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Journal ArticleDOI

Medicaid prescription drug policies and medication access and continuity: findings from ten states.

TL;DR: It is indicated that more effective Medicaid prescription drug management and financing practices are needed to promote medication continuity and improve treatment outcomes.
Abstract: Objectives: The aims of this study were to compare medication access problems among psychiatric patients in ten state Medicaid programs, assess adverse events associated with medication access problems, and determine whether prescription drug utilization management is associated with access problems and adverse events. Methods: Psychiatrists from the American Medical Association’s Masterfile were randomly selected (N=4,866). Sixty-two percent responded; 32% treated Medicaid patients and were randomly assigned a start day and time to report on two Medicaid patients (N=1,625 patients). Results: A medication access problem in the past year was reported for a mean±SE of 48.3%±2.0% of the patients, with a 37.6% absolute difference between states with the lowest and highest rates (p<.001). The most common access problems were not being able to access clinically indicated medication refills or new prescriptions because Medicaid would not cover or approve them (34.0%±1.9%), prescribing a medication not clinically preferred because clinically indicated or preferred medications were not covered or approved (29.4%±1.8%), and discontinuing medications as a result of prescription drug coverage or management issues (25.8%±1.6%). With patient case mix adjusted to control for sociodemographic and clinical confounders, patients with medication access problems had 3.6 times greater likelihood of adverse events (p<.001), including emergency visits, hospitalizations, homelessness, suicidal ideation or behavior, or incarceration. Also, all prescription drug management features were significantly associated with increased medication access problems and adverse events (p<.001). States with more access problems had significantly higher adverse event rates (p<.001). Conclusions: These associations indicate that more effective Medicaid prescription drug management and financing practices are needed to promote medication continuity and improve treatment outcomes. (Psychiatric Services 60:601– 610, 2009)

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TL;DR: Homeless and vulnerably housed individuals face significant barriers to medication adherence and health care providers serving this population should be particularly attentive to nonadherence among younger patients and those with harmful or hazardous drinking patterns.
Abstract: Objectives: Medication adherence is an important determinant of successful medical treatment. Marginalized populations, such as homeless and vulnerably housed individuals, may face substantial barr...

54 citations

Journal ArticleDOI
TL;DR: To estimate the impact of adherence to and persistence with atypical antipsychotics on health care costs and risk of hospitalization by controlling potential sources of endogeneity.
Abstract: Study Objective To estimate the impact of adherence to and persistence with atypical antipsychotics on health care costs and risk of hospitalization by controlling potential sources of endogeneity. Design Retrospective cohort study using medical and pharmacy claims data. Data Source Humana health care insurance database. Patients A total of 32,374 patients with a diagnosis of schizophrenia or bipolar disorder and who had a prescription for noninjectable atypical antipsychotics (aripiprazole, asenapine, clozapine, iloperidone, lurasidone, olanzapine, paliperidone, quetiapine, risperidone, or ziprasidone), after a washout period of at least 180 days during which there was no use of any atypical antipsychotics, between January 2007 and June 2013. Measurements and Main Results The effects of adherence (proportion of days covered by all atypical antipsychotic prescription fills) to and persistence (time from initiation to discontinuation of therapy) with atypical antipsychotics on outcomes (all-cause total health care costs, medication costs, medical services costs, and inpatient admissions) were examined. To exclude potential bias due to mutual causality between drug use patterns and health care utilization, the effects of adherence and persistence measured in the first year on outcomes measured in the second year were investigated. Instrumental variable regressions using reimbursement rate and mail order as instrumental variables were conducted to correct potential endogeneity due to omitted variable bias. Being adherent decreased total costs by $19,497 (p<0.05), increased medication costs by $8194 (p<0.001), decreased medical services costs by $27,664 (p<0.001), and reduced hospitalization risk by 27% (p<0.001). Being persistent decreased individual total costs by $23,927 (p<0.05), increased medication costs by $10,278 (p<0.001), and decreased medical services costs by $34,178 (p<0.001). We could not identify a significant association between persistence and the risk of hospitalization. Conclusion Good adherence to and persistence with atypical antipsychotics led to lower total costs than poor adherence and persistence. Thus efforts should be made to improve adherence and persistence in patients taking atypical antipsychotics.

