Trends in Mental Health Care Use After the Medicare Improvements for Patients and Providers Act (MIPAA) by Gender Minority and Disability Status

Background: The 2008 Medicare Improvements for Patients and Providers Act (MIPPA) reduced patient cost sharing for outpatient mental health care and attempted to boost enrollment in the low-income subsidy for Medicare Part D, a key payer of psychotropic medications. Outpatient mental health co-insurance was reduced gradually from 50% to 20% between 2010-2014. This policy may have been especially important in increasing access to mental health care for groups with high mental health need, including gender minority (i.e. transgender or gender non-binary) and/or disabled beneficiaries.

Objectives: This study evaluates trends in mental health care use over time from 2009-2014, during implementation of MIPPA, by gender minority status and by Medicare eligibility (disabled vs. aged), we well as whether these trends differed within these sub-groups.

Methods: In 2009-2014 Medicare claims, we identified gender minorities using a diagnosis-code algorithm and compared them to a 5% random sample of beneficiaries. We modeled mental health care use over this time period (adjusting for age and mental health diagnoses), comparing use for gender minority beneficiaries to non-gender minority beneficiaries from the 5% sample (and further by disabled vs. aged Medicare eligibility status). We examined outpatient mental health care use as well as psychotropic drug use and inpatient mental health use over the same time period. Preliminary findings report predicted population means (marginal means) by year and cohort and qualitatively assess differences. Final analyses will assess formal significance tests for differences in use measured over time and whether changes over time differed by gender minority or disability status. Secondary analyses will adjust for potential confounders that could differentially impact the groups under the study after the 2010 MIPPA implementation.

Key Findings: Adjusting for age and presence of mental health conditions, rates of outpatient mental health care use increased more rapidly among gender minority beneficiaries (from 8.7% to 39% in disabled; 1.7% to 13.5% in aged) compared to non-gender minority beneficiaries (4.8% to 25.4% in disabled; 0.8% to 5.1% in aged). Among patients with at least one outpatient mental health visit, the number of visits also increased faster over time for gender minority cohorts (from 5.3 to 10.5 visits in disabled; 3.4 to 7.9 in aged) compared to non-gender minority peers (4.2 to 7.4 visits in disabled; 2.5 to 4.3 visits in aged). Rates of psychotropic medication fills over this time period increased for all groups, but with different relative patterns for gender minorities (from 52.2% to 58.7% in disabled and 16.7% to 27.6% in aged) compared to non-gender minorities (from 46.6% to 53.9% in disabled and from 16.3% to 22.1% in aged). By contrast, rates of inpatient mental health use did not increase over this time period for any cohorts, and may have decreased for gender minority cohorts (from 1.1% to 0.76% in disabled; and from 0.3% to 0.1% in aged; pending formal significance testing).

Implications of Findings: MIPPA, which expanded access to outpatient mental health services and psychotropic medications, may have been especially helpful in meeting unmet mental health care need for gender minority Medicare beneficiaries.