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Healthcare Utilization and Cost

of the SMI Population in Texas Medicaid:

Year 3 Final Report of the UTSPH Medicaid SMI Study

March 2017

Prepared for:

The Meadows Mental Health Policy Institute

by:

UT School of Public Health Faculty:

Paul J. Rowan, Charles Begley, Robert Morgan

UT School of Public Health Doctoral Students:

Shuangshuang Fu, Bakbergen Turibekov

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March 2017

Table of Contents

Executive Summary ………………………………………………………………. 03

I. Introduction ……………………………………………………………………….. 06

II. Data Acquisition and Linkage …………………………………………………….. 08

III. Utilization Analyses ………………………………………………...……………... 09

IV. Conclusion and Discussion ……………………………………………………….. 26

Contact:

Paul J. Rowan, Ph.D., M.P.H.

Associate Professor, The University of Texas-Houston School of Public Health

Division of Management, Policy, and Community Health

Reuel A. Stallones Building, Room E303

1200 Herman Pressler

Houston, TX 77030

(713) 500-9183 phone

(713) 500-9171 fax

[email protected]

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Year 3 Interim Report of the UTSPH Medicaid SMI Study

Executive Summary

In 2014, the UTSPH SMI Study team began obtaining and linking several administrative

databases from Texas state healthcare agencies in order to document the use and cost of

healthcare for adults with severe mental illness (SMI) across public programs. Our main focus is

on determining the average use and cost of services of the Medicaid enrolled adult population

with SMI, how they compare to Medicaid adults without SMI, and how they vary by diagnostic

(schizophrenia, bipolar, depression), medical comorbidity (with/without), and Medicaid

eligibility (SSI/non-SSI, Medicaid/Medicare dual eligibles, etc.) subgroup. We have also

conducted interviews with healthcare providers and managed care plan representatives regarding

issues in payment models and service delivery for this population.

Two previous reports completed in 2015 and 2016, available from the authors or from the

website of the UTSPH Center for Health Services Research, provide more details on the

objectives of the study, the databases obtained and linked, the methods used to identify cases,

services, and costs, findings on the characteristics of the Medicaid SMI population, their

enrollment patterns, their total and per capita healthcare costs, and preliminary results from the

healthcare provider interviews.

In this report, we present findings on utilization and cost patterns of Medicaid-enrolled

adults with SMI in 2012, the latest year for which we have data, including: variation in

hospitalizations and emergency room (ER) visits as compared to adults without SMI and

differences within diagnostic, comorbidity, and eligibility subgroups. We also identify the

https://sph.uth.edu/research/centers/chsr/

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characteristics of adults with SMI with the highest costs and their relative proportion of total

Medicaid service use and costs.

Major Findings

Compared to Medicaid adults without SMI, those with SMI had a significantly higher

likelihood of being hospitalized during the year (OR 2.3; 95% CI 2.2-2.3) and having one or

more ER visits (OR 3.1; 95% CI 3.1-3.1). Further, Medicaid adults with SMI had significantly

higher annual hospital and ER rates than non-SMI adults (hospitalizations: 0.54 versus 0.38 per

12 months for SMI and non-SMI, respectively; ER visits: 2.38 versus 0.87 per 12 months,

respectively). The primary reason for the visits were more often medical than psychiatric

(hospitalizations: primary medical diagnosis 70%, primary psychiatric diagnosis 29%; ER visits:

primary medical diagnosis 88%, primary psychiatric diagnosis 11%). Medicaid adults with more

than one SMI diagnosis (combinations of bipolar, depression and schizophrenia) have

significantly higher rates of inpatient and ER utilization relative to those with only one SMI

diagnosis (i.e. hospitalizations: major depression 0.25 per 12 months, major depression plus

bipolar disorder 0.30, major depression plus schizophrenia 0.29, all three 0.47; ER visits: major

depression 0.53, major depression plus bipolar disorder 0.65, major depression plus

schizophrenia 0.54, all three 0.70).

Although the magnitude of differences varied, the excess utilization of the SMI

population compared to non-SMI applied across sub-groups with different numbers of medical

comorbidities and eligibility status. Likelihood ratios comparing SMI/non-SMI varied from 1.3

to 3.0 for hospitalizations and from 1.5 to 4.0 for ER visits across subgroups with 0 to 6+

comorbidities. Similarly, the likelihood ratios comparing SMI/non-SMI varied from 1.9 to 2.6

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for hospitalizations and from 2.3 to 5.2 for ER visits across subgroups of SSI and non-SSI

eligibles.

The excess utilization of Medicaid adults with SMI is also reflected in their

disproportionate share of costs. While adults with SMI represent 12.5% of all adult Medicaid

enrollees in 2012, their costs were 24.9% of total costs. Adults with SMI with the highest costs

(top 10%) accounted for almost half (46.9%) of total costs for all SMI adults.

