Reduced Medicare cost sharing results in unequal increase in access to mental health care

Medicare policy changes that reduced out-of-pocket mental health and substance use disorder (MHSUD) outpatient fees, to achieve parity with typical cost-sharing under Medicare , have been associated with uneven improvements in the use of these services across races and ethnic groups. ethnic groups, according to a study.

Specifically, visits by MHSUD specialists among white beneficiaries increased during the periods of introduction and implementation of the reduced cost-sharing policy (2010-2013; 2014-2018) compared to a control group. of beneficiaries who received free care throughout the study period (2008 -2018; P<0.001). But the changes were smaller for black, Hispanic and Asian patients, reported Vicki Fung, PhD, of Massachusetts General Hospital and Harvard University in Boston, and her colleagues.

In addition, the reduction in cost sharing was also associated with an increase in the proportion of white recipients filling MHSUD prescriptions (P<0.001). While there were also increases for black and Hispanic beneficiaries in the cost-sharing reduction group, these changes "lagged significantly" behind those for white beneficiaries, the authors noted in Health Affairs.

In response to legislation passed in 2008, Medicare introduced cost-sharing parity for MHSUD outpatient services equal to that of other medical services, gradually reducing beneficiaries’ share of MHSUD expenditures from 50% in 2009 to 20%. in 2014. .

“We hoped this policy would help increase overall access, and over the study period, usage increased across all groups, but increased less for recipients of color than for recipients of white” , said Fung. MedPage Today.

White beneficiaries in the cost-sharing group also experienced a drop in ER visits and MHSUD hospitalizations (P=0.03). However, among Asian beneficiaries, the reduction in cost-sharing was related to the relative increase in such visits during the phased implementation of the policy compared to the pre-policy period (P=0.01).

Fung said the reasons for the increase were unclear, adding that there is literature to suggest “Asians may be more likely to wait and not seek treatment for their psychiatric symptoms until they become more serious”.

With respect to expenditures, Fung and his team noted that for white beneficiaries, the reduction in cost sharing was linked to relative increases in MHSUD drug expenditures and relative decreases in hospital and total MHSUD expenditures. For racial and ethnic minorities, changes in MHSUD drug spending associated with reduced cost sharing were “smaller” than those for white beneficiaries.

Previous research has shown that poverty and out-of-pocket expenses contribute to underutilization of MHSUD services and gaps in access to specialty care for racial and ethnic minorities, the authors said.

While parity efforts may have helped improve the affordability of MHSUD care, they have failed to address other “systemic barriers to treatment,” including racism and discrimination, language barriers, scarcity of culturally competent providers and lack of investment in health insurance literacy and navigation. support, Fung and his colleagues explained.

“I don’t want the takeaway that these policies aren’t important or helpful, they are, but without addressing other structural and systemic barriers, there are likely to be disproportionately high barriers to care for communities in color,” Fung said.

Regarding clinicians, Fung emphasized the importance of screening and the need to be “aware of all the barriers that patients face when trying to seek this care.”

Study details

Fung said she believes parity policies could have the potential to reduce disparities in care, so she and her team analyzed changes in MHSUD service utilization and spending from 2008 to 2018 and plotted. leveraged “an event study to plot differences in differences within each racial and ethnic group,” while comparing a cost-sharing reduction cohort with a control group that received free care throughout of the study period.

The study included 286,276 traditional Medicare beneficiaries with reduced cost-sharing who had incomes from 100% to 135% of the federal poverty level (mean age 77, 71% female) and 734,280 beneficiaries who had received free care in 2008 and had incomes below 100% of the federal poverty level (average age 77, 70% female).

Most recipients were white. In the reduced cost-sharing group, 15% were black, 9% were Hispanic, and 2% were Asian, and for the free care group, 16% were black, 20% were Hispanic, and 15% were Asian.

One limitation of the study was that the sample did not include enough Native American/Alaskan recipients to detect significant differences.

Fung also noted that she and her colleagues were unable to assess certain variables, such as “who really needed mental health treatment or who sought mental health treatment but did not could receive it”.

Also, because the study focused on low-income recipients, the results may not be generalizable to higher-income recipients.