High-Risk Prescribing to Medicaid Enrollees Receiving Opioid Analgesics: Individual- and County-Level Factors.

BACKGROUND: Prescription opioid overdoses have increased dramatically in recent years, with the highest rates among Medicaid enrollees. High-risk prescribing includes practices associated with overdoses and a range of additional opioid-related problems. OBJECTIVES: To identify individual- and county-level factors associated with high-risk prescribing among Medicaid enrollees receiving opioids. METHODS: In a four-states, cross-sectional claims data study, Medicaid enrollees 18-64 years old with a new opioid analgesic treatment episode 2007-2009 were identified. Multivariate regression analyses were conducted to identify factors associated with high-risk prescribing, defined as high-dose opioid prescribing (morphine equivalent daily dose ≥100 mg for >6 days), opioid overlap, opioid-benzodiazepine overlap. RESULTS: High-risk prescribing occurred in 39.4% of episodes. Older age, rural county of residence, white race, and major depression diagnosis were associated with higher rates of all types of high-risk prescribing. Individuals with prior opioid, alcohol, and hypnotic/sedative use disorder diagnoses had lower odds of high-dose opioid prescribing but higher odds of opioid overlap and opioid-benzodiazepine overlap than individuals without such disorders. High-dose opioid prescribing in Massachusetts was less common than in California, Illinois, and New York, whereas the rate of benzodiazepine overlap in Massachusetts was more common than in other states. Conclusions/Importance: High-risk prescribing was common and associated with several important demographic, clinical, and community factors. Findings can be used to inform targeted interventions designed to reduce such prescribing, and given state variation observed, further research is needed to better understand the effects of state policies on high-risk prescribing.

Where Is Buprenorphine Dispensed to Treat Opioid Use Disorders? The Role of Private Offices, Opioid Treatment Programs, and Substance Abuse Treatment Facilities in Urban and Rural Counties.

POLICY POINTS: Buprenorphine is an effective opioid dependence treatment that has expanded access to care since its 2002 approval, but it can only be prescribed by physicians waivered to treat a limited number of individuals. We examined the impact of 2006 legislation that increased waivered physician patient limits from 30 to 100 on buprenorphine use, and found that 100-patient-waivered physicians were significantly associated with growth in buprenorphine use, with no such relationship for 30-patient-waivered physicians. Policies relaxing patient limits may be more effective in increasing buprenorphine use than alternatives such as opening new substance abuse treatment facilities or increasing the overall number of waivered physicians. CONTEXT: Opioid use disorders are a significant public health problem. In 2002, the FDA approved buprenorphine as an opioid use disorder treatment when prescribed by waivered physicians who were limited to treating 30 patients at a time. In 2006, federal legislation raised this number to 100 patients. Although federal legislators are considering increasing these limits further and expanding prescribing privileges to nonphysicians, little information is available regarding the impact of such changes on buprenorphine use. We therefore examined the impact of the 2006 legislation-as well as the association between urban and rural waivered physicians, opioid treatment programs, and substance abuse treatment facilities-on buprenorphine distributed per capita over the past decade. METHODS: Using 2004-2011 state-level data on buprenorphine dispensed and county-level data on the number of buprenorphine-waivered physicians and substance abuse treatment facilities using buprenorphine, we estimated a multivariate ordinary least squares regression model with state fixed effects of a state's annual total buprenorphine dispensed per capita as a function of the state's number of buprenorphine providers. FINDINGS: The amount of buprenorphine dispensed has been increasing at a greater rate than the number of buprenorphine providers. The number of physicians waivered to treat 100 patients with buprenorphine in both rural and urban settings was significantly associated with increased amounts of buprenorphine dispensed per capita. There was no significant association in the growth of buprenorphine distributed and the number of physicians with 30-patient waivers. CONCLUSIONS: The greater amounts of buprenorphine dispensed are consistent with the potentially greater use of opioid agonists for opioid use disorder treatment, though they also make their misuse more likely. The changes after the 2006 legislation suggest that policies focused on increasing the number of patients that a single waivered physician could safely and effectively treat could be more effective in increasing buprenorphine use than would alternatives such as opening new substance abuse treatment facilities or raising the overall number of waivered physicians.

Psychometric investigation of a brief measure of outcomes in children's mental health.

