Joan Dilonardo

Factors associated with the receipt of treatment following detoxification

This paper examines the determinants of whether an individual received continuing treatment/rehabilitation services 30 days after receiving inpatient substance abuse detoxification. Data came from 1997-1999 employer health insurance claims. Only 49.4% of detoxification episodes were followed by continuing mental health or substance abuse treatment within 30 days after discharge. Some of the factors positively associated with receiving continuing treatment after receiving detoxification included: female gender, being in a behavioral health carve-out plan, and lower cost-sharing requirements for an outpatient substance abuse visit.

The impact of managed care on the substance abuse treatment patterns and outcomes of medicaid beneficiaries: Maryland's health choice program

The introduction of Medicaid managed care raises concern that profit motives lead to the undersupply of substance abuse (SA) services. To test effects of the Maryland Medicaid HealthChoice program on SA treatment patterns and outcomes, Medicaid eligibility files were linked to treatment provider records and two study designs were used to estimate program impact: a quasi-experimental design with matched comparison groups and a natural experiment. Patient sociodemographic and clinical characteristics were adjusted using multiple regression. Under managed care, there was a shift from residential, correctional-only, and detoxification-only treatment toward outpatient-only treatment. Among beneficiaries entering treatment, those enrolled in managed care organizations (MCOs) had similar utilization and outcomes to those in Medicaid fee-for-service; those enrolling in MCOs during treatment had longer and more intensive episodes and, as a result, better outcomes. Thus, the study disclosed no empirical evidence that health plans respond to capitation by reducing SA services.

State Substance Abuse and Mental Health Managed Care Evaluation Program

The articles in this special section of the Journal of Behavioral Health Services & Research (30:1) present results from evaluations of publicly funded managed care initiatives for substance abuse and mental health treatment in Arizona, Iowa, Maryland, and Nebraska. This overview outlines the four managed care programs and summarizes the results from the studies. The evaluations used administrative data and suggest a continuing challenge to structure plans so that undesired deleterious effects associated with adverse selection are minimized. Successful plans balanced risk with limited revenues so that they permitted greater access to less intensive services. Shifts from inpatient services to outpatient care were noted in most states. Future evaluations might conduct patient interviews to examine the effectiveness and quality of services for mental health and substance abuse problems more closely.

How Did the Introduction of Managed Care for the Uninsured in Iowa Affect the Use of Substance Abuse Services

Concerns about access under managed care have been raised for vulnerable populations such as publicly funded patients with substance abuse problems. To estimate the effects of the Iowa Managed Substance Abuse Care Plan (IMSACP) on substance abuse service use by publicly funded patients, service use before and after IMSACP was compared; adjustments were made for changes in population sociodemographic and clinical characteristics. Between fiscal years 1994 and 1997, patient case mix was marked by a higher burden of illness and the use of inpatient, residential non-detox, outpatient counseling, and assessment services declined, while use of intensive outpatient and residential detox services increased. Findings were similar among women, children, and homeless persons. Thus, care moved away from high-cost inpatient settings to less costly venues. Without knowing the impact on treatment outcomes, these changes cannot be interpreted as improved provider efficiency versus simply cost containment and profit maximization.

Transforming Mental Health and Substance Abuse Data Systems in the United States

State efforts to improve mental health and substance abuse service systems cannot overlook the fragmented data systems that reinforce the historical separateness of systems of care. These separate systems have discrete approaches to treatment, and there are distinct funding streams for state mental health, substance abuse, and Medicaid agencies. Transforming mental health and substance abuse services in the United States depends on resolving issues that underlie separate treatment systems--access barriers, uneven quality, disjointed coordination, and information silos across agencies and providers. This article discusses one aspect of transformation--the need for interoperable information systems. It describes current federal and state initiatives for improving data interoperability and the special issue of confidentiality associated with mental health and substance abuse treatment data. Some achievable steps for states to consider in reforming their behavioral health data systems are outlined. The steps include collecting encounter-level data; using coding that is compliant with the Health Insurance Portability and Accountability Act, including national provider identifiers; forging linkages with other state data systems and developing unique client identifiers among systems; investing in flexible and adaptable data systems and business processes; and finding innovative solutions to the difficult confidentiality restrictions on use of behavioral health data. Changing data systems will not in itself transform the delivery of care; however, it will enable agencies to exchange information about shared clients, to understand coordination problems better, and to track successes and failures of policy decisions.

Type of health insurance and the substance abuse treatment gap

OBJECTIVE Most individuals reporting symptoms consistent with substance use disorders do not receive care. This study examines the correlation between type of insurance coverage and receipt of substance abuse treatment, controlling for other observable factors that may influence treatment receipt. METHOD Descriptive and multivariate analyses are conducted using pooled observations from the 2002-2007 editions of the National Survey on Drug Use and Health. The likelihood of treatment entry is estimated by type of insurance coverage controlling for personal characteristics and characteristics of the individuals substance use disorder. RESULTS Multivariate analyses that control for type of substance and severity of disorder (dependence vs. abuse) find that those with Civilian Health and Medical Program of the Uniformed Services/Veterans Affairs, Medicaid only, Medicare only, and Medicare and Medicaid (dual eligibles) have 50% to almost 90% greater odds of receiving treatment relative to those with private insurance. CONCLUSIONS The privately insured population has substantially lower treatment entry rates than those with publicly provided insurance. Additional research is warranted to understand the source of the differences across insurance types so that improvements can be achieved.

