York State Medicaid Research Articles

Detection and treatment of mental health issues by pediatric PCPs in New York State: an evaluation of Project TEACH.

The authors evaluated Project TEACH (PT), a statewide training and consultation program for pediatric primary care providers (PCPs) on identification and treatment of mental health conditions. An intervention group of 176 PCPs who volunteered for PT training was compared with a stratified random sample of 200 PCPs who did not receive PT training. Data on prescription practices, diagnoses, and follow-up care were from New York State Medicaid files (2009-2013) for youths seen by the trained (N=21,784) and untrained (N=46,607) PCPs. The percentage of children prescribed psychotropic medication increased after PT training (9% to 12%, p<.001), a larger increase than in the untrained group (4% to 5%, p<.001) (comparison, p<.001). Fewer differences were noted in diagnoses and in medication use and follow-up care among children with depression. This intervention may have an impact on providers' behaviors, but further research is needed to clarify its effectiveness.

Factors Associated With Initiation on Clozapine and on Other Antipsychotics Among Medicaid Enrollees

Demographic and clinical factors associated with starting clozapine and other antipsychotics were examined. New York State Medicaid claims from 2008 to 2009 identified individuals with a schizophrenia spectrum disorder, continuous Medicaid eligibility during the study, and at least one clinic service and antipsychotic fill. The sample included individuals who initiated an antipsychotic without any fills for the same medication in the prior 90 days (N=7,035). Only 144 patients (2%) started on clozapine. They were more likely to be younger, white males who had received services in a state-operated facility, with more hospital admissions and higher total psychiatric costs. African Americans and Hispanics were less likely than whites to start on clozapine. Individuals with substance use disorders were less likely than those without them to start on clozapine. Clozapine was rarely prescribed, and problematic disparities were found. Quality improvement efforts are needed to ensure that patients are offered this effective treatment when appropriate.

Table of Contents

AbstractSUD Providers Make Recommendations for New York State Medicaid WaiverD.C. Clinic Founded by Allem Targets the Insured IndividualNarconon Brings Commissions for Referrals into Light of DayThe Narconon LetterCoalition for Whole Health Meets with HHS on Parity, ACANew NAATP CEO Vows to Make Insurance Cover TreatmentASAP Launches New Certification Board for N.Y.Briefly NotedNames in the NewsComing up

Adherence to Chronic Disease Medications among New York City Medicaid Participants

Medication adherence is critical for cardiovascular disease prevention and control. Local health departments are well positioned to address adherence issues, however relevant baseline data and a mechanism for monitoring impact of interventions are lacking. We performed a retrospective analysis using New York State Medicaid claims from 2008 to 2009 to describe rates and predictors of adherence among New York City Medicaid participants with dyslipidemia, diabetes, or hypertension. Adherence was measured using the medication possession ratio, and multivariable logistic regression was used to assess factors related to adherence. Medication regimen adherence was 63%. Greater adherence was observed in those who were older, male, and taking medications from ≥3 drug classes. Compared with whites, blacks and Hispanics were less likely to be adherent (adjusted odds ratio [OR]=0.67, 95% confidence interval [CI]: 0.65-0.70 and adjusted OR=0.76, 95% CI: 0.73-0.78, respectively), while Asians were as likely. Medication adherence was inadequate and racial disparities were identified in NYC Medicaid participants on stable medication regimens for chronic disease. This study demonstrates a claims-based model that may be used by local health departments to monitor and evaluate efforts to improve adherence and reduce disparities.

The NIMH-CATIE Schizophrenia Study: What Did We Learn?

