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Continuity of Primary Care Saves Lives
Diabetes and Mental Illness
Diabetes is a Serious Health Risk
The one system of care variable that changes the risk of developing worse diabetes relates to continuity of primary care.  Fragmentation of primary care at baseline and moving from continuous to fragmented care in follow-up is associated with worse diabetes, while a  move from fragmented to continuous care appears protective.
Mental illness is not “just another co-morbidity.” The impact on worsening diabetes of any one behavioral health disorder is generally as great or greater than having 3 or even 4 other medical comorbidities
Persons with Serious Mental Illness (SMI), Non SMI Mental Illness and dual diagnosis (a mental health and substance abuse diagnosis) have higher rates of diabetes, pre-diabetes and complicated diabetes at baseline; and they are more likely to develop worse diabetes in follow up years.

Maine MCC Project

Introduction

The Maine AHRQ MCC study focuses on its long term Medicaid population, a group of Mainers with high rates of poverty, health risk behaviors, housing instability, poor nutrition and low educational attainment. Half of this cohort has a behavioral health disorder (mental illness, substance abuse, both mental illness and substance abuse, or developmental disabilities/brain injury). Those with behavioral health disorders have significantly higher rates of multiple medical co-morbidities, higher total and non-behavioral health costs and higher rates of utilization of medical services, including emergency room use, hospitalization, avoidable hospitalization, readmission and outpatient care.

Findings

Impact of Cost and Service Use

While it is long been known that total costs are influenced by behavioral health conditions, we find that:

  • Medical costs are significantly impacted by behavioral health status.
  • Behavioral health costs are significantly impacted by medical comorbidity.

Fragmented Care Matters

  • Fragmentation of care is higher among people with behavioral health disorders, multiple medical co-morbidities and complicated diabetes.
  • Fragmentation of primary care is associated with signficantly higher costs and utilization of emergency room and other services.

Impact on Diabetes Complications

  • Persons with certain mental illnesses have higher rates of diabetes, risk for diabetes and complicated diabetes at baseline.
  • Physician directed interventions such as statins, antidiabetic agents, and processes of care are more likely to be delivered after complications have developed in this population. For Maine Medicaid members, they are not protective.
  • Preventing acute episodes (potentially avoidable event) may have value in preventing chronic complications.
  • The one system of care variable that changes the risk of developing worse complicated diabetes relates to continuity of primary care.

Who Develops a New Diagnosis of Diabetes?

  • People with certain behavioral health disorders convert to new diabetes at a higher rate than those with no behavioral health disorders.
  • The model for Risk for Diabetes is sufficiently robust for predicting who might get diabetes, so behavioral health and primary care might target this population to improve monitoring and statin and metformin use.
  • We should explore other ways of defining Risk for Diabetes to be more effective in primary prevention.

Who Gets Worse? Who Dies?

  • Persons with behavioral health disorders are more likely to develop worse diabetes in follow-up years.
  • Change in behavioral health status affects the likelihood of developing worse diabetes.
  • Fragmentation of primary care is associated with worsening diabetes status in the follow-up years.
  • Change from fragmented to continuous care is associated with better diabetes status in follow-up years.
  • Persons with behavioral health disorders die at a higher rate.
  • Other factors that predict death in persons with diabetes -- antipsychotic use, worse behavioral health status.

Policy Implications

Improving the outcomes and cost effectiveness of care for Medicaid members with diabetes and co-morbid behavioral health disorders will require coordinated attention from both physical and behavioral health systems of care.

Physician directed interventions that have been shown to prevent complications of diabetes in commercially insured populations may be less effective, without additional supports, for Medicaid members who have high rates of additional medical and behavioral health co-morbidities.

Interventions that support improvement of mental health status and continuity of primary care have promise for improving the health status of Medicaid members with diabetes.