Higher primary care Medicaid reimbursement rates improve behavioral health outcomes among enrollees, according to a new report by the National Bureau of Economic Research.
The report analyzed spillover effects of the largest federally-mandated increase in Medicaid primary care reimbursement rates (between 2013 and 2014 through the Affordable Care Act) on behavioral health outcomes such as mental illness, substance use disorders (SUDs) and tobacco use over the time period 2010 to 2016.
The improvement in outcomes came without beneficiaries seeking more behavioral health services outside of primary care, suggesting that primary care providers are efficient in improving behavioral health among the Medicaid population.
The federal mandate greatly increased Medicaid reimbursement rates for a myriad of primary care services, prompted more providers to participate in Medicaid and increased visits and health among Medicaid enrollees. This study, however, is a look at spillover effects to behavioral health outcomes and service use.
For the 2010 to 2012 pre-ACA fee bump period for Medicaid recipients, the study found 30.8% of the sample met criteria for a mental illness, 11.6% for a SUD in the past year and 41.6% for tobacco use in the past 30 days. Of that population, 23.4% reported any mental illness treatment and 4.5% reported any SUD treatment.
Following the fee boost, behavioral health outcomes among these lower-income populations improved while behavioral health service use was not altered. Medicaid beneficiaries were not expanding their treatment beyond primary care, yet there was a 9.7% decrease in mental illness, a 15.2% decrease in SUD treatment and a 6.0% decrease in tobacco use.
The study’s results suggest that primary care is efficient in delivering services to Medicaid enrollees that improve behavioral health — perhaps more efficiently than specialty care, it points out, where a substantial amount of behavioral health treatment has been delivered in the past.
The study also found that the fee bump had differential effects across states that did and did not expand Medicaid with the ACA, as well as along gender lines.
The study didn't find statistically significant evidence that the bump changed the probability of Medicaid coverage. In other words, the value of better access to care — or higher quality care — didn't incentivize people to enroll in Medicaid.
Low reimbursement rates have often been cited by physicians as a barrier for the Medicaid participation, along with administrative burdens, delays in payment and complex caseloads.
Proponents of lowered spending decry the federal Medicaid fee bump ($7 billion to $12 billion over the two year period) as a significant raise, prompting questions about the fiscal practicality of the program.
However, the social costs of behavioral health in the U.S. are estimated to be as high as $1.31 trillion per year, meaning that programs that work to fix behavioral health at the ground level may cost pennies to save millions.
These findings are also important from a workforce and policy perspective, given current shortages of behavioral healthcare providers and the ability of such providers to cost-effectively treat behavioral health conditions. Similarly, they hint at the ineffectivenss of siloing behavioral and primary health, given that the study found improved outcomes with primary care physicians and not specialists.
And, as use of telebehavioral health mounts, the findings reiterate the importance of primary care providers, who may also be able to improve outcomes without in-person visits.