These findings suggest the substantial opportunity for preventable utilization and cost-

savings from better care of adults with SMI enrolled in Medicaid. A high proportion of their use

and cost appears to be due to comorbid medical conditions; this suggests the need for more

integrated care. The concentration of costs among high utilizers within this population suggests

that care improvements should be targeted on identified high utilizers.

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Introduction

Serious Mental Illness (SMI) affects cognition and emotions, and impacts interpersonal

relationships, productivity, and the ability to work and be self-sufficient. Because of this impact,

a high portion of this population relies on publically subsidized programs, such as Medicaid, to

access needed healthcare. To better understand the characteristics of the SMI population enrolled

in Medicaid and their utilization and cost patterns, the Texas Institute for Health Care Quality

and Efficiency, the Texas Department of Health and Human Services, and the Meadows Mental

Health Policy Institute, have funded our UTSPH research team to obtain and link several

administrative databases and conduct analyses of utilization and cost patterns of the SMI adult

population with Medicaid coverage. The analyses are designed to produce useful information for

policymakers, advocates, and healthcare providers concerned with identifying strategies for

increasing effectiveness, efficiency, and equity of care for this population. Our previous reports

are available from the authors or from the website of the UTSPH Center for Health Services

Research.

In this report, we have focused on describing the proportion of Medicaid SMI adults with one

or more hospital and/or emergency room visit in 2012, describing the variation within SMI

subgroups and between SMI and non-SMI adults, and on describing the characteristics and

utilization patterns of high utilizers. Hospital visits and ER visits are significant because of their



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preventability and high cost, and it is significant to examine those with high utilization in order

to consider the proportion of care that may be devoted to this population, and the degree that

savings could be achieved by more optimally managing this care.

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I. Data Acquisition and Linkage

The data acquisition objectives for this part of the project were to obtain the following

updates from the Texas Health and Human Services Commission (HHSC):

Medicaid acute care and pharmacy claims and encounters for 2013-2014,

Medicaid acute care and pharmacy claims and encounters refresh for 2008-2012, and

Medicare acute care and pharmacy claims for 2013-2014;

from the Department of Aging and Disability Services (DADS):

LTSS encounters and payments for Medicaid adults with SMI; and

from the Department of State Health Services:

Local Mental Health Authority and State Hospital (LMHA/SH) encounters and

payments, and

statewide hospital discharges (THCIC) of Medicaid adults with SMI.

Data requests to HHSC were submitted in mid-2015 and are awaiting final approval of a

Memorandum of Understanding (MOU) so the Medicaid and Medicare updates can be

transferred. HHSC staff obtained a signed Data Use Agreement with the University of Texas to

allow the data transfer once the MOU between HHSC and UTSPH is approved. The MOU has

been delayed as it is being further developed by HHSC staff as part of an agency-wide data

sharing plan. Once we receive the updated Medicaid and Medicare files, we can identify those

with an SMI diagnosis, and prepare the data update requests, for these Medicaid adults, to DADS

and the DSHS.

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II. Utilization Analyses

Overview

We identified 232,348 adult Medicaid enrollees with a SMI diagnosis in 2012. This

population accounted for 12.5% of all 1,863,880 adult Medicaid adults. We examined utilization

and costs of services of adults with and without SMI in four dimensions.

First, we calculated the counts and the percentage of Medicaid enrolled adults who had

one or more hospitalization or ER visit. This addresses overall use of hospital and ER services

among Medicaid adults with and without an SMI diagnosis. To control for differences in

continuity of enrollment among Medicaid adults, which would affect the opportunity for

accessing hospital or ER services, we limited the utilization analyses to those with continuous

enrollment throughout the year. The continuously enrolled SMI adult population of 152,872

represented 66% of the total SMI adult population. The utilization of this population was

compared to the 679,686 non-SMI Medicaid adults with continuous enrollment, representing

42% of all adult non-SMI adults. These counts are compared between those with and without an

SMI diagnosis for the following characteristics: number of medical comorbidities; SSI status;

and specific Medicaid program. To explore the degree that utilization by Medicaid adults with

SMI is related to the mental illness or other conditions, we examined the primary diagnosis for

the hospitalization or ER event by the primary diagnosis for these events, and by diagnosis of the

enrollee. We also examined the number and percent of hospitalizations and ER visits for

Medicaid adults with SMI by dual-enrollment status with Medicare, and by the intersections of

diagnostic group, dual-enrollment, and SSI status.

