Impact of a Usual Source of Care on Health Care Use, Spending, and Quality Among Adults With Mental Health Conditions.

Physical comorbidities associated with mental health conditions contribute to high health care costs. This study examined the impact of having a usual source of care (USC) for physical health on health care utilization, spending, and quality for adults with a mental health condition using Medicaid administrative data. Having a USC decreased the probability of inpatient admissions and readmissions. It decreased expenditures on emergency department visits for physical health, 30-day readmissions, and behavioral health inpatient admissions. It also had a positive effect on several quality measures. Results underscore the importance of a USC for physical health and integrated care for adults with mental health conditions.

The rise and fall of gabapentin for bipolar disorder: a case study on off-label pharmaceutical diffusion.

CONTEXT: Rising drug costs have increased focus on how new pharmaceuticals diffuse into the marketplace. The case of gabapentin use in bipolar disorder provides an opportunity to study the roles of marketing, clinical evidence, and prior authorization (PA) policy on off-label medication use. DESIGN: Observational study using Medicaid administrative and Verispan marketing data. We examined the association between marketing, clinical trials, and prior authorization on gabapentin use. SETTING AND PATIENTS: Florida Medicaid, bipolar disorder-diagnosed enrollees ages 18 to 64 for fiscal years 1994 to 2004. RESULTS: Gabapentin prescriptions increased from 8/1000 enrollees per quarter in 1994 to a peak of 387/1000 enrollees in 2002. Its uptake tracked marketing efforts towards psychiatrists. The publication of 2 negative clinical trials in 2000 and the discontinuation of marketing expenditures towards psychiatrists were associated with an end to the steep rise in gabapentin prescriptions. After these events gabapentin use remained between 319/1000 and 387/1000 enrollees per quarter until the PA policy, which was associated with a 45% decrease in prescriptions filled. After 1 year, scientific evidence and marketing discontinuation were associated with a 5.4 percentage point decrease in the predicted probability of filling a gabapentin prescription and the PA policy, a 7.1 percentage point decrease. CONCLUSIONS: Pharmaceutical marketing can influence off-label medication prescribing, particularly when pharmacologic options are limited. Evidence of inefficacy and/or the cessation of pharmaceutical marketing, and a restrictive formulary policy can alter prescriber behavior away from targeted pharmacologic treatments. These results suggest that both information and policy are important means in altering physician prescribing behavior.

Reducing Behavioral Health Inpatient Readmissions for People With Substance Use Disorders: Do Follow-Up Services Matter?

OBJECTIVE: Individuals with substance use disorders are at high risk of hospital readmission. This study examined whether follow-up services received within 14 days of discharge from an inpatient hospital stay or residential detoxification reduced 90-day readmissions among Medicaid enrollees whose index admission included a substance use disorder diagnosis. METHODS: Claims data were analyzed for Medicaid enrollees ages 18-64 with a substance use disorder diagnosis coded in any position for an inpatient hospital stay or residential detoxification in 2008 (N=30,439). Follow-up behavioral health services included residential, intensive outpatient, outpatient, and medication-assisted treatment (MAT). Analyses included data from ten states or fewer, based on a minimum number of index admissions and the availability of follow-up services or MAT. Survival analyses with time-varying independent variables were used to test the association of receipt of follow-up services and MAT with behavioral health readmissions. RESULTS: Two-thirds (67.7%) of these enrollees received no follow-up services within 14 days. Twenty-nine percent were admitted with a primary behavioral health diagnosis within 90 days of discharge. Survival analyses showed that MAT and residential treatment were associated with reduced risk of 90-day behavioral health admission. Receipt of outpatient treatment was associated with increased readmission risk, and, in only one model, receipt of intensive outpatient services was also associated with increased risk. CONCLUSIONS: Provision of MAT or residential treatment for substance use disorders after an inpatient or detoxification stay may help prevent readmissions. Medicaid programs should be encouraged to reduce barriers to MAT and residential treatment in order to prevent behavioral health admissions.

Effect of Having a Usual Source of Care on Health Care Outcomes Among Children With Serious Emotional Disturbance.

OBJECTIVE: To determine the influence of a usual source of care (USC) on health care utilization, expenditures, and quality for Medicaid-insured children and adolescents with a serious emotional disturbance (SED). METHODS: Administrative claims data for 2011-2012 were extracted from the Truven Health MarketScan Multi-State Medicaid Research Database for 286,585 children and adolescents with a primary diagnosis of SED. We used propensity score-adjusted multivariate regressions to determine whether having a USC had a significant effect on utilization and expenditures for high-cost services that are considered potentially avoidable with appropriate outpatient care: physical and behavioral health inpatient admissions, emergency department (ED) visits, and hospital readmissions. RESULTS: Propensity score-adjusted regressions indicated that children with a USC had fewer inpatient admissions related to behavioral health (adjusted odds ratio [AOR] = 0.87; 95% confidence interval [CI], 0.79-0.97) and physical health (AOR = 0.91; 95% CI, 0.89-0.93) and lower expenditures for behavioral health inpatient admissions, physical health ED visits, and readmissions. Having a USC also was associated with a higher likelihood of receiving quality health care for 4 physical health and 2 behavioral health measures. CONCLUSIONS: Having a USC improved the health care of Medicaid-insured children and adolescents with an SED. However, despite having insurance, approximately one-fourth of this patient population did not appear to have a USC. This information can be used in developing programs that encourage connections with comprehensive health care that provides coordination among various providers.

