Integrated care models and behavioral health care utilization: Quasi-experimental evidence from Medicaid health homes.
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SUBMITTER: McClellan C
PROVIDER: S-EPMC7863583 | biostudies-literature | 2020 Sep
REPOSITORIES: biostudies-literature
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Integrated care models and behavioral health care utilization: Quasi-experimental evidence from Medicaid health homes.
McClellan Chandler C Maclean Johanna Catherine JC Saloner Brendan B McGinty Emma E EE Pesko Michael F MF
Health economics 20200422 9
Integration of behavioral and general medical care can improve outcomes for individuals with behavioral health conditions-serious mental illness (SMI) and substance use disorder (SUD). However, behavioral health care has historically been segregated from general medical care in many countries. We provide the first population-level evidence on the effects of Medicaid health homes (HH) on behavioral health care service use. Medicaid, a public insurance program in the United States, HHs were create ...[more]
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Project description:BackgroundIn 2014, only 26 states and the District of Columbia chose to implement the Patient Protection and Affordable Care Act (ACA) Medicaid expansions for low-income adults.ObjectiveTo evaluate whether the state Medicaid expansions were associated with changes in insurance coverage, access to and utilization of health care, and self-reported health.DesignComparison of outcomes before and after the expansions in states that did and did not expand Medicaid.SettingUnited States.ParticipantsCitizens aged 19 to 64 years with family incomes below 138% of the federal poverty level in the 2010 to 2014 National Health Interview Surveys.MeasurementsHealth insurance coverage (private, Medicaid, or none); improvements in coverage over the previous year; visits to physicians in general practice and specialists; hospitalizations and emergency department visits; skipped or delayed medical care; usual source of care; diagnoses of diabetes, high cholesterol, and hypertension; self-reported health; and depression.ResultsIn the second half of 2014, adults in expansion states experienced increased health insurance (7.4 percentage points [95% CI, 3.4 to 11.3 percentage points]) and Medicaid (10.5 percentage points [CI, 6.5 to 14.5 percentage points]) coverage and better coverage than 1 year before (7.1 percentage points [CI, 2.7 to 11.5 percentage points]) compared with adults in nonexpansion states. Medicaid expansions were associated with increased visits to physicians in general practice (6.6 percentage points [CI, 1.3 to 12.0 percentage points]), overnight hospital stays (2.4 percentage points [CI, 0.7 to 4.2 percentage points]), and rates of diagnosis of diabetes (5.2 percentage points [CI, 2.4 to 8.1 percentage points]) and high cholesterol (5.7 percentage points [CI, 2.0 to 9.4 percentage points]). Changes in other outcomes were not statistically significant.LimitationObservational study may be susceptible to unmeasured confounders; reliance on self-reported data; limited post-ACA time frame provided information on short-term changes only.ConclusionThe ACA Medicaid expansions were associated with higher rates of insurance coverage, improved quality of coverage, increased utilization of some types of health care, and higher rates of diagnosis of chronic health conditions for low-income adults.Primary funding sourceNone.
| S-EPMC5021068 | biostudies-literature
Project description:ImportanceMany states have moved from models that carve out to those that carve in or integrate behavioral health in their Medicaid managed care organizations (MCOs), but little evidence exists about the effect of this change.ObjectiveTo assess the association of the transition to integrated managed care (IMC) in Washington Medicaid with health services use, quality, health-related outcomes, and measures associated with social determinants of health.Design, setting, and participantsThis cohort study used difference-in-differences analyses of Washington State's 2014 to 2019 staggered rollout of IMC on claims-based measures for enrollees in Washington's Medicaid MCO. It was supplemented with interviews of 24 behavioral health agency leaders, managed care administrators, and individuals who were participating in the IMC transition. The data were analyzed between February 1, 2023, and September 30, 2023.Main outcomes and measuresClaims-based measures of utilization (including specialty mental health visits and primary care visits); health-related outcomes (including self-harm events); rates of arrests, employment, and homelessness; and additional quality measures.ResultsThis cohort study included 1 454 185 individuals ages 13 to 64 years (743 668 female [51.1%]; 14 306 American Indian and Alaska Native [1.0%], 132 804 Asian American and Pacific Islander [9.1%], 112 442 Black [7.7%], 258 389 Hispanic [17.8%], and 810 304 White [55.7%] individuals). Financial integration was not associated with changes in claims-based measures of utilization and quality. Most claims-based measures of outcomes were also unchanged, although enrollees with mild or moderate mental illness experienced a slight decrease in cardiac events (-0.8%; 95% CI, -1.4 to -0.2), while enrollees with serious mental illness experienced small decreases in employment (-1.2%; 95% CI -1.9 to -0.5) and small increases in arrests (0.5%; 95% CI, 0.1 to 1.0). Interviews with key informants suggested that financial integration was perceived as an administrative change and did not have substantial implications for how practices delivered care; behavioral health agencies lacked guidance on how to integrate care in behavioral health settings and struggled with new contracts and regulatory policies that may have inhibited the ability to provide integrated care.Conclusions and relevanceThe results of this cohort study suggest that financial integration at the MCO level was not associated with significant changes in most measures of utilization, quality, outcomes, and social determinants of health. Additional support, including monitoring, training, and funding, may be necessary to drive delivery system changes to improve access, quality, and outcomes.
