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CORK Bibliography: Health Insurance

44 citations. January 2009 to present

Prepared: June 2011

Aseltine RH; DeMarco FJ; Wallenstein GV; Jacobs DG. Assessing barriers to change in drinking behavior: Results of an online employee screening program. Work: A Journal of Prevention, Assessment & Rehabilitation 32(2): 165-169, 2009. (20 refs.)

Background: The impact of alcohol abuse on worker productivity is considerable and appears to be increasing over time. Although early screening and intervention may help prevent or reduce the damaging health and productivity effects of problem drinking, barriers to behavioral change may render broad-based prevention efforts ineffectual. This study examined the correlates of two potential barriers to changes in drinking behavior - underestimation of drinking and lack of knowledge of helping resources - using data from web-based employee alcohol screenings. Methods: Anonymous screening data from 1185 employees of ten companies participating in the 2003 National Alcohol Screening Day were analyzed. The AUDIT, a 10-item screening instrument developed by the World Health Organization, was used to measure drinking behavior; employees' subjective assessments of their drinking were also obtained. Results: Over 53% of participants subjectively underestimated their drinking relative to their AUDIT results, and 58% of respondents did not know whether their medical insurance included benefits for alcohol treatment. Logistic regression analysis revealed that younger and male respondents tended to have the highest AUDIT scores and also ( along with married respondents) were most likely to underestimate their drinking. Younger, unmarried respondents were least likely to be aware of their alcohol treatment insurance benefits. Conclusions: Current corporate efforts to curtail problem drinking among employees may not adequately address barriers to change. Targeting at-risk employee groups for alcohol screening and dissemination of information about health insurance benefits and treatment options is recommended, as is providing personalized feedback based on screening results to raise awareness of at-risk drinking and available helping resources.

Barry CL; Huskamp HA; Goldman HH. A political history of federal mental health and addiction insurance parity. Milbank Quarterly 88(3): 404-433, 2010. (48 refs.)

Methods: Twenty-nine structured interviews were conducted with key informants in the federal parity debate, including members of Congress and their staff; lobbyists for consumer, provider, employer, and insurance groups; and other key contacts. Historical documentation, academic research on the effects of parity regulations, and public comment letters submitted to the U.S. Departments of Labor, Health and Human Services, and Treasury before the release of federal guidance also were examined. Findings: Three factors were instrumental to the passage of this law: the emergence of new evidence regarding the costs of parity, personal experience with mental illness and addiction, and the political strategies adopted by congressional champions in the Senate and House of Representatives. Conclusions: Challenges to implementing the federal parity policy warrant further consideration. This law raises new questions about the future direction of federal policymaking on behavioral health.

Cisneros GO; Douaihy AB; Kirisci L. Access to healthcare among injection drug users at a needle exchange program in Pittsburgh, PA. Journal of Addiction Medicine 3(2): 89-94, 2009. (7 refs.)

Objectives: The purpose of this study was to explore healthcare access among injection drug users (IDUs) at a needle exchange program in Pittsburgh, PA. Methods: A 2-page survey was conducted using a questionnaire adapted from a previous study, focusing on demographics, health characteristics, health service utilization, and healthcare satisfaction. Binary logistic regression analyses were performed to identify statistically significant associations between IDU characteristics and healthcare access. Results: Among 95 subjects surveyed, 48% were uninsured, 31%, reported having health conditions not followed by a physician, and 68% reported not seeing a physician regularly. The hospital emergency room was the site where most medical care was reportedly obtained. Twenty-three percent reported having problems as a result of not seeking needed medical care. The most commonly reported reason for not seeing a physician regularly was "financial." Young age and marriage/cohabitation were significantly associated with lacking health insurance (P < 0.005 and P < 0.05, respectively). Young age. uninsured Status, and non-white race were significantly associated with not seeing a physician regularly (P < 0.05. P < 0.005, and P < 0.05, respectively). Conclusion: The results Suggest that many IDUs at the needle exchange site have overall poor access to healthcare. Needle exchange programs May use the results of this Study to develop services that address uninsured status as a barrier to healthcare access and further improve the health of the IDU community.

Clark RE; Samnaliev M; McGovern MP. Impact of substance disorders on medical expenditures for medicaid beneficiaries with behavioral health disorders. Psychiatric Services 60(1): 35-42, 2009. (27 refs.)

Objective: This study measured the impact of substance use disorders on Medicaid expenditures for behavioral and physical health care among beneficiaries with behavioral health disorders. Methods: Claims for Medicaid beneficiaries with behavioral health diagnoses in 1999 from Arkansas, Colorado, Georgia, Indiana, New Jersey, and Washington were analyzed. Behavioral health and general medical expenditures for individuals with diagnoses of substance use disorders were compared with expenditures for those without such diagnoses. States were analyzed separately with adjustment for confounders. Results: A total of 148,457 beneficiaries met selection criteria, and 43,457 (29.3%) had a substance use diagnosis. Compared with other beneficiaries with behavioral health disorders, individuals with diagnoses of substance use disorders had significantly higher expenditures for physical health problems in five of six states. Approximately half of the additional care and expenditures were for treatment of physical conditions. Differences declined but remained statistically significant after adjustment for higher overall disease burden among beneficiaries with addictions. Medical expenditures for individuals with diagnoses of substance use disorders increased significantly with age in five of six states, whereas behavioral health expenditures were stable or declined. Hospital admissions for psychiatric and general medical reasons were higher for those with diagnoses of substance use disorders. Conclusions: The impact of addiction on Medicaid populations with behavioral health disorders is greater than the direct cost of mental health and addictions treatment. Higher medical expenditures can be partly attributed to greater prevalence of co-occurring physical disorders, but expenditures remained higher after adjustment for disease burden. Spending estimates based only on behavioral health diagnoses may significantly underestimate addictions-related costs, particularly for older adults.

Clark RE; Weir S; Ouellette RA; Zhang JY; Baxter JD. Beyond health plans behavioral health disorders and quality of diabetes and asthma care for Medicaid beneficiaries. Medical Care 47(5): 545-552, 2009. (34 refs.)

Background: Most health insurance plans monitor ambulatory care quality using the Healthcare Effectiveness Data and Information Set (HEDIS), publicly reporting results at the plan level. Plan-level comparisons obscure the influence of patients served or settings where care is delivered. Mental illness, substance abuse, and other physical comorbidities, particularly prevalent among Medicaid beneficiaries, can impact adherence to recommended care. We analyzed individual-level HEDIS measures for diabetes and asthma from 5 Medicaid managed care plans to understand how these factors contribute to quality. Methods: We used claims and medical records to study HEDIS measures for persistent asthma (n = 9103) and diabetes (n = 1790) among beneficiaries enrolled in Massachusetts' Medicaid program during 2004 and 2005. Logistic regression models included patient-level demographic and health factors, provider type, region, and managed care plan. Results: Alcohol and drug use disorders and emergency department use were associated with lower quality care for most measures. Glycemic control was better for patients with diabetes and severe mental illness. Patients with higher illness burden and with more frequent ambulatory visits received higher quality care for both conditions. Younger adults received recommended care less often than older adults. Quality varied across plans. Conclusions: Additional efforts to improve quality of care for asthma and diabetes for Medicaid beneficiaries are needed for individuals with substance use disorders and young adults. Although evidence of higher quality for patients with multiple conditions is encouraging, improving quality for comparatively healthier individuals might also produce significant long-term benefits.