The Impact Of Medicare ACOs On Improving Integration And Coordination Of Physical And Behavioral Health Care.

The accountable care organization (ACO) model holds the promise of reducing costs and improving the quality of care by realigning payment incentives to focus on health outcomes instead of service volume. One key to managing the total cost of care is improving care coordination for and treatment of people with behavioral health disorders. We examined qualitative data from ninety organizations participating in Medicare ACO demonstration programs from 2012 through 2015 to determine whether and how they focused on behavioral health care. These ACOs had mixed degrees of engagement in improving behavioral health care for their populations. The biggest challenges included a lack of behavioral health care providers, data availability, and sustainable financing models. Nonetheless, we found substantial interest in integrating behavioral health care into primary care across a majority of the ACOs.

Intermediate Services After Behavioral Health Hospitalization: Effect on Rehospitalization and Emergency Department Visits.

OBJECTIVE: This study examined the effect of intermediate service use on behavioral health inpatient readmissions and subsequent emergency department (ED) visits among Medicaid enrollees. METHODS: Data were from fee-for-service inpatient admissions from the 2008 Medicaid Analytic eXtract files for adults with a primary diagnosis of a mental or substance use disorder. A multivariate survival analysis estimated the association between posthospital services-particularly intermediate services (residential, partial hospital, intensive outpatient, and other rehabilitative services)-and time to readmission or ED visit. A propensity score-matched sample was used to examine the relationship between time to readmission and ED visit in the nondisabled and disabled populations more closely. RESULTS: The sample included 32,037 adults (nondisabled, 27.6%; disabled, 72.4%). Only 2.5% of nondisabled adults and 5.4% of disabled adults used intermediate services within seven days of hospital discharge. In the multivariate analysis, significant associations were found between intermediate service use and readmissions and ED visits in the nondisabled population (hazard ratio [HR]=.71, p=.04, and HR=.68, p<.01, respectively), but not in the disabled population. Significant associations were also found between use of other health care in the seven-day posthospitalization period and decreased time to readmission and ED visits in the nondisabled population and increased time to readmission and ED visits in the disabled population. In the propensity score--matched analysis, use of intermediate services was not significant in either population. CONCLUSIONS: The low use of intermediate services may reflect limited availability as well as Medicaid coverage limits. Research is needed to determine the optimal number and type of intermediate services for this population to minimize the need for additional hospital services.

Acute effects of mecamylamine and varenicline on cognitive performance in non-smokers with and without schizophrenia.

RATIONALE: Nicotinic acetylcholine receptors (nAChRs) have been implicated in the pathophysiology of cognitive deficits in the domains of attention and memory in schizophrenia. While nicotinic agonists and antagonists have been proposed as smoking cessation aids, few comparisons have been made of these agents on cognitive performance in individuals with schizophrenia. OBJECTIVES: This study investigated the acute effects of a nAChR antagonist, mecamylamine, and partial agonist, varenicline, on cognitive function in non-smokers with and without schizophrenia. METHODS: Single oral doses of mecamylamine 10 mg, varenicline 1 mg, and placebo were administered 1 week apart in random order to adults with schizophrenia (n = 30) and to healthy volunteers (n = 41) in a double-blind, crossover design. The primary outcome of interest was sustained attention as assessed with hit reaction time variability (HRT-SD) on the identical pairs continuous performance test (CPT-IP). RESULTS: Mecamylamine worsened performance on CPT-IP HRT-SD, a measure of attention, compared to varenicline in both groups. Performance on mecamylamine was worse than performance on both placebo and varenicline on several additional measures of attention, including CPT-IP hit reaction time (HRT) and random errors at various levels of task difficulty. There was a treatment by diagnosis interaction, such that mecamylamine worsened performance on CPT-IP 2-digit HRT, 3-digit random errors, and 4-digit hit rate compared to placebo and varenicline in participants with schizophrenia; effects not observed in controls. CONCLUSIONS: These findings support a role for nAChRs in attention and suggest that those with schizophrenia may be particularly sensitive to nAChR blockade.

Intended and unintended consequences of the gabapentin off-label marketing lawsuit among patients with bipolar disorder.

