1. Diabetes Care Among Medicaid Psychiatric Patients
Jim E. Banta, PhD, MPH,1 Elaine H .Morrato, MPH., DrPH,2 Scott W. Lee, MD,3
1 School of Public Health, Loma Linda University;2 School of Medicine, University of Colorado; 3 School of Medicine, Loma Linda University
Method
Design: A cross-sectional study of adults, ages 18 to 59, served by the San Bernardino County Department of Behavioral Health.
Data Source: Socio-demographic data (age, gender, race, marital status) for all patients seen between November 1 and 15, 2004 were obtained from the County’s billing database. Patients were defined as being primarily clinic or Fee-for-Service based on where services were provided during that two week period.
Data Access: California Department of Health Services matched patient birthdate and social security numbers against the Medicaid paid claims file, and all services provided between May 2004 and April 2005 were extracted.
Measures: The primary diagnosis field in paid Medicaid claims was examined to find identify claims/patients having diabetes (ICD-9 codes 250.xx), any Schizophrenia, any bipolar, or any depression diagnoses. Adherence to American Diabetes Association guidelines for quality of care4 was examined by searching claims for CPT codes indicating lipid testing, HbA1c testing, and eye examinations
Analysis: Chi-squared tests used for bivariate comparisons of prevalence. Multi-variable logistic regression models for examining likelihood of receiving tests
Principal Findings
Ten percent of patients had diabetes, with the prevalence increasing from 4% to 18% between ages 18 and 59 years.  Diagnosed diabetes was more common in married individuals, females, Blacks, and those with schizophrenia or depression.  
Only 61 patients with diabetes (15.1% of 405) received all three screenings during the year, while 57.3% received lipid testing, 51.4% received HbA1c testing, and 32.1% received eye exams.
There was no disparity in diabetes care due to age, gender, race/ethnicity, and psychiatric diagnosis. However, being married was associated with a higher likelihood of receiving an eye exam (odds ratio 1.8, 95% Confidence Interval of 1.1 to 3.2) and all three exams (O.R. 2.5, 95% C.I. of 1.3 to 4.8).
FFS patients, who receive outpatient mental health services from a private physician, were more likely to have lipids testing (O.R. 2.9, 95% C.I. of 1.6 to 5.4) and eye exams (O.R. 1.9, 95% C.I. of 1.1 to 3.2).
Research Objectives
To examine prevalence of diabetes and levels of recommended screening among Medicaid patients in a County mental health program.
To examine patient and system-level factors associated with receipt / non-receipt of screening services.
Introduction
Diabetes is more common among adults with schizophrenia1 and depression,2 with outcomes being worse among those with comorbid bipolar disorder.3
There is evidence that individuals with severe mental illness receive suboptimal care for diabetes.4
At a system level, four major factors are commonly associated with poor care of persons with both serious mental and physical illness: geographic (mental and physical treatment in different locations), financial (different funding streams), organizational difficulty (communication), and cultural (focus on different problems, rather than patient).5
Medicaid enrollees with serious and persistent mental illness have been identified as a population with special health needs.6
California county mental health programs served more than 197,000 adults with a serious mental illness in Fiscal Year in a system that is carved-out from physical health care.7
Multivariable regression models for receipt of testing during a 12-month period (n=405)
References
Carney CP, Jones L, Woolson RF. (2006). Medical comorbidity in women and men with schizophrenia: a population-based controlled study. J Gen Intern Med. 21(11):
Carnethon MR, Biggs ML, Barzilay JI,Smith NL, Vaccarino V, Bertoni AG, Arnold A, Siscovick D.(2007). Longitudinal Association Between Depressive Symptoms and Incident Type 2 Diabetes Mellitus in Older Adults The Cardiovascular Health Study. Arch Intern Med. 167:
McIntyre RS, Konarski JZ, Misener VL, Kennedy SH. (2005). Bipolar disorder and diabetes mellitus: epidemiology, etiology, and treatment implications. Ann Clin Psychiatry. 17(2):83-93.
Frayne SM, Halanych JW, Miller DR, Wang F, Lin H, Pogach L, et al, (2005). Disparities in Diabetes Care. Arch Intern Med. 165:
Druss BG. (2007).Improving Medical Care for Persons With Serious Mental Illness: Challenges and Solutions. J Clin Psych. 2007;68(Supplement 4):40-44.
Shalala, D.E. (2000). Report to Congress: Safeguards for Individuals with Special Health Care Needs Enrolled in Medicaid Managed Care. Washington, DC, Department of Health and Human Services.
Mayberg, S.W. (2003). California's Community Mental Health Performance Outcome Report, Fiscal Year , California Department of Mental Health.
Conclusions
Diabetes is common among Medicaid beneficiaries being treated for psychiatric conditions; but many are not receiving the recommended diabetes tests.
More effort is needed to ensure that patients in public mental health clinics receive recommended diabetes care.