Conover CJ; Weaver M; Arno P; Ang A; Ettner SL. Insurance coverage among people living with combined HIV/AIDS, chronic mental illness, and substance abuse disorders. Journal of Health Care for the Poor and Underserved 21(3): 1006-1030, 2010. (59 refs.)

HIV triply-diagnosed adults (those with chronic mental illness and substance abuse disorders) must rely heavily on public insurance to cover high annual medical costs (similar to $50,000). This study examines the nature and determinants of insurance coverage (including managed care) for this population, along with annual transitions in coverage. Relative to people living with HIV/AIDS in general, fewer triply-diagnosed adults rely on private coverage (3% vs. 30%), but their rate of being uninsured is only slightly lower (16% vs. 20%). More than one third of such adults below poverty are uninsured a matter of significant policy concern since the annual income of this group is less than 10% of the amount needed to cover their expected medical expenses. Those with the lowest mental health status were disproportionately represented in managed care. While coverage appears relatively stable over time, those with low incomes and moderate mental health status may face barriers in securing Medicaid.

Crail J; Lahtinen A; Beck-Mannagetta J; Benzian H; Enmark B; Jenner T et al. Role and models for compensation of tobacco use prevention and cessation by oral health professionals. International Dental Journal 60(1): 73-79, 2010. (10 refs.)

Appropriate compensation of tobacco use prevention and cessation (TUPAC) would give oral health professionals better incentives to provide TUPAC, which is considered part of their professional and ethical responsibility and improves quality of care. Barriers for compensation are that tobacco addiction is not recognised as a chronic disease but rather as a behavioural disorder or merely as a risk factor for other diseases. TUPAC-related compensation should be available to oral health professionals, be in appropriate relation to other dental therapeutic interventions and should not be funded from existing oral health care budgets alone. We recommend modifying existing treatment and billing codes or creating new codes for TUPAC. Furthermore, we suggest a four-staged model for TUPAC compensation. Stages 1 and 2 are basic care, stage 3 is intermediate care and stage 4 is advanced care. Proceeding from stage 1 to other stages may happen immediately or over many years. Stage 1: Identification and documentation of tobacco use is part of each patient's medical history and included into oral examination with no extra compensation. Stage 2: Brief intervention consists of a motivational interview and providing information about existing support. This stage should be coded/reimbursed as a short preventive intervention similar to other advice for oral care. Stage 3: Intermediate care consists of a motivational interview, assessment of tobacco dependency, informing about possible support and pharmacotherapy, if appropriate. This stage should be coded as preventive intervention similar to an oral hygiene instruction. Stage 4: Advanced care. Treatment codes should be created for advanced interventions by oral health professionals with adequate qualification. Interventions should follow established guidelines and use the most cost-effective approaches.

Deck D; Wiitala W; McFarland B; Campbell K; Mullooly J; Krupski A et al. Medicaid coverage, methadone maintenance, and felony arrests: Outcomes of opiate treatment in two states. Journal of Addictive Diseases 28(2): 89-102, 2009. (52 refs.)

A modest number of clinics in Oregon and Washington provide MMT maintenance treatment (MMT) services. More than 10,000 clients in each state were followed for 3 years after an initial admission for opiate use between 1993 and 2000. Medicaid clients in both states had far greater access to MMT than their non-Medicaid counterparts, controlling for differences in client characteristics using propensity scores. Months in MMT were associated with much lower arrest rates than time not in treatment, but unexpectedly this was only true for clients participating in MMT for many months. Despite differences in the treatment systems for opiate addiction in these two states observed in previous studies, the current findings generalized across both states.

Dixon K. Implementing mental health parity: The challenge for health plans. Health Affairs 28(3): 663-665, 2009. (0 refs.)

By design, the new mental health parity law should work harmoniously with innovations that have helped slow down growth in mental health and substance abuse (MH/SA) treatment costs and improve their quality. The main purpose of the new law is to put coverage of MH/SA benefits on an equal footing with general medical benefits. But some unique features of care for MH/SA disorders will pose challenges in aligning benefits with general medical care. Successful navigation of these challenges will require, as in the passage of the parity law itself, cooperation from all stakeholder groups.

Downing SR; Oyetunji TA; Greene WR; Jenifer J; Rogers SO; Haider AH et al. The impact of insurance status on actuarial survival in hospitalized trauma patients: When do they die? Journal of Trauma, Injury, Infection and Critical Care 70(1): 130-135, 2011. (11 refs.)

Background: Previous work has suggested that insurance status, gender, and ethnicity all have an independent association with mortality after trauma. The purpose of this study is to investigate whether these factors exerted survival impact that could be observed throughout the hospital stay. Methods: Using the National Trauma Data Bank (version 7.0), a Cox proportional hazards survival analysis was performed on young (19-30 years old) trauma patients to mitigate the impact of comorbid confounders. Variables included in the model were age, gender, ethnicity, Injury Severity Score, presence of shock at presentation, mechanism of injury, insurance status, year of admission, teaching status of the hospital, diagnosis of substance abuse or psychotic disorders, and complications after admission. Rate ratios (RRs) comparing the slopes of the adjusted survival curves were calculated using the Mantel-Cox method. Results: A total of 192,488 young trauma patients were identified with complete data. Increased hazard of death was seen in patients who were uninsured (hazard ratio [HR] = 1.69, 95% confidence interval [CI] = 1.59-1.80, p < 0.001), of a minority ethnicity (HR = 1.08, 95% CI = 1.01-1.15, p = 0.025) or men (HR = 1.14, 95% CI = 1.04-1.23, p = 0.004). RRs were significantly larger between insurance status (RR = 1.75, 95% CI = 1.58-1.94, p < 0.001) than between race (RR = 1.23, 95% CI = 1.10-1.37, p < 0.001) or between gender (RR = 1.16, 95% CI = 1.01-1.32, p = 0.030). Conclusion: Risk of death on the first hospital day after injury differs by insurance status, and this disparity becomes more pronounced throughout the hospital stay. Further study is necessary to determine whether this is a result of additional unmeasured patient covariates with insurance status or a difference in provider behavior in response to patient insurance status.

Estee S; Wickizer T; He LJ; Shah MF; Mancuso D. Evaluation of the Washington State Screening, Brief Intervention, and Referral to Treatment project cost outcomes for medicaid patients screened in hospital emergency departments. Medical Care 48(1): 18-24, 2010. (47 refs.)

Background: Substance abuse is a major determinant of morbidity, mortality, and health care resource consumption. We evaluated a screening, brief intervention, and referral to treatment (SBIRT) program, implemented in 9 hospital emergency departments (ED) in Washington State. Methods: Working-age, disabled Medicaid patients who were screened and received a brief intervention (BI) from April 12, 2004 through September 30, 2006 were included in the study's intervention group (N = 1557). The comparison group (N = 1557), constructed using (one-to-one) propensity score matching, consisted of Medicaid patients who received care in one of the counties in which an intervention hospital ED was located but who did not receive a BI. We estimated difference-in-difference (DiD) regression models to assess the effects of the SBIRT program for different patient groups. Results: The SBIRT program was associated with an estimated reduction in Medicaid costs per member per month of $366 (P = 0.05) for all patients, including patients who received a referral for chemical dependency (CD) treatment. For patients who received a BI only and had no CD treatment in the year before or the year after the ED visit, the estimated reduction in Medicaid per member per month costs was $542 (P = 0.06). The SBIRT program was also associated with decreased inpatient utilization (P = 0.04). Conclusion: SBIRT programs have potential to limit resource consumption among working-age, disabled Medicaid patients. The hospital ED seems especially well suited for SBIRT programs given the large number of injured patients treated in the ED and the fact that many conditions treated are related to substance abuse.