OBJECTIVE: The number of lawsuits accusing pharmaceutical companies of off-label marketing has risen in recent years. The impact of such lawsuits on drug prescribing and spending has not been examined. We evaluated a nationwide sample to determine whether the $430 million gabapentin off-label marketing lawsuit and accompanying media coverage affected gabapentin market share, substitution of other scientifically substantiated and unsubstantiated anticonvulsants, and anticonvulsant spending of Medicare/Medicaid patients diagnosed with bipolar disorder. METHOD: Using a national 5% sample of Medicare recipients linked to Medicaid claims, we used an interrupted times series design to evaluate the impact of the lawsuit on monthly market share, utilization, and spending from January 1, 2001, to December 31, 2005. RESULTS: The start of the lawsuit was associated with a 28% relative reduction in gabapentin market share (from ∼ 21% to ∼ 15%) and a reduction in the rate of prescribing from 108 prescriptions per 1,000 patients per month before the start of the lawsuit to 90 by the end of follow-up (P < .001). We also observed increases in market share for 3 other anticonvulsants. Total anticonvulsant use and spending per 1,000 patients increased by 13% and 74%, respectively, after the intervention. The increase in anticonvulsant spending was equivalent to $7,554 per 1,000 patients per year higher than expected compared with the baseline trend (P = .01). CONCLUSIONS: We conclude that the lawsuit resulted in a reduction in gabapentin market share, increased market share for other anticonvulsants, and substantially increased total anticonvulsant spending to approximately half of the settlement amount, not counting substitutions of newer drugs for other illnesses affected by the lawsuit. These findings support the need for further study of the effects of current lawsuits regarding off-label drug marketing.

Medication use and spending trends among children with ADHD in Florida's Medicaid program, 1996-2005.

OBJECTIVE: How the introduction of new pharmaceuticals affects spending for treatment of children with attention-deficit hyperactivity disorder (ADHD) is unknown. This study examined trends in use of pharmaceuticals and their costs among children with ADHD from 1996 to 2005. METHODS: This observational study used annual cohorts of children ages three to 17 with ADHD (N=107,486 unique individuals during the study period) from Florida Medicaid claims to examine ten-year trends in the predicted probability for medication use for children with ADHD with and without psychiatric comorbidities as well as mental health spending and its components. Additional outcome measures included average price per day and average number of days filled for medication classes. RESULTS: Overall, the percentage of children with ADHD treated with ADHD drugs increased from 60% to 63%, and the percentage taking antipsychotics more than doubled, from 8% to 18%. In contrast, rates of antidepressant use declined from 21% to 15%, and alpha agonist use was constant, at 15%. Mental health spending increased 61%, with pharmaceutical spending representing the fastest-rising component (up 192%). Stimulant spending increased 157%, mostly because of increases in price per prescription. Antipsychotic spending increased 588% because of increases in both price and quantity (number of days used). By 2005, long-acting ADHD drugs accounted for over 90% of stimulant spending. CONCLUSIONS: Long-acting ADHD drugs have rapidly replaced short-acting stimulant use among children with ADHD. The use of antipsychotics as a second-tier agent in treating ADHD has overtaken traditional agents such as antidepressants or alpha agonists, suggesting a need for research into the efficacy and side effects of second-generation antipsychotics among children with ADHD.

Ten-year trends in quality of care and spending for depression: 1996 through 2005.

CONTEXT: During the past decade, the introduction of generic versions of newer antidepressants and the release of Food and Drug Administration warnings regarding suicidality in children, adolescents, and young adults may have had an effect on cost and quality of depression treatment. OBJECTIVES: To examine longitudinal trends in health service utilization, spending, and quality of care for depression. DESIGN: Observational trend study. SETTING: Florida Medicaid enrollees, between July 1, 1996, and June 30, 2006. Patients  Annual cohorts aged 18 to 64 years diagnosed as having depression. MAIN OUTCOME MEASURES: Mental health care spending (adjusted for inflation and case mix), as well as its components, including inpatient, outpatient, and medication expenditures. Quality-of-care measures included medication adherence, psychotherapy, and follow-up visits. RESULTS: Mental health care spending increased from a mean of $2802 per enrollee to $3610 during this period (29% increase). This increase occurred despite a mean decrease in inpatient spending from $641 per enrollee to $373 and was driven primarily by an increase in pharmacotherapy spending (up 110%), the bulk of which was due to spending on antipsychotics (949% increase). The percentage of enrollees with depression who were hospitalized decreased from 9.1% to 5.1%, and the percentage who received psychotherapy decreased from 56.6% to 37.5%. Antidepressant use increased from 80.6% to 86.8%, anxiety medication use was unchanged at 62.7% and 64.4%, and antipsychotic use increased from 25.9% to 41.9%. Changes in quality of care were mixed, with antidepressant use improving slightly, psychotherapy utilization fluctuating, and follow-up visits decreasing. CONCLUSIONS: During a 10-year period, spending for Medicaid enrollees with depression increased substantially, with minimal improvements in quality of care. Antipsychotic use contributed significantly to the increase in spending, while contributing little to traditional measures of quality of care.