Mental Health Service Use by Medicaid-Enrolled Children and Adolescents in Primary Care Safety-Net Clinics
Abstract
Objective:
Methods:
Results:
Conclusions:
HIGHLIGHTS
Methods
Data
Cohorts
Safety-Net Measure
Quality of Care
Covariates
Individual-level measures.
County-level measures.
Analysis
Results
Mental Health Visits in a Primary Care Safety-Net Setting
Youths initiating ADHD medication (N=6,433) | Youths with an index depression diagnosis (N=13,209) | |||
---|---|---|---|---|
ADHD- or depression-related visit | N | % | N | % |
No visits | 5,566 | 86.5 | 12,266 | 92.9 |
Some visits (but fewer than the majority) | 256 | 4.0 | 365 | 2.8 |
Majority of visits | 611 | 9.5 | 578 | 4.4 |
Any visits to an FQHC | 354 | 5.5 | 482 | 3.6 |
Any visits to an RHC (no FQHC visit) | 513 | 8.0 | 461 | 3.5 |
Correlates Associated With Mental Health Treatment in a Primary Care Safety-Net Clinic
Child-level correlates.
ADHD-related visits (N=6,433)b | Depression-related visits (N=13,209)b | |||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|
None (N=5,566) | Some (but fewer than majority) (N=256) | Majority (N=611) | None (N=12,266) | Some (but fewer than majority) (N=365) | Majority (N=578) | |||||||
Characteristic | N | % | N | % | N | % | N | % | N | % | N | % |
Demographic | ||||||||||||
Race-ethnicity | ||||||||||||
Non-Hispanic white | 2,560 | 46.0 | 129 | 50.4 | 354 | 57.9*** | 5,770 | 47.0 | 219 | 60.0*** | 325 | 56.2*** |
Black | 1,703 | 30.6 | 75 | 29.3 | 134 | 21.9*** | 3,863 | 31.5 | 78 | 21.4*** | 131 | 22.7*** |
Hispanic | 827 | 14.9 | 35 | 13.7 | 75 | 12.3 | 1,828 | 14.9 | 54 | 14.8 | 89 | 15.4 |
Other or unknown | 476 | 8.6 | 17 | 6.6 | 48 | 7.9 | 805 | 6.6 | 14 | 3.8** | 33 | 5.7 |
Age (M±SD) | 8.2±1.6 | 8.0±1.6* | 8.2±1.6 | 12.8±3.0 | 13.8±2.6*** | 13.3±2.8*** | ||||||
Female (reference: male) | 1,786 | 32.1 | 79 | 30.9 | 203 | 33.2 | 6,685 | 54.5 | 245 | 67.1*** | 355 | 61.4*** |
Medicaid plan type | ||||||||||||
Fee for service (no carve-out) | 362 | 6.5 | 31 | 12.1** | 127 | 20.8*** | 1,346 | 11.0 | 68 | 18.6*** | 116 | 20.1*** |
Primary care case management (no carve-out) | 1,011 | 18.2 | 35 | 13.7* | 186 | 30.4*** | 1,656 | 13.5 | 60 | 16.4 | 174 | 30.1*** |
Comprehensive managed care plan (no carve-out)c | 2,517 | 45.2 | 114 | 44.5 | 158 | 25.9*** | 7,311 | 59.6 | 195 | 53.4* | 202 | 34.9*** |
Mixed pland | 1,676 | 30.1 | 76 | 29.7 | 140 | 22.9*** | 1,953 | 15.9 | 42 | 11.5** | 86 | 14.9 |
Medicaid eligibility type: blind, disabled, or foster care | 967 | 17.4 | 65 | 25.4** | 91 | 14.9 | 2,843 | 23.2 | 65 | 17.8** | 77 | 13.3*** |
Mental illness comorbidity | ||||||||||||
ADHD | — | — | — | — | — | — | 3,947 | 32.2 | 90 | 24.7** | 182 | 31.5 |
Any depressive disorder | 240 | 4.3 | 24 | 9.4** | 28 | 4.6 | — | — | — | — | — | — |
Depression not otherwise specified only | — | — | — | — | — | — | 5,670 | 46.2 | 103 | 28.2*** | 351 | 60.7*** |
Dysthymia (no major depression) | — | — | — | — | — | — | 1,443 | 11.8 | 25 | 6.9*** | 51 | 8.8* |
