCI group. This was largely driven by a $3521.15 savings (P = 0.046) in inpatient medical costs, in addition to relative savings in outpatient psychiatric ($21.54, P < 0.001) and substance abuse service costs ($16.42, P = 0.013), compared to the non-CCI group. The CCI group, related to the non-CCI group, had decreases in expected mean counts of ED visits (for those who had any) and psychiatric hospitalizations of 15.6 (95 % CI: -21, -9) and 40.7 (95 % CI: -57, -18) percentage points respectively. LIMITATIONS: We do not measure quality of care and cannot make conclusions about the overall cost-effectiveness or long-term effects of the CCI. CONCLUSIONS: The CCI was associated with substantial cost savings, attributable primarily to reduced inpatient costs, among a high-risk group of Medicaid patients, who may disproportionally benefit from care management in patient-centered medical homes.

Implementing an E-prescribing system in outpatient mental health programs.

This study describes the implementation and evaluation of an electronic prescription ordering system and feedback report in three community-based mental health outpatient agencies and the usefulness of the system in improving psychiatrists' prescribing behavior. Using the e-prescribing system as a data collection tool, feedback on evidence based prescribing practices for patients diagnosed with schizophrenia spectrum disorder or major affective disorder was provided to agency directors and prescribers via a monthly report. The results of the project were that e-prescribing tools can be installed at a reasonable cost with a short start up period. Although the feedback intervention did not show a significant reduction in questionable prescribing patterns, we should continue to investigate how to best use HIT to improve safety, reduce costs, and enhance the quality of healthcare. A better understanding of what prescribers find useful and the reasons why they are prescribing non-evidenced based medications is needed if interventions of this type are to be effective. Given the availability of administrative claims data and electronic prescribing technology, considerable potential exists to provide useful information for monitoring and clinical decision making in public mental health systems.

Use of HIV and psychotropic medications among persons with serious mental illness and HIV/AIDS.

Persons with serious mental illness (SMI) have higher rates of co-morbid HIV disorders compared to the general population. There are concerns that the SMI/HIV population may be receiving fewer HIV and psychotropic medications due to problems of access and concerns by providers associated with following complex medication regimes. The purpose of this study was to examine any disparity in medication treatment of the SMI/HIV population by comparing medication use and continuity of prescription fills to groups that had HIV or SMI only versus those with SMI/HIV. Study participants were adult Medicaid recipients aged 19-64 with serious mental illness and HIV receiving services in Philadelphia from 2002 through 2003. Differences between the groups in case mix characteristics, medication use rates, and continuity of psychotropic and antiretroviral medication use were compared using Chi-square, t-tests of significance, and logistic regression. Co-morbid individuals were as likely to have filled prescriptions for psychotropic and antiretroviral medications as those with a single disorder and equally persistent in their continuity of antiretroviral medication refills as those with HIV only. However, persons with co-morbid condition had lower continuity of psychotropic medication use compared to those with SMI only. Our findings suggest the need to develop an integrated medical and behavioral healthcare model to improving coordination and treatment for patients with co-occurring disorders. Future research is warranted to investigate the reasons for the discrepancy in continuity of psychotropic adherence for the SMI/HIV population.

Treatment disparities in Parkinson's disease.

We sought to identify racial disparities in the treatment of Parkinson's disease (PD). We identified 307 incident PD cases using Pennsylvania State Medicaid claims, and extracted claims for medications, physical therapy, and healthcare visits for the 6 months after diagnosis. After controlling for age, sex, and geography, African-Americans were four times less likely than whites to receive any PD treatment (odds ratio, 0.24; 95% confidence interval, 0.09-0.64), especially indicated medications. In a group with the same healthcare insurance, disparities in PD treatment exist. Physician and community awareness of these racial differences in PD treatment is the first step in addressing healthcare disparities.

Racial differences in the diagnosis of Parkinson's disease.

