Medicaid managed care and the unmet need for mental health care among children with special health care needs.

The proportion of the Medicaid population enrolled in managed care rose from 9.5 percent in 1991 to 60.7 percent in 2004 (Mitchell and Gaskin 2004; CMS 2005), reflecting states' decisions to convert Medicaid programs from traditional fee-for-service (FFS) to managed care. As part of this trend, many states have switched their pediatric mental health programs to managed care; for example, 42 states adopted Medicaid behavioral health managed care by 2000 (Stroul, Pires, and Armstrong 2001). These programs can be subdivided into two major types: (1) carve-out managed care in which mental and physical health services are financed and/or administered separately, and (2) integrated managed care in which these services are together (Hanson and Huskamp 2001; Stroul, Pires, and Armstrong 2001). While the organization of a managed care program has been shown to influence children with special health care needs' (CSHCN's) utilization of health care services (Shenkman et al. 2003), the theoretical association between behavioral health managed care and unmet mental health care need is unclear. Behavioral health managed care programs could lead to cost savings which could be used to improve services, but may also result in adverse selection, restrictions on choosing providers, and other barriers that could reduce access to care (Kastner 2004). Managed care carve-outs could improve management and enhance mental health services (Inkelas 2005), but may also create fragmented care (Kastner 2004). Integrated approaches would be expected to facilitate coordination between physical and mental health services (Hutchinson and Foster 2003). Despite the rising importance of Medicaid managed care, and its theoretical effects, there have been few empirical studies on the association between behavioral health managed care and any unmet need for pediatric mental health services. Some research has suggested managed care improved access to mental health care compared with FFS models (Burns et al. 1999; Hutchinson and Foster 2003), while others found reduced access (Mandell, Boothroyd, and Stiles 2003) or no changes (Mitchell and Gaskin 2004). One study suggested the degree of managed care penetration within a community can improve access to care (Stockdale et al. 2007). There is also a lack of data on the effect of behavioral health managed care on the mental health needs of CSHCN. CSHCN are an important population for research because they are particularly vulnerable to the effects of managed care due to their increased service utilization and expenses compared with the general pediatric population (Newacheck et al. 1996). An insufficient supply of mental health providers, including trained psychiatrists, psychologists, and social workers, likely contributes to reduced access to care (Flisher et al. 1997; U.S. Department HHS Report of the Surgeon General 2000a). Studies show reimbursement rates influence the participation of these providers in Medicaid programs (Berman et al. 2002). Sturm et al. (2003) found unmet mental health care need differed significantly by state, speculating the design of state Medicaid programs and primary care and mental health provider supply contributed to this state variation. Given the higher prevalence of mental health conditions among CSHCN compared with other children (Bennett 1994), mental health services are critical for CSHCN. Studies from the 1994 National Health Interview Survey on Disability (NHIS-D) indicated 1.2 percent of children with chronic conditions had unmet mental health care need (Silver and Stein 2001) and 58.2 percent of those with poor psychosocial adjustment had unmet need (Witt, Kasper, and Riley 2003). Studies from the 2000–2001 NHIS found 3 percent of CSHCN with health insurance coverage had unmet mental health care need due to excessive out-of-pocket costs (Davidoff 2004a). Using the National Survey of CSHCN, Ganz and Tendulkar (2006) showed that the unmet mental health need among CSHCN was related to nonmetropolitan area residence, non-Hispanic, older age, lower income, uninsured (versus private), mildly severe to severe conditions, not having a usual source of care, other family members having unmet mental health needs, and having an emotional, developmental, or behavioral disability. We propose to focus on key state-level factors in the Medicaid population that influence the unmet need for mental health care. This study uses the National Survey of CSHCN (NSCSHCN), a cross-sectional survey representative on both the national and state levels, providing a unique opportunity to analyze state policies and unmet need for health care. Analyzing a subsample of CSHCN with only Medicaid for insurance, and a further subsample of CSHCN with only Medicaid and an emotional, developmental, or behavioral (EDB) disorder, we use multilevel logistic regression models to assess potential differences in reported unmet need among Medicaid-receiving CSHCN living in states with Medicaid managed care pediatric behavioral health programs compared with those living in states with Medicaid FFS programs. We hypothesize that states with Medicaid managed care, including both the carve-out and integrated types, will be associated with higher rates of unmet mental health care need compared with FFS programs, for both the overall Medicaid population and for children insured by Medicaid with parent-reported EDB problems. We hypothesize that among state-level variables, low reimbursement rates, short supply of primary care pediatricians, and fewer number mental health professionals will be associated with unmet mental health care need.