Garfield RL; Lave JR; Donohue JM. Health reform and the scope of benefits for mental health and substance use disorder services. Psychiatric Services 61(11): 1081-1086, 2010. (23 refs.)

The Patient Protection and Affordable Care Act will expand insurance coverage to millions of Americans with mental disorders. One particularly important implementation issue is the scope of mental health and substance abuse services under expanded health insurance coverage. This article examines current public and commercial insurance coverage of the range of services used by individuals with mental illnesses and substance use disorders and assesses the implications of newly mandated standards for benefit packages offered by public and private plans. The authors note that many services needed by individuals with mental or substance use disorders fall outside the scope of benefits currently covered by a typical private insurance plan. Compared with other insurers, Medicaid currently covers a broader range of behavioral health services; however, individuals moving into Medicaid under new eligibility pathways will receive "benchmark" or "benchmark-equivalent" coverage rather than full Medicaid benefits. If behavioral health benefits are set at those currently available in typical private plans or in benchmark coverage, some newly insured individuals with mental illnesses or substance use disorders who are covered by private plans or Medicaid expansions are still likely to face gaps in covered services. Policy makers have several options for addressing these likely gaps in coverage, including requiring states to maintain coverage of some support services, including certain behavioral health services in the "essential benefits package," and expanding eligibility for full Medicaid benefits.

Harwood HJ; Zhang YD; Dall TM; Olaiya ST; Fagan NK. Economic implications of reduced binge drinking among the military health system's TRICARE prime plan beneficiaries. Military Medicine 174(7): 728-736, 2009. (33 refs.)

This study examines the economic burden of alcohol misuse to the Department of Defense (DoD) and the benefits of reduced binge drinking among beneficiaries in the DoD's TRICARE Prime plan. Data analyzed include administrative records for approximately 3 million beneficiaries age 18 to 64, DoD's Survey of Health Related Behaviors Among Military Personnel, and the National Survey on Drug Use and Health. Alcohol misuse among Prime beneficiaries cost the DoD an estimated $1.2 billion in 2006-$425 million in higher medical costs and $745 million in reduced readiness and misconduct charges. Potential annual gross benefits to the DoD of reduced binge drinking are simulated for three scenarios: (I) implementing a comprehensive alcohol screening with referral to brief intervention or treatment by primary care ($87 million/$129 million in short/long-term benefits); (2) increasing the price of alcoholic beverages on military installations by 20% ($75 million/$115 million); and (3) implementing a Web-based education program ($81 million/$123 million).

Hodgkin D; Horgan CM; Garnick DW; Merrick EL. Benefit limits for behavioral health care in private health plans. Administration and Policy in Mental Health Services Research 36(1): 15-23, 2009. (36 refs.)

Data from a nationally representative sample of private health plans reveal that special lifetime limits on behavioral health care are rare (used by 16% of products). However, most plans have special annual limits on behavioral health utilization; for example, 90% limit outpatient mental health and 93% limit outpatient substance abuse treatment. As a result, enrollees in the average plan face substantial out-of-pocket costs for long-lasting treatment: a median of $2,710 for 50 mental health visits, or $2,400 for 50 substance abuse visits. Plans' access to new managed care tools has not led them to stop using benefit limits for cost containment purposes.

Hoffmann F; Hies M; Glaeske G. Regional variations of private prescriptions for the non-benzodiazepine hypnotics zolpidem and zopiclone in Germany. Pharmacoepidemiology and Drug Safety 19(10): 1071-1077, 2010. (28 refs.)

Purpose: Although evidence is lacking, there is general perception that zolpidem and zopiclone ('Z-drugs') are more effective and safer than benzodiazepines leading to an increased prescribing of Z-drugs. In Germany, 85% of the inhabitants are covered by statutory health insurance (SHI), the rest is privately insured. Z-drugs are covered by SHIs but physicians can also provide private prescriptions for SHI insured persons, who then have to pay for these out of pocket. Since private prescriptions are not documented in SHI claims data, physicians might prescribe drugs associated with abuse as private prescriptions. We aim to quantify SHE versus private prescriptions of Z-drugs and analyze regional variations. Methods We studied a sample of 2500 community pharmacies located across Germany from 2006 to 2008. We analyzed the amount of private prescriptions in numbers of packages. Drug utilization was expressed in defined daily doses (DDDs) per 1000 inhabitants per day (DID). Results: The proportions of private prescriptions ranged between 36.7% and 36.9% per annum for zopiclone, this was significantly higher for zolpidem (49.4-49.6% per annum). There are substantial regional variations for zolpidem (28.8-82.6%) and zopiclone (22.5-68.6%). In all federal states the proportion of zolpidem not reimbursed by SHIs is higher than that of zopiclone (6.3-15.4%). The nation-wide outpatient consumption was 2.5 DID for zolpidem and 2.7 DID for zopiclone with large regional variations. Conclusions In addition to large regional variations, zolpidem is more often prescribed as a private prescription than zopiclone. This might be a signal for a higher abuse potential of zolpidem.

Holtrop JS; Meghea C; Raffo JE; Biery L; Chartkoff SB; Roman L. Smoking among pregnant women with Medicaid insurance: Are mental health factors related? Maternal and Child Health Journal 14(6): 971-977, 2010. (33 refs.)

Smoking during pregnancy is the single most modifiable risk factor for poor birth outcomes, yet it remains prevalent among low-income women. This study examined factors associated with continued smoking and quitting among pregnant women. A total of 2,203 Medicaid-eligible pregnant women were screened at their first enhanced prenatal services visit for risk factors including demographics, health behaviors (smoking, alcohol and drug use), mental health (history of mental health disorders, current depressive symptoms), and stress. Smoking status was divided into non-smokers, quitters (quit smoking since learning of pregnancy), and continuing smokers. Descriptive statistics and logistic regression models were used to describe the sample and analyze relationships between smoking status and other characteristics. Overall, 57% were non-smokers, 17% quitters, and 26% continuing smokers. Approximately 18% had severe depressive symptoms, 53% had a high stress score, and 33% had a history of mental health problems. Younger women had lower odds of continued smoking as compared to both non-smokers (OR = 0.48, p < 0.01) and quitters (OR = 0.56, p < 0.05). Older women with less than a 12th grade education had higher odds of continued smoking (OR = 2.17, p < 0.01) and quitting (OR = 1.62, p < 0.05) as compared to non-smokers. Alcohol use (OR = 2.81, p < 0.05) and drug use before pregnancy (OR = 5.32, p < 0.01) predicted continued smoking compared to non-smoking. Women with a mental health history (OR = 1.81, p < 0.01) and high stress scores (OR = 1.39, p < 0.05) had higher odds of continued smoking compared to non-smokers. Mental health history, stress, demographics, current alcohol and past drug use are strongly related to continued smoking in this population.

Horgan CM; Garnick DW; Merrick EL; Hodgkin D. Changes in how health plans provide behavioral health services. Journal of Behavioral Health Services and Research 36(1): 11-24, 2009. (29 refs.)

Health plans appear to be moving toward less stringent management, but it is not known whether behavioral health care arrangements mirror the overall trend. To improve access to and quality of behavioral health services, it is critical to track plans' delivery of these services. This study examined plans' behavioral health care arrangements and changes over time using a nationally representative health plan survey regarding alcohol, drug abuse, and mental health services in 1999 (N = 434, 92% response) and 2003 (N = 368, 83% response). Findings indicate health plans' behavioral health service provision changed significantly since 1999, including a large increase in contracting with managed behavioral health care organizations. Some evidence of loosening administrative controls such as prior authorization implies easier access to services. However, increased prevalence of higher levels of cost sharing suggests financial barriers have grown. These changes have important implications for enrollees seeking care and for providers working to meet patients' needs.

