Readmissions of Youth for Suicidality Rise After Missouri Medicaid MCO Expansion
Abstract
The near-doubling of readmissions points to a link between shortened length of stay and the switch of patients to Medicaid MCOs.
Children and adolescents on Medicaid in Missouri were almost twice as likely to be rehospitalized for suicidality following an initial hospitalization after the state transferred most of its Medicaid population into managed care plans in 2017, according to a report by the Missouri Hospital Association (MHA).
“We will know that the big, national MCOs are serious when they decide on their own to incorporate social determinants in their prior authorization and utilization management decisions,” said psychiatrist Joseph Parks, M.D., medical director of the National Council for Behavioral Health.
Across both periods—before and after the statewide expansion of Medicaid managed care—children and adolescents in Medicaid managed care plans had significantly shorter hospital stays compared with those in Medicaid fee-for-service (FFS) plans. Moreover, the average length of stay for dropped by a little more than two days after the statewide expansion.
Mental health professionals in the state said that the MHA report substantiated a problem that had been apparent to them well before the expansion: Medicaid managed care organizations (MCOs) are authorizing hospital days for children based on criteria that reflect resolution of only the most acute symptoms.
“The proprietary tools used by [MCOs for determining authorization of hospital days] consider only current symptom severity and risk to self or others,” said psychiatrist Joe Parks, M.D., medical director of the National Council for Behavioral Health and former director of Medicaid in Missouri.
The three Medicaid MCOs in Missouri are MissouriCare (which is operated by WellCare), UnitedHealthcare, and Home State Health (which is operated by Centene). Psychiatric News sought a response to the report from the Missouri Health Plan Association, which represents the three managed care plans, and from Missouri Medicaid Director Todd Richardson (see sidebar).
Missouri State Medicaid Program, Managed Care Plans Respond
“We take these findings very seriously, and we in Missouri want to be better,” said Missouri Medicaid Director Todd Richardson when asked for a response to the Missouri Hospital Association report on rates of rehospitalization under Medicaid managed care.
In an interview with Psychiatric News, Richardson said he wants to look at a host of factors that may affect risk for suicidality among children and adolescents and not just length of stay. He added that the Medicaid population is “an incredibly complex universe,” that the connection between length of stay and outcome may vary across patients, and that the cohort that was the focus of the study is likely to be especially sick.
“So it is reasonable to assume you are going to have higher rates [of rehospitalization] within this group,” he said.
Richardson also emphasized the dire shortage of mental health professionals throughout the state, but especially in rural areas—95.6% of Missouri counties are designated mental health shortage areas. “We want to look holistically at the mental health system in our state, including those factors that were not included in the report, such as follow-up care of adolescents after discharge and access gaps due to a shortage of mental health professionals.”
In a statement issued in response to the report, the Missouri Health Plan Association, which represents the three Medicaid MCOs, said, “This study is not peer reviewed. It is based on a very small sample size and was clearly commissioned to attempt to further a predetermined hypothesis. While we believe this study is fundamentally flawed, the health and safety of our members is our highest priority, and we are taking these claims very seriously. We welcome all productive discussions with our State, provider, and hospital partners to ensure that our members receive the highest quality care.”
In fact, Parks and others who spoke with Psychiatric News said that the data on length of stay and rehospitalization for suicidality (defined as suicide ideation or attempt) speak to an entire system in crisis and a perfect storm of contributing factors: a dire shortage of mental health professionals, especially in rural areas; lack of oversight of MCOs by the Medicaid program; insufficient hospital staffing to follow up and appeal denials of care by managed care companies; and a failure on the part of hospitals to connect with mental health professionals in the community after the discharge of a child or adolescent.
Those interviewed for this article insisted, however, that the most acute problem is the MCOs’ aggressive application of criteria for authorization of hospitalization and length of stay. “As a result, our psychiatrists have been in knock-down, drag-out arguments [with MCOs] over diagnosis and treatment,” Al Greimann, executive of Royal Oaks Hospital, a 54-bed behavioral health hospital in Windsor, Mo., told Psychiatric News. “In order for hospitals to stay in business, we are having to discharge kids much sooner. We are still eating the cost for a number of days and getting paid for only two-thirds of our costs.”