It has been over 10 years since the initiation of the National Institute of Mental Health (NIMH) Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) study and 5 years since the first publication of its primary results (1). In this period, the initial report has been cited in the literature over 1,600 times (2) while more than 80 articles from the study’s extensive database (Table 1), as well as a book serving as an archive of the study’s results and implications (3), have been published. In the meantime, several more randomized trials comparing the effectiveness of antipsychotics have been completed (4–6), meta-analyses that bear on the findings of the CATIE study have been performed (7, 8), and commentaries on CATIE’s findings and critiques of its methodology have been published (9–11). All of these help us to view the CATIE study in a broader context and enable us to determine what we really learned from it. When the CATIE study was designed in 1999– 2000, the prevailing opinion of researchers and clinicians alike was that the newer (second-generation) antipsychotic drugs were vastly superior to the older (first-generation) antipsychotic drugs in efficacy and safety. This largely reflected the results of studies sponsored by the manufacturers of the new drugs (12, 13), marketing messages of pharmaceutical companies and the hopes of many who wanted better treatments. Indeed, the hypothesis and expectation of the CATIE study investigators was that the firstgeneration antipsychotic perphenazine would be inferior to the newer agents. Consequently, the finding that perphenazine was similar in effectiveness to most other medications had a profound effect that extended beyond the scientific and psychiatric communities to the lay public and various stakeholder groups. Somewhat sensational news reports decried the preferential use and greater cost of the newer medications and the marketing practices that led to them. For example, the September 21, 2005, editorial page of The New York Times opined, “A government-financed study has provided the strongest evidence yet that the system for approving and promoting drugs is badly out of whack. The study compared five drugs used to treat schizophrenia and found that most of the newest, most heavily prescribed drugs were no better than an older drug that is far cheaper. The nation is wasting billions of dollars on heavily marketed drugs that have never proved themselves in head-to-head competition against cheaper competitors” (14). But what did we really learn from the CATIE study? In this commentary, we summarize its major implications and their relevance to clinical practice. We will also address some of the study’s most relevant critiques.

The Eight Elements of an “Effective” Compliance Program

This article outlines practical suggestions that home health care providers can utilize to develop an effective compliance program that meets the standards and requirements. The program model was designed to meet the New York State Medicaid regulations but is easily transferable to other state and federal compliance program requirements. By using these elements, a compliance program can be put in place for other state Medicaid programs providing services in the home care setting. The article is intended to expand the home health care provider’s organizational inquiry into identifying the most salient areas to be considered in the development of the compliance program’s eight required elements. Providers are encouraged to compare existing compliance programs to the required eight elements to assure ongoing comprehensiveness of their existing programs.

Adjuvant hormone therapy use in early-stage breast cancer patients insured by the New York State Medicaid program.

6031 Background: Adjuvant hormone therapy (HRx) improves outcomes for women with hormone receptor positive (HR+) early stage breast cancer (EBC). We evaluated predictors of appropriate use of adjuv...

Early Childhood Exposure to Anesthesia and Risk of Developmental and Behavioral Disorders in a Sibling Birth Cohort

