Policies, Interventions May Be Needed to Address Low Care Levels Among Medicare Beneficiaries With Serious Mental Illness

By Julie Gould

According to recent study findings published online in JAMA Network Open, although beneficiary costs for outpatient behavioral health care decreased and there was no link between cost-sharing reductions and changes in behavioral health care visits, policies or interventions that target nonfinancial barriers to behavioral health care may be needed.

“Medicare has historically imposed higher beneficiary coinsurance for behavioral health services than for medical and surgical care but gradually introduced parity between 2009 and 2014,” the study authors wrote. “Although Medicare insures many people with serious mental illness (SMI), there is limited information on the impact of coinsurance parity in this population.” 

To better understand the findings, we spoke with Vicki Fung, PhD, assistant professor, Mongan Institute Health Policy Research Center, Massachusetts General Hospital and in the Department of Medicine at Harvard Medical School. Dr Fung explains why her recent study findings highlight the need for additional efforts to identify and address barriers to care for low-income Medicare beneficiaries with serious mental illness.

What existing data led you and your co-investigators to conduct this research? 

One-in-five adults with mental illness report having difficutly geeting needed treatment, with many citing cost as a barrier. Medicare is a major source of coverage for people with disabling mental illness. Until recently, however, Medicare included an outpatient mental health treatment limitation that limited reimbursement and resulted in higher beneficary coinsurance (out-of-pocket costs) for behavioral health (including mental health and substance use disorder) treatment compared with medical and surgical care. Medicare gradually phased-in coinsurance parity for behavioral health services between 2009-2014, which reduced beneficiaries’ coinsurance from 50% to the standard 20% rate. The removal of this long-standing disparity in coverage could have reduced financial barriers to care – especially for lower income beneficiaries with SMI–and improved use, but the impact of the policy was yet unknown.

Please briefly describe your study and its findings. Were any of the outcomes particularly surprising? 

We used 2008-2016 Medicare claims data for a national sample of low-income Medicare beneficiaries with SMI, including those with diagnoses of schizophrenia, bipolar disorder, and major depressive disorder. We compared changes in the proportion of beneficiaries that had at least one annual outpatient behavioral health visit among those that faced the cost-sharing reduction, compared with a control group of beneficiaries that received free care throughout the study because they qualified for full cost-sharing subsidies. We considered our primary outcome measure of having at least one annual outpatient behavioral health visit to represent minimally adequate care for this sample of beneficiaries with SMI. We included behavioral health visits with psychiatrists, primary care providers, nurse practitioners, psychologists, and social workers.

We found that the implementation of coinsurance parity was associated with reductions in out-of-pocket costs for behavioral health visits from about $132 to $64 per year between 2008-2016. At baseline, fewer than half of beneficiaries in both groups had an annual behavioral health visit. Despite these surprisingly low levels of use, we found that the policy change was not associated with increases in outpatient behavioral health visits or spending.

What are the possible real-world applications of these findings in clinical practice?

These findings highlight the need for additional efforts to identify and address barriers to care for low-income Medicare beneficiaries with SMI. Commonly cited non-financial barriers to care, including shortages of and difficulty accessing specialty behavioral health providers could be especially prevalent in this population. Fragmented care delivery, and beneficiaries’ attitudinal or knowledge barriers, such as lack of perceived need for treatment, stigma concerns, or distrust of physicians, could also contribute to low rates of use and limited impact of the policy change. People with SMI are also more likely to face social risk factors such as unstable housing, which could contribute to poor access to care. It could also be the case that even with coinsurance parity, the remaining out-of-pocket costs continue to present a financial barrier to care for this low-income population. 

Do you and your co-investigators intend to expand upon this research? 

Yes, our findings provide a first step in understanding the average impact of Medicare’s coinsurance parity policy on low-income beneficiaries with SMI; however, there could be important heterogeneity of the policy’s effects across patient subgroups, such as racial/ethnic minorities, those living in rural vs. urban areas, and those receiving care in different types of settings. We will examine these issues in future research.  

About Dr Fung:

Vicki Fung, PhD, is an Assistant Professor at the Mongan Institute Health Policy Research Center at Massachusetts General Hospital and in the Department of Medicine at Harvard Medical School.  

She is  a health services researcher who studies health care policy and financing for disadvantaged populations, including people living with mental illness. Her work leverages large-scale data resources and natural policy expeirments with the goal of identifying effective and and sustaintable policy levers to improve access to and quality of care, especially within the Medicare and Medicaid programs.

Reference:

Fung V, Price M, Nierenberg AA, Hsu J, Newhouse JP, Cook BL. Assessment of Behavioral Health Services Use Among Low-Income Medicare Beneficiaries After Reductions in Coinsurance Fees. JAMA Netw Open. 2020;3(10):e2019854. Published 2020 Oct 1. doi:10.1001/jamanetworkopen.2020.19854