The objective of this cohort study was to determine the incidence of Parkinson's disease (PD) and the effects of race/ethnicity, other demographic characteristics, geography, and healthcare utilization on probability of diagnosis. The authors used the Pennsylvania state Medicaid claims dataset from 1999 to 2003 to identify newly diagnosed cases of PD among the 182,271 Medicaid enrolled adults age 40-65; 319 incident cases of PD were identified. The 4-year cumulative incidence of PD was 45 per 100,000; 54 per 100,000 among whites, 23 per 100,000 among African-Americans and 40 per 100,000 among Latinos (P < 0.0001), corresponding to a relative risk (RR) of PD of 0.43 for African-Americans (P < 0.0001) compared with whites. After adjusting for age, sex, geography, reason for Medicaid eligibility, and average number of visits, African-Americans were still half as likely to be diagnosed with PD as whites (RR 0.45, P < 0.0001). Older age, more healthcare visits and Medicaid eligibility because of income alone also were significantly associated with PD diagnosis, while male sex was not. Observed racial differences in incidence of PD are not explained by differences in age, sex, income, insurance or healthcare utilization but still may be explained by biological differences or other factors such as education or aging beliefs. Better understanding of the complex biological and social determinants of these disparities is critical to improve PD care.

Impact of a medical home model on costs and utilization among comorbid HIV-positive Medicaid patients.

OBJECTIVES: The Pennsylvania Chronic Care Initiative (CCI) was a statewide patient-centered medical home (PCMH) initiative implemented from 2008 to 2011. This study examined whether the CCI affected utilization and costs for HIV-positive Medicaid patients with both medical and behavioral health comorbidities. STUDY DESIGN: Nonrandomized comparison of 302 HIV-positive Medicaid patients treated in 137 CCI practices and 2577 HIV-positive Medicaid patients treated elsewhere. METHODS: All patients had chronic medical conditions (diabetes, chronic obstructive pulmonary disease, asthma, or congestive heart failure) and a psychiatric and/or substance use disorder. Analyses used Medicaid claims data to examine changes in total per patient costs per month from 1 year prior to 1 year following an index episode. Propensity score weighting was used to adjust for potential sample differences. Secondary outcomes included costs and utilization of emergency department, inpatient, and outpatient/pharmacy services. RESULTS: We identified an average total cost savings of $214.10 per patient per month (P = .002) for the CCI group relative to the non-CCI group. This was a function of decreased inpatient medical (-$415.69; P = .007) and outpatient substance abuse treatment (-$4.86; P = .001) costs, but increased non-HIV pharmacy costs ($158.43; P = .001). Utilization for the CCI group, relative to the non-CCI group, was correspondingly decreased for inpatient medical services (odds ratio [OR], 0.619; P = .002) and inpatient services overall (OR, 0.404; P = .001), but that group had greater numbers of outpatient medical service claims when they occurred (11.7%; P = .003) and increased non-HIV pharmacy claims (9.7%; P = .001). CONCLUSIONS: There was increased outpatient service utilization, yet relative cost savings, for HIV-positive Medicaid patients with medical and behavioral health comorbidities who were treated in PCMHs.

Quality of Diabetes Care Among Adult Medicaid Enrollees With Mental Disorders.

OBJECTIVE: In light of the national trend toward integrating mental and general medical care, this study examined disparities in diabetes treatment among Medicaid recipients in a nonintegrated, managed care behavioral health carve-out system. METHODS: A retrospective study of Medicaid claims (July 2009-June 2010) compared quality of diabetes treatment among 21,015 patients with and without mental disorders. RESULTS: Presence of a mental disorder was associated with higher use of outpatient and primary care services for diabetes, lower rates of hospitalizations for diabetes, and higher odds of receiving three or more quality measures for diabetes care. Patients with serious mental illness had better diabetes care compared with patients with other mental disorders and patients with no mental disorders. CONCLUSIONS: Findings suggest that managed care behavioral health carve-out systems should be considered among the range of approaches for improving treatment for diabetes among persons with comorbid mental disorders, particularly serious mental disorders.

