Rural-Urban Differences in Utilization of Mental Health Outpatient Services among Individuals Aged 18-64 years with Employer Sponsored Health Insurance, United States, 2005 and 2014

Background: In 2015, 43.4 million Americans suffered from a mental illness. While there are evidence-based treatments for these conditions, disparities in access and utilization remain. Insurance coverage for mental health services has improved since the implementation of Mental Health Parity and Addition Equity Act (2008) and the Affordable Care Act, but disparities persist in the utilization, quality, and cost of mental healthcare.

Objective: To assess rural-urban differences in utilization of outpatient services for treating anxiety, and depression among individuals with employer-sponsored (health) insurance (ESI) in 2005 and 2014.

Methods: Ten years (2005−2014) of outpatient claims data extracted from the MarketScan Commercial Claims and Encounters Database were used for the analyses. Specifically, we assess the rural-urban differences in both utilization and intensity of outpatient care utilization for these two mental health conditions, both overall as well as stratified by primary care or specialist provider type. We calculate access rate of outpatient care and number of outpatient visits by primary care and specialists separately among individual with depression and anxiety in 2005 and 2014. We use logistic regression with and without covariates to estimate the association between rural/urban residence and probability of using outpatient primary care or specialist services for depression and anxiety. We use negative binomial regression with and without covariates to assess whether living in rural/urban is associated with a greater number of outpatient care primary care or specialists visits among those have at least one outpatient visit for depression and anxiety.

Results: Rural ESI enrollees are more likely to use primary care for mental health conditions (depression OR: 1.265, p-value <0.001; anxiety OR: 1.172, p-value <0.001) but are less likely to use specialists for both depression (OR: 0.647, p-value <0.001) and anxiety (OR: 0.66, p-value <0.001) in 2005. In addition, individuals living in rural areas have fewer number of visits than those in the urban areas for both primary care (depression IRR: 0.866, p-value <0.001; anxiety IRR: 0.972, p-value <0.001) and specialists (depression IRR: 0.702, p-value <0.001; anxiety IRR: 0.874, p-value <0.001) outpatient care in 2005. Similar results were observed in 2014.

Conclusions: Rural-urban differences exist in both utilization and intensity of outpatient services for depression and anxiety in 2005 and 2014. These differences persist event after controlling for key covariates. Stratifying the analysis by provider type indicates that individuals living in the rural areas have a rate to utilizing primary care for mental health than those in urban areas. However, rural residents still have fewer number of both primary care and specialist visits for depression and anxiety than urban residents. Overall, our findings are consistent with previous studies, which indicate that urban residents are more likely to both access and use more outpatient healthcare for mental health treatment than those living in the rural areas. Limited supply of specialists for treating mental health in rural areas could be a factor driving these observed differences.