1. Expedited Medicaid Restoration: Introduction & Overview Joe Morrissey University of North Carolina 6 th Annual Academic and Health Policy Conference on Correctional Health Chicago – March 22, 2013

2. Expediting Medicaid Benefits Focus: Comparative costs of policies restoring Medicaid benefits prior to release from state prisons Target Group: Persons with severe mental illness (SMI) Study Sites: Washington and Connecticut 2

3. Acknowledgements Funding NIMH Research Grant “Community Reentry of Persons with Severe Mental Illness Released from State Prisons” (MH086232) Assistance 10 state agencies in WA and CT Hsiu-Ju Lin, Connecticut Department of Mental Health & Addiction Services Shirley Richards and Jennifer Jolley, University of North Carolina at Chapel Hill Jeffrey Swanson and Allison Robertson, Duke University David Mancuso, Division of Research and Data Analysis, Washington State Department of Social and Health Services Colleen Gallagher and Dan Bannish, Connecticut Department of Correction 3

4. Seminar Presenters* 1.Joe Morrissey – Introduction & Overview 2.Linda Frisman – Outcomes in Connecticut 3.Gary Cuddeback – Outcomes in Washington 4.Marisa Domino – Cost Findings in Washington * No conflicts of interest to declare 4

5. Medicaid and Community Reentry Medicaid is the single largest payer of mental health services for persons w SMI in the US today – Council of State Government suggests Medicaid is critical to successful community reentry – Without sustaining health & welfare benefits justice- involved persons with mental illness will be unable to “break the cycle of recidivism” (Bazelon Center) Federal regulations require suspension or termination of Medicaid benefits after 30 days of incarceration or hospitalization A number of states have introduced policies to expedite the restoration of Medicaid benefits prior to release from prison and other institutions 5

6. What’s the Evidence Base for Expedited Medicaid? Wenzlow et al. (2011) small study (N= 77) of expedited Medicaid in 3 Oklahoma prisons – Increased Medicaid enrollment on day of release by 15 percentage points vs. controls (p=.012) – Increased Medicaid mental health service use by 16 percentage points (p=.009) vs. controls at 90 days post release Morrissey, Cuddeback et al. (2006, 2007) showed that persons w SMI in jail with Medicaid at release had: – Quicker service access & more community service use (p<.001) – Fewer re-arrests, more days in community (p<.01) To date, no comparative study of prison re-entry nationally or in different states, no studies with large sample sizes 6

7. Current Study Response to NIMH solicitation in 2008 for use of administrative data to address state-level behavioral health policies NIMH required comparison of at least two states Assembled a research team from UNC, CT- DMHAS, and Duke that had prior experiences using administrative data to address state policy issues in Washington & Connecticut 7

8. Expedited Medicaid Policy start date – Connecticut: April 2005 – Washington: January 2006 Benefits affected by restoration – Federal Medicaid via SSI/SSDI eligibility » (i.e., Aged, Blind, Disabled) – State Medicaid, a less generous benefit often used as an initial or transitional status pending Federal Medicaid restoration » SAGA in Connecticut » GAU in Washington 8

9. Policy Implementation Connecticut in 2005 DOC only Discharge Planners (6) working for Correctional Managed Health Care & based in correctional facilities complete paperwork to apply for Medicaid prior to release & fax to state Medicaid agency Entitlement specialists (2) based at state Medicaid agency process applications Daily e-feed of population list results in benefits being “switched on” Washington in 2006 DOC, jails, state hospitals Two step process ①Referral: DOC staff identified inmates and prepared applications prior to release ②Approval: Following release, inmate had to appear at local Community Service Office to activate application Legislature funded and distributed 14 FTE Community Service Officers statewide to prioritize expedited cases 9

10. Other Differences b/w States Connecticut Unitary corrections system: State DOC operates prisons and jails Much of Medicaid was fee-for- service in the study period State Administered General Assistance (SAGA) covered services at a similar rate Virtually no one is denied benefits Even prisoners not expedited had 2-4 weeks of Rx at the time of discharge Washington Dual corrections system: State DOC operates prisons and County Sheriffs operate jails Medicaid managed care with HMO for medical care and carve-outs for behavioral health care Federal Medicaid required for access to specialty mental health services State Medicaid (GAU) covers meds from primary care MDs 10

11. Research Design Case-control study with data available 3-yrs. pre and 3-yrs.post start of expedited Medicaid policy Administrative data on inmates with SMI, service contacts for mental health (inpatient & outpatient), substance use, arrests & incarcerations Propensity score analysis used to construct comparison group of inmates with SMI who were not expedited and released during same time period 11

12. Core Analysis for Inmates w SMI Released from CT & WA Prisons * Comparison groups matched on propensity scores created from demographics, clinical diagnoses, and behavioral health/criminal justice history for the 3-yrs. prior to an index release 12 Usual Release * Usual Release * Release w/ Expedited Medicaid * 12-mo post- release service use and costs 12-mo arrest and incarceration

13. Expedited Medicaid Restoration in Connecticut Linda Frisman CT DMHAS and UConn SSW 6 th Annual Academic and Health Policy Conference on Correctional Health Chicago – March 22, 2013

