Maryland Medicaid: Behavioral health problems predict skyrocketing medical hospitalizations

Earlier this summer the Maryland Department of Health and Mental Hygiene released four years of aggregated data on Maryland Medicaid patients and some measures of health care utilization, such as hospitalizations. The data can be found here (look at the July 11 meeting materials called Data Book). This is in the context of Maryland's attempts to integrate mental health, addictions, and somatic health (see Crazy Busy for more details).

The data show hospital admissions for the top 25 conditions -- such as stroke, diabetes, pneumonia, etc -- and further break up these data into four groups of people:

• people who also have a mental health disorder
• people who also have a substance use disorder
• people who have both a mental health and a substance use disorder
• people who have neither of these conditions (ie, just a somatic disorder, like asthma or diabetes)

Taking this data and analyzing it in more detail led to some amazing discoveries that are buried in the data tables. For example, in 2011, adult patients in Maryland Medicaid's HealthChoice program who had co-occurring mental health (MH) and substance use (SU) disorders were admitted to hospitals 800-1500% more often than those without these co-occurring conditions -- hospitalized 8-15 times more often for things like pneumonia, asthma, diabetes, epilepsy, and cellulitis.

That is worth saying one more time:

Patients with both mental health and substance use disorders were hospitalized 8-15 times more often for things like pneumonia, asthma, diabetes, epilepsy, and cellulitis.

Here is a graph demonstrating this amazing connection. People with co-occurring mental health problems were admitted 2-4 times more often for these 6 types of medical conditions, and people with co-occurring substance use problems were admitted 4-7 times more often. This is based on claims data submitted to Medicaid and analyzed by the Hilltop Institute. The data are normalized such those without mental health or addiction comorbidity have a relative risk of 1 for hospitalization

The six conditions are the primary diagnoses as indicated by the Medicaid data: epilepsy; HIV-related illness; cellulitis/septicemia; congestive heart failure; respiratory conditions (bronchitis, pneumonia, asthma, and COPD); and diabetes mellitis.

It's no wonder there is data that people with chronic mental health conditions treated in the public health system die 25 years earlier.

If there was ever a reason to better integrate mental health care, addiction treatment, and primary care, this is it.

HIMSS EMR Adoption Model: 2009 Level 4 (CPOE) Only 14%

Hospitals in 2009 continued to have low CPOE adoption (Level 4), but they did manage to jump from 5.8% to 13.5% having CPOE (Computerized Provider Order Entry) from 2008 to 2009.

Looking at the HIMSS EMR Adoption Model trends, you can see how the 5000+ hospitals in the US are gradually moving up the electronic evolutionary ladder towards Level 7, which is full implementation of a completely interoperable, paperless, electronic medical record (note that HIMSS differentiates an "EMR" (within a single organization) from an "EHR", which it defines to specifically be a "subset of each care delivery organization's (CDO) EMR, ... owned by the patient and has patient input and access that spans episodes of care across multiple CDOs within a community, region, or state...").

As a reminder, here are the definitions of the levels (from HIMSS):

It'll be interesting to see how the HITECH Act's financial incentives accelerates adoption of the higher levels (4 and up). Looking at the cumulative adoption percentages below, I'd expect Level 4 to take off in the same way that Level 3 has over the past several years. But that is the hardest transition to achieve due to the dramatic changes in physician workflow required. This is easier to achieve in hospitals where the majority of the physicians are employed by the hospital; however, physicians at most hospitals (especially community hospitals) are not employed, so these hospitals have less fortitude in requiring them to enter their own orders.

Any guesses as to what the 2010 adoption numbers will be?