Second, we calculated the rate of hospitalizations and ER visits per enrollment month to

address the question of intensity of use of these services among Medicaid adults with and

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without an SMI diagnosis. Calculating the number of events per enrollee per month allows the

inclusion of Medicaid adults enrolled for less than the entire year, consequently we used our

entire cohort of Medicaid adults with (N = 232,348) and without (N = 1,863,880) an SMI

diagnosis. We standardized the monthly rate to a rate of events per 12 months of enrollment for

ease of comparison and interpretation. These rates of events were examined by: SMI status; dual-

enrollee status; dual-enrollment status; by SMI diagnostic group, and by level of medical

comorbidities (less than 3, three or more; medical comorbidities included: diabetes mellitus,

diseases of the heart, chronic lower respiratory disease, disorders of lipid metabolism, arthritis,

cerebrevascular diseases, nephritis/nephrotic syndromes/nephrosis, influenza and pneumonia,

malignant neoplasms, septicemia, Alzheimer's Disease, osteoporosis, hepatitis C, and

unintentional injuries).

Third, we conducted a comparison of the portion of Medicaid adults with SMI with their

portion of 2012 Medicaid and Medicare costs. We also compared these combined costs for a

subset of the most costly Medicaid adults. We examined the dollars of utilization, and

percentage, for the top 01%, 05%, 10%, and 25% most costly Medicaid adults, and noted the

portion that had an SMI diagnosis. We also calculated further data for the 10% most costly

patients relative to the remaining 90%. Costs were total Medicaid and Medicare acute care

expenditures during 2012. We examined high utilizers among subgroups based on a combination

of number of medical comorbidities (< 3 versus 3 or more) and SSI eligibility status (SSI versus

non-SSI).

Finally, we examined differences in utilization and costs for Medicaid adults with and

without a SMI across subgroups based on number of comorbidities, and eligibility status.

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Use of Hospital and ER Services among Medicaid Adults with and without SMI

We analyzed hospitalization and ER utilization differences between Medicaid adults with

and without SMI, and the extent of the differences among SMI adults by SSI status and by

specific Medicaid program. Analyses were limited to Medicaid adults with continuous

enrollment during FY 2012. Table 1 shows the number and percent of Medicaid adults with and

without SMI who had one or more hospitalization and/or ER visit in 2012, and odds ratios

comparing the two populations. As indicated in the table, the likelihood of an adult with SMI

having one of these events was 2.3 times that of adults without SMI for hospitalizations and 3.1

times that of the adults without SMI for ER visits.

Table 1. Number and percent of Medicaid adults with hospitalizations and/or ER visits:

SMI versus Non-SMI.

Adults with SMI Adults without SMI Odds Ratio (95% CI)

Hospitalizations 39,262 (25.7%) 90,441 (13.3%) 2.3 (2.2 to 2.3)

ER Visits 84,339 (55.2%) 193,117 (28.4%) 3.1 (3.1 to 3.1)

Total Adults 152,872 (100.0%) 679,686 (100.0%)

The percentage of individuals with hospital admissions and/or ER visits rises with the

number of comorbidities for adults both with and without SMI, although, compared to the non-

SMI population the odds were consistently higher for SMI adults across increasing numbers of

comorbidities (Table 2).

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Table 2. Number and percentage of Medicaid adults with hospitalizations or ER visits:

SMI versus non-SMI by medical comorbidity count.

Hospitalizations

SMI Adults Non-SMI Adults

Number of

Comorbidities N

N (%) with

Hospitalizations N

N (%) With

Hospitalizations Odds Ratio (95% CI)

0 67,601 10,917 (16.1%) 401,117 24,325 (6.1%) 3.0 (2.9, 3.1)

1 37,244 8,043 (21.6%) 115,318 13,337 (11.6%) 2.1 (2.0, 2.2)

2 22,697 6,960 (30.7%) 77,601 15,945 (20.5%) 1.7 (1.7, 1.8)

3 13,223 5,692 (43.0%) 46,513 15,342 (33.0%) 1.5 (1.5, 1.6)

4 7,060 3,930 (55.7%) 23,845 11,204 (47.0%) 1.4 (1.3, 1.5)

5 3,201 2,200 (68.7%) 10,156 6,306 (62.1%) 1.3 (1.2, 1.5)

6+ 1,846 1,520 (82.3%) 5,136 3,982 (77.5%) 1.4 (1.2, 1.5)

Total 152,872 39,262 (25.7%) 679,686 90,441 (13.3%) 2.3 (2.2, 2.3)

ER Visits

SMI Adults Non-SMI Adults

Number of

Comorbidities N

N (%) With ER

Visits N

N (%) With ER

Visits Odds Ratio (95% CI)

0 67,601 33,254 (49.2%) 401,117 72,361 (18.0%) 4.4 (4.3, 4.5)

1 37,244 20,006 (53.7%) 115,318 39,309 (34.1%) 2.2 (2.2, 2.3)