The current investigation sought to provide reliability and validity evidence for the Child Outcomes Survey (COS), a brief measure designed with a dual purpose to measure functioning and therapeutic relationship and to serve as a clinician-caregiver communication tool. Exploratory (EFA) and confirmatory factor analyses (CFA) were performed using a sample of 774 responses collected from 15 provider sites throughout the state of Pennsylvania. Results of the EFA (n = 387) uncovered a three factor structure (family functioning, child functioning, and therapeutic relationship) which was confirmed in the CFA (n = 387). The internal consistency reliability of the three subscales ranged from α = .76 to α = .91. There was a significant relationship between the therapeutic relationship subscale and the use of the COS as a communication aid (r s = .50, p < .001). Findings support the COS as an accurate measure of functioning and therapeutic relationship and its utility as a communication aid between clinician and caregiver.

Determining engagement in services for high-need individuals with serious mental illness.

This study examined whether Medicaid claims and other administrative data could identify high-need individuals with serious mental illness in need of outreach in a large urban setting. A claims-based notification algorithm identified individuals belonging to high-need cohorts who may not be receiving needed services. Reviewers contacted providers who previously served the individuals to confirm whether they were in need of outreach. Over 10,000 individuals set a notification flag over 12-months. Disengagement was confirmed in 55 % of completed reviews, but outreach was initiated for only 30 %. Disengagement and outreach status varied by high-need cohort.

Predictors of adequate depression treatment among Medicaid-enrolled youth.

PURPOSE: To determine if Medicaid-enrolled youth with depressive symptoms receive adequate acute treatment, and to identify the characteristics of those receiving inadequate treatment. METHODS: We used administrative claims data from a Medicaid-enrolled population in a large urban community to identify youth aged 6-24 years who started a new episode of treatment for a depressive disorder between August 2006 and February 2010. We examined rates and predictors of minimally adequate psychotherapy (four visits in first 12 weeks) and pharmacotherapy (filled antidepressant prescription for 84 of the first 144 days) among youth with a new treatment episode during the study period (n = 930). RESULTS: Fifty-nine percent of depressed youth received minimally adequate psychotherapy, but 13 % received minimally adequate pharmacotherapy. Youth who began their treatment episode with an inpatient psychiatric stay for depression and racial minorities were significantly less likely to receive minimally adequate pharmacotherapy and significantly more likely to receive inadequate overall treatment. CONCLUSIONS: While the majority of youth appear to be receiving minimally adequate acute care for depression, a substantial number are not. Given current child mental health workforce constraints, efforts to substantially improve the provision of adequate care to depressed youth are likely to require both quality improvement and system redesign efforts.

Use of a computerized medication shared decision making tool in community mental health settings: impact on psychotropic medication adherence.

Healthcare reform emphasizes patient-centered care and shared decision-making. This study examined the impact on psychotropic adherence of a decision support center and computerized tool designed to empower and activate consumers prior to an outpatient medication management visit. Administrative data were used to identify 1,122 Medicaid-enrolled adults receiving psychotropic medication from community mental health centers over a two-year period from community mental health centers. Multivariate linear regression models were used to examine if tool users had higher rates of 180-day medication adherence than non-users. Older clients, Caucasian clients, those without recent hospitalizations, and those who were Medicaid-eligible due to disability had higher rates of 180-day medication adherence. After controlling for sociodemographics, clinical characteristics, baseline adherence, and secular changes over time, using the computerized tool did not affect adherence to psychotropic medications. The computerized decision tool did not affect medication adherence among clients in outpatient mental health clinics. Additional research should clarify the impact of decision-making tools on other important outcomes such as engagement, patient-prescriber communication, quality of care, self-management, and long-term clinical and functional outcomes.

State Policy and the Breadth of Buprenorphine-Prescriber Networks in Medicaid Managed Care.

Provider networks in Medicaid Managed Care (MMC) play a crucial role in ensuring access to buprenorphine, a highly effective treatment for opioid use disorder. Using a difference-in-differences approach that compares network breadth across provider specialties and market segments within the same state, we investigated the association between three Medicaid policies and the breadth of MMC networks for buprenorphine prescribers: Medicaid expansion, substance use disorder (SUD) network adequacy criteria, and SUD carveouts. We found that both Medicaid expansion and SUD network adequacy criteria were associated with substantially increased breadth in buprenorphine-prescriber networks in MMC. In both cases, we found that the associations were largely driven by increases in the network breadth of primary care physician prescribers. Our findings suggest that Medicaid expansion and SUD network adequacy criteria may be effective strategies at states' disposal to improve access to buprenorphine.

