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Changes in drug coverage generosity and untreated serious mental illness: transitioning from Medicaid to Medicare Part D.

ABSTRACT: More than 1 in 5 disabled people with dual Medicare-Medicaid enrollment have schizophrenia or a bipolar disorder (ie, a serious mental illness). The effect of their transition from Medicaid drug coverage, which varies in generosity across states, to the Medicare Part D drug benefit is unknown. Many thousands make this transition annually.To determine the effect of transitioning from Medicaid drug benefits to Medicare Part D on medication use by patients with a serious mental illness and to determine the influence of Medicaid drug caps.In time-series analysis of continuously enrolled patient cohorts (2004-2007), we estimated changes in medication use before and after transitioning to Part D, comparing states that capped monthly prescription fills with states with no prescription limits. We used Medicaid and Medicare claims from a 5% national sample of community-dwelling, nonelderly disabled dual enrollees with schizophrenia (n?=?5554) or bipolar disorder (n?=?3675).Psychotropic treatments included antipsychotics for schizophrenia and antipsychotics, anticonvulsants, and lithium for bipolar disorder. We measured monthly rates of untreated illness, intensity of treatment, and overall prescription medication use.Prior to Part D, the prevalence of untreated illness among patients with a bipolar disorder was 30.0% in strict-cap states and 23.8% in no-cap states. In strict-cap states, the proportion of untreated patients decreased by 17.2% (relatively) 1 year after Part D, whereas there was no change in the proportion of untreated patients in no-cap states. For patients with schizophrenia, the untreated rate (20.6%) did not change in strict-cap states, yet it increased by 23.3% (from 11.6%) in no-cap states. Overall medication use increased substantially after Part D in strict-cap states: prescription fills were 35.5% higher among patients with a bipolar disorder and 17.7% higher than predicted among schizophrenic patients; overall use in no-cap states was unchanged in both cohorts.The effects of transitioning from Medicaid to Medicare Part D on essential treatment of serious mental illness vary by state. Transition to Part D in states with strict drug benefit limits may reduce rates of untreated illness among patients with bipolar disorders, who have high levels of overall medication use. Access to antipsychotic treatment may decrease after Part D for patients with a serious mental illness living in states with relatively generous uncapped Medicaid coverage.

SUBMITTER: Madden JM

PROVIDER: S-EPMC4505620 | biostudies-literature | 2015 Feb

REPOSITORIES: biostudies-literature

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Changes in drug coverage generosity and untreated serious mental illness: transitioning from Medicaid to Medicare Part D.

Madden Jeanne M JM Adams Alyce S AS LeCates Robert F RF Ross-Degnan Dennis D Zhang Fang F Huskamp Haiden A HA Gilden Daniel M DM Soumerai Stephen B SB

JAMA psychiatry 20150201 2

<h4>Importance</h4>More than 1 in 5 disabled people with dual Medicare-Medicaid enrollment have schizophrenia or a bipolar disorder (ie, a serious mental illness). The effect of their transition from Medicaid drug coverage, which varies in generosity across states, to the Medicare Part D drug benefit is unknown. Many thousands make this transition annually.<h4>Objectives</h4>To determine the effect of transitioning from Medicaid drug benefits to Medicare Part D on medication use by patients with ...[more]

PMID: 25588123

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Project description:BackgroundPatients with serious mental illness (i.e., SMI; bipolar disorder, major depressive disorder, and schizophrenia) are at increased risk of readmission, yet little is known about the extent to which readmission rates among these patients vary across hospitals. The purpose of this study was to examine the variation across hospitals in readmissions for patients with SMI and differences in the characteristics of hospitals with the highest and lowest adjusted readmission rates.MethodsWe conducted a cross-sectional analysis of pooled inpatient claims from 2013-2016. Mixed logit models with hospital random effects were used to estimate the hospital-level variance. The sample included patients with SMI from a 5% sample of fee-for-service Medicare beneficiaries.ResultsWe identified 2066 hospitals with at least 30 index admissions for Medicare beneficiaries with SMI. In multivariate analyses, factors most strongly associated with increased risk of readmission included substance use disorder (OR 2.311; p < 0.001) and end stage renal disease (OR 2.024; p < 0.001). Unadjusted readmission for hospitals at the 5th and 95th percentiles of performance were 7.05% and 15.24%, respectively, constituting an 8.2% difference. Adjusting for patient and community characteristics reduced the spread in readmission rates between the 5th and 95th percentiles of hospitals by 1.0% (i.e. to 7.2%). Hospitals in the lowest vs. highest quintiles of adjusted readmission rates were more likely to be teaching hospitals (11.1% vs. 16.7%; p < 0.05) and located in the South (37.7% vs. 40.4%) or Midwest (19.8% vs. 30.0%; p < 0.001 for region differences).ConclusionsThere is substantial hospital-level variation in readmission rates among patients with serious mental illness, even after adjusting for patient and community characteristics. This has implications for policy guiding investment in hospital-based services and community resources, to improve transitions of care for patients with SMI.

Project description:ImportanceAccess to specialty mental health care remains challenging for people with serious mental illnesses, such as schizophrenia and bipolar disorder. Whether expansion of telemedicine is associated with improved access and quality of care for these patients is unclear.ObjectiveTo assess whether greater telemedicine use in a nonmetropolitan county is associated with quality measures, including use of specialty mental health care and medication adherence.Design, setting, and participantsIn this cohort study, the variable uptake of telemental health visits was examined across a national sample of fee-for-service claims from Medicare beneficiaries in 2916 nonmetropolitan counties between January 1, 2010, and December 31, 2018. Beneficiaries with schizophrenia and related psychotic disorders and/or bipolar I disorder during the study period were included. For each year of the study, each county was categorized based on per capita telemental health service use (none, low, moderate, and high). The association between telemental health service use in the county and quality measures was tested using a multivariate model controlling for both patient characteristics and county fixed effects. Analyses were conducted from January 1 to April 11, 2022. Before the COVID-19 pandemic, telemedicine reimbursement was limited to nonmetropolitan beneficiaries.Main outcomes and measuresReceipt of a minimum of 2 specialty mental health service visits (telemedicine or in-person) in the year, number of months per year with medication, hospitalization rate, and outpatient follow-up visits after a mental health hospitalization in a year.ResultsIn 2018, there were 2916 counties with 118 170 patients (77 068 [65.2%] men; mean [SD] age, 58.3 [15.6] years) in the sample. The fraction of counties that had high telemental health service use increased from 2% in 2010 to 17% in 2018. In 2018 there were 1.08 telemental health service visits per patient in the high telemental health counties. Compared with no telemental health care in the county, patients in high-use counties were 1.2 percentage points (95% CI, 0.81-1.60 percentage points) (8.0% relative increase) more likely to have a minimum number of specialty mental health service visits, 13.7 percentage points (95% CI, 5.1-22.3 percentage points) (6.5% relative increase) more likely to have outpatient follow-up within 7 days of a mental health hospitalization, and 0.47 percentage points (95% CI, 0.25-0.69 percentage points) (7.6% relative increase) more likely to be hospitalized in a year. Telemental health service use was not associated with changes in medication adherence.Conclusions and relevanceThe findings of this study suggest that greater use of telemental health visits in a county was associated with modest increases in contact with outpatient specialty mental health care professionals and greater likelihood of follow-up after hospitalization. No substantive changes in medication adherence were noted and an increase in mental health hospitalizations occurred.

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Changes in drug coverage generosity and untreated serious mental illness: transitioning from Medicaid to Medicare Part D.

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Changes in drug coverage generosity and untreated serious mental illness: transitioning from Medicaid to Medicare Part D.

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