2 22,697 13,198 (58.1%) 77,601 31,795 (41.0%) 2.0 (1.9, 2.1)

3 13,223 8,653 (65.4%) 46,513 23,618 (50.8%) 1.8 (1.8, 1.9)

4 7,060 5,061 (71.7%) 23,845 14,553 (61.0%) 1.6 (1.5, 1.7)

5 3,201 2,532 (79.1%) 10,156 7,295 (71.8%) 1.5 (1.3, 1.6)

6+ 1,846 1,635 (88.6%) 5,136 4,186 (81.5%) 1.8 (1.5, 2.1)

Total 152,872 84,339 (55.2%) 679,686 193,117 (28.4%) 3.1 (3.1, 3.1)

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Table 3 shows the proportions of SMI and non-SMI Medicaid adults with hospitalizations

or ER visits by SSI eligibility status. Regardless of SSI eligibility status, Medicaid adults with

SMI were more likely to use hospital or ER services. However, the odds ratios were consistently

higher for the non-SSI adults than for those with SSI eligibility.

Table 3. Number and percentage of Medicaid SMI versus non-SMI adults with

hospitalizations and ER visits: SSI versus non-SSI.

Non-SSI

SMI Adults

Total N = 22,038

Non-SMI Adults

Total N = 271,455

Odds Ratio

(95% CI)


ER Visits 12,260 (55.6%) 52,498 (19.3%) 5.2 (5.1 to 5.4)

SSI

SMI

Number (percent);

Total N = 130,834

Non-SMI

Number (percent);

Total N = 408,231

Odds Ratio

(95% CI),

SMI vs. Non-SMI


ER Visits 72,079 (55.1%) 140,619 (34.5%) 2.3 (2.3 to 2.4)

Table 4 compares hospitalizations and ER visits for Medicaid adults with and without

SMI by Medicaid program. Generally, hospitalizations are twice as common in adults with SMI

versus without, and ER visits are two to three times as common in adults with SMI.

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Table 4. Number and percentage of Medicaid adults with hospitalizations and ER visits:

SMI versus non-SMI by Medicaid program.

Hospitalizations

SMI Adults Non-SMI Adults OR (95% CI)

Medicaid Program Total Hospitalizations Total Hospitalizations

SSI 106,977 26,675 (24.9%) 352,519 53,357 (15.1%) 1.9 (1.8, 1.9)

SSI-Related MAO 20,901 6,910 (33.1%) 46,391 9,425 (20.3%) 1.9 (1.9, 2.0)

Catastrophic

Healthcare:

Qualified Medicare

Beneficiary

10,345 2,316 (22.4%) 76,157 8,547 (11.2%) 2.3 (2.2, 2.4)

TANF and Medicaid 5,227 1,154 (21.9%) 26,769 4,321 (16.1%) 1.5 (1.4, 1.6)

“Federally

Mandated

Children” 18 +

2,108 382 (18.1%) 7,267 822 (11.3%) 1.7 (1.5, 2.0)

TANF-UP and

Medicaid 754 165 (21.9%) 7,467 858 (11.5%) 2.2 (1.8, 2.6)

Other 6,510 1,660 (25.5%) 163,116 13,111 (8.0%) 3.9 (3.7, 4.2)

Total 152,872 39,262 (26.7%) 679,686 90,441 (13.3%) 2.3 (2.2, 2.3)

ER Visits

SSI 106,977 60,530 (56.6%) 352,519 123,568 (35.1%) 2.4 (2.4, 2.4)

SSI-Related MAO 20,901 9,847 (47.1%) 46,391 14,194 (30.6%) 2.0 (2.0, 2.1)

Catastrophic

Healthcare:

Qualified Medicare

Beneficiary

10,345 5,220 (50.5%) 76,157 17,983 (23.6%) 3.3 (3.2, 3.4)

TANF and Medicaid 5,227 3,603 (68.9%) 26,769 14,321 (53.5%) 1.9 (1.8, 2.0)

Federally

Mandated Children 2,108 1,104 (52.4%) 7,267 2,519 (34.7%) 2.1 (1.9, 2.3)

TANF-UP+ Medicaid 754 501 (66.4%) 7,467 3,254 (43.6%) 2.6 (2.2, 3.0)

Other 6,510 3,534 (54.3%) 163,116 17,278 (10.6%) 10.0 (9.5, 10.6)

Total 152,872 84,339 (55.2%) 679,686 193,117 (28.4%) 3.1 (3.1, 3.1)

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Variation in Utilization by Diagnosis

Approximately 30% of hospitalizations of SMI adults were primarily for psychiatric

conditions (depression, bipolar disorder, and schizophrenia), approximately 1% were primarily

related to substance use, and the majority, 69.8%, were primarily for a medical or other reason

(all remaining codes). The comparable percentages for ER visits are 10%, 2%, and 88%,

respectively (Table 5).

