Abstract
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. Although Medicare insures many people with serious mental illness (SMI), there is limited information on the impact of coinsurance parity in this population. To examine the association between coinsurance parity and outpatient behavioral health care use among low-income beneficiaries with SMI. This cohort study used Medicare claims data for a 50% national sample of lower-income Medicare beneficiaries from January 1, 2007, to December 31, 2016. The study sample included patients with SMI (schizophrenia, bipolar disorder, or major depressive disorder). Data analysis was performed from August 1, 2018, to July 15, 2020. Reduction in behavioral health care coinsurance from 50% to 20% between January 1, 2009, and January 1, 2014. Total annual spending for outpatient behavioral health care visits and the percentage of beneficiaries with an annual outpatient behavioral health care visit overall, with a prescriber, and with a psychiatrist. A difference-in-difference approach was used to compare outcomes before and after the reduction in coinsurance for beneficiaries with and without cost-sharing decreases. Linear regression models with beneficiary fixed effects that adjusted for time-changing beneficiary- and area-level covariates were used to examine changes in outcomes. The study included 793 275 beneficiaries with SMI in 2008; 518 893 (65.4%) were younger than 65 years (mean [SD] age, 57.6 [16.1] years), 511 265 (64.4%) were female, and 552 056 (69.6%) were White. In 2008, the adjusted percentage of beneficiaries with an outpatient behavioral health care visit was 40.7% (95% CI, 40.4%-41.0%) among those eligible for the cost-sharing reduction and 44.9% (95% CI, 44.9%-45.0%) among those with free care. The mean adjusted out-of-pocket costs for outpatient behavioral health care visits decreased from $132 (95% CI, $129-$136) in 2008 to $64 (95% CI, $61-$66) in 2016 among those with reductions in cost-sharing. The adjusted percentage of beneficiaries with behavioral health care visits increased to 42.2% (95% CI, 41.9%-42.5%) in the group with a reduction in coinsurance and to 47.2% (95% CI, 47.0%-47.3%) in the group with free care. The cost-sharing reduction was not positively associated with visits (eg, relative change of -0.76 percentage points [95% CI, -1.12 to -0.40 percentage points] in the percentage of beneficiaries with outpatient behavioral health care visits in 2016 vs 2008). This cohort study found that beneficiary costs for outpatient behavioral health care decreased between 2009 and 2014. There was no association between cost-sharing reductions and changes in behavioral health care visits. Low levels of use in this high-need population suggest the need for other policy efforts to address additional barriers to behavioral health care.
Highlights
Medicare is a major source of coverage for individuals with disabling mental illness
In 2008, the adjusted percentage of beneficiaries with an outpatient behavioral health care visit was 40.7% among those eligible for the cost-sharing reduction and 44.9% among those with free care
The adjusted percentage of beneficiaries with behavioral health care visits increased to 42.2% in the group with a reduction in coinsurance and to 47.2% in the group with free care
Summary
Medicare is a major source of coverage for individuals with disabling mental illness. Many policy efforts to improve access to behavioral health services for both mental health care and substance use treatment have focused on reducing cost-related barriers to care.[1] The Medicare Improvements for Patients and Providers Act of 2008 required parity in cost-sharing for outpatient behavioral health care. Starting in 2010, Medicare reduced behavioral health cost-sharing, to 45% in 2010 and 2011, 40% in 2012, 35% in 2013, and 20% in 2014 onward.[2]. Whether the introduction of cost-sharing parity increased use of behavioral health services for traditional Medicare beneficiaries is not known. One study[3] found that outpatient follow-up after psychiatric hospitalization was higher among Medicare Advantage beneficiaries enrolled in private plans that voluntarily implemented mental health cost-sharing parity. Traditional fee-for-service Medicare does not impose utilization management restrictions; to the extent that such tactics might have offset use in prior parity policies, there could be larger effects associated with coinsurance reductions in traditional Medicare than in commercial insurance
Sign-in/Register to view highlights & summary Sign-in/Register to access full text options 
Free) 
Talk to us
Join us for a 30 min session where you can share your feedback and ask us any queries you have
Schedule a call
