The effects of behavioral health integration in Medicaid managed care on access to mental health and primary care services—Evidence from early adopters

Abstract

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.

Access, Utilization, and Quality of Behavioral Health Integration in Medicaid Managed Care

“…We also tested the association of integrated care with measures associated with social determinants of health, including rates of homelessness, arrests, and employment, reflecting the increased interest by states in these measures and the hypothesis that if integration improves overall health, it could translate to improvements in these broader measures of well-being. We conducted separate analyses for (1) enrollees with SMI, (2) enrollees with mild or moderate mental illness (MMI), and (3) enrollees classified as having no mental illness, anticipating that the IMC effort would have heterogeneous associations with these populations . We supplemented the quantitative analyses with qualitative interviews, providing context of the on-the-ground experience of the IMC implementation.…”

“…A separate study of access measures in IMC focused exclusively on group 1, allowing for 15 quarters (almost 4 years) of postintervention observations. 18 That study found a slight increase in access to primary care (an increase of 2 percentage points from a baseline of 61%) but no changes in access to outpatient mental health services or the use of hospital or ED services for mental health. Our claims data may not be a full representation of all behavioral health encounters during the study period, and…”

“…Because preliminary analyses indicated that its prepolicy trends were significantly different than other groups and because a separate article assessed changes that isolated the first group, 18 we omitted these counties in our main analysis. We tested the implications of this group's inclusion in sensitivity analyses.…”

“…We observed at most 8 postintervention quarters, and only 4 quarters for group 3, the largest of the county groups. A separate study of access measures in IMC focused exclusively on group 1, allowing for 15 quarters (almost 4 years) of postintervention observations . That study found a slight increase in access to primary care (an increase of 2 percentage points from a baseline of 61%) but no changes in access to outpatient mental health services or the use of hospital or ED services for mental health.…”

“…We conducted separate analyses for (1) enrollees with SMI, (2) enrollees with mild or moderate mental illness (MMI), and (3) enrollees classified as having no mental illness, anticipating that the IMC effort would have heterogeneous associations with these populations. 18,19 We supplemented the quantitative analyses with qualitative interviews, providing context of the on-the-ground experience of the IMC implementation.…”