Table 5. Number and percentage of Medicaid SMI adults with hospitalizations and ER

visits by primary diagnosis of event.a

SMI Adults (N = 152,872)

Hospitalizations Primary Diagnosis 39,262 (25.7%)b

SMI 11,546 (29.4%)c

Substance-Related 518 (1.3%)c

Neither SMI nor Substance-Related 27,422 (69.8%)c

ER Visits 84,339 (55.2%)b

SMI 8,824 (10.5%)d

Substance-Related 2,066 (2.5%)d

Neither SMI nor Substance-Related 74,072 (87.8%)d

a Individuals could have had more than one category of hospitalization. b Percent of all SMI adults. c Percent of hospitalizations. d Percent of ER visits.

Table 6 shows the proportions of Medicaid adults with SMI, by SMI diagnosis, who had

hospitalizations or ER visits. The proportion with hospitalizations or ER visits were lowest

among Medicaid adults with a diagnosis of schizophrenia (without comorbid depression or

bipolar disorder), and highest among those with all three SMI diagnoses.

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Table 6. Number and percentage of Medicaid adults with SMI with hospitalizations and/or

ER visits, by patient diagnosis.

Diagnosis Total Adults Hospitalizations ER Visits

Major Depression 55,092 (36.0%) 13,723 (24.9%) 29,288 (53.2%)

Bipolar Disorder 20,849 (13.6%) 3,571 (17.1%) 11,529 (55.3%)

Schizophrenia 19,013 (12.4%) 2,796 (14.7%) 7,180 (37.8%)

Major Depression and Bipolar Disorder 26,378 (17.3%) 7,801 (29.6%) 17,206 (65.2%)

Schizophrenia and Bipolar Disorder 8,996 (5.9%) 2,362 (26.3%) 4,756 (52.9%)

Major Depression and Schizophrenia 8,701 (5.7%) 2,496 (28.7%) 4,671 (53.7%)

All 3 SMI Diagnoses 13,843 (9.1%) 6,513 (47.1%) 9,709 (70.1%)

Total 152,872 (100.0%) 39,262 (25.7%) 84339 (55.2%)

Table 7 shows the proportions of Medicaid SMI adults with hospitalizations or ER visits

by Medicaid and Medicare dual enrollment status. Hospitalization rates are similar between the

two enrollment groups; however, ER visit rates are almost 10% greater for Medicaid-only adults.

Table 7. Number and percent of Medicaid adults with SMI with hospitalizations and/or ER

visits: Medicaid-only versus Medicaid-Medicare dual-eligible adults.

Eligibility Total SMI cohort Hospitalizations ER Visits

Medicaid only 81,411 20,067 (24.6%) 48,273 (59.3%)

Medicaid-Medicare 71,461 19,195 (26.9%) 36,066 (50.5%)

Total 152,872 39,262 (25.7%) 84,339 (55.2%)

Finally, Table 8 shows the proportions of Medicaid SMI adults having hospitalizations or

ER visits across SMI diagnosis groups, SSI status, and Medicaid-only/Dual-enrollee subgroups.

In general, the proportions with hospitalization are similar across Medicaid-only versus

Medicaid-Medicare dual enrollment status, while ER visits are notably lower for Medicaid-

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Medicare dual enrollee adults, regardless of SSI status or diagnostic group. Also, the portion

with hospitalizations, and with ER visits, was greater for those with two or all three SMI

diagnoses than for those with one.

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Table 8. Number and percentage of Medicaid adults with SMI with hospitalizations and

ER visits: Patient diagnosis by SSI and Medicaid-only/Dual status.

Medicaid-Only

Diagnostic Group

SSI Status

Number

Hospitalizations

ER Visits

Major Depression Non-SSI 5,009 974 (19.4%) 2,896 (57.8%)

SSI 18,662 4,090 (21.9%) 10,920 (58.5%)

Bipolar Disorder Non-SSI 1,791 359 (20.0%) 1,129 (63.0%)

SSI 11,392 1,843 (16.2%) 6,552 (57.5%)

Schizophrenia Non-SSI 65 15 (23.1%) 37 (56.9%)

SSI 10,541 1,526 (14.5%) 4,272 (40.5%)

Major Depression and Bipolar Disorder Non-SSI 3,296 807 (24.5%) 2,156 (65.4%)

SSI 12,994 3,776 (29.1%) 8,897 (68.5%)

Schizophrenia and Bipolar Disorder Non-SSI 100 26 (26.0%) 67 (67.0%)

SSI 5,165 1,427 (27.6%) 2,910 (56.3%)