| S-EPMC10755612 | biostudies-literature
Project description:ObjectiveThere has been little evidence of the impact of preventive services during pregnancy covered under the Affordable Care Act (ACA) on birthing parent and infant outcomes. To address this gap, this study examines the association between Medicaid expansion under the ACA and birthing parent and infant outcomes of low-income pregnant people.MethodsThis study used individual-level data from the 2004-2017 annual waves of the Pregnancy Risk Assessment Monitoring System (PRAMS). PRAMS is a surveillance project of the Centers for Disease Control and Prevention and health departments that annually includes a representative sample of 1,300 to 3,400 births per state, selected from birth certificates. Birthing parents' outcomes of interest included timing of prenatal care, gestational diabetes, hypertensive disorders of pregnancy, cigarette smoking during pregnancy, and postpartum care. Infant outcomes included initiation and duration of breastfeeding, preterm birth, and birth weight. The association between ACA Medicaid expansion and the birthing parent and infant outcomes were examined using difference-in-differences estimation.ResultsThere was no association between Medicaid expansion and the outcomes examined after correcting for multiple testing. This finding was robust to several sensitivity analyses.Conclusions for practiceStudy findings suggest that expanded access to more complete insurance benefits with limited cost-sharing for pregnant people, a group that already had high rates of insurance coverage, did not impact the birthing parents' and infant health outcomes examined.
| S-EPMC11001670 | biostudies-literature
Project description:Although many children with medical complexity (CMC) use home health care (HHC), little is known about all pediatric HHC utilizers. Our objective was to assess characteristics of pediatric HHC recipients, providers, and payments. We conducted a retrospective analysis of 5 209 525 children age 0-to-17 years enrolled Medicaid in the 2016 IBM Watson MarketScan Medicaid Database. HHC utilizers had ≥ 1 HHC claim. Healthcare Common Procedure Coding System (HCPCS) and Current Procedural Terminology (CPT) codes were reviewed to codify provider types when possible: registered nurse (RN), licensed practical nurse (LPN), home health aide (HHA), certified nursing assistant (CNA), or companion/personal attendant. Enrollee clinical characteristics, HHC provider type, and payments were assessed. Chronic conditions were evaluated with Agency for Healthcare Research and Quality's Chronic Condition Indicators and Feudtner's Complex Chronic Conditions. Of the 0.8% of children who used HHC, 43.8% were age <1 year, 25% had no chronic condition, 38.6% had a noncomplex chronic condition, 21.5% had a complex chronic condition without technology assistance, and 15.5% had technology assistance (eg, tracheostomy). HHC for children with technology assistance accounted for 72.6% of all HHC spending. Forty-five percent of HHC utilizers received RN/LPN-level care, 7.9% companion/personal attendant care, 5.9% HHA/CNA-level care, and 36% received care from an unspecified provider. For children with technology assistance, the majority (77.2%) received RN/LPN care, 17.5% companion/personal assistant care, and 13.8% HHA/CNA care. Children using HHC are a heterogeneous population who receive it from a variety of providers. Future investigations should explore the role of nonnurse caregivers, particularly with CMC.
