Literature Collection

A high prevalence of mental health diagnoses in adults alongside ongoing shortages of mental health specialists and expansion of the patient-centered medical home have increased the involvement of primary care clinicians in treating mental health concerns. Using nationally representative serial cross-sectional data from the 2006-18 National Ambulatory Medical Care Surveys regarding visits to outpatient primary care physicians by patients ages eighteen and older, we sought to characterize temporal trends in primary care visits addressing a mental health concern. Based on a sample of 109,898 visits representing 3,891,233,060 weighted visits, we found that the proportion of visits that addressed mental health concerns increased from 10.7 percent of visits in 2006-07 to 15.9 percent by 2016 and 2018. Black patients were 40 percent less likely than White patients to have a mental health concern addressed during a primary care visit, and Hispanic patients were 40 percent less likely than non-Hispanic patients to have a mental health concern addressed during a primary care visit. These findings emphasize the need for payment and billing approaches (that is, value-based care models and billing codes for integrated behavioral health) as well as organizational designs and supports (that is, colocated therapy or psychiatry providers, availability of e-consultation, and longer visits) that enable primary care physicians to adequately address mental health needs.

AIMS: To compare healthcare costs over 2 years between those who did and did not receive an alcohol brief intervention (BI) among adult primary care patients screening positive for unhealthy alcohol use. DESIGN: Population-based observational study, using electronic health record data. SETTING: Kaiser Permanente Northern California, a non-profit, integrated healthcare delivery system of socio-economically and demographically diverse members in California, USA. PARTICIPANTS: Adult primary care patients, aged 18-85 years, who screened positive for unhealthy alcohol use between 1 January 2014 and 31 December 2017 as part of a systematic alcohol Screening, Brief Intervention and Referral to Treatment (SBIRT) program (n = 287 551). Patients either received a BI for unhealthy alcohol use (BI group) or did not receive a BI (non-BI group). MEASUREMENTS: Total emergency department (ED) and inpatient costs summarized in 6-month intervals from index screening through 24 months post-index; multivariable models examined associations between BI receipt and cost, and potential moderation by patient characteristics (age, sex, race/ethnicity, insurance type, clinical characteristics including body mass index, smoking status, physical activity level, the Charlson index of comorbidity, baseline drinking levels, drug and alcohol use disorders and mental health conditions in the prior year and the corresponding cost in the year prior to index date). FINDINGS: Adjusting for patient characteristics and prior-year cost, the largest declines in cost were found in the 6 months immediately following the index date for both BI and non-BI groups, and patients receiving a BI had greater reductions [estimate = -$209, 95% confidence interval (95% CI) = -$298 to -$119; estimate = -$11, 95% CI = -$14 to -$7, respectively] in total and ED costs, respectively, during this period compared with those who did not. Patients with a Charlson score ≥3 receiving a BI had lower total costs (estimate = -$621, 95% CI = -$1196 to -$46) and lower ED costs (estimate = -$24, 95% CI = -$47 to -$1) over 2 years, and patients with AUD receiving a BI had lower ED costs (estimate = -$33, 95% CI = -$66 to $0, respectively) than those who did not. CONCLUSION: Among US adult primary care patients screening positive for unhealthy alcohol use, individuals who receive an alcohol brief intervention at the time of screening appear to have statistically significantly greater declines in healthcare costs in the 6 months following screening than individuals who do not receive an alcohol brief intervention. Moreover, receipt of an alcohol brief intervention appears to be associated with statistically significantly lower costs in two particularly vulnerable (and historically costly) patient groups: patients with alcohol use disorders and those with a Charlson score ≥3 (indicative of significant medical comorbidity).

This report reflects significant input from hundreds of Maryland stakeholders, and the committed efforts of many individuals across the Department of Health and Mental Hygiene (Department). It builds upon work conducted by the Department in 2011 that culminated in a consultant report. The 2011 Consultant Report recommended that Maryland should better align and integrate behavioral health services.The recommendation of a model that improves the integration of Medicaid-financed behavioral health services, presented in this report, represents a major milestone. Significant work still lies ahead. The Department greatly appreciates the contributions of everyone who has participated thus far and we look forward to continuing to work with stakeholders in the coming months to improve health care in Maryland.