Nonfinancial barriers could be contributing to the problem; new care models recommended

Behavioral health services are often underused by people with serious mental illness (SMI). According to recent study findings, Medicare cost-sharing reductions designed to help make care more affordable for lower-income individuals with SMI have not increased visits with behavioral health professionals when compared to people eligible to receive free care.

“We found no increase in behavioral health use or spending associated with parity implementation, even within a fee-for-service context with little utilization management,” wrote study first author Vicki Fung, PhD, a researcher with The Mongan Institute at Massachusetts General Hospital, and colleagues, in JAMA Network Open. “These findings may indicate that [cost reductions] continue to present a financial barrier to care for this low-income population or that, with reduced out-of-pocket costs, beneficiaries shifted their spending elsewhere. In a separate analysis, we also did not find an association between parity and visit rates among high-income beneficiaries, suggesting that other, nonfinancial barriers to behavioral health care could continue to limit use.”

Among the 11.4 million adults living with SMI in the U.S. in 2018, nearly half believed their behavioral health needs were unmet, according to estimates. One-third of these patients received no care at all.

Efforts to improve access to behavioral health services frequently focus on cost-related barriers to care. One of the most prominent among such efforts came about as a result of the Medicare Improvements for Patients and Providers Act of 2008. This law reduced Medicare beneficiary coinsurance rates to 45% in 2010 and 2011, 40% in 2012, 35% in 2013, and 20% beginning in 2014.

Despite the substantial reductions, existing evidence has not shown significant increases in the use of behavioral health services in this population. One prior analysis cited by Fung and colleagues found that mental health-related visits did not increase when compared with commercial enrollees. However, no previous study had compared beneficiaries of cost-sharing reductions with lower-income patients who receive free care.

“We investigated the association of behavioral health care coinsurance parity with cost-sharing levels, outpatient behavioral health care visits, and spending among low-income traditional Medicare beneficiaries with serious mental illness (SMI),” Fung and colleagues wrote.

They analyzed claims data for 793,275 randomly selected, lower-income Medicare beneficiaries with SMI between 2007 and 2016, with 153,070 beneficiaries receiving cost-sharing benefits and 640,205 receiving free care.

Of the full cohort, 518,893 (65.4%) were younger than 65 years of age (mean [SD] age, 57.6 [16.1] years), 511,265 (64.4%) were female, and 552,056 (69.6%) were white. Beneficiaries with cost-sharing reductions were less likely to have diagnoses of schizophrenia (24,893 [16.3%] versus 154,457 [24.1%]) and bipolar disorder (32,887 [21.5%] versus 169,957 [26.5%]).

Average out-of-pocket costs for behavioral health visits decreased from $132 (95% CI $129-$136) in 2008 to $64 (95% CI $61-$66) in 2016 among beneficiaries who received the cost-sharing reductions. But even as out-of-pocket costs decreased, however, no major changes emerged in the use of behavioral health services.

When measured per patient per year, visits actually went down between 2008 and 2016 for those receiving cost-sharing reductions, from 2.7 (95% CI 2.6-2.7) to 2.4 (95% CI 2.4-2.5). Among those receiving free care, visits also decreased from 3.3 (95% CI 3.3-3.3) to 3.1 (95% CI 3.1-3.1).

Overall, only 40.7% (95% CI 40.4%-41.0%) of cost-sharing beneficiaries used behavioral health services, compared with 44.9% (95% CI 44.9%-45.0%) of those receiving free care.

“Despite having comprehensive insurance coverage, outpatient behavioral health care use among beneficiaries with SMI was low throughout the study period, including for those with free care,” Fung and colleagues wrote. “At baseline, about half or fewer had at least 1 annual outpatient behavioral health care visit with any health care professional type, including psychiatrists, primary care physicians, psychologists, nurse practitioners, and social workers; fewer than one-quarter had an annual visit with a psychiatrist.”

Fung and colleagues identified several nonfinancial barriers that could be suppressing the use of behavioral health services among lower-income people with SMI, including workforce shortages and gaps in the wider delivery system.

“Commonly cited nonfinancial barriers to behavioral health care may be greater in this disadvantaged population, including greater difficulty accessing specialty behavioral health care providers owing to local supply constraints, lack of insurance participation, fragmented care delivery, and attitudinal or knowledge barriers such as lack of perceived need for treatment, stigma concerns, or distrust of physicians,” Fung and colleagues wrote.

In an accompanying editorial, Krisda Chaiyachati, MD, MPH, a physician and health services researcher with the University of Pennsylvania Perelman School of Medicine, and colleagues, none of whom were affiliated with the study, wrote that a combination of financial and nonfinancial measures may be needed to increase the use of behavioral health services in these populations. In particular, new care delivery models could make an impact, they wrote, although they added that changes in wider societal attitudes regarding behavioral and mental health are an essential piece of the puzzle.

“Although many of these changes require our society to recognize and accept the importance of behavioral health care and the multiple barriers preventing those with SMI from accessing care, policy makers can speed progress by using new care delivery approaches,” Chaiyachati and colleagues wrote. “For example, telemedicine can overcome nonfinancial barriers by helping to deliver care to patients at home. Peer support and affinity group strategies have been successful in substance use treatment and could be used among patients with SMI to improve their motivation to access care. Leaders could also leverage behavioral incentives…For instance, via so-called ’know your numbers’ campaigns. Similar programs could be created for behavioral health care and implemented widely to undercut stigma.”

  1. Cost-sharing reductions enacted by the Medicare Improvements for Patients and Providers Act did not increase the use of behavioral health services among lower-income individuals with serious mental illness.

  2. Experts argued that lower out-of-pocket costs are only one piece of a larger strategy to overcome barriers to care, and will require both financial and non-financial components.

Scott Harris, Contributing Writer, BreakingMED™

No source appearing in this article disclosed any relevant financial relationship with industry.

Cat ID: 494

Topic ID: 398,494,282,494,255,146,925