Center for Health Systems Effectiveness, Oregon Health & Science University, Portland.
Department of Family Medicine, Oregon Health & Science University, Portland.
JAMA Health Forum. 2023 Dec 1;4(12):e234593. doi: 10.1001/jamahealthforum.2023.4593.
Many states have moved from models that carve out to those that carve in or integrate behavioral health in their Medicaid managed care organizations (MCOs), but little evidence exists about the effect of this change.
To assess the association of the transition to integrated managed care (IMC) in Washington Medicaid with health services use, quality, health-related outcomes, and measures associated with social determinants of health.
DESIGN, SETTING, AND PARTICIPANTS: This cohort study used difference-in-differences analyses of Washington State's 2014 to 2019 staggered rollout of IMC on claims-based measures for enrollees in Washington's Medicaid MCO. It was supplemented with interviews of 24 behavioral health agency leaders, managed care administrators, and individuals who were participating in the IMC transition. The data were analyzed between February 1, 2023, and September 30, 2023.
Claims-based measures of utilization (including specialty mental health visits and primary care visits); health-related outcomes (including self-harm events); rates of arrests, employment, and homelessness; and additional quality measures.
This cohort study included 1 454 185 individuals ages 13 to 64 years (743 668 female [51.1%]; 14 306 American Indian and Alaska Native [1.0%], 132 804 Asian American and Pacific Islander [9.1%], 112 442 Black [7.7%], 258 389 Hispanic [17.8%], and 810 304 White [55.7%] individuals). Financial integration was not associated with changes in claims-based measures of utilization and quality. Most claims-based measures of outcomes were also unchanged, although enrollees with mild or moderate mental illness experienced a slight decrease in cardiac events (-0.8%; 95% CI, -1.4 to -0.2), while enrollees with serious mental illness experienced small decreases in employment (-1.2%; 95% CI -1.9 to -0.5) and small increases in arrests (0.5%; 95% CI, 0.1 to 1.0). Interviews with key informants suggested that financial integration was perceived as an administrative change and did not have substantial implications for how practices delivered care; behavioral health agencies lacked guidance on how to integrate care in behavioral health settings and struggled with new contracts and regulatory policies that may have inhibited the ability to provide integrated care.
The results of this cohort study suggest that financial integration at the MCO level was not associated with significant changes in most measures of utilization, quality, outcomes, and social determinants of health. Additional support, including monitoring, training, and funding, may be necessary to drive delivery system changes to improve access, quality, and outcomes.
许多州已经从划出模式转变为在其医疗补助管理式医疗组织 (MCO) 中纳入或整合行为健康模式，但关于这种转变的效果证据很少。
评估华盛顿州医疗补助的综合管理式医疗 (IMC) 过渡对健康服务使用、质量、健康相关结果以及与健康相关社会决定因素相关措施的影响。
设计、设置和参与者：这项队列研究使用了华盛顿州在 2014 年至 2019 年期间交错推出的 IMC 的差异差异分析，以评估基于索赔的措施对参与华盛顿州 MCO 医疗补助的参与者的影响。它还补充了对 24 名行为健康机构负责人、管理式医疗管理员和正在参与 IMC 过渡的个人的访谈。数据分析于 2023 年 2 月 1 日至 9 月 30 日进行。
索赔为基础的利用率衡量指标（包括特殊心理健康就诊和初级保健就诊）；健康相关结果（包括自残事件）；逮捕率、就业率和无家可归率；以及其他质量措施。
这项队列研究纳入了 1454185 名 13 至 64 岁的个体（743668 名女性[51.1%]；14306 名美洲印第安人和阿拉斯加原住民[1.0%]，132804 名亚裔美国人及太平洋岛民[9.1%]，112442 名非裔美国人[7.7%]，258389 名西班牙裔[17.8%]和 810304 名白人[55.7%]）。财务整合与索赔为基础的使用和质量衡量指标的变化无关。大多数基于索赔的结果衡量指标也没有变化，尽管患有轻度或中度精神疾病的参与者的心脏事件略有减少（-0.8%；95%CI，-1.4 至 -0.2），而患有严重精神疾病的参与者的就业率略有下降（-1.2%；95%CI，-1.9 至 -0.5），逮捕率略有上升（0.5%；95%CI，0.1 至 1.0）。对主要信息提供者的访谈表明，财务整合被视为行政变更，对实践提供护理的方式没有实质性影响；行为健康机构缺乏关于如何在行为健康环境中整合护理的指导，并且难以适应新的合同和监管政策，这些政策可能会抑制提供综合护理的能力。
这项队列研究的结果表明，MCO 层面的财务整合与大多数利用、质量、结果和健康相关社会决定因素的衡量指标的显著变化无关。可能需要额外的支持，包括监测、培训和资金，以推动交付系统的变革，以改善获取、质量和结果。
