Evidence-Based Practices for Medicaid Beneficiaries with Schizophrenia and Bipolar Disorder - Executive Summary

Jonathan D. Brown, Allison Barrett, Henry Ireys, Emily Caffery, and Kerianne Hourihan

Mathematica Policy Research

April 9, 2012

As the largest payer of mental health services in the United States, Medicaid programs have an opportunity to promote high-quality care for serious and persistent mental illnesses (SPMI) through the use of reimbursement strategies and policies that encourage the delivery of evidence-based practices (EBPs). These EBPs, which include pharmacologic, psychosocial, and physical health services, help beneficiaries with SPMI avoid costly institutional care, maintain employment, and engage in the community.

Few studies have examined the extent to which Medicaid beneficiaries with SPMI receive EPBs, and most of those studies have focused on Medicaid beneficiaries in a single state or smaller geographic area. Given the wide variation in state Medicaid mental health benefits and mental health service delivery systems, the receipt of EBPs is likely to vary--perhaps substantially--between states. Understanding state-to-state variation in the receipt of EBPs and identifying factors associated with the receipt of EBPs, including beneficiary demographic characteristics and specific features of state mental health systems and Medicaid programs, may help state Medicaid agencies, mental health commissioners, providers, consumers, and other stakeholders design service systems and Medicaid policies that encourage the delivery of EBPs.

This project, conducted by Mathematica Policy Research for the Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services, used standardized Medicaid claims data from 22 states to measure the extent to which beneficiaries with schizophrenia and bipolar disorder received EBPs in calendar year 2007, and identify characteristics of beneficiaries, state mental health systems, and Medicaid programs associated with the receipt of EBPs. The EBPs investigated included receipt of medications, continuity of medications, medication monitoring, psychosocial services, and preventive physical health care.

Although there was some state-to-state variation in the findings, the study found that, while more than 90 percent of beneficiaries with schizophrenia or bipolar disorder received an evidence-based medication during the year, only 61 percent of those beneficiaries continuously refilled their prescriptions. Medication level monitoring was provided to about half of beneficiaries taking lithium or anticonvulsants, and screening for common side effects of antipsychotics was provided even less frequently. Only 30 percent of beneficiaries received any preventive physical health services. In some states, less than half of beneficiaries received psychosocial services. Overall, only 5 percent received all of the following: a continuous supply of evidence-based medications, medication level monitoring and screenings for medication side effects, and psychosocial services. Medication continuity and monitoring was particularly poor among African American beneficiaries. Younger beneficiaries also had difficulty in maintaining continuous use of evidence-based medications.

Several Medicaid program characteristics and features of state mental health systems were associated with the receipt of EBPs. Specifically, copayments and prior authorization requirements for certain types of prescription drugs were associated with worse medication continuity even after accounting for several other Medicaid program and beneficiary characteristics. For both schizophrenia and bipolar disorder, enrollment in a comprehensive managed care plan was associated with worse medication continuity. However, these findings should be interpreted with caution, since the data for this study included relatively few managed care plans from few states. Although this study could not measure every factor that may influence the delivery of EBPs, the preliminary findings point to certain features of Medicaid programs and mental health systems that may impede the receipt of evidence-based care.

The findings underscore the need to improve the receipt of EBPs for Medicaid beneficiaries with schizophrenia and bipolar disorder, and point to some specific Medicaid policies, populations, and intervention strategies that require further consideration. With respect to Medicaid policies, the findings suggest that states should carefully consider the impact that prior authorization requirements and copayment amounts have on the ability of certain populations to receive continuous medications--medications that help beneficiaries maintain their stability and avoid hospitalization. An increase of even one dollar in the copayment amount may inversely impact the ability of some beneficiaries to receive needed medications. Other medication management practices that we were unable to measure in this study, such as fail-first policies, may also require further examination. Likewise, due to data limitations, we were unable to measure Medicaid policies and practices that may influence the delivery of psychosocial and preventive health services. Given the poor rates of these services in many states, there is a need to determine if any state-specific Medicaid practices or mental health system characteristics facilitate or impede the delivery of these services. Finally, we found a particular need to focus on improving care for African American and transition-age beneficiaries.

There are several national and state initiatives aimed at improving the quality of care for Medicaid beneficiaries with SPMI. These include efforts to integrate behavioral and physical health services and bolster the adoption of EBPs through provider certification and reimbursement. Several resources described in this report provide Medicaid programs, state mental health agencies, and providers with technical assistance and guidance to establish reimbursement strategies and service systems that support the delivery of EBPs. As state and federal agencies work to improve the delivery of EBPs, they may wish to use these findings as a benchmark for future progress and use Medicaid claims data for continued monitoring of services.