Primary and Behavioral Health Care Integration Program: Impacts on Health Care Utilization, Cost, and Quality.

This article describes an extension of the RAND Corporation's evaluation of the Substance Abuse and Mental Health Services Administration's Primary and Behavioral Health Care Integration (PBHCI) grants program. PBHCI grants are designed to improve the overall wellness and physical health status of people with serious mental illness or co-occurring substance use disorders by supporting the integration of primary care and preventive PH services into community behavioral health centers where individuals already receive care. From 2010 to 2013, RAND conducted a program evaluation of PBHCI, describing the structure, process, and outcomes for the first three cohorts of grantee programs (awarded in 2009 and 2010). The current study extends previous work by investigating the impact of PBHCI on consumers' health care utilization, total costs of care to Medicaid, and quality of care in three states. The evidence suggests that PBHCI was successful in reducing frequent use of emergency room and inpatient services for physical health conditions, reducing costs of care, and improving follow-up after hospitalization for a mental illness. However, PBHCI evidence does not suggest that PBHCI had a consistent effect on quality of preventive care and health monitoring for chronic physical conditions. These findings can guide the design of future cohorts of PBHCI clinics to build on the strengths with respect to shifting emergency department and inpatient care to less costly and more effective settings and address the continuing challenge of integrating care between specialty behavioral health providers and general medical care providers.

Predictors of timely follow-up care among medicaid-enrolled adults after psychiatric hospitalization.

OBJECTIVE: This study examined whether predictors of timely follow-up care after inpatient psychiatric discharge in non-Medicaid populations also predicted timely follow-up care among Medicaid-enrolled adults. METHODS: The study examined the rates of seven- and 30-day follow-up care for 6,730 Medicaid-enrolled adults discharged from inpatient psychiatric facilities during 2004 and 2005 by using claims data from the largest Medicaid managed behavioral health organization in a large mid-Atlantic state. The relationship between predictor variables and timely aftercare was examined by using multiple logistic regression. RESULTS: Thirty percent of individuals received follow-up care within seven days, and 49% received follow-up care within 30 days. After the analysis controlled for age and gender, those receiving clinical services in the 30 days before hospitalization were significantly more likely to receive follow-up care within seven days (odds ratio [OR]=3.59, 95% confidence interval [CI]=3.20-4.03) than individuals with longer inpatient stays (ten or more days) (OR=1.34, CI=1.15-1.57) and individuals from urban communities (OR=1.18, CI=1.05-1.34). African Americans (OR=.69, CI=.60-.78), individuals with co-occurring behavioral health and substance use disorders (OR=.78, CI=.68-.89), individuals involuntarily admitted (OR=.79, CI=.68-.91), and individuals discharged against medical advice (OR=.59, CI=.39-.87) were significantly less likely than their comparison groups to receive follow-up care within seven days. Thirty-day follow-up care results were similar. CONCLUSIONS: Patient sociodemographic, clinical, and service utilization characteristics predicted timely follow-up care. Efforts to improve follow-up care utilization should target higher-risk individuals while developing and evaluating interventions to address specific barriers in these groups.

Simulated Effects of Policies to Reduce Diabetes Risk Among Adults With Schizophrenia Receiving Antipsychotics.

OBJECTIVE: Second-generation antipsychotics increase the risk of diabetes and other metabolic conditions among individuals with schizophrenia. Although metabolic testing is recommended to reduce this risk, low testing rates have prompted concerns about negative health consequences and downstream medical costs. This study simulated the effect of increasing metabolic testing rates on ten-year prevalence rates of prediabetes and diabetes (diabetes conditions) and their associated health care costs. METHODS: A microsimulation model (N=21,491 beneficiaries) with a ten-year time horizon was used to quantify the impacts of policies that increased annual testing rates in a Medicaid population with schizophrenia. Data sources included California Medicaid data, National Health and Nutrition Examination Survey data, and the literature. In the model, metabolic testing increased diagnosis of diabetes conditions and diagnosis prompted prescribers to switch patients to lower-risk antipsychotics. Key inputs included observed diagnoses, prescribing rates, annual testing rates, imputed rates of undiagnosed diabetes conditions, and literature-based estimates of policy effectiveness. RESULTS: Compared with 2009 annual testing rates, ten-year outcomes for policies that achieved universal testing reduced exposure to higher-risk antipsychotics by 14%, time to diabetes diagnosis by 57%, and diabetes prevalence by .6%. These policies were associated with higher spending because of testing and earlier treatment. CONCLUSIONS: The model showed that policies promoting metabolic testing provided an effective approach to improve the safety of second-generation antipsychotic prescribing in a Medicaid population with schizophrenia; however, the policies led to additional costs at ten years. Simulation studies are a useful source of information on the potential impacts of these policies.

