Association for Public Policy Analysis & Management

Background: Seventeen U.S. states and D.C. have used the Affordable Care Act (ACA) Medicaid health home waiver to create behavioral health home (BHH) programs for Medicaid beneficiaries with serious mental illness (SMI). BHH programs integrate physical health care management and coordination into specialty mental health programs; the ACA waiver allows state Medicaid programs to bill for these care management and coordination services. People with SMI die 10-20 years earlier than the overall U.S. population, primarily due to high rates of poorly managed cardiovascular disease. About seventy percent of people with SMI in the U.S. are insured by Medicaid, and prior research has shown that Medicaid beneficiaries with SMI receive sub-optimal quality of care for cardiovascular disease and its risk factors, such as diabetes. Thus, a key goal of BHH programs created through the ACA waiver is to improve delivery of effective cardiovascular care for this population. However, no prior studies have evaluated the effects of such programs on measures of receipt of guideline-concordant cardiovascular care among Medicaid beneficiaries with SMI. Our study fills this gap in the research.

Objective: To study the effects of Maryland’s Medicaid BHH program, which was created through the ACA Medicaid health home waiver and implemented October 1, 2013, on quality of cardiovascular care among adults with SMI.

Design: Retrospective cohort analysis using Maryland Medicaid administrative claims data from October 1, 2010 – September 30, 2016.

Participants: Study participants were Maryland Medicaid beneficiaries with diabetes or cardiovascular disease participating in psychiatric rehabilitation programs, the setting in which Maryland's BHH program is implemented. To qualify for psychiatric rehabilitation services, individuals must have serious mental illness defined as significant functional impairment resulting from mental illness. The sample included a group of BHH participants and a comparison group equated to the BHH group on measurable characteristics using inverse probability of treatment weighting.

Main Measures: HEDIS measures of cardiovascular care quality including annual receipt of diabetic eye and foot exams; hemoglobin A1c, diabetic neuropathy; and cholesterol testing; and statin therapy receipt and adherence among individuals with diabetes, as well as HEDIS measures of annual receipt of cholesterol testing and statin therapy and adherence among individuals with CVD.

Statistical Analysis: We used marginal structural modeling to evaluate the effects of BHH enrollment on quality of cardiovascular care outcome measures, relative to the comparison group. The marginal structural modeling approach accounted for potential time-dependent confounding and used inverse probability of treatment weighting to equate the comparison group to the BHH group on measurable characteristics.

Key Results: Maryland’s program was associated with no changes in any cardiovascular care quality measures among BHH participants relative to comparison group participants.

Conclusions: While the BHH model has been shown to improve quality of cardiovascular care in randomized clinical trials, our evaluation of Maryland's real-world program using rigorous non-experimental methods for causal inference showed to effects. Additional financing, infrastructure, and implementation supports may be needed to realize the potential of Maryland’s BHH to improve cardiovascular care for people with SMI.