Major Depression and Schizophrenia Non-SSI 88 25 (28.4%) 58 (65.9%)

SSI 4,314 1,260 (29.2%) 2,509 (58.2%)

All 3 SMI Diagnoses Non-SSI 254 105 (41.3%) 179 (70.5%)

SSI 7,740 3,834 (49.5%) 5,691 (73.5%)

Total Non-SSI 10,603 2,311 (21.8) 6,522 (61.5)

SSI 70,808 17,756 (25.1) 41,751 (59.0)

Medicaid-Medicare

Diagnostic Group

SSI Status

Number

Hospitalizations

Emergency Visits

Major Depression Non-SSI 4,163 868 (20.9%) 2,049 (49.2%)

SSI 27,258 7,791 (28.6%) 13,423 (49.2%)

Bipolar Disorder Non-SSI 1,908 315 (16.5%) 954 (50.0%)

SSI 5,758 1,054 (18.3%) 2,894 (50.3%)

Schizophrenia Non-SSI 1,634 189 (11.6%) 539 (33.0%)

SSI 6,773 1,066 (15.7%) 2,332 (34.4%)

Major Depression and Bipolar Disorder Non-SSI 1,740 500 (28.7%) 1,089 (62.6%)

SSI 8,348 2,718 (32.6%) 5,064 (60.7%)

Schizophrenia and Bipolar Disorder Non-SSI 691 179 (25.9%) 335 (48.5%)

SSI 3,040 730 (24.0%) 1,444 (47.5%)

Major Depression and Schizophrenia Non-SSI 514 113 (22.0%) 253 (49.2%)

SSI 3,785 1,098 (29.0%) 1,851 (48.9%)

All 3 SMI Diagnoses Non-SSI 785 332 (42.3%) 519 (66.1%)

SSI 5,064 2,242 (44.3%) 3,320 (65.6%)

Total Non-SSI 11,435 2,496 (21.8) 5,738 (50.2)

SSI 60,026 16,699 (27.8) 30,328 (50.5)

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Rate of Hospitalizations and ER Visits per 12 months of Enrollment

Table 9 presents ER visit rates and hospitalization rates per 12 months of enrollment for

Medicaid adults with and without SMI, and presents these data by Medicaid/Medicare dual-

enrollment and SSI status. Table 10 presents ER visit rates and hospitalization rates per 12

months of enrollment for Medicaid adults with and without SMI, by clinical characteristics

including: level of medical comorbidity (less than 3, three or more), and SMI diagnosis groups.

Table 9. Twelve-Month Emergency Room Visit Rates and Hospitalization Rates, Medicaid

adults with and Without SMI, by Enrollment Characteristics: Medicaid/Medicare dual

enrollment, SSI benefit status.

# ER Visits Per

12 Mo Enrollment

# Hospitalizations Per

12 Mo Enrollment

SMI Status

SMI 2.38 0.54

Non-SMI 0.87 0.38

Dual Enrollee Status

SMI Medicaid-Only 2.91 0.51

Medicaid-Medicare 1.72 0.59

Non-SMI Medicaid-Only 0.93 0.41

Medicaid-Medicare 0.75 0.33

SSI Status:

SMI Non-SSI 2.49 0.46

SSI 2.36 0.56

Non-SMI Non-SSI 0.81 0.42

SSI 0.95 0.34

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Table 10. Twelve-Month Emergency Room Visit Rates and Hospitalization Rates, Medicaid

adults with and Without SMI, by Clinical Characteristics: Comorbidity Level, Specific

SMI Diagnostic Group.

# ER Visits Per

12 Mo Enrollment

# Hospitalizations Per

12 Mo Enrollment

Medical Comorbidity Level

SMI Less Than 3 2.19 0.39

3 or More 3.45 1.37

Non-SMI Less Than 3 0.77 0.32

3 or More 1.94 1.06

Diagnostic Group

Schizophrenia 1.24 0.27

Major Depression 2.04 0.53

Bipolar Disorder 2.25 0.33

Schizophrenia and Dep 2.19 0.58

Schizophrenia and Bipolar 2.19 0.52

Major Depr and Bipolar 3.22 0.61

All 3 4.51 1.23

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High Utilizers

Table 11 and Figure 1 present the relative portion of 2012 Medicaid and Medicare

combined acute care costs for adults with and without SMI. While adults with SMI are 12.5% of

all enrolled adults, the proportion of costs they account for is disproportionately high, at 24.8%.

Table 11. Relative portion of count of 2012 Medicaid adults with and without SMI, and

corresponding 2012 Medicaid and Medicare costs.

# of adults % total adults

Combined cost, in

millions

Percent

total cost

SMI 232,348 12.5% $3,594m 24.9%

non-SMI 1,631,532 87.5% $10,848m 75.1%

Figure 1. Relative portion of count of 2012 Medicaid adults with and without SMI, and

corresponding 2012 Medicaid and Medicare combined costs.