Ireys HT; Barrett AL; Buck JA; Croghan TW; Au M; Teich JL. Medicaid beneficiaries using mental health or substance abuse services in fee-for-service plans in 13 States, 2003. Psychiatric Services 61(9): 871-877, 2010. (15 refs.)

Objective: This study identified Medicaid beneficiaries using mental health or substance abuse services in fee-for-service plans in 13 states in 2003 (N=1,380,190) and examined their use of medical services. Methods: Administrative and fee-for-service claims data from Medicaid Analytic eXtract files were analyzed to identify mutually exclusive groups of beneficiaries who used either mental health or substance abuse services and to describe patterns of medical service use. Results: Overall, 11.7% of Medicaid beneficiaries were identified as using mental health or substance abuse services (10.9% and.7% used each of these services, respectively), with substantial variation across age and eligibility groups. Among beneficiaries using mental health services, 47.4% had visited an emergency room for any reason, 7.8% were treated for their disorder in inpatient settings, 13.8% received inpatient treatment for problems other than their mental or substance use disorders, and 70.4% received prescriptions for psychotropic medications. Among beneficiaries using substance abuse services, 60.7% had visited an emergency room, 12.6% were treated for their disorder in inpatient settings, 24.7% received other inpatient treatment, and 46.1% received prescriptions for psychotropic medications. Among beneficiaries not using either mental health or substance use services, 29.0% had visited an emergency room, 12.7% received inpatient treatment, and 10.1% received prescriptions for psychotropic medications. Conclusions: Beneficiaries who used mental health or substance abuse services entered general inpatient settings and visited emergency rooms more frequently than other beneficiaries.

King B; Kaplan S; Hofstedt T. A field experiment in capitated payment systems and recovery management: The women's recovery association pilot study. Journal of Psychoactive Drugs Supplement 6: 287-293, 2010. (9 refs.)

Against the backdrop of shifting perspectives regarding substance abuse policy, upcoming changes to the health care system, and progress toward parity for mental health and substance abuse treatment, an exploratory pilot study is being conducted in San Mateo County, California, to assess the potential of a capitated case rate combined with a recovery management approach in a community-based substance abuse treatment program for women. The rationale for developing the approach, planning, and implementation of the pilot project, the struggle of the agency to transform from episodic treatment to a chronic care model, and a case study that highlights organizational changes are discussed. Lessons learned and implications for the second year of the pilot project are also discussed.

Kranzler HR; Montejano LB; Stephenson JJ; Wang SH; Gastfriend DR. Effects of naltrexone treatment for alcohol-related disorders on healthcare costs in an insured population. Alcoholism: Clinical and Experimental Research 34(6): 1090-1097, 2010. (27 refs.)

Objective: To determine the impact of treatment with oral naltrexone on healthcare costs in patients with alcohol-related disorders. Methods: Using data from the MarketScan Commercial Claims and Encounters Database for 2000-2004, we identified a naltrexone group (with an alcohol-related diagnosis and at least one pharmacy claim for oral naltrexone) and two control groups. Alcohol controls had an alcohol-related diagnosis and were not prescribed an alcoholism treatment medication. Nonalcohol controls had no alcohol-related diagnosis and no prescription for an alcoholism treatment medication. The control groups were matched three to one to the naltrexone group on demographic and other relevant measures. Healthcare expenditures were calculated for the 6-month periods before and after the index naltrexone drug claim (or matched date for controls). Univariate and multivariate analyses were used to compare the groups on key characteristics and on healthcare costs. Results: Naltrexone patients (n = 1,138; 62% men; mean age 45 +/- 11 years) had significantly higher total healthcare expenditures in the pre-index period than either of the control groups. In the postindex period, naltrexone patients had a significantly smaller increase than alcohol controls in total alcohol-related expenditures. Total nonalcohol-related expenditures also increased significantly less for the naltrexone group than for the alcohol control group. Multivariate analyses showed that naltrexone treatment significantly reduced alcohol-related, nonalcohol-related, and total healthcare costs relative to alcohol controls. Conclusions: Although prior to treatment patients with alcohol-related disorders had higher healthcare costs, treatment with oral naltrexone was associated with reductions both in alcohol-related and nonalcohol-related healthcare costs.

Land T; Rigotti NA; Levy DE; Paskowsky M; Warner D; Kwass JA et al. A longitudinal study of Medicaid coverage for tobacco dependence treatments in Massachusetts and associated decreases in hospitalizations for cardiovascular disease. PLoS Medicine 7(12): e1000375, 2010. (25 refs.)

Background: Insurance coverage of tobacco cessation medications increases their use and reduces smoking prevalence in a population. However, uncertainty about the impact of this coverage on health care utilization and costs is a barrier to the broader adoption of this policy, especially by publicly funded state Medicaid insurance programs. Whether a publicly funded tobacco cessation benefit leads to decreased medical claims for tobacco-related diseases has not been studied. We examined the experience of Massachusetts, whose Medicaid program adopted comprehensive coverage of tobacco cessation medications in July 2006. Over 75,000 Medicaid subscribers used the benefit in the first 2.5 years. On the basis of earlier secondary survey work, it was estimated that smoking prevalence declined among subscribers by 10% during this period. Methods and Findings: Using claims data, we compared the probability of hospitalization prior to use of the tobacco cessation pharmacotherapy benefit with the probability of hospitalization after benefit use among Massachusetts Medicaid beneficiaries, adjusting for demographics, comorbidities, seasonality, influenza cases, and the implementation of the statewide smoke-free air law using generalized estimating equations. Statistically significant annualized declines of 46% (95% confidence interval 2%-70%) and 49% (95% confidence interval 6%-72%) were observed in hospital admissions for acute myocardial infarction and other acute coronary heart disease diagnoses, respectively. There were no significant decreases in hospitalizations rates for respiratory diagnoses or seven other diagnostic groups evaluated. Conclusions: Among Massachusetts Medicaid subscribers, use of a comprehensive tobacco cessation pharmacotherapy benefit was associated with a significant decrease in claims for hospitalizations for acute myocardial infarction and acute coronary heart disease, but no significant change in hospital claims for other diagnoses. For low-income smokers, removing the barriers to the use of smoking cessation pharmacotherapy has the potential to decrease short-term utilization of hospital services.

Land T; Warner D; Paskowsky M; Cammaerts A; Wetherell L; Kaufmann R et al. Medicaid coverage for tobacco dependence treatments in Massachusetts and associated decreases in smoking prevalence. PLoS Oone 5(3): e9770, 2010. (12 refs.)