In vitro and in vivo studies of anesthetics have demonstrated serious neurotoxic effects on the developing brain. However, the clinical relevance of these findings to children undergoing anesthesia remains unclear. Using data from a sibling birth cohort, we assessed the association between exposure to anesthesia in the setting of surgery in patients younger than 3 years and the risk of developmental and behavioral disorders. We constructed a retrospective cohort of 10,450 siblings who were born between 1999 and 2005 and who were enrolled in the New York State Medicaid program. The exposed group was 304 children without a history of developmental or behavioral disorders who underwent surgery when they were younger than 3 years. The unexposed group was 10,146 children who did not receive any surgical procedures when they were younger than 3 years. Exposed children were entered into analysis at the date of surgery. Unexposed children were entered into analysis at age 10 months (the mean age at which exposed children underwent surgery). Both exposed and unexposed children were followed until diagnosis with a developmental or behavioral disorder, loss to follow-up, or the end of 2005. The association of exposure to anesthesia with subsequent developmental and behavioral disorders was assessed with both proportional hazards modeling, and pair-matched analysis. The incidence of developmental and behavioral disorders was 128.2 diagnoses per 1000 person-years for the exposed cohort and 56.3 diagnoses per 1000 person-years for the unexposed cohort. With adjustment for sex and history of birth-related medical complications, and clustering by sibling status, the estimated hazard ratio of developmental or behavioral disorders associated with any exposure to anesthesia when they were younger than 3 years was 1.6 (95% confidence interval [CI]: 1.4, 1.8). The risk increased from 1.1 (95% CI: 0.8, 1.4) for 1 operation to 2.9 (94% CI: 2.5, 3.1) for 2 operations and 4.0 (95% CI: 3.5, 4.5) for ≥3 operations. The relative risk in a matched analysis of 138 sibling pairs was 0.9 (95% CI: 0.6, 1.4). The risk of being subsequently diagnosed with developmental and behavioral disorders in children who were enrolled in a state Medicaid program and who had surgery when they were younger than 3 years was 60% greater than that of a similar group of siblings who did not undergo surgery. More tightly matched pairwise analyses indicate that the extent to which the excess risk is causally attributable to anesthesia or mediated by unmeasured factors remains to be determined.

An Expenditure Analysis of High-Cost Medicaid Recipients with HIV Disease in New York State

A retrospective analysis was conducted of federal fiscal year (FFY) 2007 New York State Medicaid claims and expenditure data to examine variation in expenditures among New York State Medicaid recipients with HIV disease and the extent to which this variation could be attributed to the prevalence of comorbidities and other chronic conditions unrelated to HIV disease. Median expenditures per person for the period for a high-cost group (those for whom expenditures exceeded $100,000 for the period) were over $157,000, with 40% of total expenditures for this group for treatment unrelated to their HIV disease. The prevalence of comorbidities in the high-cost population is very high, the most common being substance abuse and mental illness.

Valproate Prescription Prevalence Among Women of Childbearing Age

Valproate is associated with polycystic ovary syndrome as well as congenital malformations and developmental delays of infants who were prenatally exposed. The frequency of valproate use for mental health conditions among women of childbearing age was determined. Using New York State Medicaid claims for persons with psychiatric disorders, 40,526 individuals with active prescriptions for mood stabilizers (non-antipsychotic) on May 1, 2009, were identified. Chi square tests were used to compare valproate use among women of childbearing age with similarly aged men and older women. Valproate was the most commonly prescribed agent for young women (23.4%). Men were more likely than women, and older women more likely than younger women, to take valproate. Over 20% of childbearing-aged women receiving mood stabilizers were treated with valproate, although increasing data on the reproductive toxicity of this agent compel consideration of other non-antipsychotic mood stabilizers as first-line choices.

Valproate Prescription Prevalence Among Women of Childbearing Age

Objective: Valproate is associated with polycystic ovary syndrome as well as congenital malformations and developmental delays of infants who were prenatally exposed. The frequency of valproate use for mental health conditions among women of childbearing age was determined. Methods: Using New York State Medicaid claims for persons with psychiatric disorders, 40,526 individuals with active prescriptions for mood stabilizers (non-antipsychotic) on May 1, 2009, were identified. Chi square tests were used to compare valproate use among women of childbearing age with similarly aged men and older women. Results: Valproate was the most commonly prescribed agent for young women (23.4%). Men were more likely than women, and older women more likely than younger women, to take valproate. Conclusions: Over 20% of childbearing-aged women receiving mood stabilizers were treated with valproate, although increasing data on the reproductive toxicity of this agent compel consideration of other non-antipsychotic mood stabilizers as first-line choices. (Psychiatric Services 62:218–220, 2011)

Building Capacity to Assess Cancer Care in the Medicaid Population in New York State