Table 12 presents the portion, from among Medicaid adults with and without SMI, of

Medicaid and Medicare combined costs associated with the most costly adults, including top 1%,

87.5%75.1%

12.5%24.9%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

% total enrollees % total cost

SMI

non-SMI

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5%, 10%, and 25%. The top 10% most expensive Medicaid adults with SMI accounted for

46.9% of 2012 combined Medicaid-Medicare expenses (Figure 2), while the top 10% most

expensive Medicaid adults without SMI accounted for 66.9% of 2012 Medicaid-Medicare

expenses (Figure 3; Figure 4).

Table 12. Medicaid and Medicare 2012 Combined Costs and Percentages Associated with

Top Portions of Medicaid Utilizers.

SMI Non-SMI

2012 Expense 2012 Medicaid Costs

(in thousands)

Percent of total

2012 Medicaid

Costs

2012 Medicaid Costs

(in thousands)

Percent of total

2012 Medicaid

Costs

Top 01% $221,600, 13.4% $1,053,800, 22.0%

Top 05% $553,530, 35.1% $2,323,300, 48.6%

Top 10% $802,760, 51.0% $3,121,000, 65.3%

Top 25% $1,217,900, 77.3% 4,260,400, 89.1%

Total $1,575,233, 100.0% 4,781,677, 100.0%

Figure 2. Medicaid and Medicare 2012 Combined Costs and Percentages Associated with

Top Portions of Medicaid Utilizers, Medicaid Adults with SMI.

90.0%

53.1%

10.0%

46.9%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

Total enrollees Total combined cost

Top 10 percent most costlyenrollees

Other 90 percent enrollees

23

Figure 3. Medicaid and Medicare 2012 Combined Costs and Percentages Associated with

Top Portions of Medicaid Utilizers, Medicaid Adults with SMI.

Figure 4. Texas Medicaid and Medicare 2012 combined costs, by top ten percent most

costly Medicaid adults.

90.0%

33.1%

10.0%

66.9%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

Total enrollees Total combined cost

Top 10 percent most costlyenrollees

Other 90 percent enrollees

$1,684,100,000 $1,909,505,695

$7,260,200,000

$3,588,166,259

Top 10 percent most costly enrollees Other 90 percent enrollees

SMI non-SMI

24

SMI/non-SMI Differences by Number of Comorbidities and SSI Status

Higher utilization should be expected in those with more medical comorbidities, and in

those with, versus without, SSI. Table 13 presents mean Medicaid and Medicare costs combined,

for Medicaid adults with and without SMI, at differing levels of medical comorbidities: those

with fewer than 3 medical comorbidities, and those with 3 or more medical comorbidities. These

data are illustrated in Figure 4, as well.

For this population, adults with SMI had significantly greater 2012 costs relative to those

without SMI, but the magnitude of difference was not as great for those with three or more

medical comorbidities, and was not as great for those with SSI. For Medicaid adults with fewer

than three medical comorbidities, mean 2012 cost per non-SSI adult with SMI was $5,968, while

mean 2012 cost was $2,825 for those without SMI. For Medicaid adults with three or more

medical comorbidities, mean 2012 cost per non-SSI adult with SMI was $30,683, while mean

2012 cost was $$26,452 for those without SMI. For SSI-enrolled Medicaid adults with SMI,

mean 2012 costs for those with fewer than three medical comorbidities was $12,685, while mean

2012 costs for SSI-enrolled Medicaid adults without SMI was $9,130. For SSI-enrolled Medicaid

adults with SMI, mean 2012 costs for those with three or more medical comorbidities was

$44,784, while mean 2012 costs for SSI-enrolled Medicaid adults without SMI was $36,814.

25

Table 13. Combined 2012 Medicaid and Medicare combined costs by level of medical

comorbidity and by SSI status, Medicaid adults with and without SMI.

SMI Non-SMI

Comorbidity Level Number Mean Cost Per

Enrollee

Number Mean Cost Per

Enrollee

Less than three Non-SSI 55,553 $5,968 1,073,915 $2,825

SSI 143,564 $12,685 451,941 $9,130

Three or more Non-SSI 3,347 $30,683 19,538 $26,452

SSI 29,884 $44,784 86,138 $36,814

Figure 4. Mean combined cost for 2012 Medicaid adult enrollees, by indicators of level of

medical need: SSI status and number of medical comorbidities.

