title: Second-generation antipsychotic use among stimulant-using children, by organization of medicaid mental health.
abstract: OBJECTIVE
  Reducing overuse of second-generation antipsychotics among Medicaid-enrolled children is a national priority, yet little is known about how service organization affects use. This study compared differences in second-generation antipsychotic utilization among Medicaid-enrolled children across fee-for-service, integrated managed care, and managed behavioral health carve-out organizational structures.
  
  
  METHODS
  Organizational structures of Medicaid programs in 82 diverse counties in 34 states were categorized and linked to child-level cross-sectional claims data from the Medicaid Analytic Extract covering fiscal years 2004, 2006, and 2008. To approximate the population at risk of antipsychotic treatment, the sample was restricted to stimulant-using children ages three to 18 (N=419,226). The sample was stratified by Medicaid eligibility group, and logistic regression models were estimated for probability of second-generation antipsychotic use. Models included indicators of county-level organizational structure as main predictors, with sequential adjustment for personal and county-level covariates.
  
  
  RESULTS
  With adjustment for person-level covariates, second-generation antipsychotic use was 31% higher among youths in foster care in fee-for-service counties than for youths in counties with carve-outs (odds ratio [OR]=1.69, 95% confidence interval [CI]=1.26-2.27). Foster care youths in integrated counties had the second highest adjusted odds (OR=1.31, CI=1.08-1.58). Similar patterns of use also were found for youths eligible for Supplemental Security Income but not for those eligible for Temporary Assistance for Needy Families. Differences persisted after adjustment for county-level characteristics.
  
  
  CONCLUSIONS
  Carve-outs, versus other arrangements, were associated with lower second-generation antipsychotic use. Future research should explore carve-out features (for example, tighter management of inpatient or restricted access, as well as care coordination) contributing to lower second-generation antipsychotic use.
authors.affiliation: Dr. Saloner is with the Department of Health Care Policy, Johns Hopkins University, Baltimore (e-mail: bsaloner@gmail.com ). Ms. Matone, Ms. Kreider, Mr. Budeir, Ms. Miller, and Dr. Rubin are with PolicyLab, Children's Hospital of Philadelphia, Philadelphia. Dr. Rubin is also with the Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia. Ms. Huang is with Division of General Pediatrics and Healthcare Analytics Unit, Children's Hospital of Philadelphia. Dr. Raghavan is with the George Warren Brown School of Social Work, Washington University in St. Louis, St. Louis, Missouri. Dr. French is with the Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia.
authors.forename: Brendan
authors.initials: B
authors.lastname: Saloner
authors.forename: Meredith
authors.initials: M
authors.lastname: Matone
authors.forename: Amanda R
authors.initials: AR
authors.lastname: Kreider
authors.forename: M Samer
authors.initials: MS
authors.lastname: Budeir
authors.forename: Dorothy
authors.initials: D
authors.lastname: Miller
authors.forename: Yuan-Shung
authors.initials: YS
authors.lastname: Huang
authors.forename: Ramesh
authors.initials: R
authors.lastname: Raghavan
authors.forename: Benjamin
authors.initials: B
authors.lastname: French
authors.forename: David
authors.initials: D
authors.lastname: Rubin
mesh_terms: D000293:Adolescent; D014150:Antipsychotic Agents / Q000627:therapeutic use*; D000697:Central Nervous System Stimulants / Q000627:therapeutic use*; D002648:Child; D002675:Child, Preschool; D004608:Eligibility Determination; D018588:Fee-for-Service Plans; D006801:Humans; D057970:Inappropriate Prescribing / Q000517:prevention & control*; D008297:Male; D008329:Managed Care Programs / Q000706:statistics & numerical data; D008484:Medicaid / Q000191:economics / Q000706:statistics & numerical data; D001523:Mental Disorders / Q000188:drug therapy*; D008603:Mental Health / Q000191:economics / Q000706:statistics & numerical data; D014481:United States
chemical_list: D014150:Antipsychotic Agents; D000697:Central Nervous System Stimulants