Mental health service utilization review patterns in a Medicaid managed care program.

OBJECTIVES: The current study investigated mental health utilization review (UR) clinical service authorization requests, denials, and reasons for denial in a statewide Medicaid managed care organization (MMCO) program. STUDY DESIGN: Retrospective analysis of utilization review data reported by MMCOs in New York State. METHODS: Data from the utilization review practices of 15 MMCOs were collected and analyzed for calendar years 2017 and 2018. The data reported are specific to mental health services and include the number of authorization requests, number of clinical denials, and the reasons specified for each denial. Analyses were undertaken to determine the UR denial rates and most common reasons for denials. RESULTS: A total of 264,901 requests for inpatient mental health service authorizations and 53,687 requests for outpatient mental health service authorizations were made in 2017 and 2018. Of these, 1.5% of inpatient authorization requests and 0.4% of outpatient authorization requests were denied for reasons related to medical necessity. The most common reason for inpatient mental health service denials was that the patient no longer met the standard for the requested level of care. CONCLUSIONS: Low UR denial rates warrant further examination of the relationship between UR and both quality of care and patient outcomes in mental health care. With the substantial resources spent on UR, findings could point to areas of potential reforms to the system that may minimize these costs and improve care for patients with mental illness.

Using claims data to generate clinical flags predicting short-term risk of continued psychiatric hospitalizations.

OBJECTIVE: As health information technology advances, efforts to use administrative data to inform real-time treatment planning for individuals are increasing, despite few empirical studies demonstrating that such administrative data predict subsequent clinical events. Medicaid claims for individuals with frequent psychiatric hospitalizations were examined to test how well patterns of service use predict subsequent high short-term risk of continued psychiatric hospitalizations. METHODS: Medicaid claims files from New York and Pennsylvania were used to identify Medicaid recipients ages 18-64 with two or more inpatient psychiatric admissions during a target year ending March 31, 2009. Definitions from a quality-improvement initiative were used to identify patterns of inpatient and outpatient service use and prescription fills suggestive of clinical concerns. Generalized estimating equations and Markov models were applied to examine claims through March 2011, to see what patterns of service use were sufficiently predictive of additional hospitalizations to be clinically useful. RESULTS: A total of 11,801 individuals in New York and 1,859 in Pennsylvania identified met the cohort definition. In both Pennsylvania and New York, multiple recent hospitalizations, but not failure to use outpatient services or failure to fill medication prescriptions, were significant predictors of high risk of continued frequent hospitalizations, with odds ratios greater than 4.0. CONCLUSIONS: Administrative data can be used to identify individuals at high risk of continued frequent hospitalizations. Payers and system administrators could use such information to authorize special services (such as mobile outreach) for such individuals to promote service engagement and prevent rapid rehospitalizations.

Factors associated with initiation on clozapine and on other antipsychotics among Medicaid enrollees.

OBJECTIVE: Demographic and clinical factors associated with starting clozapine and other antipsychotics were examined. METHODS: New York State Medicaid claims from 2008 to 2009 identified individuals with a schizophrenia spectrum disorder, continuous Medicaid eligibility during the study, and at least one clinic service and antipsychotic fill. The sample included individuals who initiated an antipsychotic without any fills for the same medication in the prior 90 days (N=7,035). RESULTS: Only 144 patients (2%) started on clozapine. They were more likely to be younger, white males who had received services in a state-operated facility, with more hospital admissions and higher total psychiatric costs. African Americans and Hispanics were less likely than whites to start on clozapine. Individuals with substance use disorders were less likely than those without them to start on clozapine. CONCLUSIONS: Clozapine was rarely prescribed, and problematic disparities were found. Quality improvement efforts are needed to ensure that patients are offered this effective treatment when appropriate.