Background: Approximately 50% of smokers die prematurely from tobacco-related diseases. In July 2006, the Massachusetts health care reform law mandated tobacco cessation coverage for the Massachusetts Medicaid population. The new benefit included behavioral counseling and all medications approved for tobacco cessation treatment by the U. S. Food and Drug Administration (FDA). Between July 1, 2006 and December 31, 2008, a total of 70,140 unique Massachusetts Medicaid subscribers used the newly available benefit, which is approximately 37% of all Massachusetts Medicaid smokers. Given the high utilization rate, the objective of this study is to determine if smoking prevalence decreased significantly after the initiation of tobacco cessation coverage. Methods: and Findings: Smoking prevalence was evaluated pre- to post-benefit using 1999 through 2008 data from the Massachusetts Behavioral Risk Factor Survey (BRFSS). The crude smoking rate decreased from 38.3% (95% C. I. 33.6%-42.9%) in the pre-benefit period compared to 28.3% (95% C. I.: 24.0%-32.7%) in the post-benefit period, representing a decline of 26 percent. A demographically adjusted smoking rate showed a similar decrease in the post-benefit period. Trend analyses reflected prevalence decreases that accrued over time. Specifically, a joinpoint analysis of smoking prevalence among Massachusetts Medicaid benefit-eligible members (age 18-64) from 1999 through 2008 found a decreasing trend that was coincident with the implementation of the benefit. Finally, a logistic regression that controlled for demographic factors also showed that the trend in smoking decreased significantly from July 1, 2006 to December 31, 2008. Conclusion: These findings suggest that a tobacco cessation benefit that includes coverage for medications and behavioral treatments, has few barriers to access, and involves broad promotion can significantly reduce smoking prevalence.

Lillie-Blanton M; Stone VE; Jones AS; Levi J; Golub ET; Cohen MH et al. Association of race, substance abuse, and health insurance coverage with use of highly active antiretroviral therapy among HIV-Infected women, 200518. American Journal of Public Health 100(8): 1493-1499, 2010. (18 refs.)

Objectives. We examined racial/ethnic disparities in highly active antiretroviral therapy (HAART) use and whether differences are moderated by substance use or insurance status, using data from the Women's Interagency HIV Study (WIHS). Methods. Logistic regression examined HAART use in a longitudinal cohort of women for whom HAART was clinically indicated in 2005 (N=1354). Results. Approximately 3 of every 10 eligible women reported not taking HAART. African American and Hispanic women were less likely than were White women to use HAART. After we adjusted for potential confounders, the higher likelihood of not using HAART persisted for African American but not for Hispanic women. Uninsured and privately insured women, regardless of race/ethnicity, were less likely than were Medicaid enrollees to use HAART. Although alcohol use was related to HAART nonuse, illicit drug use was not. Conclusions. These findings suggest that expanding and improving insurance coverage should increase access to antiretroviral therapy across racial/ethnic groups, but it is not likely to eliminate the disparity in use of HAART between African American and White women with HIV/AIDS.

Liu F. Effect of Medicaid coverage of tobacco-dependence treatments on smoking cessation. International Journal of Environmental Research and Public Health 6(12): 3143-3155, 2009. (34 refs.)

Smoking cessation aids (nicotine replacement products and anti-depressant medication) have been proven to double quitting rates compared to placebo in several randomized controlled trials. But the high initial cost of cessation aids might create a financial barrier to cessation for low-income smokers. In the U.S., Medicaid provides health insurance coverage to low-income people, and in some states covers smoking cessation products. This paper uses nationally representative data of the U. S. to examine how the Medicaid coverage of cessation aids affect smoking behavior. The results indicate the Medicaid coverage of cessation products is positively associated with successful quitting among women aged 18-44.

Liu F. Quit attempts and intention to quit cigarette smoking among Medicaid recipients in the USA. Public Health 124(10): 553-558, 2010. (30 refs.)

Objectives: To examine the effect of Medicaid coverage of tobacco dependence treatments (TDT) on quitting attempts and intention to quit by Medicaid recipient smokers. Study design: Multiple cross-sectional study. Method: Data from the national 1996-2007 Tobacco Use Supplements to the Current Population Survey in the USA were analysed (n = 6585). Measures included self-reported quit attempts during the last 12 months, and serious intention to quit in the next 6 months and in the next 30 days. Results: In the baseline model, Medicaid coverage of TDT was associated with attempted quitting [odds ratio (OR) 1.23, 95% confidence interval (CI) 1.05-1.45], intention to quit in the next 6 months (OR 1.32, 95% CI 1.09-1.59) and intention to quit in the next 30 days (OR 1.27, 95% CI 1.01-1.58). After controlling for cigarette taxes and the antismoking sentiment index for each state, the magnitude became smaller and the association was only statistically significant for intention to quit in the next 6 months. Conclusions: Covering smoking cessation aids and eliminating copayments with Medicaid can encourage more quitting attempts and facilitate intentions to quit.

Lowe RA; Fu RW; Gallia CA. Impact of policy changes on emergency department use by medicaid enrollees in Oregon. Medical Care 48(7): 619-627, 2010. (30 refs.)

Objective: In 2003, Oregon's Medicaid expansion program, the Oregon Health Plan (OHP), implemented premiums and copayments and eliminated outpatient behavioral health services. We ascertained whether these changes, including $50 copayments for emergency department (ED) visits, affected ED use. Methods: This study used statewide administrative data on 414,009 adult OHP enrollees to compare ED utilization rates (adjusted for patient characteristics) in 3 time periods: (1) before the cutbacks, (2) after the cutbacks, and (3) after partial restoration of benefits. We examined overall ED visits and several subsets of ED visits: visits requiring hospital admission, injury-related, drug-related, alcohol-related, and other psychiatric visits. Because the policy changes affected only the expansion program (OHP Standard), we ascertained the impact of these changes compared with a control group of categorically eligible Medicaid enrollees (OHP Plus). Results: Compared with the control group, case-mix-adjusted ED utilization rates fell 18% among OHP Standard enrollees after the cutbacks. The rate of ED visits leading to hospitalization fell 24%. Injury-related visits and psychiatric visits excluding chemical dependency exhibited a similar pattern to overall ED visits. Drug-related ED visits increased 32% in the control group, perhaps reflecting the closure of drug treatment programs after the cutbacks reduced their revenue. Conclusion: The policy changes were followed by a substantial reduction in ED use. That ED visits requiring hospital admission fell to about the same extent as overall ED use suggests that OHP enrollees may have been discouraged from using EDs for emergencies as well as less-serious problems.

McCarty D; Perrin NA; Green CA; Polen MR; Leo MC; Lynch F. Methadone maintenance and the cost and utilization of health care among individuals dependent on opioids in a commercial health plan. Drug and Alcohol Dependence 111(3): 235-240, 2010. (18 refs.)

Background: Few health plans provide maintenance medication for opioid dependence. This study assessed the cost of treating opioid-dependent members in a commercial health plan and the impacts of methadone maintenance on costs of care. Methods: Individuals with diagnoses of opioid dependence (two or more diagnoses per year) and at least 9 months of health plan eligibility each year were extracted from electronic health records for the years 2000 through 2004 (1,518 individuals and 2,523 observations across the study period-some individuals were in multiple years) Analyses examined the patterns and costs of health care for three groups of patients (1) one or more methadone visits during the year (n = 1 298; 51%) (2) no methadone visits and 0 or 1 visits in the Addiction Medicine Department (n = 370 15%) (3) no methadone visits and 2 or more visits in addiction medicine (n = 855, 34%) Results: Primary care (86%) emergency department (48%) and inpatient (24%) visits were common. Mean total annual costs to the health plan were $11,200 (2004 dollars) per member per year. The health plan's costs for members receiving methadone maintenance were 50% lower ($7,163) when compared to those with two or more outpatient addiction treatment visits but no methadone ($14,157) and 62% lower than those with one or zero outpatient addiction treatment visits and no methadone treatment ($18, 694) Conclusions: Use of opioid maintenance services was associated with lower total costs of care for opioid-dependent members in a commercial health plan.

