Changes to Medicare policy that lower out-of-pocket costs for outpatient mental health and substance use disorder (MHSUD) care, to achieve parity with typical cost-sharing under Medicare, have been associated with disproportionate improvements in use of these services across race and ethnic groups, a study suggests. .
Specifically, visits to MHSUD specialists increased among white beneficiaries during the cost reduction policy implementation and implementation periods (2010-2013; 2014-2018) when compared to a control group of beneficiaries who received free care throughout the entire study period (2008-2018); s<0.001). But the changes were smaller for black, Hispanic, and Asian patients, according to Vicki Fong, PhD, of Massachusetts General Hospital and Harvard University in Boston, and colleagues.
In addition, reduced cost-sharing was also associated with an increased proportion of white recipients filling MHSUD prescriptions (s<0.001). While there were also increases for black and Hispanic beneficiaries in the cost-sharing reduction group, these changes "lag 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 outpatient MHSUD services equal to that for other Medicare services, gradually reducing the beneficiaries’ share of MHSUD spending from 50% in 2009 to 20% in 2014.
“We hoped that this policy would help increase access overall. During the study period, use increased across all groups, but it increased less for recipients of color than for white recipients,” Fung said. MedPage today.
White beneficiaries in the cost-sharing group also experienced a decrease in MHSUD emergency department visits and hospitalizations (s= 0.03). However, among Asian beneficiaries, reduced cost-sharing was associated with relative increases in such visits during the policy phase compared to the pre-policy period (s= 0.01).
The reasons for this increase are not clear, Fung said, adding that there is literature suggesting that “Asians may be more vulnerable…to wait and not seek care for their psychiatric symptoms until they become more severe.”
In terms of spending, Fong and team noted that for white recipients, reduced cost-sharing was associated with relative increases in MHSUD drug spending and relative decreases in MHSUD inpatient expenditures and overall spending. For racial and ethnic minorities, changes in spending on MHSUD drugs associated with the cost-sharing reduction were ‘smaller’ than for white recipients.
The study authors said that previous research has shown that poverty and out-of-pocket costs contribute to underutilization of MHSUD services and to gaps in access to specialized care for racial and ethnic minorities.
While equity efforts may have helped improve affordability of MHSUD care, they fail to address “other systemic barriers to treatment,” including racism and discrimination, language barriers, lack of culturally competent providers, and lack of investment. In Surfing Literacy in Health Insurance Support, Fung and colleagues explain.
“I don’t want the takeaway to be that these policies are not important or helpful, but without addressing other structural and systemic barriers, it is likely that disproportionately high barriers to caring for communities of color will continue,” Fong said.
For clinicians, Fung stressed the importance of screening and the need to “be aware of all the barriers that patients face when they try to access this care.”
Fong said she believes equity policies may have the potential to reduce disparities in care, so she and her team analyzed changes in MHSUD service use and spending from 2008 to 2018 and made use of an “event study to map differences in differences within each racial and ethnic group,” while comparing The cost-reducing group shared with a control group that received free care throughout the study period.
The study included 286,276 traditional Medicare beneficiaries with cost-sharing reduction who had incomes between 100% and 135% of the federal poverty level (mean age 77 years, 71% women) and 734,280 beneficiaries who received free care in 2008 and their income was lower. 100% of the Federal Poverty Level (median age 77 years, 70% women).
Most of the recipients were white. Of the combined cost reduction group, 15% were Black, 9% Hispanic, and 2% Asian, and for the free care group, 16% were Black, 20% Hispanic, and 15% Asian.
A limitation of the study was that the sample did not include enough American Indian/Alaska Native recipients to be able to detect meaningful differences.
Fung also noted that she and her colleagues were not able to assess certain variables, such as “who really needed mental health treatment or who sought mental health treatment but was not able to receive it.”
In addition, because the study focused on low-income recipients, the results may not be generalizable to higher-income recipients.
This study was supported by grants from the National Institute on Minority Health and Health Disparities, the Agency for Healthcare Research and Quality, the Centers for Medicare and Medicaid Services, the Office of Minority Health, and the Health Equity Data Access Program.
Fong did not make any disclosures. Co-authors report multiple relationships with industry.
Source reference: Fung V, et al “Coverage of parity and racial and ethnic disparities in mental health and substance use care among health care beneficiaries” Health Affairs 2023; doi: 10.1377/hlthaff.2022.00624.