Health Care for Common Mental Illnesses: The Impact of National Insurance Reforms on Utilization and Spending and A Study of Services Provided in General Medical Settings

Depression and anxiety affect more Americans than any other mental illness. Although effective treatments are available, treatment is often inadequate, delayed, or absent altogether. Individuals with depression or anxiety and groups at risk of developing these problems face a range of barriers to appropriate treatment, including difficulties obtaining health insurance, limitations in coverage for mental health services, and challenges accessing specialized care relative to general medical care. Recent policies aimed to improve access to mental health care by expanding insurance coverage, improving fairness in insurance benefits, and strengthening services in general medical settings. The objectives of this dissertation were to examine: 1) the impact of insurance expansion on mental health care among individuals with depression and anxiety, including changes that may signal adverse selection; 2) the association between insurance benefits reform and mental health care among individuals with depression and anxiety; and 3) the correlates of depression care and the role of screening in diagnosis and treatment among outpatient primary care visits. The first study estimated changes in the probability and quantity of mental health service use and total and out-of-pocket spending among young adults and a separate sample of new enrollees after the dependent coverage provision (DCP) of the Affordable Care Act was implemented. The DCP was associated with increased service use and spending without higher intensity service use by new enrollees, suggesting those who gained coverage needed treatment but not at higher levels. The second study estimated changes in the probability and quantity of mental health service use and total and out-of-pocket spending among young adults after the Mental Health Parity and Addiction Equity Act (MHPAEA) was implemented. The MHPAEA was associated with small shifts in service use without increased financial protection, suggesting modest changes in this population that were attributable to the policy. The third study assessed the correlates of depression screening, diagnosis, and treatment in representative primary care settings and estimated the relationship between screening rates and the probability of diagnosis and treatment. Patterns of depression care suggested that physicians focused on high-risk patients. Additionally, higher screening rates were associated with higher rates of depression identification and treatment

Health Care for Common Mental Illnesses: The Impact of National Insurance Reforms on Utilization and Spending and A Study of Services Provided in General Medical Settings

Depression and anxiety affect more Americans than any other mental illness. Although effective treatments are available, treatment is often inadequate, delayed, or absent altogether. Individuals with depression or anxiety and groups at risk of developing these problems face a range of barriers to appropriate treatment, including difficulties obtaining health insurance, limitations in coverage for mental health services, and challenges accessing specialized care relative to general medical care. Recent policies aimed to improve access to mental health care by expanding insurance coverage, improving fairness in insurance benefits, and strengthening services in general medical settings. The objectives of this dissertation were to examine: 1) the impact of insurance expansion on mental health care among individuals with depression and anxiety, including changes that may signal adverse selection; 2) the association between insurance benefits reform and mental health care among individuals with depression and anxiety; and 3) the correlates of depression care and the role of screening in diagnosis and treatment among outpatient primary care visits. The first study estimated changes in the probability and quantity of mental health service use and total and out-of-pocket spending among young adults and a separate sample of new enrollees after the dependent coverage provision (DCP) of the Affordable Care Act was implemented. The DCP was associated with increased service use and spending without higher intensity service use by new enrollees, suggesting those who gained coverage needed treatment but not at higher levels. The second study estimated changes in the probability and quantity of mental health service use and total and out-of-pocket spending among young adults after the Mental Health Parity and Addiction Equity Act (MHPAEA) was implemented. The MHPAEA was associated with small shifts in service use without increased financial protection, suggesting modest changes in this population that were attributable to the policy. The third study assessed the correlates of depression screening, diagnosis, and treatment in representative primary care settings and estimated the relationship between screening rates and the probability of diagnosis and treatment. Patterns of depression care suggested that physicians focused on high-risk patients. Additionally, higher screening rates were associated with higher rates of depression identification and treatment

Racial and Ethnic Disparities in Buprenorphine and Extended-Release Naltrexone Filled Prescriptions During the COVID-19 Pandemic

Importance: COVID-19 disrupted delivery of buprenorphine and naltrexone treatment for opioid use disorder (OUD), and during the pandemic, members of racial and ethnic minority groups experienced increased COVID-19 and opioid overdose risks compared with White individuals. However, whether filled buprenorphine and naltrexone prescriptions varied across racial and ethnic groups during the COVID-19 pandemic remains unknown. Objective: To investigate whether disruptions in filled buprenorphine and naltrexone prescriptions differed by race and ethnicity and insurance status or payer type. Design, setting, and participants: This cross-sectional study used retail pharmacy claims from May 2019 to June 2021 from the Symphony Health database, which includes 92% of US retail pharmacy claims, with race and ethnicity data spanning all insurance status and payer categories. Interrupted time series were used to estimate levels and trends of dispensed buprenorphine and naltrexone prescriptions before and after pandemic onset. Included individuals were those who filled buprenorphine and extended-release naltrexone prescriptions. Data were analyzed from July 2021 through March 2022. Main outcomes and measures: Weekly rates of dispensed buprenorphine and extended-release naltrexone prescription fills per 1000 patients and proportion of longer (ie, ≥14 days' supply) buprenorphine prescription fills were calculated. Analyses were stratified by patient race and ethnicity and further by insurance status and payer type for White and Black patients. Results: A total of 1 556 860 individuals who filled buprenorphine prescriptions (4359 Asian [0.3%], 94 657 Black [6.1%], 55 369 Hispanic [3.6%], and 664 779 White [42.7%]) and 127 506 individuals who filled extended-release naltrexone prescriptions (344 Asian [0.3%], 8186 Black [6.4%], 5343 Hispanic [4.2%], and 53 068 White [41.6%]) from May 6, 2019, to June 5, 2021, were analyzed. Prepandemic increases in buprenorphine fill rate flattened for all groups after COVID-19 onset (30.5 percentage point difference in trend; P < .001) compared with prepandemic trends. Significant level decreases in buprenorphine fills (ranging from 2.5% for Black patients; P = .009 to 4.0% for Hispanic patients; P = .009) at pandemic onset were observed for members of racial and ethnic minority groups but not White patients. At pandemic onset, rate of buprenorphine fills decreased in level for Medicare and cash-paying patients but with greater decreases for Black patients (Medicare: 10.0%; P < .001; cash: 20.0%; P < .001) than White patients (Medicare: 3.5%; P = .004; cash: 15.0%; P < .001). No decreases were found among Medicaid patients. Unlike buprenorphine, extended-release naltrexone had uniform level (from 10.0% for White patients with private insurance; P < .001 to 23.3% for Black patients with Medicare; P < .001) and trend (from 15.5 percentage points for White patients with Medicaid; P = .001 to 52.0 percentage points for Black patients with private insurance; P < .001) decreases across groups. Conclusions and relevance: This study found that the COVID-19 pandemic was associated with immediate decreases in filled buprenorphine prescriptions by members of racial and ethnic minority groups but not White individuals. These findings suggest that members of racial and ethnic minority groups had larger losses in buprenorphine access during the pandemic across payer types