부산대학교 도서관

Objective: To evaluate the impacts of a transition to an 'integrated managed care' model, wherein Medicaid managed care organizations moved from a 'carve-out' model to a 'carve-in' model integrating the financing of behavioral and physical health care. Data Sources/Study Setting: Medicaid claims data from Washington State, 2014-2019, supplemented with structured interviews with key stakeholders. Study Design: This mixed-methods study used difference-in-differences models to compare changes in two counties that transitioned to financial integration in 2016 to 10 comparison counties maintaining carve-out models, combined with qualitative analyses of 15 key informant interviews. Quantitative outcomes included binary measures of access to outpatient mental health care, primary care, the emergency department (ED), and inpatient care for mental health conditions. Data Collection: Medicaid claims were collected administratively, and interviews were recorded, transcribed, and analyzed using a thematic analysis approach. Principal Findings: The transition to financially integrated care was initially disruptive for behavioral health providers and was associated with a temporary decline in access to outpatient mental health services among enrollees with serious mental illness (SMI), but there were no statistically significant or sustained differences after the first year. Enrollees with SMI also experienced a slight increase in access to primary care (1.8%, 95% CI 1.0%-2.6%), but no sustained statistically significant changes in the use of ED or inpatient services for mental health care. The transition to financially integrated care had relatively little impact on primary care providers, with few changes for enrollees with mild, moderate, or no mental illness. Conclusions: Financial integration of behavioral and physical health in Medicaid managed care did not appear to drive clinical transformation and was disruptive to behavioral health providers. States moving towards 'carve-in' models may need to incorporate support for practice transformation or financial incentives to achieve the benefits of coordinated mental and physical health care. KEYWORDS managed care, Medicaid, mental health What is known on this topic * Managed care 'carve outs' of behavioral health charge a separate entity for holding financial risk and managing behavioral health services. * Many state Medicaid programs are moving away from 'carve outs' to an integrated 'carve in' model (with a single managed care organization responsible for managing physical and behavioral health). * Relatively little is known about the potential implications of these models on access to mental health services and whether impacts vary by severity of mental health conditions. What this study adds * A transition to financially integrated care in Washington State was initially disruptive for behavioral health providers but had relatively little impact on primary care providers. * Integrated managed care was not associated with sustained, significant changes in access to outpatient mental health care, although enrollees with serious mental illness experienced slight increases in access to primary care. * Carving in behavioral health may create some administrative simplification for enrollees, but additional efforts-such as support for practice transformation--may be necessary to enhance access to care.
1 | INTRODUCTION Medicaid is the single largest financier of mental health care in the United States, (1) paying for at least 25% of all mental health services in the [...]