Increasing Access to Therapy Services for Medicaid Children with Mental Health Needs in a Western State
AuthorBowlen, Tiana L.
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Background: Children, ages (0 to 21), who were enrolled in a Western State's fee for service (FFS) plan under Medicaid were being placed on waiting lists and experienced limited availability of providers to deliver therapeutic services. As a result, the State's Medicaid program implemented a reformulation of its behavioral health system with the intention of increasing access to behavioral health services, increasing the capacity of behavioral health providers, and expanding coverage of behavioral health services. The increase in access to therapeutic services was intended to relax the capacity constraint, subsequently increasing the level of care for children with behavioral health needs. Aims of Study: This study evaluates whether the reformulation actually increased access to behavioral health services for children (0-21 years old) and if the reformulation is associated with improved outcomes. Outcomes will be measured as both quantities and costs. Methods: The data was extracted from medical and pharmacy claims, the eligibility file, and the prior authorization file beginning 1 January two years before implementation of the program changes, through 31 December three years after implementation. The study design is a pre-post comparison for the treatment group of eligible persons defined as those who with behavioral health diagnoses in the before period, compared to those who did not. Children were identified as having a behavioral health diagnosis if they had any treatment coded with a behavioral health diagnosis, a prescription for a behavioral health medication or treatment by a behavioral health provider. Therefore, a non-linear difference in difference (DD) approach is used to examine the impact of the increase in access to therapy on stated outcomes. Additionally, analysis will be performed separately on those who are in state custody and those who are in parental custody. Results: There are four main implications from the research. First, the increase in access to therapeutic services decreased the overall costs from Medicaid claims. This was primarily due to a decrease in physical health costs, which refutes the null hypothesis that the reduction would be in mental health costs. However, it is thought that this is a result of the child receiving better care under the expansion of services, thereby reducing the number of inconsequential physical health visits. Second, the increase in access to therapeutic services resulted in lower therapeutic costs as well as lower overall therapeutic visits. The number of visits of therapeutic services provided by specialty therapists decreased by almost the same amount that visits for therapeutic services with physicians and nurse practitioners increased, indicating a substitution of services. It was originally assumed that this finding was due to a reduction in the marginal use of services; however, in discussions with the state it was found that there may have been a simultaneous reduction in rates. Future research should include time dummy variables for each six month period to account for possible rate changes.Third, indicators of whether or not the increase in services resulted in better care for children yield mixed results. Mental health drugs increased, which could indicate that children are now receiving the medications that they need or are being ove-rmedicated. The number of visits, length of stay, and costs of Residential Treatment Center's increased except for children in parental custody, which resulted in a decrease in cost. These coefficients were also shown to change significantly in magnitude when the robustness of the results was checked by taking out patients with negative overall physical health paid. However, one irrefutable outcome is inpatient psychiatric facility admissions. This DD estimate decreased for all patients, regardless of custodianship, and this is one of the most expensive and intensive forms of treatment, which is a positive outcome for patients who received more access to therapy.Lastly, the impact of reformulation on the service mix differs for children in state custody compared to those in parental custody. One difference is in RTC's, in which children in parental custody had less visits and shorter lengths of stay. Another notable difference is in physical health paid, children in state custody had a larger reduction in physical health care, yet children in parental custody had a much larger decrease in physical health prescriptions.