McMenamin SB; Halpin HA; Bellows NM; Husten CG; Rosenthal A. State Medicaid coverage for tobacco-dependence treatments --- United States, 2007. MMWR. Morbidity and Mortality Weekly Review 58(43): 1199-1204, 2009. (10 refs.)

In 2007, the Center for Health and Public Policy Studies at the University of California, Berkeley, surveyed all 51 Medicaid programs. This report summarizes the results of that survey, which found that 43 (84%) programs offered coverage for some form of tobacco-dependence treatment to Medicaid enrollees in traditional fee-for-service (FFS) Medicaid, with four Medicaid programs adding coverage since 2006 and 20 programs adding coverage in the past decade. Only two states (New Mexico and New Jersey) reported access to tobacco-dependence treatments without any limitations or restrictions. Of the 25 states covering pharmacotherapy for Medicaid enrollees in both FFS and managed-care organizations (MCOs), only 13 covered the same tobacco-dependence treatments for enrollees in both populations. Research demonstrates that providing access to comprehensive tobacco-dependence treatments increases quit rates.

Public Domain

McMenamin SB; Halpin HA; Ingram M; Rosenthal A. State Medicaid coverage for tobacco-dependence treatments --- United States, 2009. MMWR. Morbidity and Mortality Weekly Review 59(41): 1340-1343, 2010. (10 refs.)

Medicaid enrollees have nearly twice the smoking rates (37%) of the general adult population (21%), and smoking-related medical costs are responsible for 11% of Medicaid expenditures (1,2). In 2008, the Public Health Service released clinical practice guidelines recommending comprehensive coverage of effective tobacco-dependence medications and counseling by health insurers. To monitor progress toward that objective, the Center for Health and Public Policy Studies at the University of California, Berkeley, in collaboration with CDC, surveyed Medicaid programs in the 50 states and the District of Columbia (DC) to document their 2009 tobacco-dependence treatment coverage and found that 47 programs offered coverage. Only eight state programs offered coverage of all recommended pharmacotherapy and counseling for all Medicaid enrollees, and 16 programs reported coverage for fee-for-service enrollees that differed from that provided for Medicaid managed-care enrollees. Among the 33 programs that covered at least one combination therapy, the nicotine patch plus bupropion slow release (SR) was the one combination covered by all.

Public Domain

Penz ED; Manns BJ; Hebert PC; Stanbrook MB. Governments, pay for smoking cessation. (editorial). Canadian Medical Association Journal 182(18): E810-E810, 2010. (5 refs.)

Peterson JA; Schwartz RP; Mitchell SG; Reisinger HS; Kelly SM; O'Grady KE et al. Why don't out-of-treatment individuals enter methadone treatment programmes? International Journal of Drug Policy 21(1): 36-42, 2010. (54 refs.)

Background: Despite the proven effectiveness of methadone treatment, the majority of hero in-dependent individuals are out-of-treatment. Methods: Twenty-six opioid-dependent adults who met the criteria for methadone maintenance who were neither seeking methadone treatment at the time of study enrollment, nor had participated in such treatment during the past 12 months, were recruited from the streets of Baltimore, Maryland through targeted sampling. Ethnographic interviews were conducted to ascertain participants' attitudes toward methadone treatment and their reasons for not seeking treatment. Results: Barriers to treatment entry included: waiting lists, lack of money or health insurance, and requirements to possess a photo identification card. For some participants, beliefs about methadone such as real or rumored side effects, fear of withdrawal from methadone during an incarceration, or disinterest in adhering to the structure of treatment programmes kept them from applying. In addition, other participants were not willing to commit to indefinite "maintenance" but would have accepted shorter time-limited methadone treatment. Conclusion: Barriers to treatment entry could be overcome by an infusion of public financial support to expand treatment access, which would reduce or eliminate waiting lists, waive treatment-related fees, and/or provide health insurance coverage for treatment. Treatment programmes could overcome some of the barriers by waiving their photo I.D. requirements, permitting time-limited treatment with the option to extend such treatment upon request,and working with corrections agencies to ensure continued methadone treatment upon incarceration.

Reda AA; Kaper J; Fikrelter H; Severens JL; van Schayck CP. Healthcare financing systems for increasing the use of tobacco dependence treatment. (review). Cochrane Database of Systematic Reviews 2009(2): article CD004305, 2009. (56 refs.)

Background: We hypothesized that provision of financial assistance for smokers trying to quit, or reimbursement of their care providers, could lead to an increased rate of successful quit attempts. Objectives The primary objective of this review was to assess the impact of reducing the costs of providing or using smoking cessation treatment by health care financing interventions on abstinence from smoking and utilization of smoking cessation treatment. Search strategy: We searched the Cochrane Tobacco Addiction group specialized register; the Cochrane Central Register of Controlled Trials (CENTRAL) Issue 3, 2008; MEDLINE (from January 1966 to August 2008) and EMBASE (from January 1980 to August 2008) to identify trials. Selection criteria: We included randomized controlled trials (RCTs) and controlled trials involving financial benefit interventions to smokers or their health care providers or both. Data collection and analysis: Three reviewers independently extracted data and assessed the quality of the included studies. Rate ratios (RR) were calculated for individual studies on an intention-to-treat basis and meta-analysis was performed using a random effects model. We included economic evaluations when a study presented the costs and effects of two or more alternatives. Main results: We found nine trials involving financial interventions directed at smokers and two studies directed at health care providers. There was a statistically significant favourable effect of full financial interventions directed at smokers on continuous abstinence compared to no interventions with a risk ratio (RR) of 4.38 (95% CI 1.94 to 9.87). There was also a significant effect of full financial interventions when compared to no interventions on the number of participants making a quit attempt (RR 1.19; 95% CI 1.07 to 1.32; N = 3). There was a significant effect of financial interventions directed at health care providers in increasing the utilization of behavioural interventions for smoking cessation (RR 1.33; 95% CI 1.01 to 1.77). Comparison of full benefit with partial or no benefit resulted in costs per additional quitter ranging from $260 to $1453. Authors' conclusions: Full financial interventions directed at smokers when compared to no financial interventions could increase the proportion quitting, quit attempts and utilization of pharmacotherapy by smokers. Although the absolute differences were small the costs per additional quitter were low. The methodological qualities of the included studies need to be taken into consideration in interpreting the conclusions.

Risser J; Cates A; Rehman H; Risser W. Gender differences in social support and depression among injection drug users in Houston, Texas. American Journal of Drug and Alcohol Abuse 36(1): 18-24, 2010. (34 refs.)

Background: Injection drug is the second most frequent HIV/AIDS exposure in the United States. Social support and depression may mediate risky behaviors among drug injectors. Objectives: To describe differences in perceived social support and depressive symptoms between male and female injection drug users, and to describe factors associated with depressive symptoms. Methods: Using respondent-driven sampling, we recruited and interviewed injection drug users in Houston, Texas. Data were from the Centers for Disease Control and Prevention's National HIV Behavioral Surveillance Program. We used the short Center for Epidemiologic Studies Depression Scale (CES-D 10) and scales for perceived social support from family, friends, and significant others from the Multidimensional Scale of Perceived Social Support. Four-hundred seventy-one participants had complete data and were included in this analysis. Results: Seventy-five percent of male and female participants had CES-D scores indicating depressive symptoms. In a multivariate logistic regression, depressive symptoms among men were positively associated with frequent use of speedballs (injecting heroin and cocaine together) and never having tested for HIV, and negatively associated with perceived social support from a special person. Among women, depressive symptoms were positively associated with currently smoking cigarettes, having no health insurance, and more years of injection drug use, and negatively associated with perceived social support from a special person. Conclusions: Lack of social support from a special person or significant other was associated with depressive symptoms in both males and females. Our findings suggest that depression and social support should be addressed when developing HIV prevention programs among injection drug users.