| S-EPMC9003864 | biostudies-literature
Project description:Exploiting a discontinuity in childhood Medicaid eligibility based on date of birth, we find that more years of childhood eligibility are associated with fewer hospitalizations in adulthood. For blacks, we find a 7-15% decrease in hospitalizations and a suggestive 2-5% decrease in emergency department visits, but no similar effect for non-blacks. The effects are pronounced for utilization related to chronic illnesses and for patients living in low-income zip codes. Calculations suggest that lower rates of hospitalizations during one year in adulthood for blacks offset between 2 and 4 percent of the initial costs of expanding Medicaid for all children.
| S-EPMC6497159 | biostudies-literature
Project description:BackgroundFrailty interventions such as Comprehensive Geriatric Assessment (CGA) can provide significant benefits for older adults living with frailty. However, incorporating such proactive interventions into primary care remains a challenge. We developed an IT-assisted CGA (i-CGA) process, which includes advance care planning (ACP). We assessed if, in older care home residents, particularly those with severe frailty, i-CGA could improve access to advance care planning discussions and reduce unplanned hospitalisations.MethodAs a quality improvement project we progressively incorporated our i-CGA process into routine primary care for older care home residents, and used a quasi-experimental approach to assess its interim impact. Residents were assessed for frailty by General Practitioners. Proactive i-CGAs were completed, including consideration of traditional CGA domains, deprescribing and ACP discussions. Interim analysis was conducted at 1 year: documented completion, preferences and adherence to ACPs, unplanned hospital admissions, and mortality rates were compared for i-CGA and control (usual care) groups, 1-year post-i-CGA or post-frailty diagnosis respectively. Documented ACP preferences and place of death were compared using the Chi-Square Test. Unplanned hospital admissions and bed days were analysed using the Mann-Whitney U test. Survival was estimated using Kaplan-Meier survival curves.ResultsAt one year, the i-CGA group comprised 196 residents (severe frailty 111, 57%); the control group 100 (severe frailty 56, 56%). ACP was documented in 100% of the i-CGA group, vs. 72% of control group, p < 0.0001. 85% (94/111) of severely frail i-CGA residents preferred not to be hospitalised if they became acutely unwell. For those with severe frailty, mean unplanned admissions in the control (usual care) group increased from 0.87 (95% confidence interval ± 0.25) per person year alive to 2.05 ± 1.37, while in the i-CGA group they fell from 0.86 ± 0.24 to 0.68 ± 0.37, p = 0.22. Preferred place of death was largely adhered to in both groups, where documented. Of those with severe frailty, 55% (62/111) of the i-CGA group died, vs. 77% (43/56) of the control group, p = 0.0013.ConclusionsProactive, community-based i-CGA can improve documentation of care home residents' ACP preferences, and may reduce unplanned hospital admissions. In severely frail residents, a mortality reduction was seen in those who received an i-CGA.
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Project description:This study assessed the impact of the Integrated Care Program (ICP), a new Medicaid managed care model in Illinois, on health services utilization and costs for adults with behavioral health conditions. Data sources included Medicaid claims, encounter records, and state payment data for 28,127 persons with a behavioral health diagnosis. Difference-in-differences models, in conjunction with propensity score weighting, were used to compare utilization and costs between ICP enrollees and a fee-for-service (FFS) comparison group. The model considered the impact of the SMART Act, which restricted access to care for the comparison group. Before the SMART Act, ICP was associated with 2.8 fewer all-cause primary care visits, 34.6 fewer behavioral health-specific outpatient visits, and 2.5 fewer all-cause inpatient admissions per 100 persons per month, and $228 lower total costs per member per month relative to the FFS group. After the SMART Act, ICP enrollees had increased outpatient and dental services utilization without significantly higher costs. The relative increase in utilization was due primarily to decreased utilization in the restricted FFS group after the SMART Act. By the end of the study period, the ICP group had 13.3 more all-cause primary care visits, 1.5 more emergency department visits, and 1.4 more dental visits per 100 persons per month relative to the FFS program. A fully-capitated, integrated managed care program has the potential to reduce overall Medicaid costs for people with behavioral health conditions without negative effects on service utilization.
