Second-generation antipsychotic use among stimulant-using children, by organization of medicaid mental health

Area of Science:

• Health Services Research
• Pediatric Psychiatry
• Health Policy

Background:

• Overuse of second-generation antipsychotics (SGAs) in children enrolled in Medicaid is a significant concern.
• Understanding how different Medicaid service organization structures impact SGA utilization is crucial for policy development.
• Limited research exists on the comparative effectiveness of fee-for-service, integrated managed care, and managed behavioral health carve-out models in pediatric SGA use.

Purpose of the Study:

• To compare second-generation antipsychotic utilization rates among Medicaid-enrolled children across three distinct service organization structures: fee-for-service, integrated managed care, and managed behavioral health carve-outs.
• To identify which organizational structures are associated with higher or lower rates of antipsychotic prescribing in pediatric populations.

Main Methods:

• Cross-sectional analysis of child-level claims data from the Medicaid Analytic Extract (2004, 2006, 2008) across 82 counties in 34 states.
• Sample restricted to stimulant-using children aged 3-18 (N=419,226) to approximate the population at risk for antipsychotic treatment.
• Logistic regression models estimated SGA use probability, with county-level organizational structure as a primary predictor, adjusting for individual and county covariates.

Main Results:

• Youth in foster care using SGAs were 31% more likely in fee-for-service counties compared to carve-out counties (OR=1.69).
• Foster care youth in integrated managed care counties showed the second-highest adjusted odds of SGA use (OR=1.31).
• Similar patterns were observed for Supplemental Security Income-eligible youth, but not for Temporary Assistance for Needy Families recipients; differences persisted after covariate adjustment.

Conclusions:

• Managed behavioral health carve-outs were associated with significantly lower second-generation antipsychotic use among Medicaid-enrolled children compared to fee-for-service and integrated managed care models.
• Further investigation into specific features of carve-out models, such as enhanced inpatient management or restricted access protocols, is warranted.
• Care coordination mechanisms within carve-out structures may contribute to reduced antipsychotic prescribing, offering potential strategies for optimizing pediatric mental healthcare delivery.