Roy K; Miller M. Parity and the medicalization of addiction treatment. Journal of Psychoactive Drugs 42(2): 115-120, 2010. (0 refs.)

Parity, the idea that insurance coverage for the treatment of addiction should be on a par with insurance coverage for the treatment of other medical illnesses, is not a new idea, but the path to achieving "real parity" has been a long, hard and complex journey. Action by Congress to pass major parity legislation in 2008 was a huge step forward, but does not mean that parity has been achieved. Parity has required a paradigm shift in the understanding of addiction as a biological illness: many developments of science and policy changes by professional organizations and governmental entities have contributed to that paradigm shift. Access to adequate treatment for patients must acknowledge the paradigm shift reflected in parity as it has evolved to the current point: that this biological illness is widespread, that it is important that it be treated effectively, that appropriate third party payment for physician-provided or physician-supervised addiction treatment is critical for addiction medicine to become a part of the mainstream of our nation's healthcare delivery system, and that medical specialty care provides the most effective and cost effective benefit to patients and therefore to our society.

Ruetsch C. Empirical view of opioid dependence. Journal of Managed Care Pharmacy 16(1, Supplement B): s9-s13, 2010. (28 refs.)

BACKGROUND: The impact of opioid dependence on employers, managed care, and society is significant. Inappropriate use of narcotic analgesics leads to uncontrolled pain management, dependence, and may lead to patient deaths, creating a tremendous cost burden to the health care system. OBJECTIVE: To provide an overview of the clinical and economic impact of treating opioid dependence on managed care, employers, and society. SUMMARY: An estimated 6% to 15% of people in the United States abuse drugs, and approximately 20% of Americans report using prescription opioids for nonmedical use. This is associated with an annual cost of nearly half a trillion dollars, taking into account the medical, economic, social, and criminal impact of this abuse. A recent study showed that patients who abuse opioids generate mean annual direct health care costs 8.7 times higher than nonabusers. The National Survey on Drug Use and Health (NSDUH), conducted by the Substance Abuse and Mental Health Services Administration (SAMHSA), found that patients who report opioid abuse miss more than 2.2 days of work monthly, compared with the 0.83 days per month reported for the average person. Presenteeism and productivity are also affected by misuse and dependence on opioids. CONCLUSION: The costs associated with opioid dependence are significant. Physicians, employers, and managed care organizations must be proactive in appropriately diagnosing and treating patients who suffer from substance abuse disorders in order to lessen this economic burden.

Shern DL; Beronio KK; Harbin HT. After parity: What's next. Health Affairs 28(3): 660-662, 2009. (5 refs.)

A new law prohibiting unequal treatment limits and financial requirements for mental health and substance abuse (MH/SA) benefits establishes critical protections for 113 million Americans. The new parity law doesn't mandate coverage for MH/SA treatment and anticipates management of the benefit. Given these features, clear regulations mapping the intent of the law are critical. Education regarding the costs of untreated or ineffectively treated MH/SA conditions is needed to encourage comprehensive coverage, because academic performance and worker productivity are at stake. As health care reform proceeds, we must use the new law to reinforce the centrality of mental health to overall health.

Smaldone A; Cullen-Drill M. Mental health parity legislation understanding the pros and cons. Journal of Psychosocial Nursing and Mental Health Services 48(9): 26-34, 2010. (21 refs.)

Although recognition and treatment of mental health disorders have become integrated into routine medical care, inequities remain regarding limits on mental health outpatient visits and higher copayments and deductibles required for mental health services when accessed. Two federal laws were passed by Congress in 2008: The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act and the Medicare Improvements for Patients and Providers Act. Both laws became effective on January 1, 2010. The purpose of this article is to discuss provisions of each act and provide clinical examples describing how patients are affected by lack of parity and may potentially benefit from implementation of these new laws. Using available evidence, we examine the potential strengths and limitations of mental health parity legislation from the health policy perspectives of health care access, cost, and quality and identify the important role of nurses as patient and mental health parity advocates.

Smith DE; Lee DR; Davidson LD. Health care equality and parity for treatment of addictive disease. Journal of Psychoactive Drugs 42(2): 121-126, 2010. (32 refs.)

Substance abuse represents a significant underlying cause of the health issues faced in the United States, which severely impacts the nation's health care system and economy. Recently enacted parity legislation mandates that benefits for addiction and mental health treatment be provided on an equal footing with those for treatment for physical health. Diversion and abuse of prescription medications is growing in young people, with much of the diversion occurring between family and friends. Addiction has been accepted by mainstream medicine as a brain disease, and is associated with many other medical disorders. Early intervention and treatment for addiction provides extraordinary cost-benefit outcomes. Additional training for addiction professionals will be necessary. Stigmatization of substance abusers continues to exist at the state and federal levels, although research during the past 10 years indicates that patient compliance and relapse rates for substance abusers are not significantly different than those for individuals with other chronic diseases, e.g. diabetes, hypertension, and cardiac issues. While parity for addiction treatment has become policy at the federal level, great challenges lie ahead in funding access, facilities, and training, as well as redirecting societal perceptions and legislated penalties.

Sterling S; Weisner C; Hinman A; Parthasarathy S. Access to treatment for adolescents with substance use and co-occurring disorders: Challenges and opportunities. (review). Journal of The American Academy of Child and Adolescent Psychiatry 49(7): 637-646, 2010. (76 refs.)

Objective: To review the research on economic and systemic barriers faced by adolescents needing treatment for alcohol and drug problems, particularly those with co-occurring conditions. Method: We reviewed the literature on adolescent access to alcohol and drug services, including early intervention, and integrated and specialty mental health treatment for those with co-occurring disorders, examining the role of health care systems, public policy (health reform), treatment financing and reimbursement systems (public and private), implementation of evidence-based practices, confidentiality practices, and treatment costs and cost/benefits. Results: Barriers to treatment, particularly integrated treatment, are largely rooted in our organizationally fragmented health care system, which encompasses public and private, carved-out and integrated systems, and different funding mechanisms (Medicaid versus block grants versus private insurance that include "high deductible" plans and other cost controls.) In both systems, carved-out programs de-link services from other mental health and general health care. Barriers are also rooted in disciplinary differences and weak clinical linkages between psychiatry, primary care and substance use, and in confidentiality policies that inhibit communication and coordination, while protecting patient privacy. Conclusion: In this era of health care reform, we have the opportunity to increase access for adolescents and develop new models of integrated services for those with co-occurring conditions. We discuss opportunities for improving treatment access and implementation of evidence-based practices, examine implications of health reform and parity legislation for psychiatric and substance use treatment, and comment on key unanswered questions and future research opportunities.

Terplan M; Smith EJ; Glavin SH. Trends in Injection Drug Use Among Pregnant Women Admitted into Drug Treatment: 1994-2006. Journal of Women's Health 19(3): 499-505, 2010. (31 refs.)

