摘要：Objectives. We investigated whether health insurance type (private vs Medicaid) influences the delivery of acute mental health care to patients with deliberate self-harm. Methods. Using National Medicaid Analytic Extract Files (2006) and MarketScan Research Databases (2005–2007), we analyzed claims focusing on emergency episodes of deliberate self-harm of Medicaid- (n = 8228) and privately (n = 2352) insured adults. We analyzed emergency department mental health assessments and outpatient mental health visits in the 30 days following the emergency visit for discharged patients. Results. Medicaid-insured patients were more likely to be discharged (62.7%), and among discharged patients they were less likely to receive a mental health assessment in the emergency department (47.8%) and more likely to receive follow-up outpatient mental health care (52.9%) than were privately insured patients (46.9%, 57.3%, and 41.2%, respectively). Conclusions. Acute emergency management of deliberate self-harm is less intensive for Medicaid- than for privately insured patients, although discharged Medicaid-insured patients are more likely to receive follow-up care. Programmatic reforms are needed to improve access to emergency mental health services, especially in hospitals that serve substantial numbers of Medicaid-insured patients. In several medical contexts, insurance status affects access and quality of care. 1,2 In relation to privately insured patients, Medicaid-insured patients are generally less likely to receive care, and the care they receive less often meets guideline-based standards. 3,4 At a time of intense pressure to rein in Medicaid costs, the risks of insurance-related disparities in access and quality of care are especially great. Despite keen interest among health care policymakers, however, little information exists in the peer-reviewed literature on the comparative access and quality of mental health care provided to Medicaid- and commercially insured patients. The emergency department is an important setting in which to evaluate mental health care of Medicaid-insured and privately insured adults. In the management of deliberate self-harm, emergency departments have an opportunity to provide potentially lifesaving services. A key goal involves improving the recognition and treatment of psychiatric disorders in high-risk patients. 5 One particularly high-risk group includes patients who go to emergency departments pursuant to self-harm, which may or may not involve suicidal intent. 6,7 During the first year following emergency treatment of deliberate self-harm, suicide risk increases 30- to 130-fold. 8–10 Psychiatric disorders, though exceedingly prevalent among adults with deliberate self-harm, 11,12 are not always recognized or treated. Because of strong connections between psychiatric disorder, self-harm, and suicide, the National Institute for Clinical Excellence recommends that all individuals attending emergency departments with deliberate self-harm receive a mental health evaluation before emergency department discharge. 13 Mental health assessment provides opportunities to evaluate aggression, impulsivity, hopelessness, and other symptoms that bear on suicide risk. 14 The quality of mental health care in emergency departments varies. In 1 statewide survey, most emergency departments did not have a mental health professional to evaluate and treat patients with self-harm. 15 Only about one half of emergency department patients in the Medicaid program who come in with deliberate self-harm and are discharged to the community receive a mental health assessment. 16 We compared the mental health care received by adult Medicaid and privately insured beneficiaries who came to emergency departments with deliberate self-harm. We first compared these 2 groups with respect to the likelihood of hospital admission. Among those who were discharged to the community, we assessed the probability of receiving a mental health assessment in the emergency department and of receiving outpatient mental health treatment within the following 30 days. We hypothesized that Medicaid-insured patients with self-harm would be less likely than would their privately insured counterparts to be admitted to the hospital and that Medicaid-insured patients who were discharged to the community would be less likely than would privately insured patients to receive an emergency mental health assessment and follow-up outpatient mental health care.
