Literature Collection

Patient-centered medical homes based at federally-qualified health centers (FQHCs) can benefit patients with complex health needs, such as severe mental illness (SMI). However, little is known about FQHC characteristics associated with changes in health care expenditures and utilization for individuals with SMI. Using North Carolina Medicaid claims and FQHC data from the Uniform Data System, multivariate regression identified FQHC characteristics associated with total expenditures, medication adherence and emergency department utilization among adults with SMI, controlling for time-invariant differences by health center. Few of the FQHC-level factors affected the outcomes-not even offering on-site behavioral health services. Although the FQHCs in the analysis sample exhibited considerable variation in the provision of specialty behavioral services and in staffing configurations, it may be the case that the examination of average effects across a heterogeneous group of adults with SMI mask benefits of FQHCs to certain subgroups. These findings support the conclusion that there is no "one-size-fits-all" model that works best for this diverse patient population. Study results are relevant for practices embarking on expanded medical home services for people with SMI.

To identify whether medical homes in FQHCs have advantages over other group and individual medical practices in caring for people with severe mental illness. Models estimated the effect of the type of medical home on monthly service utilization, medication adherence, and total Medicaid spending over a 4-year period for adults aged 18 or older with a major depressive disorder (N = 65,755), bipolar disorder (N = 19,925), or schizophrenia (N = 8501) enrolled in North Carolina's Medicaid program. Inverse probability of treatment weights (IPTW) were used to adjust for nonrandom assignment of patients to practices. Generalized estimating equations for repeated measures were used with gamma distributions and log links for the continuous measures of medication adherence and spending, and binomial distributions with logit links for binary measures of any outpatient or any emergency department visits. Adults with major depression or bipolar disorders in FQHC medical homes had a lower probability of outpatient service use than their counterparts in individual and group practices. The probability of emergency department use, medication adherence, and total Medicaid spending were relatively similar across the three settings. This study suggests that no one type of medical practice setting-whether FQHC, other group, or individual-consistently outperforms the others in providing medical home services to people with severe mental illness.

OBJECTIVES: To assess primary care contributions to behavioral health in addressing unmet mental healthcare needs due to the COVID-19 pandemic. METHODS: Secondary data analysis of 2016 to 2018 Medical Expenditure Panel Survey of non-institutionalized US adults. We performed bivariate analysis to estimate the number and percentage of office-based visits and prescription medications for depression and anxiety disorders, any mental illness (AMI), and severe mental illness (AMI) by physician specialty (primary care, psychiatry, and subspecialty) and medical complexity. We ran summary statistics to compare the differences in sociodemographic factors between patients with AMI by seeing a primary care physician versus those seeing a psychiatrist. Binary logistic regression models were estimated to examine the likelihood of having a primary care visit versus psychiatrist visit for a given mental illness. RESULTS: There were 394 023 office-based visits in the analysis sample. AMI patients seeing primary care physician were thrice as likely to report 1 or more chronic conditions compared to those seeing psychiatrist. Among patients with a diagnosis of depression or anxiety and AMI the proportion of primary care visits ([38% vs 32%, P < .001], [39% vs 34%, P < .001] respectively), and prescriptions ([50% vs 40%, P < .001], [47% vs 44%, P < .05] respectively) were higher compared to those for psychiatric care. Patients diagnosed with SMI had a more significant percentage of prescriptions and visits to a psychiatrist than primary care physicians. CONCLUSION: Primary care physicians provided most of the care for depression, anxiety, and AMI. Almost a third of the care for SMI and a quarter of the SMI prescriptions occurred in primary care settings. Our study underscores the importance of supporting access to primary care given primary care physicians' critical role in combating the COVID-19 related rise in mental health burden.