Psychiatric and medical comorbidities, associated pain, and health care utilization of patients prescribed buprenorphine.

This study describes the comorbidities and health care utilization of individuals treated with buprenorphine using the 2007-2009 MarketScan Research Databases. Buprenorphine recipients had a high prevalence of comorbidities associated with chronic pain, including back problems (42%), connective tissue disease (24-27%), and nontraumatic joint disorders (20-23%). Approximately 69% of recipients filled prescriptions for opioid agonist medications in the 6 months before buprenorphine initiation. Buprenorphine recipients were frequently diagnosed with anxiety (23-42%) and mood disorders (39-51%) and filled prescriptions for antidepressants (47-56%) and benzodiazepines (47-56%) at high rates. Surprisingly, only 53-54% of patients filling a prescription for buprenorphine had a coded opioid abuse/dependence diagnosis. Research is needed to better understand buprenorphines effectiveness in the context of prescription drug abuse and the best way to coordinate services to address the patients comorbid addiction, pain, and psychiatric illnesses.

Inpatient Utilization for Persons With Co-occurring Disorders

People with co-occurring mental and substance use disorders have been shown to be frequent users of inpatient care (1). Such studies, however, are limited to a single funding stream, type of disorder, or locale. Given recent emphasis on improving care for people with such co-occurring disorders, better estimates of inpatient utilization are important to aid design of effective, efficient public mental health and substance abuse services. This column describes use of inpatient care in Delaware, Oklahoma, and Washington by clients who received at least one mental health or substance abuse service from the state mental health, substance abuse, or Medicaid agency in calendar year 1997 (2). Administrative files of these clients were matched across those agencies and categorized into three diagnostic groups: mental disorder only, substance use disorder only, and co-occurring mental and substance use disorders. Results were expected to differ across states because of potential differences in the case mix of patients served, types and amounts of services supported, regional variation in clinical practice, population dispersion and density, organization of each state authority administering services, managed care involvement, total dollars devoted to such services, and other factors. Clients with co-occurring disorders were three to four times more likely to be hospitalized than clients with mental illness only and ten to 20 times more likely to be admitted than clients with a substance use disorder only. The average number of inpatient days per admitted client differed across states by more than 100% for each diagnostic group (Figure 1). Despite the divergence in absolute values across states, in each state the length of inpatient stays were longest for admitted clients with mental illness only, followed by those with co-occurring disorders and those with a substance use disorder only. Yet across all clients, not just those admitted, the annual average number of hospital days per group was highest for the group with co-occurring disorders (data not shown). Further study is needed to assess factors associated with higher admission rates for clients with co-occurring mental and substance use disor

Mental health and substance abuse treatment utilization among individuals served by multiple public agencies in 3 states.

Patterns of mental health (MH) and substance abuse (SA) treatment utilization among populations receiving services through multiple public programs are not well known. This study examines to what extent populations with MH and/or SA conditions utilize treatment services through Medicaid and State MH/SA Agencies. Data are from the Substance Abuse and Mental Health Services Administration Integrated Database, a multiyear file for 3 states combining Medicaid and State MH/SA Agency administrative data into a uniform database. Although populations with co-occurring conditions and those served by both Medicaid and State MH/SA Agencies have substantial contact with the public treatment system, a majority of the MH/SA populations examined here utilize few services over brief periods of time. Utilization is most limited among individuals with MH-only conditions and those served exclusively by Medicaid. While a lack of data on clinical outcomes prevents us from drawing conclusions about the effectiveness of MH/SA services, results of this analysis indicate that public programs in the states examined here do not provide services that are primarily utilized on a frequent or chronic basis.

Healthcare utilization of individuals with opiate use disorders: an analysis of integrated medicaid and state mental health/substance abuse agency data.

Data from the Substance Abuse and Mental Health Services Administration’s Integrated Database (IDB) were used to examine the service use patterns of individuals with possible opiate use disorders in Washington State. Results indicate that regardless of Medicaid enrollment status, individuals who received mental health (MH) or substance abuse (SA) services only through state agencies received no inpatient substance abuse service. Furthermore, when compared with individuals who received at least one MH/SA service through Medicaid, those who received services only through the state agencies were less likely to have received any MH services and were more likely to have received residential SA services. This analysis highlights the importance of using integrated client data in providing a more comprehensive understanding of services to inform policy and raises significant questions about how regulatory requirements affecting different funding mechanisms might drive settings of care in ways not related to the care needed.