Quantitatively determined survivin expression levels are of prognostic value in human gliomas.

PURPOSE: Survivin is a novel antiapoptotic gene that has been recently cloned and characterized. Its expression has been found to be of prognostic significance in several tumor types. This is the first study on the prognostic significance of survivin expression in human gliomas. MATERIALS AND METHODS: We used quantitative Western blot analysis with densitometry to determine survivin protein expression levels in 92 glioma cases for which frozen tissue was available for analysis. Survivin positivity and expression levels were correlated with histopathologic features of the tumors, apoptosis (as measured by cleaved, or activated, caspase 3 levels), and clinical outcome. RESULTS: Survivin expression has clear prognostic value in human gliomas. Patients with detectable survivin expression had significantly shorter overall survival times (P <.0001) compared with those without detectable expression when all glioma patients were considered. Although glioblastoma multiforme (GBM) patients had significantly higher rates of survivin positivity and higher levels of survivin expression (P <.0001) than their non-GBM counterparts, the prognostic value of survivin expression seemed to be independent of histology alone. Survivin-positive GBM patients had significantly shorter overall survival times compared with survivin-negative GBM patients (P <.0001). Likewise, survivin-positive non-GBM patients had shorter survival times compared with survivin-negative non-GBM patients (P =.029). Furthermore, increasing levels of survivin expression significantly correlated with reduced survival times when all glioma patients were considered, and markedly so for GBM patients (P <.0001). Increasing survivin levels significantly correlated with reduced expression of cleaved caspase 3, indicating its association with antiapoptotic activity. CONCLUSION: Survivin positivity and protein expression levels, as determined quantitatively, are of significant prognostic value in human gliomas and seem to be associated with reduced apoptotic capacity of these tumors.

Monetary incentives in support of academic achievement: results of a randomized field trial involving high-achieving, low-resource, ethnically diverse urban adolescents.

Significant resources have been directed at understanding and alleviating the achievement gap in education. Most programs focused on this aim rely on a top-down approach, including funding for infrastructure improvement, curriculum development, class size, and teacher salaries. This article presents findings from a randomized field trial that evaluates a bottom-up approach in which high-achieving students of diverse racial and ethnic backgrounds from poor families are given monetary incentives to maintain their academic standing. The evaluation was designed to explore the role of monetary incentives as a mechanism for promoting resiliency in the face of poverty-related challenge. Discussion of what motivates students to learn is framed as a function of normal cognitive and socioemotional development in challenging environments. Evaluation findings indicate that monetary incentives are effective in promoting academic success to different degrees and for different reasons depending on students' perception of the meaning of the incentive in relation to their emergent identity.

Length of inpatient stay of persons with serious mental illness: effects of hospital and regional characteristics.

OBJECTIVE: This study examined the extent to which hospital and regional characteristics are associated with length of hospitalization among patients with serious mental illness. METHODS: Data from the Pennsylvania Health Care Cost Containment Council and 2006 American Hospital Association data were obtained. The sample consisted of 106 hospitals from which 45,497 adults with serious mental illness were discharged in 2006. Guided by the extended version of Andersen's health care utilization model, hierarchical linear modeling, including patient case mix, hospital, and regional characteristics, was used to explain variations in hospitalization length. RESULTS: The average length of stay was 10.0 ± 3.0 days. Stays were longer at psychiatric hospitals than at general acute care facilities and at hospitals with a greater percentage of Medicare patients and patients with serious mental illness and a higher rate of readmission. In terms of regional characteristics, stays were also longer at hospitals in counties where the county mental health program received a larger percentage of the state's mental health budget and a smaller share of the budget was used for residential care. CONCLUSIONS: Hospital type and case mix, along with the presence of housing resources funded by county mental health programs, were found to be associated with variations in length of hospitalization. Further research of a longitudinal or prospective nature is required to determine whether the availability of housing programs for persons with mental disorders leads to shorter hospital stays for those in crisis and to determine whether longer stays are the result of differences in hospital practices.

