The Effects of Medicaid Section 1115 Serious Mental Illness Waivers on Healthcare Utilization and Suicide-Related Behaviors

项目摘要 在美国，随着临床上显著的心理疾病的流行， 痛苦在增加，而获得行为健康服务的机会显然在恶化。出现了 特别是危机服务和住院病床的短缺，给医院造成更大的负担， 急诊室，并可能与较高的无家可归率， 患有严重精神疾病和健康状况较差的人。精神科住院病床短缺 部分原因是医疗补助政策不允许联邦支付“精神病院”的费用 疾病”（IMDs），设施超过16张病床，专门从事行为健康治疗。 最近，医疗保险和医疗补助服务中心（CMS）为各州申请 对患有严重精神疾病（SMI）的成年人在IMD住院期间获得联邦付款的豁免，以及 严重情绪障碍（SED）儿童。11个州已收到SMI/SED豁免，并且 五项待决。豁免有可能改善危机护理和门诊心理健康护理， 可能减少急诊室的使用和寄宿，改善护理协调， 减少自杀和自杀相关行为。然而，目前尚不清楚豁免是否导致了 服务的变化或哪些国家的实施在改善成果方面最成功。 这项全面的混合方法研究将评估通过以下方法去除IMD排除的影响： SMI豁免。交错的豁免批准过程创造了一个自然的实验，比较国家， 对那些不这样做的人实施豁免。我们的定量分析将使用转换后的医疗补助 统计信息系统分析文件（TAF），国家医疗补助数据集，包括以下信息 资格、入组和与服务使用和处方使用相关的索赔。我们的定性分析将 探索可能导致结果变化的州一级因素。针对PAR-21-316，我们的 拟议的研究将确定影响获取、利用和结果的政策和因素， 医疗补助要求数据集和利用现有的数据管理方法来推进我们的研究。

PROJECT SUMMARY There is a growing mental health crisis in the US, with the prevalence of clinically significant psychological distress growing while access to behavioral health services apparently worsening. There has been a particular shortage in the availability of crisis services and inpatient beds, placing a greater burden on emergency departments and potentially associated with higher rates of homelessness, incarceration of persons with serious mental illness, and worse health and wellbeing. The shortage of inpatient psychiatric beds can be tied in part to Medicaid policies that do not allow federal payment for stays in “Institutions for Mental Diseases” (IMDs), facilities with more than 16 beds that specialize in behavioral health treatment. Recently, the Centers for Medicare & Medicaid Services (CMS) created an opportunity for states to apply for waivers to receive federal payments for stays in IMDs for adults with serious mental illness (SMI) and children with serious emotional disturbances (SED). Eleven states have received an SMI/SED waiver, and five are pending. The waivers have the potential to improve crisis care and outpatient mental health care, potentially reducing emergency department use and boarding, improving the coordination of care, and reducing suicide and suicide-related behaviors. However, it is not yet clear whether the waivers have led to changes in services or what state implementations are most successful in improving outcomes. This comprehensive mixed-methods study will assess the effects of removing the IMD exclusion through the SMI waivers. The staggered waiver approval process creates a natural experiment to compare states that implement the waiver to those that do not. Our quantitative analysis will use the Transformed Medicaid Statistical Information System Analytic Files (TAF), a national Medicaid data set that includes information on eligibility, enrollment, and claims related to service utilization and prescription use. Our qualitative analysis will explore state-level factors that may contribute to changes in outcomes. In response to PAR-21-316, our proposed study will identify policies and factors that affect access, utilization, and outcomes, using large Medicaid claims datasets and leveraging an existing data management approach to advance our research.