14. Methods for CT Data Started with DOC discharges w/ 1 year FU Experimental group defined by DSS Propensity Scoring – 1,511 Pre-Release Entitlement (PRE) = E – 1,511 Propensity-matched cases (Non-PRE) = C Survival Analysis (Cox Regression) – Time to event (enrollment, OP Tx, IP, arrest, etc) Poisson Models for count data 14

15. Poisson Models Used in a “conditional” situation: e.g., rate of use of EDs & # visits – First part is about the likelihood of the situation happening – Second part is the count of the event Poisson models involve different assumptions – Poisson regression: assumes equally dispersion (the conditional variance equals the conditional mean) – Negative binomial regression (NB): allows for over-dispersion – Zero inflated Poisson model (ZIP): allows for excess zeros – Zero inflated Poisson negative binomial regression (ZINB): allows for over-dispersion and excess zeros Need to use the model best-suited to the data 15

16. Propensity-Matched Groups (1) Prior to matching, all were significantly different 16

17. Propensity-Matched Groups (2) Prior to match, all were sig. different except crime severity 17

18. Health Outcomes, 12 months 18

19. Criminal Justice Outcomes, 12 months 19

20. Cox Regression 20

21. Survival to Medicaid Enrollment 21

22. Survival to First OP Visit 22

23. Negative Binomial 23

24. ZINB results for re-arrest 24

25. ZINB results for ED/Crisis 25

26. Summary of CT Findings In Connecticut, the Pre-Release Enrollment Program resulted in: – Quicker access to Medicaid – Quicker use & more use of Outpatient services – Reduced use of Inpatient Care – More community days – NS difference in # of visits to EDs/crisis overall – BUT people in PRE were more likely to use EDs – No difference in CJ outcomes 26

27. Expedited Medicaid Restoration in Washington State Gary Cuddeback and Jennifer Jolley University of North Carolina 6 th Annual Academic and Health Policy Conference on Correctional Health Chicago – March 22, 2013

28. Research Question & Methods What is the impact of an expedited Medicaid restoration program for SMI persons released from prison in Washington State? Quasi-experimental design w/PSM – Individuals with SMI released from prison in 2006 or 2007 Approved for expedited Medicaid restoration vs. those who were referred but not approved or eligible but not referred – 12-month follow-up after index release in 2006 or 2007 28

29. Definitions and Data Severe mental illness defined as having a diagnosis of schizophrenia or other psychotic disorders and/or bipolar disorder (with some exceptions) – Dx came from community mental health or DOC Linked administrative data available from 2003 to 2010 from Washington State CODB – Demographics, diagnoses, Medicaid (program type), inpatient and outpatient mental health service use, substance use service use, homelessness, employment, arrests, jail (some), violator facilities, prisons – Linked at person-level to create longitudinal file 29

30. Data Analysis Regression and survival models with PSM weights and robust standard errors HB1290 approval = independent variable Dependent variables … – Logistic regression Probability of Medicaid Probability of outpatient service Probability of arrest – OLS and survival models Time to Medicaid Time to first service Time to arrest PSM balanced groups on all observables (more later) 30

31. Sample Characteristics: Approved, Denied and Not Referred Approved (658) Denied* (258) Not Referred (2538) % (n) Male77 (504)73 (189)73 (1823) White69 (451)73 (189)73 (1823) Age (M(SD))36 (8.9)37 (11.9)36 (9.5) Psychotic disorder60 (395)48 (123)40 (1020) SMI/SA90 (594)84 (217)80 (2010) Prior ABD Medicaid79 (517)40 (104)27 (683) Prior GAU Medicaid30 (197)21 (55)16 (403) 31 * Note: Denial reasons included: living arrangement (32%), failed incapacity requirement (26%), voluntary withdrawal (6%), and other reasons (46%)

32. 12-mo. Post-release Outcomes ApprovedDeniedNot Referred % (n) Homeless56 (339)67 (161)60 (1407) Unemployed86 (523)82 (198)70 (1645) Medicaid (ABD)93 (568)63 (153)47 (1102) Medicaid (GAU)30 (181)52 (120)48 (1070) Any MH outpatient svc22 (132)12 (28)7 (161) Any AOD outpatient svc43 (275)33 (83)32 (777) Anti-psychotic meds49 (309)28 (71)15 (371) Anti-depress meds48 (306)32 (81)21 (495) Any inpatient service10 (63)7 (16)4 (96) Arrest56 (338)60 (144)51 (1186) 32

33. 12-mo. Post-release Outcomes* OutcomeCoeff (SE)p+/- Probability of ABD Medicaid2.35 (.18).001+39% Probability of GAU Medicaid-.12 (.11)ns Probability of other Medicaid-.76 (.14).001-13% Probability of outpatient service1.16(.14).001+14% Probability of inpatient admit.62 (.18)ns Probability of arrest.11 (.11)ns Probability of incarceration-.05 (.18)ns 33 * Logistic regression with PSM weights used

