An analysis of Medicaid data released today from five states indicates that psychiatric and substance abuse services may be missing their mark if they are limited to community settings, such as community clinics and therapist's offices.
"Although most intervention policies for co-occurring substance abuse and mental disorders are community-based, a significant number of people with co-occurring disorders never appear in these settings," said study co-author Robin E. Clark, Director of Research, Center for Health Policy and Research, University of Massachusetts Medical School. "Substance abuse actually lowers the odds of being treated in a community setting."
The study, funded by the Robert Wood Johnson Foundation's Substance Abuse Policy Research Program (SAPRP), shows that when Medicaid beneficiaries have co-occurring disorders, their odds of inpatient and emergency department use and hospital-based psychiatric treatment go up and use of community services goes down, as compared to beneficiaries with just one disorder.
This pattern was clear both for persons with severe and less severe mental disorders. The study was published in the July 2007 issue of Psychiatric Services.
This is occurring despite the fact that primary care studies indicate that continuity of treatment is weaker and costs are higher in hospital settings and data suggest that people treated in these settings have higher rates of inpatient treatment, the authors say.
"We need to provide treatment to people wherever they appear in the treatment system instead of increasing treatment in one settingsuch as the community-based settingand hoping they come there," said Clark.
Psychiatric disorders and substance abuse are major problems for the Medicaid population. Diagnosed psychiatric and substance use disorders are from fifty percent to one hundred percent more prevalent among Medicaid beneficiaries than in the general population. Medicaid funds half of state and local support of mental illness treatments and one-third of specialty substance abuse treatment.
The authors set out to understand where integrated psychiatric and substance abuse services may need to be provided for Medicaid beneficiaries. They examined the location of services used by persons with mental and substance use disorders from 1999 Medicaid data obtained from the Centers for Medicare and Medicaid Services for five states: Arkansas, Colorado, Indiana, New Jersey, and Washington.
Robin E. Clark, Ph.D., and Mihail Samnaliev, Ph.D., at the Center for Health Policy and Research, University of Massachusetts Medical School, and Mark P. McGovern, Ph.D., Psychiatric Research Center, Dartmouth Medical School, analyzed whether beneficiaries with co-occurring disorders were treated in community-based settings, inpatient facilities, emergency departments, or hospital outpatient departments.
The full dataset of close to 126,513 beneficiaries ages 21 through 64 included 17,952 Medicaid beneficiaries with co-occurring disorders. Three-fourths of patients with co-occurring disorders were younger than age 45. Racial and ethnic minorities made up a substantial proportion of the population, ranging from 20.8% in Indiana to 61.2% in New Jersey.
Heavy inpatient and emergency department use were common among Medicaid beneficiaries with co-occurring disorders. One in five beneficiaries treated in these settings received no Medicaid funded behavioral health treatment elsewhere. Beneficiaries with co-occurring disorders were three to six times more likely to be hospitalized for psychiatric treatment during 1999 than were those with a mental health diagnosis alone.
Arkansas was the one state in which co-occurring disorders did not reduce the odds that patients would receive community-based mental health treatment. The authors suggest that reimbursement policies favoring community mental health centers may increase the likelihood of receiving community treatment.
Calling for a 'no wrong door' approach for Medicaid populations, the authors conclude that attempts to improve mental health and substance abuse treatment for Medicaid beneficiaries with co-occurring disorders should be broad based, focusing on hospital inpatient, emergency department, and outpatient services as well as on community based providers.
In fact, " Promising brief interventions for co-occurring disorders designed especially for emergency departments and trauma centers are currently available," says Clark.