The influence of race, gender and mental disorder on healthcare service utilization and costs among the medicare elderly.

In the general population, the research literature consistently shows that African Americans have higher morbidity rates for various types of diseases including strokes, kidney problems, diabetes, cancer, cardiovascular disorders, AIDS, and sickle cell disease (Barnett, Armstrong & Casper, 1997). However, studies of race differences in psychiatric morbidity report discrepant findings (Howard, Cornille, Lyons, Vessey, et al., 1996). Importantly, researchers have begun to assess the impact of mental health on physical health (Everson et al., 1996; Fiscella & Franks, 1997; Anderson & Armstead, 1995; Anda et al., 1993; Frasure-Smith et al., 1993; Miller et al., 1996). Studies have demonstrated that individuals with psychological morbidity are less prone to take preventive health measures, more likely to suffer from a variety of physical health problems, and have higher rates of mortality (Bums et al., 2000; Everson et al., 1996; Fiscella & Franks, 1997; Anderson & Armstead, 1995; Anda et al., 1993; Frasure-Smith et aL, 1993; Miller et al., 1996). Race differences in psychological morbidity may help explain some of the race disparities in physical health (Wilkinson, 1997; Geronimus 1992; Krieger et al., 1993; Pappas et al., 1993). Contemporary assessments have also shown that health care costs are significantly higher for elderly persons who suffer from mental health problems (Husaini et al., 1999, 2002).

In this article, we investigate the impact of race, gender, and psychiatric diagnosis on healthcare costs for Medicare recipients. Using a 5 percent sample of all Medicare beneficiaries in the state of Tennessee from 1991-1993 (n = 33,680), we examine race and gender differences in psychiatric morbidity. We go on to investigate the impact of race, gender, and psychiatric morbidity on healthcare costs. Our study underscores the importance of race, gender and mental health for the management of healthcare costs.

RACE, GENDER, AND PSYCHIATRIC DISORDERS

A large body of research has addressed the relationship between race and mental illness, and gender and mental illness--though relatively few studies have investigated variations in psychiatric morbidity by race and gender. Studies examining race differences have focused on both untreated and treated individuals, and mixed results are reported in both types of studies. While some examinations of treated populations reported no significant racial differences (Pasamanick, 1962; Simon, 1965), others found higher rates of disorders among African Americans (Warheit, Holzer & Schwab, 1973; Warheit, Holzer & Arey, 1975). Examinations of treated cases for specific diagnoses show that while whites have higher treated rates of alcoholism and depression, African Americans have higher treated rates of schizophrenia and other psychosis (Flaskerud & Hu, 1992; Holzer et al., 1995). In studies of untreated populations based upon symptom scales, African Americans report higher rates of symptoms than whites, however when socio-economic status (SES), age, and sex were taken into account in the analyses, the racial differences in symptoms disappeared (Warheit, Holzer & Schwab, 1973; Warheit, Holzer & Arey, 1975; Gift & Harder, 1985; Neff & Husaini, 1987; Hargrave et al., 1998; Pastenak et al., 1998).

Gender differences in the prevalence of psychiatric morbidity have also been a topic of considerable research. Generally, studies have found little gender difference in the prevalence of mental illness, but higher rates of mood and anxiety disorder among women, and a greater frequency of schizophrenia and substance abuse disorders among men (cf. Sachs-Ericsson & Ciarlo, 2000; Hankin, 1990; Timms, 1998). Studies of elderly populations also show a higher rate of dementia in women, even controlling for age (Peris, 1995; George, 1990), and that women with dementia more often present with multiple psychiatric diagnoses that further complicate treatment (Cohen et al., 1993). There is also evidence that race and gender interact to influence the prevalence of psychiatric disorder, with African American men and white women having higher rates of disorder (Williams, Takeuchi & Adair, 1992). Biases and misdiagnoses in assessments of psychiatric morbidity may impact these race-gender differences (George, 1990; Loring & Powell, 1988).

