Effects of eliminating drug caps on racial differences in antidepressant use among dual enrollees with diabetes and depression

Abstract

Purpose: Black patients with diabetes are at greater risk of underuse of antidepressants even when they have equal access to health insurance. This study aimed to evaluate the impact of removing a significant financial barrier to prescription medications (drug caps) on existing black-white disparities in antidepressant treatment rates among patients with diabetes and comorbid depression.

Methods: We used an interrupted time series with comparison series design and a 5% representative sample of all fee-for-service Medicare and Medicaid dual enrollees to evaluate the removal of drug caps on monthly antidepressant treatment rates. We evaluated the impact of drug cap removal on racial gaps in treatment by modeling the month-to-month white-black difference in use within age strata (younger than 65 years of age or 65 years of age or older). We compared adult dual enrollees with diabetes and comorbid depression living in states with strict drug caps (n = 221) and those without drug caps (n = 1133) before the policy change. Our primary outcome measures were the proportion of patients with any antidepressant use per month and the mean standardized monthly doses (SMDs) of antidepressants per month.

Findings: The removal of drug caps in strict drug cap states was associated with a sudden increase in the proportion of patients treated for depression (4 percentage points; 95% CI, 0.03-0.05, P < 0.0001) and in the intensity of antidepressant use (SMD: 0.05; 95% CI, 0.03-0.07, P < 0.001). Although antidepressant treatment rates increased for both white and black patients, the white-black treatment gap increased immediately after Part D (0.04 percentage points; 95% CI, 0.01-0.08) and grew over time (0.04 percentage points per month; 95% CI, 0.002-0.01; P < 0.001).

Implications: Policies that remove financial barriers to medications may increase depression treatment rates among patients with diabetes overall while exacerbating treatment disparities. Tailored outreach may be needed to address nonfinancial barriers to mental health services use among black patients with diabetes.

Keywords: access to care; comorbidity; diabetes; disparities; health policy.

Figure 1

Description of the application of inclusion and exclusion criteria and impact on sample size.

Figure 2. Changes in the Prevalence of Antidepressant Use Before and After Part D by Drug Cap Status*

*Monthly Prevalence (A) and Intensity of Antidepressant Use (B) Before and After the Transition from Medicaid to Part D among Dual Enrollees with Diabetes and Co-Morbid Major Depression in Strict Drug Cap Compared to No Drug Cap States; Solid black circle=observations in drug cap states; solid black line=estimated utilization in drug cap states from time series models; Black dashed line=predicted utilization in drug cap states based on baseline trends; Open grey circle=observations in non-drug cap states; solid grey line=estimated utilization in non-drug cap states from time series models; Black dashed line=predicted utilization in non-drug cap states based on baseline trends

Figure 3. Changes in the Prevalence and Intensity of Antidepressant Use among Dual Enrollees Pre and Post Part D in States with Drug Cap by Race*

*Monthly Prevalence (A) and Intensity of Antidepressant Use (B) Before and After the Transition from Medicaid to Part D among Black and White Dual Enrollees with Diabetes and Co-Morbid Major Depression in Strict Drug Cap States Only; Solid black diamond=observed utilization of black patients; solid black line=estimated utilization for black patients from time series model; Open grey square=observed utilization of white patients; solid grey line=estimated utilization for white patients from time series model; dotted black line=estimated difference in utilization between whites and blacks from time series models