Tetlow Sonia M, Phillips Victoria L, Hockenberry Jason M
Department of Health Policy and Management, Emory University, Atlanta, Georgia.
Now with Global Health Center, Centers for Disease Control and Prevention, Atlanta, Georgia.
JAMA Netw Open. 2025 May 1;8(5):e258491. doi: 10.1001/jamanetworkopen.2025.8491.
Less than half of the US population with any mental health condition receives services. Cost is the most commonly cited barrier to treatment.
To examine whether service use and out-of-pocket expenditures among Medicare beneficiaries with depression changed after Medicare implemented equal cost-sharing for outpatient mental health and medical services (Medicare parity).
DESIGN, SETTING, AND PARTICIPANTS: This economic evaluation used a single-group, interrupted time series design and examined data from the Medical Expenditure Panel Survey Household Component from 2008 to 2019. The sample included Medicare beneficiaries aged 65 years or older with depression. Data were analyzed from June 2, 2023, to June 17, 2024.
Under the Medicare Improvements for Patients and Providers Act of 2008, beneficiary cost-sharing for outpatient mental health services decreased from 50% prior to 2010 to 20% in 2014, creating parity with equivalent medical care.
The primary outcomes were outpatient mental health service use, as assessed by mean use, proportion of beneficiaries with any use, and intensity of use (ie, mean use among users), and out-of-pocket expenditures.
The analysis included 5831 Medicare beneficiaries. Using the Medical Expenditure Panel Survey person-level survey weights, this number corresponded to a nationally representative sample of 72 436 656 beneficiaries (median [IQR] age, 72 [68-79] years; 64.2%-72.2% female per study year). After Medicare parity, mean use of outpatient mental health services among beneficiaries with depression increased by 0.54 visits per year (95% CI, 0.31-0.76 visits per year), and proportion of use increased by 6.61% per year (95% CI, 2.23%-10.99% per year). Intensity of use decreased at parity by a factor of 0.90 (95% CI, 0.82-1.00) and increased after parity by a multiple of 1.07 per year (95% CI, 1.04-1.10 per year). Mean out-of-pocket expenditures for these services increased after parity by $12.25 per year (95% CI, $2.42-$22.08 per year). Sensitivity analysis using the 2016 US Preventive Services Task Force recommendation for routine adult depression screening indicated that the proportion of use increased 28.26% (95% CI, 24.33%-32.19%) once the recommendation was issued.
In this economic evaluation of Medicare parity, implementation of Medicare parity coupled with routine adult depression screening was associated with significant increases in outpatient mental health service use among Medicare beneficiaries with depression. These findings suggest that parity policies alone may not be sufficient to effectively address multiple barriers to mental health care but in tandem with physician screening, diagnosis, and referral practices, may increase the accessibility of mental health services.
美国患有任何心理健康问题的人群中，接受治疗的不到一半。费用是最常被提及的治疗障碍。
研究医疗保险对门诊心理健康和医疗服务实施同等费用分摊（医疗保险平价）后，患有抑郁症的医疗保险受益人的服务使用情况和自付费用是否发生变化。
设计、设置和参与者：这项经济评估采用单组中断时间序列设计，研究了2008年至2019年医疗支出面板调查家庭部分的数据。样本包括65岁及以上患有抑郁症的医疗保险受益人。数据于2023年6月2日至2024年6月17日进行分析。
根据2008年《医疗保险改善患者和提供者法案》，门诊心理健康服务的受益人费用分摊从2010年前的50%降至2014年的20%，与同等医疗护理实现平价。
主要结局是门诊心理健康服务的使用情况，通过平均使用次数、有任何使用情况的受益人的比例以及使用强度（即使用者中的平均使用次数）来评估，以及自付费用。
分析包括5831名医疗保险受益人。使用医疗支出面板调查个人层面的调查权重，这个数字相当于全国代表性样本中的72436656名受益人（年龄中位数[四分位间距]为72[68 - 79]岁；各研究年份女性占64.2% - 72.2%）。医疗保险实现平价后，患有抑郁症的受益人门诊心理健康服务的平均使用次数每年增加0.54次就诊（95%置信区间，每年0.31 - 0.76次就诊），使用比例每年增加6.61%（95%置信区间，每年2.23% - 10.99%）。使用强度在平价时下降了0.90倍（95%置信区间，0.82 - 1.00），平价后每年增加1.07倍（95%置信区间，每年1.04 - 1.10）。这些服务的平均自付费用在平价后每年增加12.25美元（95%置信区间，每年2.42 - 22.08美元）。使用2016年美国预防服务工作组关于成人常规抑郁症筛查的建议进行的敏感性分析表明，该建议发布后，使用比例增加了28.26%（95%置信区间，24.33% - 32.19%）。
在这项关于医疗保险平价的经济评估中，医疗保险平价的实施以及成人常规抑郁症筛查与患有抑郁症的医疗保险受益人门诊心理健康服务使用的显著增加相关。这些发现表明，仅平价政策可能不足以有效解决心理健康护理的多重障碍，但与医生的筛查、诊断和转诊实践相结合，可能会提高心理健康服务的可及性。