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Project description:ABSTRACTUnstable housing among persons diagnosed with HIV (PDWH) has been consistently linked to poor HIV-related care engagement. We examined the relationship between enrollment in a supportive housing program and health care utilization (use of outpatient services, emergency department (ED) visits, and hospitalizations) for a group of unstably housed, Medicaid and Health Homes (HH)-enrolled PDWH in New York State. We analyzed monthly longitudinal data consisting of linked supportive housing data, HH data, and Medicaid claims from New York State (excluding New York City) between 2012 and 2017 using time series models. Participants who had at least six consecutive months of supportive housing at month t had 20% higher odds of using an outpatient service, 19% lower odds of visiting the ED, and 24% lower odds of being hospitalized compared to those with less than six consecutive months of supportive housing after adjusting for covariates. Supportive housing may promote better medical management by increasing outpatient visits among chronically homeless PDWH.
| S-EPMC10272282 | biostudies-literature
Project description:BackgroundPrograms addressing social determinants of health for high-utilizing patients are gaining interest among health systems as an avenue to promote health and decrease utilization.ObjectiveTo evaluate impacts of a social needs screening and navigation program for adult predicted high utilizers on total medical visit utilization.DesignA prospective, quasi-experimental study using an intent-to-treat propensity-weighted difference-in-differences approach. Stratified analyses assessed intervention effects among three low-socioeconomic status sub-samples: patients in low-income areas, in low-education areas, and with Medicaid insurance.ParticipantsPredicted high utilizers-patients predicted to be in the highest 1% for total utilization in a large integrated health system.InterventionA telephonic social needs screening and navigation program.Main measuresPrimary difference-in-difference analyses compared total visit count utilization, including outpatient, emergency department (ED), and inpatient utilization, between the intervention and control groups at both in-network and out-of-network facilities. Prevalence of social needs among sample patients and their connection rates to social needs resources are also described.Key resultsThe study included 34,225 patients (7107 intervention, 27,118 control). Most (53%) patients screened reported social needs, but only a minority (10%) of those with a need were able to connect with resources to address these needs. Primary analysis found total utilization visits decreased 2.2% (95% CI - 4.5%, 0.1%; p = 0.058) in the intervention group. Stratified analyses showed decreases in total utilization for all low-socioeconomic status subgroups receiving the intervention compared with controls: - 7.0% (95% CI - 11.9%, - 1.9%; p = 0.008) in the low-income area group, - 11.5% (- 17.6%, 5.0%; p < 0.001) in the low-education area group, and - 12.1% (- 18.1%, - 5.6%; p < 0.001) in the Medicaid group.ConclusionsSocial needs navigation programs for high-utilizing patients may have modest effects on utilization for the population overall. However, significant decreases in utilization were found among low-socioeconomic status patients more likely to experience social needs.
| S-EPMC6848288 | biostudies-literature
Project description:Health care organizations are increasingly assessing patients' social needs (eg, food, utilities, transportation) using various measures and methods. Prior studies have assessed social needs at the point of care and many studies have focused on correlates of 1 specific need (eg, food). This comprehensive study examined multiple social needs and medical and pharmacy claims data. Medicaid beneficiaries in Louisiana (n = 10,275) completed a self-report assessment of 10 social needs during July 2018 to June 2019. Chronic health conditions, unique medications, and health care utilization were coded from claims data. The sample was predominantly female (72%), Black (45%) or White (32%), had a mean age of 42 years, and at least 1 social need (55%). In bivariate analyses, having greater social needs was associated with greater comorbidity across conditions, and each social need was consistently associated with mental health and substance use disorders. In multivariable logistic analyses, having ≥2 social needs was positively associated with emergency department (ED) visits (OR = 1.39, CI = 1.23 - 1.57) and negatively associated with wellness visits (OR = 0.87, CI = 0.77 - 0.98), inpatient visits (OR = 0.87, CI = 0.76 - 0.99), and 30-day rehospitalization (OR = 0.66, CI = 0.50 - 0.87). Findings highlight the greater concomitant risk of social needs, mental health, and substance use. Admission policies may reduce the impact of social needs on hospitalization. Chronic disease management programs offered by health plans may benefit from systematically assessing and addressing social needs outside point-of-care interactions to impact health outcomes and ED utilization. Behavioral health care management programs would benefit from integrating interventions for multiple social needs.
| S-EPMC8713253 | biostudies-literature