42 citations

Journal ArticleDOI
TL;DR: In this paper, the authors investigated rural-urban differences in system-, provider-, and individual-level barriers and access to preventive care among adults and children enrolled in a public insurance program in Minnesota and found that rural enrollees were more likely to report no past year preventive care compared to urban enrollees.
Abstract: Purpose Reduced access to care and barriers have been shown in rural populations and in publicly insured populations. Barriers limiting health care access in publicly insured populations living in rural areas are not understood. This study investigates rural-urban differences in system-, provider-, and individual-level barriers and access to preventive care among adults and children enrolled in a public insurance program in Minnesota. Methods This was a secondary analysis of a 2008 statewide, cross-sectional survey of publicly insured adults and children (n = 4,388) investigating barriers associated with low utilization of preventive care. Sampling was stratified with oversampling of racial/ethnic minorities. Results Rural enrollees were more likely to report no past year preventive care compared to urban enrollees. However, this difference was no longer statistically significant after controlling for demographic and socioeconomic factors (OR: 1.37, 95% CI: 1.00-1.88). Provider- and system-level barriers associated with low use of preventive care among rural enrollees included discrimination based on public insurance status (OR: 2.26, 95% CI: 1.34-2.38), cost of care concerns (OR: 1.72, 95% CI: 1.03-2.89) and uncertainty about care being covered by insurance (OR: 1.70, 95% CI: 1.01-2.85). These and additional provider-level barriers were also identified among urban enrollees. Conclusions Discrimination, cost of care, and uncertainty about insurance coverage inhibit access in both the rural and urban samples. These barriers are worthy targets of interventions for publicly insured populations regardless of residence. Future studies should investigate additional factors associated with access disparities based on rural-urban residence.

40 citations

Journal ArticleDOI
TL;DR: It is found that aftercare in the month post-discharge increased the likelihood of readmission but not ED visit, which may indicate a relative lack of psychiatric services for youth.
Abstract: Objective U.S. and Canadian data demonstrate decreasing inpatient days, increasing nonurgent emergency department (ED) visits, and short supply of child psychiatrists. Our study aims to determine whether aftercare reduces ED visits and/or readmission in adolescents with first psychiatric hospitalization. Method We conducted a population-based cohort analysis using linked health administrative databases with accrual from April 1, 2002, to March 1, 2004. The study cohort included all 15- to 19-year-old adolescents with first psychiatric admission. Adolescents with and without aftercare in the month post-discharge were matched on their propensity to receive aftercare. Our primary outcome was time to first psychiatric ED visit or readmission. Secondary outcomes were time to first psychiatric ED visit and readmission, separately. Results We identified 4,472 adolescents with first-time psychiatric admission. Of these, 57% had aftercare in the month post-discharge. Propensity-score–based matching, which accounted for each individual's propensity for aftercare, produced a cohort of 3,004 adolescents. In matched analyses, relative to those with no aftercare in the month post-discharge, those with aftercare had increased likelihood of combined outcome (hazard ratio [HR] = 1.22, 95% confidence interval [CI] = 1.05–1.42), and readmission (HR = 1.38, 95% CI=1.14–1.66), but not ED visits (HR = 1.14, 95% CI=0.95–1.37). Conclusions Our results are provocative: we found that aftercare in the month post-discharge increased the likelihood of readmission but not ED visit. Over and above confounding by severity and Canadian/U.S. systems differences, our results may indicate a relative lack of psychiatric services for youth. Our results point to the need for improved data capture of pediatric mental health service use.

38 citations

Journal ArticleDOI
TL;DR: Changes in the concept of adherence are described, a more comprehensive definition of adherence is presented that recognizes the role of patient‐provider transactions, and dynamic adherence, a six‐phase model, is introduced, which incorporates therole of transactional processes and other factors that influence patients’ adherence decisions.
Abstract: Nonadherence is the Achilles' heel of effective psychiatric treatment. It affects the resolution of mental health symptoms and interferes with the assessment of treatment response. The meaning of the term adherence has evolved over time and is now associated with a variety of definitions and measurement methods. The result has been a poorly operationalized and nonstandardized term that is often interpreted differently by providers and patients. Drawing extensively from the literature, this article aims to (1) describe changes in the concept of adherence, drawing from the mental health treatment literature, (2) present a more comprehensive definition of adherence that recognizes the role of patient-provider transactions, (3) introduce dynamic adherence, a six-phase model, which incorporates the role of transactional processes and other factors that influence patients’ adherence decisions, and (4) provide recommendations for providers to improve adherence as well as their relationships with patients.