Managed Care Expansion Offers a Natural Experiment
In May 2017, the Missouri General Assembly expanded the Medicaid MCO service area from 54 counties in the middle of the state to the entire state. The statewide expansion presented a unique opportunity to conduct a before-and-after study, looking at how a change of insurance coverage might affect hospital length of stay and subsequent hospitalization.
Mat Reidhead, M.A., vice president for research and analytics at the MHA Hospital Industry Data Institute, which conducted the analysis, said approximately 160,000 children were shifted to Medicaid MCO coverage following statewide expansion. Among them were 2,152 children and adolescents aged 5 to 19 years who were hospitalized for psychiatric reasons with Medicaid FFS coverage before, and with Medicaid MCO coverage after, May 1, 2017 (the “MCO expansion cohort”).
Rates of suicidality for those children within 30, 60, and 90 days of discharge were evaluated using claims data between October 1, 2015, and June 30, 2018.
After the expansion, the rates of rehospitalization for suicidal behavior roughly doubled for all three postdischarge periods studied: The 30-day postdischarge rate of rehospitalization jumped from 5.3% to 9.7%; the 60-day rate increased from 7.8% to 15%; and the 90-day suicidality rate rose from 10.4% to 18.8%.
Importantly, even after adjusting for patient risk factors (such as severity of illness and comorbidities), the suicidality rate within 30 days of discharge increased from 3.8% before the expansion to 6.9% after among the the MCO expansion cohort.
The numbers confirmed what psychiatrists and hospitals executives suspected: Children and adolescents were being discharged from an initial hospitalization before they were well. “All of us at separate hospitals were continually struggling with length of stay and our belief that patients were not getting better,” said Alyson Wysong-Harder, L.C.S.W., CEO at Heartland Behavioral Health Services in Nevada, Mo., in an interview. “When the full expansion went into effect in June 2017, our [rehospitalization] numbers began to spike.”
Wysong-Harder said the data validate the story hospitals want to tell. “We serve so many different locations—urban and rural—but what’s important is that all of the hospitals were able to tell the same story collectively,” she said.
MCO Decisions May Overlook Social Determinants of Health
Parks said that the Level of Care Utilization System (LOCUS) criteria recommended by the American Association of Community Psychiatrists and the American Academy of Child and Adolescent Psychiatry take into account “social determinants of health,” as well as prior response to treatment and medical and psychiatric comorbidities.
MCOs in Missouri are required to use LOCUS, but Parks said they frequently score patients as needing a lower level of care, typically without interviewing patients directly. (MCOs also use proprietary criteria, though those criteria cannot be more restrictive than LOCUS, according to Park.)
A result is that patients with similar presenting problems but dramatically different social determinants of health—such as family and community support systems and a stable home environment—might get the same duration of stay. In turn, hospitals do not systematically appeal such decisions.
“The state doesn’t manage conflicts about how to apply level of care criteria, in part because the state doesn’t receive patient-specific complaints and in part because of lack of staff to enforce the contract,” Parks said.
“We will know that the big, national MCOs are serious when they decide on their own to incorporate social determinants in their prior-authorization and utilization-management decisions,” Parks said. “MCOs need to start walking the walk.”
Parks pointed out, however, that MCOs alone are not to blame. He also cited poor coordination of care by hospitals. “I still see patients in Missouri, and when they get admitted, I never get called by the hospital at admission or discharge and almost never get a discharge summary if I don’t ask for it. I routinely find out about a psychiatric admission of one of my patients when they appear in clinic after discharge.”
Greimann and Wysong-Harder said that they hope for shared responsibility on the part of all stakeholders in fixing a system that is failing Missouri’s children.
“This can’t continue,” Greimann said. “We will have to do something different, and I am hopeful these statistics will prompt everyone to decide to be progressive in coming up with a better approach. Otherwise, hospital beds will disappear, and children will die.” ■
The MHA report can be accessed here.
