Timothy B. Creedon

Access To Mental Health Care Increased But Not For Substance Use, While Disparities Remain

We assessed whether early implementation of Affordable Care Act (ACA) Medicaid expansion and state health insurance exchanges increased access to mental health and substance use treatment among those in need and whether these changes differed by racial/ethnic group. We found that mental health treatment rates increased significantly but found no evidence of a reduction in the wide racial/ethnic disparities in mental health treatment that preceded ACA expansion from 2005 to 2013.

The Role of Health Plans in Supporting Behavioral Health Integration

Health plan policies can influence delivery of integrated behavioral health and general medical care. This study provides national estimates for the prevalence of practices used by health plans that may support behavioral health integration. Results indicate that health plans employ financing and other policies likely to support integration. They also directly provide services that facilitate integration. Behavioral health contracting arrangements are associated with use of these policies. Delivery of integrated care requires systemic changes by both providers and payers thus health plans are key players in achieving this goal.

Private Health Plans’ Contracts with Managed Behavioral Healthcare Organizations

Contracts between health plans and managed behavioral health care organizations (MBHOs) influence access and quality of behavioral health care. This report presents information on performance requirements, information sharing, and financial risk from a nationally representative survey of private health plans. Most contracts include geographic access to providers (93.3%) and NCQA’s performance standards (84.2%). Health plans and MBHOs share data (99.0%), generally by the MBHO sending information to the health plan (96.3%). About a quarter of contracts impose financial penalties (23.0%), but few include incentives related to performance standards (<1.0%). Contract terms can shape the provision of behavioral health services in response to changes such as parity legislation or health reform. If current trends continue towards increases in value-based purchasing in the privately financed behavioral health sector, the focus on quality in contracts between health plans and MBHOs will be critical to understand.

Availability of outpatient methadone maintenance

Background Multiple forms of effective treatment for opioid use disorders (OUDs) exist, but they have remained in short supply and have been underutilized where available. Simultaneously, OUDs persist as a large and growing public health problem across the United States, leading to epidemic levels of overdose death as well as many other damaging societal consequences. Our goal was to assess the current state of the U.S. substance abuse treatment system and measure its capacity for treating OUDs. Focusing on outpatient methadone maintenance therapy (OPMM), an effective but less frequently studied treatment in recent years, we investigated two primary questions about privately-run substance abuse treatment facilities: 1) What facility-level characteristics best predicted the provision of OPMM? 2) How much of the variation in OPMM availability was attributable to differences between states?

Enhanced Child Psychiatry Access and Engagement via Integrated Care: A Collaborative Practice Model With Pediatrics

OBJECTIVE This study examined mental health service use outcomes for children receiving integrated care via a collaborative-practice model (CPM). The study hypothesis was that the delivery of intensively integrated clinical care within pediatrics, combined with community-based parent support from family support specialists (FSSs), would facilitate mental health or substance use disorder treatment access and engagement for youths at risk of experiencing disparities. METHODS The study sample consisted of 228 children referred by pediatricians for outpatient child psychiatry evaluation within an urban safety-net hospital system in 2013. In the pilot clinic, 32 youths were referred to the CPM intervention. Among the remaining seven clinics, 196 youths were referred to usual care (control group). Differences in treatment access and engagement between the intervention and control groups were assessed using propensity-score weighted logistic regression models. RESULTS Holding all else constant, children receiving the CPM intervention had four times higher odds of accessing psychiatric evaluations than children in the usual care control group (adjusted odds ratio [AOR]=4.16, p<.01). The odds of engagement (i.e., participation in follow-up appointments) were seven times greater for youths in the CPM than youths in the control group (AOR=7.54, p<.01). CONCLUSIONS Access and engagement were significantly higher for children receiving CPM than for usual care participants. This suggests that integrated CPM warrants further investigation as an approach for improving the odds that children and families will receive needed mental health or substance use disorder treatment.

