Reduced Medicare Cost-Sharing Yields Uneven Uptick in Access to Mental Heath Care

Changes to Medicare policy that lowered out-of-pocket costs for outpatient mental health and substance use disorder (MHSUD) care, to achieve parity with typical cost-sharing under Medicare, were associated with uneven improvements in the use of these services across racial and ethnic groups, a study suggested.

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

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

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

“We hoped that this policy would help to increase access overall, and over the study period, use did increase across all groups, but it increased less for beneficiaries of color than it did for white beneficiaries,” Fung told MedPage Today.

White beneficiaries in the cost-sharing group also experienced a drop in MHSUD emergency department visits and hospitalizations (P=0.03). However, among Asian beneficiaries, cost-sharing reduction was tied to relative increases in such visits during the policy phase-in compared with the pre-policy period (P=0.01).

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

With regard to spending, Fung and team noted that for white beneficiaries, cost-sharing reduction was linked to relative increases in MHSUD medication spending and relative decreases in MHSUD inpatient and total spending. For racial and ethnic minorities, changes in MHSUD medication spending associated with the cost-sharing reduction were “smaller” than those for white beneficiaries.

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

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

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

As for clinicians, Fung stressed the importance of screening and the need to be “cognizant of all the barriers that patients face when they’re trying to seek this care.”

Study Details

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

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

Most beneficiaries were white. Of the cost-sharing reduction 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 to the study was the sample did not include enough American Indian/Alaska Native beneficiaries to be able to detect meaningful differences.

Fung also noted that she and her colleagues weren’t able to evaluate 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 beneficiaries, results may not be generalizable to higher-income beneficiaries.