To link data from a central cancer registry with Medicaid enrollment and claims files in order to assess cancer care in an economically disadvantaged population. Over 500,000 cancer patients diagnosed between 2002 and 2006 reported to the New York State Cancer Registry were linked with New York State Medicaid enrollment and claims records. A probabilistic linkage was performed between the two data sources. The resulting Medicaid and non-Medicaid populations were compared in terms of demographics and stage at diagnosis. Existing databases were used. One-quarter of cancer patients were enrolled in Medicaid at or near the time of cancer diagnosis. The Medicaid cohort was younger, more likely to be an ethnic minority, foreign born, never married, live in either an inner-city or remote rural area, and have a higher stage at diagnosis. The linked dataset will permit detailed analysis of cancer treatment and cancer treatment disparities among historically understudied groups. The linkage has also resulted in improvements in Cancer Registry quality through the identification of errors and missing values. The linkage did present technical challenges in the form of immense file sizes not easily adaptable to desktop computers.

Can Prenatal Care Impact Future Well-Child Visits? The Experience of a Low Income Population in New York State Medicaid Managed Care

To examine the association between maternal characteristics and care patterns and the subsequent utilization of well-child visits in a low income population in New York State (NYS). We analyzed Medicaid managed care birth data from 2004 to 2005 linked to an administrative database to obtain information on preventive well-care visits for the child. The outcome variable was whether the child had five or more well-child visits (WCVs) in their first 15 months of life. Of the 101,461 children in this study 67% had received five or more well-child visits by 15 months of age. This varied by region with a lesser proportion of children receiving well-child visits in New York City (NYC) and a higher proportion in the rest-of-state. Children born to mothers with intensive and adequate prenatal care were significantly more likely to have the necessary well-child visits. Foreign born women were more likely than US born women to bring their children in for well-child visits across all racial and ethnic groups. This study indicated that women who received adequate prenatal care were more likely to bring their children to well-child visits even after adjusting for maternal and infant characteristics. Maternal birthplace modified the association between race and well-child visits. The black-white disparity typically seen in WCVs in the United States was not found in NYC among children of US born women in Medicaid managed care.

Changes in guideline-recommended medication possession after implementing Kendra's law in New York.

This study examined changes in possession of guideline-recommended medication among three groups of New York State Medicaid enrollees with severe mental illness: those who received an involuntary outpatient commitment order, voluntary enhanced services, or neither of these interventions. An observational study was conducted with New York State Medicaid claims data for enrollees with bipolar, schizophrenia, or schizoaffective disorders in New York City, Long Island, and the Hudson River regions from 2000 to 2005 (N=7,762). With adjustment for clinical and demographic characteristics, logistic regression models predicted the probability of a monthly medication possession ratio (MPR) ≥ 80% for medications recommended by expert guidelines or by the U.S. Food and Drug Administration for the indicated psychiatric diagnosis. Separate models were fit by region and for patients who ever received assisted outpatient treatment (AOT), voluntary enhanced services but never AOT, or neither treatment. In all three regions, for all three groups, the predicted probability of an MPR ≥ 80% improved over time (AOT improved by 31-40 percentage points, followed by enhanced services, which improved by 15-22 points, and "neither treatment," improving 8-19 points). Some regional differences in MPR trajectories were observed. After New York implemented AOT and increased community resources for enhanced services, guideline-recommended medication possession improved among Medicaid enrollees with severe mental illness--even among those who never received these interventions or services. However, further study is needed to understand why there were different regional trajectories and why some groups did not gain similarly across regions.

Questionable Prescribing Practices Have Officials Searching for Answers

About 10 percent of adults with mental illness in the New York state Medicaid program were prescribed four or more psychotropic drugs concurrently, and 13 percent of youth were prescribed three or more.