Antipsychotic treatment among youth in foster care.

OBJECTIVE: Despite national concerns over high rates of antipsychotic medication use among youth in foster care, concomitant antipsychotic use has not been examined. In this study, concomitant antipsychotic use among Medicaid-enrolled youth in foster care was compared with disabled or low-income Medicaid-enrolled youth. PATIENTS AND METHODS: The sample included 16 969 youths younger than 20 years who were continuously enrolled in a Mid-Atlantic state Medicaid program and had ≥1 claim with a psychiatric diagnosis and ≥1 antipsychotic claim in 2003. Antipsychotic treatment was characterized by days of any use and concomitant use with ≥2 overlapping antipsychotics for >30 days. Medicaid program categories were foster care, disabled (Supplemental Security Income), and Temporary Assistance for Needy Families (TANF). Multicategory involvement for youths in foster care was classified as foster care/Supplemental Security Income, foster care/TANF, and foster care/adoption. We used multivariate analyses, adjusting for demographics, psychiatric comorbidities, and other psychotropic use, to assess associations between Medicaid program category and concomitant antipsychotic use. RESULTS: Average antipsychotic use ranged from 222 ± 110 days in foster care to only 135 ± 101 days in TANF (P < .001). Concomitant use for ≥180 days was 19% in foster care only and 24% in foster care/adoption compared with <15% in the other categories. Conduct disorder and antidepressant or mood-stabilizer use was associated with a higher likelihood of concomitant antipsychotic use (P < .0001). CONCLUSIONS: Additional study is needed to assess the clinical rationale, safety, and outcomes of concomitant antipsychotic use and to inform statewide policies for monitoring and oversight of antipsychotic use among youths in the foster care system.

Sexually transmitted infection among adolescents receiving special education services.

BACKGROUND: To estimate the relative risk of sexually transmitted infections (STIs) among children identified as having learning disabilities through the special education system. METHODS: This cross-sectional study used special education data and Medicaid data from Philadelphia, Pennsylvania, for calendar year 2002. The sample comprised 51,234 Medicaid-eligible children, aged 12-17 years, 8015 of whom were receiving special education services. Claims associated with diagnoses of STIs were abstracted, and logistic regression was used to estimate the odds of STI among children in different special education categories. RESULTS: There were 3% of males and 5% of females who were treated for an STI through the Medicaid system in 2002. Among females, those in the mental retardation (MR) category were at greatest risk (6.9%) and those in the emotionally disturbed or "no special education" category at lowest risk (4.9% each). Among males, STIs were most prevalent among those classified as mentally gifted (6.7%) and lowest among those in the MR category (3.0%). In adjusted analyses, males with specific learning disabilities and females with MR or who were academically gifted were at excess risk for STIs. CONCLUSIONS: The finding that children with learning disabilities are at similar or greater risk for contracting STIs as other youth suggests the need to further understand their risk behaviors and the potential need to develop prevention programs specific to their learning needs.

Psychosocial development in racially and ethnically diverse youth: conceptual and methodological challenges in the 21st century.

As the US population becomes more diverse in the 21st century, researchers face many conceptual and methodological challenges in working with diverse populations. We discuss these issues for racially and ethnically diverse youth, using Spencer's phenomenological variant of ecological systems theory (PVEST) as a guiding framework. We present a brief historical background and discuss recurring conceptual flaws in research on diverse youth, presenting PVEST as a corrective to these flaws. We highlight the interaction of race, culture, socioeconomic status, and various contexts of development with identity formation and other salient developmental processes. Challenges in research design and interpretation of data are also covered with regard to both assessment of contexts and developmental processes. We draw upon examples from neighborhood assessments, ethnic identity development, and attachment research to illustrate conceptual and methodological challenges, and we discuss strategies to address these challenges. The policy implications of our analysis are also considered.