ED Visits for Mental Health Among Medicaid Enrollees Varied Widely by Region

Among Medicaid enrollees, emergency department (ED) visits for mental health conditions varied substantially by region, which may signal problems accessing appropriate care, according to a cross-sectional study.

The three states with the highest rates of ED visits for mental health per 1,000 Medicaid member-months by State Economic Area (SEA; reflecting the homogeneity in socioeconomic characteristics and land use) were Ohio (10.1), Nevada (8.0), and Iowa (7.8), while the states with the lowest rates were Colorado (2.1), West Virginia (2.6), and Arizona (2.8.), reported K. John McConnell, PhD, of Oregon Health & Science University in Portland, and colleagues.

Eight states had mean ED mental health visit rates by SEA above the national 75th percentile -- Ohio, Nevada, Iowa, Missouri, New Jersey, Connecticut, Wisconsin, and Minnesota -- while nine states had mean rates that fell below the 25th percentile -- Colorado, West Virginia, Arizona, Oklahoma, Kentucky, Virginia, Delaware, California, and Vermont, they noted in Health Affairs.

McConnell and team also found wide variations in visits within states. For example, rates in Ohio ranged from 6.1 to 13.0, for an "extremal range" of 6.9.

"Given growing concerns about a national mental health crisis, Medicaid's role as the dominant payer for mental health services, and the relative scarcity of information on the variability in the quality and availability of services for enrollees, our findings suggest opportunities for exploration and improvement in mental health care," McConnell and colleagues wrote.

The researchers conducted this study to capture the differences in the prevalence, access, and quality of mental health care among Medicaid enrollees. ED visits for mental health were viewed as a proxy for "unmet needs for behavioral health care," with the rationale being that in places where specialty outpatient mental health care or primary mental health care are not available, patients will turn to EDs instead, McConnell told MedPage Today.

However, he also noted that differences in ED visits were likely a result of both "place-based" and "person-based" factors, with some states simply having a high volume of people with mental health conditions.

Looking at ED visits with mental health diagnoses and outpatient mental health visits per 1,000 Medicaid member-months by SEA, the researchers found a moderate correlation between the two measures (0.47). Some regions had above-median levels of ED visits for mental health and outpatient visits, including Steubenville, Ohio, Duluth, Minnesota, and Elk River, Minnesota.

Perhaps the mental health needs in these areas are so great that some are managed in outpatient settings, with others "spilling over into the ED setting," the authors noted.

Phoenix and Texarkana, Arkansas had relatively low rates of ED visits for mental health -- about 2-3 per 1,000 member-months -- but their rates of outpatient mental health visits were more than twice the median (140.5 per 1,000 member-months).

In contrast, St. Louis, Missouri and Jackson, Mississippi had rates of ED visits for mental health per 1,000 member-months that were more than twice the median (4.7), but outpatient mental health visits below the national median.

"The question is, if they did something to increase their availability of outpatient mental health [care], would you see ED visits drop?" McConnell said.

The researchers observed higher rates of ED visits for schizophrenia in "larger urban areas," such as Jackson, Mississippi, Charleston, South Carolina, and St. Louis, Missouri, while ED visits for anxiety were seen more often in smaller cities, which "did not necessarily have correspondingly high rates of visits for schizophrenia," they wrote.

They also noted that "although suicide and depression are linked clinically, these data suggest that at the population level the areas with the highest rates of ED visits for depressive disorder did not necessarily have the highest rates of ED visits for suicidal ideation and intentional self-harm."

Though Medicaid is a state-federal partnership that has been viewed for years as a strength, because it allows states to tailor their programs to meet their population's needs, there's also a "possible dark side" to this partnership, McConnell said, noting that some states may under-fund their Medicaid program.

"Where we want to go is to understand, how much of the variation in states is reasonable and expected and acceptable, and how much of it might make us wonder if this program is treating all Americans fairly regardless of what state they're in," he said.

For this study, McConnell and colleagues used national Medicaid claims data from 2018 for adults ages 19 to 64, with a final study sample of 42 states plus Washington, D.C.

As for limitations to the study, McConnell said he is "comfortable" with the data on high rates of visits, but he noted that he is "a little bit less confident in low rates of visits."

The study also doesn't capture "the patient side," he added.

More research is needed before researchers will be able to say, "these are programs and policies that seem to improve mental health. These are ones where the evidence isn't strong or doesn't seem to work ... that's where we need to go," he concluded.

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