Identifying Clinically Questionable Psychotropic Prescribing Practices for Medicaid Recipients in New York State

This study sought to identify and characterize rates of clinically questionable prescribing in New York State. As part of a quality improvement initiative, 34 national psychopharmacology experts identified a set of questionable prescribing practices recognizable from pharmacy claims data. Indicators of such practices were applied to Medicaid claims data for 217,216 beneficiaries in New York State who had an active psychotropic prescription on April 1, 2008. A total of 156,103 (72%) of these beneficiaries had one or more continuing (>90 days) prescriptions for a psychotropic. About 10% of adults were prescribed four or more psychotropics concurrently, and 13% of children and 2% of older adults were prescribed three or more concurrently. Prescribing an antipsychotic with a moderate-to-high risk of causing metabolic abnormalities approached 50% (46%) among individuals who had existing cardiometabolic conditions. Among beneficiaries prescribed second-generation antipsychotics with a moderate-to-high risk of causing metabolic abnormalities, over half (60%) had not received a metabolic screening test in the past year. Among women of reproductive age prescribed mood stabilizers, over one-quarter (30%) were prescribed a valproic acid-based formulation despite its potential for teratogenicity. Only 2% of youths under age 18 were prescribed benzodiazepines; however, about half (48%) had trials over 90 days' duration. Examination of pharmacy claims from Medicaid beneficiaries in New York State indicated that prescribing practices deemed clinically questionable by pharmacology experts are common. Aggregated pharmacy claims data can identify such practices, and reviews of these data can be a core component of efforts to improve prescribing practices.

Identifying Clinically Questionable Psychotropic Prescribing Practices for Medicaid Recipients in New York State

Identifying Clinically Questionable Psychotropic Prescribing Practices for Medicaid Recipients in New York State

A Retrospective Cohort Study of the Association of Anesthesia and Hernia Repair Surgery With Behavioral and Developmental Disorders in Young Children

Recent animal studies have shown that commonly used anesthetic agents may have serious neurotoxic effects on the developing brain. The purpose of this study was to assess the association between surgery for hernia repair and the risk of behavioral and developmental disorders in young children. We performed a retrospective cohort analysis of children who were enrollees of the New York State Medicaid program. Our analysis involved following a birth cohort of 383 children who underwent inguinal hernia repair during the first 3 years of life, and a sample of 5050 children frequency-matched on age with no history of hernia-repair before age 3. After controlling for age, sex, and complicating birth-related conditions such as low birth weight, children who underwent hernia repair under 3 years of age were more than twice as likely as children in the comparison group to be subsequently diagnosed with a developmental or behavioral disorder (adjusted hazard ratio 2.3, 95% confidence interval 1.3, 4.1). Our findings add to recent evidence of the potential association of surgery and its concurrent exposure to anesthetic agents with neurotoxicity and underscore the need for more rigorous clinical research on the long-term effects of surgery and anesthesia in children.

Population Psychiatric Medication Prescription Rates following a Terrorist Attack

While several population-based studies have documented behavioral health disturbances following terrorist attacks, a number of mental health service utilization analyses present conflicting conclusions. The purpose of this study was to determine if mental health service utilization increased following a terrorist attack by assessing changes in psychoactive drug prescription rates. The rate of selective serotonin reuptake inhibitor (SSRI) prescriptions was measured among New York State Medicaid enrollees before and after the terrorist attacks of 11 September 2001. The association between geographic proximity to the events and changes in the rate of SSRI prescriptions around 11 September 2001 was assessed. From September to December 2001, among individuals residing within three miles of the World Trade Center site, there was an 18.2% increase in the SSRI prescription rate compared to the previous eight-month period (p = 0.0011). While there was a 9.3% increase for non-New York City residents, this change was not statistically significant (p = 0.74). There was a quantifiable increase in the dispensing of psychoactive drugs following the terrorist attacks of 11 September 2001, and this effect varied by geographic proximity to the events. These findings build on the growing body of knowledge on the pervasive effects of disasters and terrorist events for population health, and demonstrate the need to include mental and behavioral health as key components of surge capacity and public health response to mass traumas.

Medicaid Guidelines Issued for New York

Medicaid Guidelines Issued for New York