Objective: To describe trends in the regional and demographic characteristics of injection drug use (IDU) during pregnancy. Methods: Data were obtained from the Treatment Episode Data Set (TEDS), an administrative data set that captures admissions to federally funded treatment centers in the United States. Demographic and treatment-related measures were examined and compared between injection drug and noninjection drug admissions. The results were stratified by year of admission to assess trends over time. Results: From 1994 to 2006, there were 239,511 admissions of pregnant women, of whom 34,717 (14.4%) reported IDU. There was little change in the proportion of injecting from year to year. Compared with admissions of noninjecting pregnant women, a greater proportion of injection drug users were white (68.5 vs. 48.6%), reported heroin use (70.0% vs. 13.2%), and had no health insurance (48.2% vs. 40.2%). Over the time period, the proportion of injection drug users was seen to spread from the West to the South and Northeast for heroin and to the Midwest for amphetamines. Conclusions: IDU among pregnant women in drug treatment remains a significant public health issue, especially among white women.

Tsai J; Floyd RL; Green PP; Denny CH; Coles CD; Sokol RJ. Concurrent alcohol use or heavier use of alcohol and cigarette smoking among women of childbearing age with accessible health care. Prevention Science 11(2): 197-206, 2010. (76 refs.)

This study was conducted to provide nationally representative findings on the prevalence and distribution of concurrent alcohol use or heavier use of alcohol and cigarette smoking among women of childbearing age with accessible health care. For the years 2003-2005, a total of 20,912 women 18-44 years of age who participated in the National Health Interview Survey (NHIS) reported that during the study period, there was a place where they would usually go for health care when sick or in need of advice about their health. The prevalence and distribution of concurrent alcohol use or heavier use of alcohol and cigarette smoking reported by such women was calculated. Logistic regression analysis was used to evaluate the "most often visited health care place" among concurrent users who reported having seen or talked to a health care provider during the previous 12 months. Among surveyed women with accessible health care, 12.3% reported concurrent alcohol use and cigarette smoking, and 1.9% reported concurrent heavier use of alcohol and cigarette smoking during the study period. Of women who reported either type of concurrent use, at least 84.4% also indicated having seen or talked to one or more health care providers during the previous 12 months. Such women were more likely than non-concurrent users to indicate that the "most often visited health care place" was a "hospital emergency room or outpatient department or some other place" or a "clinic or health center," as opposed to an "HMO or doctor's office." Concurrent alcohol use or heavier use of alcohol and cigarette smoking among women of childbearing age is an important public health concern in the United States. The findings of this study highlight the importance of screening and behavioral counseling interventions for excessive drinking and cigarette smoking by health care providers in both primary care and emergency department settings.

Vandivort R; Teich JL; Cowell AJ; Chen H. Utilization of substance abuse treatment services under Medicare, 2001-2002. Journal of Substance Abuse Treatment 36(4): 414-419, 2009

In 2006, the Medicare program covered 37 million elderly persons and 7 million persons younger than 65 years, but little is known about substance abuse (SA) service utilization. Using the 5% Sample of Medicare claims data, the study examines individuals who used SA detoxification ("detox") and/or rehabilitation ("rehab") services under Medicare in 2001 and 2002. SA claimants less than 65 years of age (disabled) were compared to claimants more than 65 years of age (elderly). The disabled were more likely to have a co-occurring mental disorder than elderly claimants (50% vs. 14%) and more likely to have serious mental illness (21% vs. 2.3%). Disabled claimants were more than three times as likely to receive any detox service as elderly claimants (17% vs. 6%). The rate of claimants receiving rehab services within 30 days of detox is about one third for disabled claimants and one quarter for elderly claimants.

Wells R; Morrissey JP; Lee IH; Radford A. Trends in behavioral health care service provision by community health centers, 1998-2007. Psychiatric Services 61(8): 759-764, 2010. (26 refs.)

Objective: The federal government boosted support for community health centers in medically underserved areas in 2002-2007. This investigation compared trends in behavioral health services provided by community health centers nationwide during the first several years of that initiative with immediately prior trends. Methods: Data were extracted from the Health Resources and Services Administration's Uniform Data System on community health centers for 1998-2007 (2007, N=1,067). Regression analyses revealed trends in individual community health centers' likelihood of providing on-site specialty mental health care, crisis services, and substance abuse treatment. Aggregate data were used to show national trends in numbers of behavioral health encounters, patients, and encounters per patient. Results: The number of federally funded community health centers increased 43% between 2001 and 2007, from 748 to 1,067, over twice the annual growth rate between 1998 and 2001. However, trends in individual community health centers' likelihood of providing different types of behavioral health care were generally consistent across the two time periods. In 2007, 77% of community health centers offered specialty mental health services, 20% offered 24-hour crisis intervention services, and 51% offered substance abuse treatment. The mean number of mental health encounters per mental health patient at community health centers in 2007 was 2.9. Conclusions: The behavioral health care safety net has widened through rapid recent growth in the number of community health centers as well as a continuing increase in the proportion offering specialty mental health services.

Wickizer TA; Mancuso D; Campbell K; Lucenko B. Evaluation of the Washington State Access to Recovery project: Effects on Medicaid costs for working age disabled clients. Journal of Substance Abuse Treatment 37(3): 240-246, 2009. (31 refs.)

In 2004, the federal government made a major commitment to support expanded substance abuse (SA) recovery services by initiating the Access to Recovery (ATR) program. The initial ATR I program awarded grants to 14 states, including Washington State. We evaluated Washington's ATR I program to determine its effect on Medicaid costs for working age disabled clients. We compared per member per month (PMPM) Medicaid costs during 1 year follow-up for clients who received ATR services (N = 1,347) with costs for a matched comparison group of 1,243 clients and used multiple regression techniques to estimate changes in Medicaid costs associated with ATR. ATR was found to be associated with reductions in PMPM Medicaid costs of $66 (p = 11) to $136 (p = .05) depending upon months of Medicaid eligibility. Recovery services aimed at facilitating engagement in SA treatment and aftercare appear to foster modest savings in Medicaid costs for working age disabled clients.

Ziller EC; Anderson NJ; Coburn AF. Access to rural mental health services: Service use and out-of-pocket costs. Journal of Rural Health 26(3): 214-224, 2010. (28 refs.)

Purpose: To examine rural-urban differences in the use of mental health services (mental health and substance abuse office visits, and mental health prescriptions) and in the out-of-pocket costs paid for these services. Methods: The pooled 2003 and 2004 Medical Expenditure Panel Surveys were used to assess differences in mental health service use by rural and urban residence and average per person mental health expenditures by payer and by service type. Findings: Study findings reveal a complicated pattern of greater need among rural than urban adults for mental health services, lower rural office-based mental health use and higher rural prescription use, and no rural-urban differences in total or out-of-pocket expenditures for mental health services. Conclusions: These findings raise questions about the appropriateness and quality of mental health services being delivered to rural residents. Lower mental health spending among rural residents is likely explained by lower use of psychotherapy and other office-based services, but it may also be related to these services being delivered by lower-cost providers in rural areas. Findings suggest that an approach focusing on reducing underinsurance for all health services among rural residents may help to reduce unmet mental health needs among the rural privately insured.

Zuvekas SH; Meyerhoefer CD. State variations in the out-of-pocket spending burden for outpatient mental health treatment. Health Affairs 28(3): 713-722, 2009. (19 refs.)

We examine the potential of mental health/substance abuse (MH/SA) parity laws to reduce the out-of-pocket spending burden for outpatient treatment at the state level by exploring cross-state variations and their causes, as well as the provisions of MH/SA parity laws. We find modest (yet important) variation in out-of-pocket burden across states overall, but -- because prescription medications account for two-thirds of out-of-pocket spending and are generally beyond the scope of recently enacted federal parity laws -- evidence suggests that those laws will do little to reduce the observed burden or its variation. Other policy measures, designed to expand and improve health insurance coverage or reduce racial/ethnic disparities, could have a more profound impact.