Psychosocial Treatment of Bipolar Disorder: Clinician Knowledge, Common Approaches, and Barriers to Effective Treatment.

OBJECTIVE: Nonphysician mental health clinicians were surveyed to understand their knowledge about bipolar disorder, treatment approaches, and perceived barriers to optimal treatment. METHODS: Nonphysician mental health clinicians (N=55) from five community mental health clinics reported on their therapeutic approach, knowledge, and skill related to treatment of bipolar disorder. Chi square and t tests were used to detect differences in responses by clinician characteristics. RESULTS: Most clinicians wished to improve their treatment for bipolar disorder. They felt best prepared to provide counseling and least prepared to identify medication side effects. Among psychotherapies, CBT was the most familiar to clinicians. Although knowledgeable overall about bipolar disorder, the clinicians were less knowledgeable about pharmacotherapy. The most commonly reported treatment barrier was comorbid substance use disorders. CONCLUSIONS: Clinicians would benefit from additional training in effective therapeutic approaches for bipolar disorder as well as information about pharmacotherapy and supporting individuals with comorbid substance use problems.

Implementing a Web-Based Intervention to Train Community Clinicians in an Evidence-Based Psychotherapy: A Pilot Study.

OBJECTIVE: The authors conducted a feasibility assessment of online training plus an online learning collaborative to support implementation of an evidence-based psychosocial treatment in a community mental health system. METHODS: Two mental health centers were randomly allocated to in-person training with local supervision, and three were assigned to online training plus an online learning collaborative supported by expert clinicians. Participants (N=36) were clinicians interested in interpersonal and social rhythm therapy (IPSRT), an evidence-based psychotherapy for bipolar disorder. After training, 136 patients reported monthly on the extent to which clinicians used 19 IPSRT techniques. RESULTS: Clinicians from both training groups increased use of IPSRT techniques. Patients of clinicians receiving Internet-supported e-learning and of those receiving in-person training reported comparable clinician use of IPSRT techniques. CONCLUSIONS: Internet-supported e-learning by community clinicians was found to be feasible and led to uptake of an evidence-based psychotherapy comparable to that by clinicians who received face-to-face training.

Using claims data to generate clinical flags predicting short-term risk of continued psychiatric hospitalizations.

OBJECTIVE: As health information technology advances, efforts to use administrative data to inform real-time treatment planning for individuals are increasing, despite few empirical studies demonstrating that such administrative data predict subsequent clinical events. Medicaid claims for individuals with frequent psychiatric hospitalizations were examined to test how well patterns of service use predict subsequent high short-term risk of continued psychiatric hospitalizations. METHODS: Medicaid claims files from New York and Pennsylvania were used to identify Medicaid recipients ages 18-64 with two or more inpatient psychiatric admissions during a target year ending March 31, 2009. Definitions from a quality-improvement initiative were used to identify patterns of inpatient and outpatient service use and prescription fills suggestive of clinical concerns. Generalized estimating equations and Markov models were applied to examine claims through March 2011, to see what patterns of service use were sufficiently predictive of additional hospitalizations to be clinically useful. RESULTS: A total of 11,801 individuals in New York and 1,859 in Pennsylvania identified met the cohort definition. In both Pennsylvania and New York, multiple recent hospitalizations, but not failure to use outpatient services or failure to fill medication prescriptions, were significant predictors of high risk of continued frequent hospitalizations, with odds ratios greater than 4.0. CONCLUSIONS: Administrative data can be used to identify individuals at high risk of continued frequent hospitalizations. Payers and system administrators could use such information to authorize special services (such as mobile outreach) for such individuals to promote service engagement and prevent rapid rehospitalizations.

Reengagement of high-need individuals with serious mental illness after discontinuation of services.

