Comparative Effectiveness Research and Treatment of Serious Mental Illnesses in Medicaid

Medicaid is a critical source of health care coverage for individuals with serious and persistent mental health conditions. As one of the largest purchasers of health and mental health services, state Medicaid programs have an opportunity to support the delivery of the latest evidence-based practices. Mathematica identified Medicaid policies and payment practices that might facilitate or impede the delivery of evidence-based practices for individuals with schizophrenia and bipolar disorder.

The research team conducted a literature review to identify pharmacologic and psychosocial evidence-based practices for schizophrenia and bipolar disorder and the features of state Medicaid programs and mental health systems that may influence the delivery of those practices. Researchers used Medicaid Analytic eXtract (MAX) data to examine the extent to which state-specific Medicaid features are associated with the delivery of evidence-based practices. These Medicaid features include states’ managed care arrangements, prescription medication policies, and relationships with state mental health agencies. The research team also conducted an extensive analysis of the completeness and reliability of MAX behavioral health managed care data and developed strategies for measuring evidence-based practices in MAX.

Findings

Although there was some state-to-state variation in the findings, the study found that:

• While more than 90 percent of beneficiaries with schizophrenia or bipolar disorder received an evidence-based medication during the year, only 61 percent of those beneficiaries continuously refilled their prescriptions. Medication continuity and monitoring was particularly poor among African American beneficiaries. Younger beneficiaries also had difficulty in maintaining continuous use of evidence-based medications.
• Medication level monitoring was provided to about half of beneficiaries taking lithium or anticonvulsants, and screening for common side effects of antipsychotics was provided even less frequently.
• Only 30 percent of beneficiaries received any preventive physical health services.
• In some states, less than half of the beneficiaries received psychosocial services.
• Overall, only 5 percent received all of the following: a continuous supply of evidence-based medications, medication level monitoring and screenings for medication side effects, and psychosocial services.
• Several Medicaid program characteristics and features of state mental health systems were associated with the receipt of EBPs:
• Copayments and prior authorization requirements for certain types of prescription drugs were associated with worse medication continuity even after accounting for several other Medicaid program and beneficiary characteristics.
• For both schizophrenia and bipolar disorder, enrollment in a comprehensive managed care plan was associated with worse medication continuity.

The findings underscore the need to improve the receipt of EBPs for Medicaid beneficiaries with schizophrenia and bipolar disorder, and point to some specific Medicaid policies, populations, and intervention strategies that require further consideration.