Examining racial/ethnic differences in patterns of benzodiazepine prescription and misuse

BACKGROUND Benzodiazepines (BZDs) are widely prescribed during psychiatric treatment. Unfortunately, their misuse has led to recent surges in overdose emergency visits and drug-related deaths. METHODS Electronic health record data from a large healthcare system were used to describe racial/ethnic, sex, and age differences in BZD use and dependence. Among patients with a BZD prescription, we assessed differences in the likelihood of subsequently receiving a BZD dependence diagnosis, number of BZD prescriptions, receiving only one BZD prescription, and receiving 18 or more BZD prescriptions. We also estimated multivariate hazard models and generalized linear models, assessing racial/ethnic differences after adjustment for covariates. RESULTS In both unadjusted and adjusted analyses, Whites were more likely than Blacks, Hispanics, and Asians to have a BZD dependence diagnosis and to receive a BZD prescription. Racial/ethnic minority groups received fewer BZD prescriptions, were more likely to have only one BZD prescription, and were less likely to have 18 or more BZD prescriptions. We identified greater BZD misuse among older patients but no sex differences. CONCLUSIONS Findings from this study add to the emerging evidence of high relative rates of prescription drug abuse among Whites. There is a concern, given their greater likelihood of having only one BZD prescription, that Blacks, Hispanics, and Asians may be discontinuing BZDs before their clinical need is resolved. Research is needed on provider readiness to offer racial/ethnic minorities BZDs when indicated, patient preferences for BZDs, and whether lower prescription rates among racial/ethnic minorities offer protection against the progression from prescription to addiction.

Behavioral Health Coverage Under the Affordable Care Act: What Can We Learn From Marketplace Products?

OBJECTIVE The 2008 federal parity law and the 2010 Affordable Care Act (ACA) sought to expand access to behavioral health services. There was concern that health plans might discourage enrollment by individuals with behavioral health conditions who tend to be higher cost. This study compared behavioral health benefits available in the group insurance market (nonmarketplace) to those sold through the ACA marketplaces to check for evidence of less generous behavioral health coverage in marketplace plans. METHODS Data were from a 2014 nationally representative survey of commercial health plans regarding behavioral health services (80% response rate). The sample included the most common silver marketplace product and, as a comparison, the most common nonmarketplace product of the same type (for example, health maintenance organization or preferred provider organization) from each health plan (N=106 marketplace and nonmarketplace pairs, or 212 products). RESULTS Marketplace and nonmarketplace products were similar in terms of coverage, prior authorization, and continuing review requirements. Marketplace products were more likely to employ narrow and tiered behavioral health provider networks. Narrow and tiered networks were more common in state than in federal marketplaces. CONCLUSIONS Provider network design is a tool that health plans may use to control cost and possibly discourage enrollment by high-cost users, including those with behavioral health conditions. The ACA was successful in ensuring robust behavioral health coverage in marketplace plans. As the marketplaces evolve or are replaced, these data provide an important baseline to which future systems can be compared.

Commercial Health Plan Coverage of Selected Treatments for Opioid Use Disorders from 2003 to 2014

ABSTRACT Opioid use disorders (OUDs) are receiving significant attention in the U.S. as a public health crisis. Access to treatment for OUDs is essential and was expected to improve following implementation of the federal parity law and the Affordable Care Act. This study examines changes in coverage and management of treatments for OUDs (opioid treatment programs (OTPs) as a covered service benefit, buprenorphine as a pharmacy benefit) before, during, and after parity and ACA implementation. Data are from three rounds of a nationally representative survey conducted with commercial health plans regarding behavioral health services in benefit years 2003, 2010, and 2014. Data were weighted to be representative of health plans’ commercial products in the continental United States (2003 weighted N = 7,469, 83% response rate; 2010 N = 8,431, 89% response rate; and 2014 N = 6,974, 80% response rate). Results showed treatment for OUDs was covered by nearly all health plan products in each year of the survey, but the types and patterns varied by year. Prior authorization requirements for OTPs have decreased over time. Despite the promise of expanded access to OUD treatment suggested by parity and the ACA, improved health plan coverage for treatment of OUDs, while essential, is not sufficient to address the opioid crisis.