OBJECTIVE: The study determined rates of reengagement in services for individuals with serious mental illness who had discontinued services. METHODS: As part of a quality assurance program in New York City involving continuous review of Medicaid claims and other administrative data, clinician care monitors identified 2,834 individuals with serious mental illness who were apparently in need of care but disengaged from services. The care monitors reviewed monthly updates of Medicaid claims, encouraged outreach from providers who had previously worked with identified individuals, and determined whether individuals had reengaged in services. RESULTS: Reengagement rates over a 12-month follow-up period were low, particularly for individuals who had been incarcerated or for whom no service provider was available to provide outreach. CONCLUSIONS: Subgroups of disengaged individuals with serious mental illness have different rates of reengagement. Active outreach by providers might benefit some, but such targeting is inefficient when the individual cannot be located.

Impact of a private health insurance mandate on public sector autism service use in Pennsylvania.

OBJECTIVE: Many states have implemented regulations (commonly referred to as waivers) to increase access to publicly insured services for autism spectrum disorders (ASD). In recent years, several states have passed legislation requiring improved coverage for ASD services by private insurers. This study examines the impact of such legislation on use of Medicaid-funded ASD services. METHOD: We used Medicaid claims data from July 1, 2006, through June 30, 2010, to identify children with ASD and to assess their use of behavioral health services and psychotropic medications. Service and medication use were examined in four consecutive 12-month periods: the 2 years preceding passage of the legislation, the year after passage but before implementation, and the year after implementation. We examined differences in use of services and medications, and used growth rates from nonwaiver children to estimate the impact of the legislation on Medicaid spending for waiver-eligible children with ASD. RESULTS: The number of children with ASD receiving Medicaid services increased 20% from 2006-2007 to 2009-2010. The growth rate among children affected by the legislation was comparable to that of other groups before passage of the legislation but decreased after the legislation's passage. We project that, without the legislation, growth in this population would have been 46% greater in 2009-2010 than observed, associated with spending of more than $8 million in 2009-2010. CONCLUSIONS: Passage of legislation increasing private insurance coverage of ASD services may decrease the number of families seeking eligibility to obtain Medicaid-funded services, with an associated substantial decrease in Medicaid expenditures.

Use of outcomes information in child mental health treatment: results from a pilot study.

OBJECTIVE: This study examined parents and clinicians' use in treatment sessions of routinely collected information on child functioning for children receiving ambulatory mental health treatment. METHODS: Information was obtained from 1,215 Child Outcomes Surveys completed at ten provider organizations. The Child Outcomes Survey is a collaboratively developed brief strength-based measure of child functioning and therapeutic relationship. This study examined parent-clinician discussion of information obtained in the survey from the previous session. Chi square tests were used to examine the association between sociodemographic and clinical covariates and parent-clinician discussion of information. RESULTS: In the measure that assessed the extent to which parents discussed the information about their child's functioning in the prior session with their clinician, 61% of parents reported high levels of discussion, 25% of parents reported moderate levels of discussion, and 14% reported low levels of discussion. Parents of boys, Latino children, and children of "other" races were significantly more likely to report high levels of discussion than other parents. Levels of discussion about the results of the previous Child Outcomes Survey were positively and significantly associated with successful child functioning and therapeutic relationship with clinicians. CONCLUSIONS: The findings of high rates of use of outcomes data routinely gathered with a very brief measure are encouraging given prior reports of challenges in using such information in treatment sessions. The successful treatment of children and families requires an ongoing and effective partnership between parents and clinicians, and the results suggest how important routine conversations about the progress of children in treatment can be. Further research is needed to understand the impact of gathering and using such data on the process and outcomes of mental health treatment for children and families.

Predictors of adequate depression treatment among Medicaid-enrolled adults.

OBJECTIVE: To determine whether Medicaid-enrolled depressed adults receive adequate treatment for depression and to identify the characteristics of those receiving inadequate treatment. DATA SOURCE: Claims data from a Medicaid-enrolled population in a large mid-Atlantic state between July 2006 and January 2008. STUDY DESIGN: We examined rates and predictors of minimally adequate psychotherapy and pharmacotherapy among adults with a new depression treatment episode during the study period (N=1,098). PRINCIPAL FINDINGS: Many depressed adults received either minimally adequate psychotherapy or pharmacotherapy. Black individuals and individuals who began their depression treatment episode with an inpatient psychiatric stay for depression were markedly less likely to receive minimally adequate psychotherapy and more likely to receive inadequate treatment. CONCLUSIONS: Racial minorities and individuals discharged from inpatient treatment for depression are at risk for receiving inadequate depression treatment.