$5,968

$12,685

$30,683

$44,784

$2,825

$9,130

$26,452

$36,814

non-SSI SSI non-SSI SSI

< 3 comorbidities ≥ 3 comorbidities

SMI non-SMI

26

IV. Conclusion and Discussion

Compared to Medicaid adults without SMI, those with SMI had a significantly higher

likelihood of being hospitalized during the year, and having one or more ER visits. This relative

difference was observed across a variety of differentiations, including across number of medical

comorbidities, SSI status, and Medicaid-Medicare dual enrollment. Generally, ER visits were

greater in number, and were proportionately greater than hospitalizations, likely because health

care providers and systems have more control over hospital admission than ER admission.

Among Medicaid SMI adults, those with more than one SMI diagnosis had higher rates

of inpatient and ER utilization, relative to those with only one diagnosis. This may be due to

greater clinical complexity. It may also be that some individuals present greater diagnostic

uncertainty, resulting in more difficult to manage care. Stronger emphasis on continuity of care

may be needed when adults with SMI access care in short-term care settings, such as the ER.

Hospitalizations and ER visits for Medicaid adults with SMI are more often for medical

rather than psychiatric reasons. This finding supports the need to extend and improve the

availability of integrated care services and sites for this population.

When examining utilization of Medicaid adults with SMI, the proportion with

hospitalizations are similar between Medicaid-Medicare dually enrolled adults and Medicaid-

only adults, while the proportion with ER visits is almost 20% greater for Medicaid-only adults.

The percentage of Medicaid SMI adults with hospitalizations are generally similar across

diagnostic, SSI status, and Medicaid-only/Dual-enrollee subgroups, while ER visits are notably

lower for Medicaid-Medicare dually enrolled adults, regardless of SSI status or diagnostic group.

We calculated rates of hospitalizations and ER visits per 12-months of enrollment. This

analysis showed that Medicaid adults with SMI had a greater rates, at 2.38 ER visits and 0.54

27

hospitalizations per 12 months of enrollment, compared to 0.87 ER visits and 0.38

hospitalizations per 12 months of enrollment for adults without SMI.

We examined the portion of overall Medicaid costs attributable to Medicaid adults with

SMI. While adults with SMI were 12.5% of all Medicaid enrollees, they accounted for 24.9% of

all 2012 Medicaid and Medicare combined costs. Among adults with SMI, the top ten percent

most expensive accounted for 46.9% of all costs. We also calculated costs attributable to the top

1%, 5%, and 25%. This analysis showed that a relatively small portion of Medicaid adults

accounted for a great portion of costs, and this was more extreme at more extreme definitions of

high utilizer.

Finally, we examined combined Medicaid-Medicare costs for Medicaid adults with and

without SMI, according to level of anticipated medical need. This was defined by number of

comorbidities (less than 3 versus 3 or more), and by SSI eligibility status. Again, adults with

SMI had greater 2012 costs relative to those without SMI, but the magnitude of difference was

not as great for those with three or more medical comorbidities, and was not as great for those

with SSI.

These findings suggest that Medicaid payers and providers should devote attention to

adults with SMI, since this is a cohort with higher likelihood of expensive utilization, much of

which may be preventable. A significant portion of costs seems to be associated with medical

care for these adults with SMI, so interventions such as integrated care may be warranted.

Also, examination of high utilizers suggests strategies for improving quality and lowering

costs, such as wider application of care management strategies for identified high utilizers. Our

further analyses will try to identify more specific indicators and causes of high utilization, as

well as with evaluating strategies for managing this utilization, for example integrated care.

28

Our data suggest that, among adults with Medicaid only or among those with dual

Medicaid-Medicare enrollment, rates of inpatient and ER utilization are roughly comparable

between those with or without SSI eligibility. Finally, ER visits are somewhat less common for

those dually-enrolled in both Medicaid and Medicare than for those solely in Medicaid. This

difference could be due to a greater portion of older adults accessing Medicare due to age

eligibility as opposed to disability eligibility; clinical management may be more predictable in

that population.

We plan to conduct further analyses that will include examination of the costs of care for

SMI versus non-SMI Medicaid adults and differences in utilization among managed care

organization (MCO) and non-MCO adults. Further analyses will also examine the utilization of

Medicaid adults in other programs of care, including DADS, state hospitals, and the state’s set of

Community Centers providing care for individuals with SMI. We intend to build on the set of

analyses reported here and in our earlier reports by examining utilization across these additional

data sets, including an examination of the impact of disenrollment from Medicaid on utilization

in other programs of care.

We hope these analyses are valuable for stakeholders concerned with improving the

quality and efficiency of care for Medicaid adults with SMI. We believe that analysts outside of

state healthcare administration, under proper conditions (proper data access and use agreements,

proper management of confidentiality of information, proper IRB approval), and with the

collaboration of state staff, can greatly expand the fruitful analysis of state healthcare utilization

data. These analyses are necessary for evaluation of, and improvement of, state supported

healthcare programs and policies.

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