IMPORTANCE: Opioid use disorder (OUD) is a public health crisis in the United States, but only 5% of US physicians have obtained a Drug Addiction Treatment Act (DATA) waiver to prescribe buprenorphine to treat OUD. Increasing the number of primary care physicians (PCPs) who have obtained the waiver and are able to treat patients with OUD is of utmost importance. OBJECTIVE: To determine whether a multimodal educational intervention of PCPs is associated with an increase in the number of buprenorphine waivers obtained and patients initiated into treatment in a primary care setting. DESIGN, SETTING, AND PARTICIPANTS: This quality improvement study was conducted in primary health care clinics within a large, integrated health care system. Patients included those who had received a diagnosis of OUD, and had Providence Health Plan Medicare or Medicaid insurance. Included PCPs were divided into 2 groups: those who obtained a DATA waiver after an education intervention (uptake PCPs) vs those who did not obtain a DATA waiver (nonuptake PCPs). The study took place between January 1, 2016, and December 31, 2017. Data analyses were conducted from December 2017 to August 2019. EXPOSURES: Multimodal educational intervention including video, in-person visits to clinical practitioner meetings by physician champions, and a primary care toolkit with training resources and clinic protocols. MAIN OUTCOMES AND MEASURES: The number of new uptake clinics where at least 1 PCP obtained a DATA waiver, the number of new PCPs with DATA waivers, the number of patients receiving a buprenorphine prescription, and the number of patients who received 12 or more weeks of treatment. RESULTS: Twenty-seven of 41 invited clinics implemented the intervention, and 620 PCPs were included. The number of PCPs with DATA waivers increased from 5 PCPs (0.8%) to 44 PCPs (7.1%), and the number of clinics with at least 1 buprenorphine prescriber increased from 3 clinics (7.3%) to 17 clinics (41.5%). In total, 213 patients underwent buprenorphine treatment, and 140 patients received 12 or more weeks of treatment. A total of 646 patients had Providence Health Plan Medicare or Medicaid insurance and were eligible for the study (mean [SD] age, 61.7 [16.5] years; 410 [63.5%] women). There was a statistically significant difference in treatment with buprenorphine between patients with uptake PCPs vs patients with nonuptake PCPs (23 patients [16.4%] vs 18 patients [3.5%]; odds ratio, 4.61 [95% CI, 2.32-10.51]; P = .01) after the intervention. CONCLUSIONS AND RELEVANCE: In this quality improvement study, an educational intervention was associated with an increase in the number of PCPs and clinics that could provide buprenorphine treatment for OUD and with an increase in the patients who were able to access care with medications for OUD.

IMPORTANCE: Health care spending in the United States continues to grow. Mental health and substance use disorders (MH/SUDs) are prevalent and associated with worse health outcomes and higher health care spending; alternative payment and delivery models (APMs) have the potential to facilitate higher quality, integrated, and more cost-effective MH/SUD care. OBJECTIVE: To systematically review and summarize the published literature on populations and MH/SUD conditions examined by APM evaluations and the associations of APMs with MH/SUD outcomes. EVIDENCE REVIEW: A literature search of MEDLINE, PsychInfo, Scopus, and Business Source was conducted from January 1, 1997, to May 17, 2019, for publications examining APMs for MH/SUD services, assessing at least 1 MH/SUD outcome, and having a comparison group. A total of 27 articles met these criteria, and each was classified according to the Health Care Payment Learning and Action Network's APM framework. Strength of evidence was graded using a modified Oxford Centre for Evidence-Based Medicine framework. FINDINGS: The 27 included articles evaluated 17 APM implementations that spanned 3 Health Care Payment Learning and Action Network categories and 6 subcategories, with no single category predominating the literature. APMs varied with regard to their assessed outcomes, funding sources, target populations, and diagnostic focuses. The APMs were primarily evaluated on their associations with process-of-care measures (15 [88.2%]), followed by utilization (11 [64.7%]), spending (9 [52.9%]), and clinical outcomes (5 [29.4%]). Medicaid and publicly funded SUD programs were most common, with each representing 7 APMs (41.2%). Most APMs focused on adults (11 [64.7%]), while fewer (2 [11.8%]) targeted children or adolescents. More than half of the APMs (9 [52.9%]) targeted populations with SUD, while 4 (23.5%) targeted MH populations, and the rest targeted MH/SUD broadly defined. APMs were most commonly associated with improvements in MH/SUD process-of-care outcomes (12 of 15 [80.0%]), although they were also associated with lower spending (4 of 8 [50.0%]) and utilization (5 of 11 [45.5%]) outcomes, suggesting gains in value from APMs. However, clinical outcomes were rarely measured (5 APMs [29.4%]). A total of 8 APMs (47.1%) assessed for gaming (ie, falsification of outcomes because of APM incentives) and adverse selection, with 1 (12.5%) showing evidence of gaming and 3 (37.5%) showing evidence of adverse selection. Other than those assessing accountable care organizations, few studies included qualitative evaluations. CONCLUSIONS AND RELEVANCE: In this study, APMs were associated with improvements in process-of-care outcomes, reductions in MH/SUD utilization, and decreases in spending. However, these findings cannot fully substitute for assessments of clinical outcomes, which have rarely been evaluated in this context. Additionally, this systematic review identified some noteworthy evidence for gaming and adverse selection, although these outcomes have not always been duly measured or analyzed. Future research is needed to better understand the varied qualitative experiences across APMs, their successful components, and their associations with clinical outcomes among diverse populations and settings.