Use of behavioral health care in Medicaid managed care carve‐out versus carve‐in arrangements

Abstract

Objective To evaluate differences in access to behavioral health services for Medicaid enrollees covered by a Medicaid entity that integrated the financing of behavioral and physical health care (“carve‐in group”) versus a Medicaid entity that separated this financing (“carve‐out group”). Data Sources/Study Setting Medicaid claims data from two Medicaid entities in the Portland, Oregon tri‐county area in 2016. Study Design In this cross‐sectional study, we compared differences across enrollees in the carve‐in versus carve‐out group, using a machine learning approach to incorporate a large set of covariates and minimize potential selection bias. Our primary outcomes included behavioral health visits for a variety of different provider types. Secondary outcomes included inpatient, emergency department, and primary care visits. Data Collection We used Medicaid claims, including adults with at least 9 months of enrollment. Principal Findings The study population included 45,786 adults with mental health conditions. Relative to the carve‐out group, individuals in the carve‐in group were more likely to access outpatient behavioral health (2.39 percentage points, p < 0.0001, with a baseline rate of approximately 73%). The carve‐in group was also more likely to access primary care physicians, psychologists, and social workers and less likely to access psychiatrists and behavioral health specialists. Access to outpatient behavioral health visits was more likely in the carve‐in arrangement among individuals with mild or moderate mental health conditions (compared to individuals with severe mental illness) and among black enrollees (compared to white enrollees). Conclusions Financial integration of physical and behavioral health in Medicaid managed care was associated with greater access to behavioral health services, particularly for individuals with mild or moderate mental health conditions and for black enrollees. Recent changes to incentivize financial integration should be monitored to assess differential impacts by illness severity, race and ethnicity, provider types, and other factors.

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

“…Some states have created carve‐in or carve‐out models for specific populations, such as enrollees with SMI or substance use disorders 23,43 . Given the moderately differential impacts of this study and the study by Charlesworth and colleagues, 22 additional considerations for these targeted carve‐in approaches may be warranted.…”

“…A more recent RAND assessment 35 of states' experiences in adopting a behavioral health carve-in model found only three studies that examined the outcomes of the carve-in model with rigorous quasiexperimental designs. 22,36,37 These single-state studies were somewhat inconsistent in their findings, with two studies finding increased behavioral health access with the carve-in and one finding decreased access. Our study differs from these studies in the longer (nearly fouryear) period of post-intervention observations and a relative lack of confounding policies.…”

“…Frank and Garfield's 2007 review of behavioral health carve‐outs in Medicaid and commercial markets was generally favorable, concluding that “[a]lthough not perfect, carve‐outs have been instrumental in addressing long‐standing challenges in utilization, access, and cost of behavioral health care.” 34 Within Medicaid, their review found carve‐outs to be associated with lower utilization of psychiatric inpatient services but did not find strong associations with outpatient utilization or quality. A more recent RAND assessment 35 of states' experiences in adopting a behavioral health carve‐in model found only three studies that examined the outcomes of the carve‐in model with rigorous quasi‐experimental designs 22,36,37 . These single‐state studies were somewhat inconsistent in their findings, with two studies finding increased behavioral health access with the carve‐in and one finding decreased access.…”

“…Enrollees with SMI may be more likely to receive health care through community mental health centers, which may have long‐standing relationships with behavioral health carve‐outs. Thus, they may be impacted differentially by financial integration relative to enrollees with mild or moderate mental health conditions, who may receive most of their care in primary care settings 22,23 …”

“…Thus, they may be impacted differentially by financial integration relative to enrollees with mild or moderate mental health conditions, who may receive most of their care in primary care settings. 22,23 2 | METHODS reporting guidelines (see Data S1). 24…”