Any major depression diagnosis | — | — | — | — | — | — | 5,153 | 42.0 | 237 | 64.9*** | 176 | 30.5*** |
Oppositional defiant disorder or conduct disorder | 962 | 17.3 | 56 | 21.9 | 59 | 9.7*** | 3,034 | 24.7 | 81 | 22.2 | 99 | 17.1*** |
Other mental disorder | 1,852 | 33.3 | 104 | 40.6* | 159 | 26.0*** | 6,218 | 50.7 | 225 | 61.6*** | 259 | 44.8** |
Physical health comorbidity: asthma | 915 | 16.4 | 35 | 13.7 | 70 | 11.5*** | 1,615 | 13.2 | 53 | 14.5 | 73 | 12.6 |
M | SD | M | SD | M | SD | M | SD | M | SD | M | SD | |
County-level characteristic | ||||||||||||
% living in urban area | 68.5 | 28.8 | 58.4*** | 33.3 | 49.7*** | 30.3 | 67.4 | 30.5 | 54.3*** | 33.4 | 53.9*** | 32.4 |
% living in poverty | 16.9 | 6.1 | 17.4 | 5.5 | 18.5*** | 5.4 | 16.5 | 6.3 | 17.5*** | 5.7 | 18.5*** | 6.1 |
Primary care safety-net clinics per 100,000 population | 2.9 | 5.4 | 7.4*** | 9.6 | 11.0*** | 11.8 | 3.7 | 7.4 | 9.5*** | 13.5 | 10.4*** | 13.4 |
Primary care physicians per 100,000 population | 61.5 | 28.2 | 55.1*** | 28.3 | 48.7*** | 25.8 | 62.4 | 29.6 | 55.1*** | 32.0 | 51.8*** | 27.7 |
Psychologists per 100,000 population | 16.7 | 18.0 | 15.3 | 17.7 | 10.7*** | 15.2 | 18.7 | 19.1 | 14.8*** | 16.0 | 14.1*** | 16.7 |
ADHD-related visitsb | Depression-related visitsb | |||||||
---|---|---|---|---|---|---|---|---|
Some (but fewer than majority) (intercept=3.9%) | Majority (intercept=9.6%) | Some (but fewer than majority) (intercept=2.8%) | Majority (intercept=4.3%) | |||||
Characteristic | Adjusted percentage point difference | 95% CI | Adjusted percentage point difference | 95% CI | Adjusted percentage point difference | 95% CI | Adjusted percentage point difference | 95% CI |
Demographic | ||||||||
Race-ethnicity (reference: non-Hispanic white) | ||||||||
Black | .3 | –1.0, 1.5 | .2 | –1.8, 2.2 | −.4 | –1.4, .5 | −.2 | –1.6, 1.3 |
Hispanic | −.8 | –3.1, 1.5 | .1 | –3.6, 3.8 | 1.1 | −.5, 2.6 | 1.5 | −.6, 3.6 |
Other or unknown | –1.2 | –3.1, .7 | 1.8 | –1.3, 4.9 | −.6 | –2.2, 1.0 | 1.4 | −.6, 3.4 |
Age | −.3 | −.6, .0002 | .02 | −.4, .5 | .2 | .1, .3 | .3 | .1, .4 |
Female (reference: male) | −.3 | –1.1, .6 | .1 | –1.2, 1.4 | 1.1 | .5, 1.7 | .6 | −.2, 1.4 |
Medicaid plan type (reference: fee for service [no carve-out]) | ||||||||
Primary care case management (no carve-out) | 1.5 | −.5, 3.6 | –3.1 | –6.3, .04 | .3 | –1.3, 2.0 | –1.5 | –3.9, .8 |
Comprehensive managed care plan (no carve-out)c | 2.9 | .6, 5.3 | –9.0 | –11.9, –6.1 | .5 | −.5, 1.6 | –1.9 | –3.7, –.1 |
Mixed pland | 1.9 | −.2, 4.0 | –5.8 | –8.7, –3.0 | .6 | −.5, 1.8 | −.9 | –2.8, 1.0 |
Medicaid eligibility type: blind, disabled, or foster care (reference: other type)e | 2.9 | 1.2, 4.6 | –2.0 | –4.8, .8 | −.8 | –2.0, .4 | –2.3 | –3.7, –.8 |
Mental health comorbidity | ||||||||
ADHD | — | — | — | — | .5 | −.2, 1.1 | .8 | −.04, 1.6 |
Any depressive disorder (reference: depression not otherwise specified only) | 4.1 | 1.3, 6.9 | −.1 | –3.2, 3.0 | — | — | — | — |