34. 12-mo. Post-release Outcomes (cont’d) OutcomeCoeff (SE)p+/- days Time to ABD Medicaid-115.5 (6.53).01-115.5 Time to GAU Medicaid8.9 (7.2)ns Time to other Medicaid38.4 (5.7).01+38.4 Time to outpatient service-34.5 (5.3).001-34.5 Time to inpatient admit-.22 (.58)ns Time to arrest-7.5 (6.6)ns Time to incarceration (prison)7.3 (3.6).05+7.3 34

35. LR w/o PSM: Probability of Arrest IndicatorCoeff (SE)pOR Male.37 (.04).0012.01 Race.20 (.07).0011.42 Age-.54 (.07).01.33 Homelessness.26 (.04).0011.69 Unemployment.40 (.04).0012.21 Substance use disorder.19.0011.47 Expedited Medicaid.03ns- 35

36. Key Findings Expedited benefit restoration associated with – Greater and quicker Medicaid uptake – Greater and quicker access to outpatient mental health services Restored benefits not associated with lower probability of criminal justice events – Some improvement in time in community until prison Expedited restoration is working as a health insurance program but few spill-overs for corrections But Medicaid alone is not enough as evidenced by role of substance use, homelessness and unemployment in arrest & re-incarceration! 36

37. Expedited Medicaid Restoration in Washington State: Cost-Effectiveness Marisa Domino and Jennifer Jolley University of North Carolina 6 th Annual Academic and Health Policy Conference on Correctional Health Chicago – March 22, 2013

38. Cost Analysis We examined the cost of expedited Medicaid using a government payer perspective – Costs related to medical and mental health services use and criminal justice costs were included – Short-run (12 month) time period examined We also analyzed days in the community as a measure of effectiveness, for a cost-effectiveness calculation – Days not incarcerated nor in inpatient settings 38

39. Cost Methods Costs of medical and mental health services used actual payments by Medicaid, state, and regional payers for services delivered State hospital days costed using per diems Services include: – Outpatient medical and mental health services – Inpatient services, including state hospitals and local inpatient hospitals – Emergency room, crisis treatment, and medications 39

40. Cost Methods, continued Criminal justice costs used Washington State Institute for Public Policy (WSIPP) calculated costs, including costs of: – Arrests – Jail – Prison – Parole 40

41. Analysis Methods Because of concerns over selection bias in that those receiving expedited Medicaid may differ from those not receiving expedited Medicaid, we used propensity score weighting to obtain better balance on baseline risk factors Baseline risk factors include: time in prison and jail, year of release, race/ethnicity, age, gender, prior history of mental health service use, homeless prior to index incarceration, work history, and Medicaid/state program enrollment prior to index incarceration All factors balanced after propensity weighting <=.25 SD/mean difference in groups 41

42. Selected Baseline Risk Factors Variable Weighted mean – Expedited (n=608) Weight mean – Controls (n=2554) Time served (days)531513 Minority41.0%39.5% Latino6.1%6.3% Age3534 Male75%74% Psychotic disorder45% Jail days prior58 Homeless prior51%52% Work history59%60% 42

43. Cost Results Cost typeWeighted difference between Expedited and Controls Total cost$3437** Antipsychotic medications$672** Inpatient/ER- medical$590 (p=0.051) Arrests$559 (p=0.095) OP medical$533** ER$357** AOD$258** Parole-$22* Prison costs (DOC)-$398 (p=0.067) **p<0.01; *p<0.05 43

44. Community Days We find approximately 5 more community days (p=0.076) in 12 months for those on expedited Medicaid 3437/5 ~ $687/community day 44

45. Conclusions Preliminary results indicate that Expediting Medicaid increases access to services, thus increasing costs in the short run (1 year) While the program results in a greater number of community days, this amounts to a relatively high cost per day ($687) in the short run 45

46. Conclusions/Limitations If investments in health are made in the short run, the payoff in terms of reductions in hospitalizations may not be observed until beyond the 12 month window – 36 month analysis is pending; will also look at – 30 and 90 day results re criminal justice outcomes Days in the community is a crude measure, which does not reflect quality of life – Clinical and person-centered measures are not available in our data 46

47. Conclusions In summary, expedited Medicaid in Washington State led to: – shorter time without insurance coverage – Better access to services, especially pharmaceuticals – Higher costs, in total and on most dimensions – A few more days in the community post-index release – Slight but nonsignificant reduction in DOC costs 47

48. Comparisons & Implications In both states, expedited Medicaid restoration led to quicker and greater mental health service use No strong effects re reduced criminal justice outcomes & costs Many controls went on to obtain Medicaid after release so further analyses are needed to isolate overall effects of having vs. not-having Medicaid However, our current analyses suggest that Medicaid alone might not be enough to keep people with SMI out of criminal justice system 48

49. Contacts For additional questions and copies of our presentation, please contact us: Joe Morrissey – joe_morrissey@unc.edujoe_morrissey@unc.edu Linda Frisman – lfrisman@ct.govlfrisman@ct.gov Marisa Domino – domino@unc.edudomino@unc.edu Gary Cuddeback – gcuddeba@email.unc.edugcuddeba@email.unc.ed 49