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Huskamp, Haiden

States must offer Medicaid coverage to low-income adults with disabilities; however, they have discretion in the design of eligibility criteria and enrollment processes. Using the American Community Survey, we examined the health insurance status of adults enrolled in the Supplemental Security Income (SSI) disability program including (1) the national rate of health insurance coverage; (2) state rates of uninsurance and Medicaid; and (3) the correlates of uninsurance. Uninsurance and Medicaid rates varied across states from 1% to 12% and from 63% to 91%, respectively. Nationally, 5% of the SSI population was uninsured; 77% was enrolled in Medicaid. Limited English proficiency, Black race, lack of U.S. citizenship, and residence in a state that used an enrollment process and/or eligibility criteria distinct from the SSI program were associated with uninsurance. As states streamline Medicaid enrollment processes to meet requirements of the Affordable Care Act, they should consider the needs of this vulnerable population.

Importance 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.

Objectives 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.

Design, Setting, and Participants 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).

Main Outcomes and Measures 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.

Results 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.

Conclusions and Relevance 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.

This study estimates how out-of-pocket drug costs could change for vulnerable populations (racial and ethnic minorities, the near-poor, and seniors with a greater burden of chronic conditions) who qualify for the standard Medicare drug benefit. Although the new benefit might be associated with modest-to-moderate declines in out-of-pocket spending for seniors who do not qualify for subsidies, the savings might not be shared equitably and therefore might not reduce financial barriers to medication use for these populations.

Background: The goal of the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act is to eliminate differences in insurance coverage between behavioral health and general medical care. The law requires out-of-network mental health benefits be equivalent to out-of-network medical/surgical benefits. Insurers were concerned this provision would lead to unsustainable increases in out-of-network related expenditures. We examined whether federal parity implementation was associated with significant increases in out-of-network mental health care use and spending. Methods: We conducted an interrupted time series analysis using health insurance claims from self-insured employers (2007–2012). We examined changes in the probability of using out-of-network mental health services and, conditional on out-of-network mental health service use, changes in the number of outpatient out-of-network mental health visits and total out-of-network mental health spending associated with the implementation of federal parity in 2010. Results: From 2007 to 2012, the proportion of individuals receiving any out-of-network mental health services each month declined dramatically from 18 to 12%, with a one-time drop of 3 percentage points at parity implementation (p < .01). Among out-of-network mental health service users, there was an increase in the number of visits per month (.12 visits; p < .01) and total spending per month ($49; p < .01) at parity implementation. Although there was a one-time increase in spending at parity implementation, this increase was accompanied by an attenuation of a trend toward increased spending growth, such that spending was back to original predictions by the end of our study period. Conclusions: Despite concerns expressed by the health insurance industry when federal parity was enacted, out-of-network mental health spending did not substantially increase after parity implementation. In addition, use of out-of-network mental health services appears to have contracted rather than expanded, suggesting insurers may have implemented other policies to curb out-of-network use, such as increasing access to in-network providers. Electronic supplementary material The online version of this article (doi:10.1186/s12913-017-2261-9) contains supplementary material, which is available to authorized users.

Objectives: Because of several recent clinical and regulatory changes regarding Attention Deficit Hyperactivity Disorder (ADHD) in the United States, we quantified changes in ADHD diagnosis and medication management from 2000 through 2010. Methods: We used the IMS Health National Disease and Therapeutic Index™, a nationally representative audit of office-based providers, to examine aggregate trends among children and adolescents under 18. We also quantified how diagnosis and treatment patterns have evolved based on patient and physician characteristics and the therapeutic classes used. Results: From 2000 to 2010, the number of physician outpatient visits where ADHD was diagnosed increased 66% from 6.2 million [M] (95% confidence intervals [CI] 5.5- 6.9M) to 10.4M visits (CI 9.3-11.6M). Of these visits, psychostimulants have remained the dominant treatment, used in 96% of treatment visits in 2000 and 87% of treatment visits in 2010. Atomoxetine use declined from 15% of treatment visits upon product launch in 2003 to 6% of treatment visits by 2010. The use of potential substitute therapies – clonidine, guanfacine, and bupropion – remained relatively constant (between 5-9% of treatment visits) during most of the period examined. Over this period, the ADHD management shifted towards psychiatrists (from 24% to 36% of all visits) without large changes in illness severity or the proportion of ADHD treatment visits accounted for by males (73%-77%). Conclusions: In ten years, the ambulatory diagnosis of ADHD increased by two-thirds and is increasingly managed by psychiatrists. The effects of these changing treatment patterns on children's health outcomes and their families are unknown.