Managed care linked to shorter inpatient stays, increased suicide rates in Missouri—study

Rates of childhood suicide in Missouri have climbed since the expansion of Medicaid managed care. (Getty/KatarzynaBialasiewicz)

Teens and children living in Missouri have had a far greater incidence of attempted suicide since the expansion of Medicaid managed care organizations (MCOs), according to a new study from the Missouri Hospital Association (MHA). 

The study (PDF) revealed that Medicaid MCO coverage had the highest observed rates of suicidality but also had the shortest average length of hospital stay—7.3 days compared to 10.5 days—between October 2015 and June 2018 among other payers.

To put the problem into greater context, suicide is the second leading cause of death in Missouri among children ages 5 to 19, and the state had the 11th highest rate of child and adolescent suicide in the U.S. in 2017. Between 2003 and 2017, the rate of suicide for this young population increased by 129%. 

Meanwhile, in the six quarters leading up to the statewide expansion of Medicaid MCOs—enacted in May of 2017—there was a 16% decrease in the average duration of hospitalization for these children and adolescents, in tandem with increased suicidality rates ranging from 81.7% to 93.2%. 

RELATED: CMS floats new network adequacy requirements for Medicaid managed care programs

The authors of the study state that the shortage of mental health providers for children is one of the drivers of the higher rates of suicide in Missouri. Specifically, the Health Resources and Services Administration reports that 96.5% of Missouri counties have a mental health professional shortage. In comparison to other states, there are 22% fewer psychiatrists and 14% fewer psychologists. 

Another driver for the higher rates of suicide is the strict determinants used by Medicaid MCOs when debating inpatient psychiatric hospital admissions. As a result of funding, psychiatric hospitals in the state often feel pressure to discharge patients prematurely. 

In fact, the report shows that MCOs denied one out of every four admissions claims following discharge, which is 7.9 times more than the denial rate of Medicaid fee-for-service (FFS) claims. Managed care refused reimbursement for 11.4% of the total patient days during approved hospitalizations, the report said.

The spread of Medicaid MCOs is not unique to Missouri, as current CMS Administrator Seema Verma has stated the agency’s goal to update a regulation which would give states more control over setting rates for payments and shifting providers from FFS to managed care.

In the MHA study, results varied by the primary reason for hospitalization, but 21% of children and adolescents hospitalized for schizophrenia experienced a rehospitalization or ED visit for suicide ideation or attempt within 90 days of discharge. The least prevalent rates of suicidality were found among child patients hospitalized for stress disorders. However, children with Medicaid FFS were hospitalized twice as much as children with Medicaid MCO coverage.

Still, there are potential negative sides of a fee-for-service model. 

For example, the potential for overdiagnosis and overtreatment, wrote Virginia Mason CEO Dr. Gary S. Kaplan and Dr. C. Craig Blackmore, director of the Center for Health Care Improvement Science at Virginia Mason, in an op-ed for NEJM last year. 

Despite higher rates of social and economic risk factors, Avelere estimates (PDF) Medicare Advantage beneficiaries experience 23.1% fewer inpatient stays and 32.7% fewer ER visits than the FFS patients.

Where you can find help
  • The National Suicide Prevention Lifeline can be reached at 1-800-273-8255. It provides free and confidential support 24 hours a day, seven days a week for people in suicidal crisis or distress, or for those who are helping a person in crisis.
  • For online chat, the National Suicide Prevention Lifeline provides a confidential chat window with counselors available 24/7.