Dysthymia (no major depression) | — | — | — | — | .1 | –1.5, 1.6 | –2.4 | –4.3, –.5 |
Any major depression diagnosis | — | — | — | — | 1.7 | 1.1, 2.4 | –2.7 | –3.7, –1.6 |
Oppositional defiant disorder or conduct disorder | 1.6 | −.1, 3.4 | –3.7 | –6.2, –1.3 | .03 | −.7, .8 | −.7 | –1.9, .5 |
Other mental disorder | 1.6 | .5, 2.7 | –1.9 | –3.6, –.2 | .9 | .3, 1.6 | .04 | −.8, .9 |
Physical health comorbidity: asthma | −.8 | –2.2, .7 | –2.1 | –4.1, –.03 | .2 | −.7, 1.2 | .3 | −.7, 1.3 |
County-level characteristicf | ||||||||
% living in urban area | −.3 | –1.1, .5 | –2.3 | –3.8, –.9 | −.6 | –1.1, –.1 | –1.2 | –2.0, –.4 |
% living in poverty | −.4 | –1.0, .3 | −.4 | –1.8, .9 | .001 | −.5, .5 | .2 | −.7, 1.0 |
Primary care safety-net clinic per 100,000 population | 1.8 | 1.1, 2.5 | 3.6 | 2.4, 4.8 | .5 | .2, .9 | 1.0 | .5, 1.5 |
Primary care physicians per 100,000 population | .2 | −.6, 1.0 | −.9 | –2.4, .6 | .01 | −.5, .5 | −.3 | –1.1, .4 |
Psychologists per 100,000 population | −.4 | –1.1, .3 | .8 | −.9, 2.4 | −.1 | −.6, .3 | .8 | .03, 1.6 |
County-level correlates.
Quality Measures Across Safety-Net Settings
≥1 follow-up visit in initiation phase (N=6,433)b | Continued medication (N=5,968)c | Adequate follow-up care in C&M phase (N=2,370)d | |||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Visits in safety-net clinic | Total N | N | %e | Adjusted percentage point difference (intercept=63.8)f | 95% CI | Total N | N | %e | Adjusted percentage point difference (intercept=39.7)f | 95% CI | Total N | N | %e | Adjusted percentage point difference (intercept=69.3)f | 95% CI |
None (reference) | 5,566 | 3,705 | 66.6 | — | — | 5,147 | 2,030 | 39.4 | — | — | 2,030 | 1,464 | 72.1 | — | — |
Some (but fewer than majority) | 256 | 192 | 75.0** | 7.9* | 1.5, 14.2 | 244 | 128 | 52.5*** | 7.6* | 1.4, 13.8 | 128 | 99 | 77.3 | 5.6 | –3.1, 14.4 |
Majority | 611 | 207 | 33.9*** | –27.7*** | –32.5, –23.0 | 577 | 212 | 36.7 | –6.6** | –11.2, –2.1 | 212 | 79 | 37.3*** | –24.3*** | –31.4, –17.3 |
Minimally adequate psychotherapyb | Minimally adequate pharmacotherapyc | Minimally adequate treatmentd | |||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Visits in safety-net clinic | Total N | N | %e | Adjusted percentage point difference (intercept=32.9)f | 95% CI | N | %e | Adjusted percentage point difference (intercept=16.1)f | 95% CI | N | %e | Adjusted percentage point difference (intercept=43.8)f | 95% CI |
None (reference) | 12,266 | 4,128 | 33.7 | — | — | 1,878 | 15.3 | — | — | 5,396 | 44.0 | — | — |
Some (but fewer than majority) | 365 | 126 | 34.5 | –3.1 | –8.3, 2.0 | 123 | 33.7*** | 9.3*** | 5.8, 12.9 | 199 | 54.5*** | 4.0 | –1.6, 9.7 |
Majority | 578 | 88 | 15.2*** | –19.9*** | –25.3, –14.5 | 124 | 21.5*** | 4.0* | .9, 7.1 | 196 | 33.9*** | –9.5*** | –14.6, –4.4 |
Discussion
Conclusions
Acknowledgments
Footnotes
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