Service Use of Rural and Urban Medicaid Beneficiaries Suffering From Depression: The Role of Supply (original) (raw)
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Journal of Health Care for the …, 2005
State governments throughout the country increasingly have turned to managed care for their Medicaid programs, including mental health services. We used ethnographic methods and a review of legal documents and state monitoring data to examine the impact of Medicaid reform on mental health services in New Mexico, a rural state. New Mexico implemented Medicaid managed care for both physical and mental health services in 1997. The reform led to administrative burdens, payment problems, and stress and high turnover among providers. Restrictions on inpatient and residential treatment exacerbated access problems for Medicaid recipients. These facts indicate that in rural, medically underserved states, the advantages of managed care for cost control, access, and quality assurance may be diminished. Responding to the crisis in mental health services, the federal government terminated New Mexico's program but later reversed its decision after political changes at the national level. This contradictory response suggests that the federal government's oversight role warrants careful scrutiny by advocacy groups at the local and state levels.
Patterns of rural mental health care
General Hospital Psychiatry, 1996
Recent epidemiologic studies have found that most patients with mental illness are seen exclusively in primary care medicine. These patients often present with medically unexplained somatic symptoms and utilize at least twice as many health care visits as controls. There has been an exponential growth in studies in this interface between primary care and psychiatry in the last 10 years. This special section, edited by Wayne J. Katon, M.D., will publish informative research articles that address primary care-psychiatric issues.
Few accounts document the rural context of mental health safety net institutions (SNIs), especially as they respond to changing public policies. Embedded in wider processes of welfare state restructuring, privatization has transformed state Medicaid systems nationwide. We carried out an ethnographic study in two rural, culturally distinct regions of New Mexico to assess the effects of Medicaid managed care (MMC) and the implications for future reform. After 160 interviews and participant observation at SNIs, we analyzed data through iterative coding procedures. SNIs responded to MMC by nonparticipation, partnering, downsizing, and tapping into alternative funding sources. Numerous barriers impaired access under MMC: service fragmentation, transportation, lack of cultural and linguistic competency, Medicaid enrollment, stigma, and immigration status. By privatizing Medicaid and contracting with for-profit managed care organizations, the state placed additional responsibilities on "disciplined" providers and clients. Managed care models might compromise the rural mental health safety net unless the serious gaps and limitations are addressed in existing services and funding.
Mental health is an essential component of overall health status, and mental illnesses are a leading cause of disability. In addition to expanding insurance coverage, the Affordable Care Act (ACA) reinforced parity for mental health services in insurance plans. This mixed-methods study assessed mental health service utilization by an urban and predominately African-American population following the successful implementation of the ACA and Medicaid expansion in Louisville, KY. Claims data from one Medicaid Managed Care Organization were analyzed to assess mental health care utilization patterns pre-and post-Medicaid expansion and determine differences in utilization rates between the Medicaid expansion population and other Medicaid beneficiaries, as well as differences in use of mental health services by geography across a Metropolitan region. Additionally, both mental health care providers and residents of the local community were interviewed regarding factors influencing use of mental health care. The results of the study demonstrate that beneficiaries of Medicaid expansion have used their new health insurance to access mental health ambulatory care services, vii counseling, and psychotropic medications, but may be doing so at a lower rate than other Medicaid beneficiaries in their community. Eleven distinct themes emerged from the qualitative data. Both providers and members of the community cited ongoing barriers to accessing and utilizing mental health services, including a lack of providers, stigma, poor health literacy, and the influences of social determinants of health. However, they recognized a need for mental health promotion within the toxic stress of their environment. The results of this study provide evidence supporting the continuation of policies that promote access to mental health care by reducing the burden of cost. This study also informs understanding of specific community needs that include persistent barriers beyond the scope of ACA. Thus, other policies and strategies are also needed to create health system transformation and foster a culture of health that prioritize mental health care. viii
“Bearing the burden”: Rural implications of licensed professionals’ exclusion from Medicare
Journal of Rural Mental Health, 2019
Medicare beneficiaries are unable to access mental health services provided by some licensed master's-level clinicians, including licensed professional counselors (LPCs). Provider shortages in rural localities, combined with Medicare policy exclusion of these licensed mental health professionals, exacerbates rural mental health care access disparities. Very little is known about the impact of LPC exclusion from Medicare on rural beneficiaries. This study explored the lived experiences of mental health professionals who have turned away clients because of their Medicare-ineligible provider status. Interpretative phenomenological analysis was employed as a qualitative form of inquiry to guide the research design, participant recruitment, data collection, and analysis. Semistructured interviews were conducted with 9 Medicare-ineligible mental health professionals from a single, Mid-Atlantic state in the United States who have turned away clients because of their Medicare-ineligible provider status. Evidence from rural and nonrural practitioners highlighted the contextual implications of Medicare provider exclusion on rural beneficiaries. One superordinate theme, undue burden, is described through three emergent themes from the interview data: geographical disparities, intersectional hardships, and practice constraints. The results suggest that current Medicare provider regulations may create disparities of mental health care availability and accessibility for Medicare beneficiaries from rural communities. The qualitative evidence of this study describes systemic and proximal factors that result in unexpected termination, deterred help-seeking behavior, and untimely treatment for older adults and disabled clients within rural mental health care settings.
Health affairs (Project Hope), 2018
Medicaid expansion had great potential to affect community health centers (CHCs), particularly in rural areas, because their patients are predominantly low income and disproportionately uninsured. Using data for 2011-15 on all CHCs, we found that after two years Medicaid expansion was associated with an 11.44-percentage-point decline in the share of CHC patients who were uninsured and a 13.15-percentage-point increase in the share with Medicaid. Changes in quality and volume were consistently observed in rural CHCs in expansion states, which had relative improvements in asthma treatment, body mass index screening and follow-up, and hypertension control, along with substantial increases in volumes for eighteen of twenty-one types of visits-particularly those for mammograms, abnormal breast findings, alcohol-related disorder, and other substance abuse disorder. Similar relative gains were not observed in urban CHCs in expansion states. Repealing or phasing out Medicaid expansion could...