38 citations

References
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Journal ArticleDOI
26 Sep 2007-JAMA
TL;DR: A systematic program to identify depression and promote effective treatment significantly improves not only clinical outcomes but also workplace outcomes.
Abstract: Context Althoughguideline-concordantdepressiontreatmentisclearlyeffective,treatment often falls short of evidence-based recommendations. Organized depression care programs significantly improve treatment quality, but employer purchasers have been slow to adopt these programs based on lack of evidence for cost-effectiveness from their perspective. Objective To evaluate the effects of a depression outreach-treatment program on workplace outcomes, a concern to employers. Design, Setting, and Participants A randomized controlled trial involving 604 employees covered by a managed behavioral health plan were identified in a 2-stage screening process as having significant depression. Patient treatment allocation was concealed and assessment of depression severity and work performance at months 6 and 12 was blinded. Employees with lifetime bipolar disorder, substance disorder, recent mental health specialty care, or suicidality were excluded. Intervention Atelephonicoutreachandcaremanagementprogramencouragedworkers to enter outpatient treatment (psychotherapy and/or antidepressant medication), monitored treatment quality continuity, and attempted to improve treatment by giving recommendations to providers. Participants reluctant to enter treatment were offered a structured telephone cognitive behavioral psychotherapy.

406 citations

Journal ArticleDOI
TL;DR: The assertive community treatment model of comprehensive community-based psychiatric care for persons with severe mental illness is described and issues pertaining to implementation of the model are discussed.
Abstract: This article describes the assertive community treatment model of comprehensive community-based psychiatric care for persons with severe mental illness and discusses issues pertaining to implementation of the model. The assertive community treatment model has been the subject of more than 25 randomized controlled trials. Research has shown that this type of program is effective in reducing hospitalization, is no more expensive than traditional care, and is more satisfactory to consumers and their families than standard care. Despite evidence of the efficacy of assertive community treatment, it is not uniformly available to the individuals who might benefit from it.

366 citations

Journal ArticleDOI
TL;DR: Whether a pharmacy-based measure of outpatient adherence, the medication possession ratio (MPR), is associated with adverse outcomes among patients with schizophrenia, as evidenced by increased psychiatric admission is investigated.
Abstract: Background. Health care organizations may be able to use pharmacy data to identify patients with schizophrenia and poor antipsychotic adherence.Objective. To determine whether a pharmacy-based measure of outpatient adherence, the medication possession ratio (MPR), is associated with adverse outcomes

336 citations

Journal ArticleDOI
TL;DR: Irregular medication use was one of the strongest predictors of hospital use and costs even after the analyses controlled for diagnosis, demographic characteristics, baseline functioning, and previous hospitalizations.
Abstract: OBJECTIVE: This naturalistic study used claims data to examine the relationship of medication nonadherence to hospital use and costs among severely mentally ill clients in Wisconsin. METHODS: Data for 619 clients were obtained from Medicaid drug and hospital claims, county records, and case managers as part of a larger study in eight county-based mental health systems. Study participants were eligible for Medicaid, had a severe and persistent mental illness, were 18 years or older, and were receiving neuroleptics, lithium, or antidepressants. Drug claims were analyzed for a 12-month period to determine how regularly clients obtained their medications. Regression analyses were used to assess the effects of irregular medication use on any hospitalization for psychiatric problems, the number of days hospitalized, and hospital costs. The analyses controlled for several risk factors. RESULTS: Among clients with schizophrenia or schizoaffective disorder, 31 percent used medications irregularly. The rates were 3...

291 citations

Journal ArticleDOI
TL;DR: Assertive community treatment offers significant advantages over standard case management models in reducing homelessness and symptom severity in homeless persons with severe mental illness.
Abstract: Objective: The purpose of this study was to assess the effectiveness of assertive community treatment in the rehabilitation of homeless persons with severe mental illness using a meta-analysis. Met...

226 citations