RACE, GENDER, PSYCHIATRIC MORBIDITY AND PHYSICAL HEALTH

Studies investigating the impact of mental illness on physical health have emphasized the impact of psychological symptoms and diagnoses on mortality, somatic indictors, and particular illnesses. Research has suggested that anxiety, depression, and other mental health problems have direct effects on physical health by raising blood pressure or influencing other physical precursors to morbidity. Particularly, depression, feelings of hopelessness, and psychological distress have been associated with increased risk for mortality from cardiovascular disease (FrasureSmith et al., 1993; Anda et al., 1993; Everson et al., 1996). Studies also suggest that psychological impairment inhibits communication between doctors and patients, and prevents patients from seeking or receiving care for physical ailments (Bums et al., 2000; Haug & Ory, 1987; Kaplan, 1995; Savikko, Alexanderson & Hensing, 2001). Elderly persons with psychological impairments may fail to seek healthcare until problems are more severe, and emergency treatment and inpatient hospitalization are needed. African Americans with mental disorders may have more pronounced barriers to care and to communication with health care professionals. Further, since elderly men tend to seek preventive care less frequently, engage in unhealthy behaviors, and have less experience dealing with health care professionals (Antonucci et al., 1990; Matthias et al., 1998; Verbrugge, 1985; Weaver & Gary, 1996), it is quite likely that men will also suffer more physical health setbacks then women when psychiatric morbidity is present. Importantly, race and gender interact to magnify the negative impact of psychological morbidity on physical health (Kaplan, 1995). Elderly African American men may be particularly likely to suffer from negative physical health consequences of psychiatric disorders.

DATA

We analyzed data from a 5 percent random sample of Medicare Beneficiaries in Tennessee for the years 1991-1993. The sampling frame included all beneficiaries of Medicare Part A and Part B coverage who saw a physician and for whom the Health Care Financing Administration (HCFA) received a bill in 1991, 1992, and 1993 (n = 33,680, including only whites and African Americans). This included all inpatient and outpatient hospitalizations for persons over the age of 65 under Medicare Part A, and all physician and other health care costs for those enrolled under Medicare Part B. Some elderly people do not enroll in Part B because they either (a) cannot afford it (veterans in this category would have all costs paid for by the Veteran's Administration); or (b) have private insurance or other coverage that covers those medical expenses. Since this sample only included those who saw a doctor or sought medical services in the three-year period, rates may be inflated. We note that 11 percent of the sample is African American, the comparable figure from the 1990 Census for Tennessee is 12 percent. This suggests that while African Americans are somewhat less likely to have seen a doctor or sought care, the sample largely reflected the racial composition of the elderly population of the state.

MEASURES

Health Care Costs

We investigated inpatient care costs, outpatient care costs, costs from physician visits, and total costs. All costs are calculated from the actual reimbursement data, and are expressed in dollars.

Health Care Service Utilization

We examined the number of inpatient days, emergency room visits, outpatient visits, and physician visits.

Psychiatric Disorder

We examined rates of psychiatric morbidity by race and gender and more specifically across five broad types of mental illness: dementia, schizophrenia, organic psychosis, mood disorders, and anxiety disorders. The presence of disorder and type of disorder was assessed from the diagnoses given by physicians for reimbursement by HCFA. We compared health service utilization and costs by race and gender for individuals who were diagnosed with a mental health problem with those who had no diagnosis in HCFA records.

Control Variables

In the multivariate models of service utilization and costs we controlled for age, residence in a rural county, and the socioeconomic status of the county of residence (individual level data on income and education are not available in these data). We also added a control for having multiple psychiatric diagnoses.

RESULTS

Race, Gender and Psychiatric Diagnoses

Exhibit 1 presents race and gender differences in psychiatric diagnoses. White females have the highest rates of psychiatric diagnosis, and differ significantly from white men and African American women and men. African American women have higher overall rates of diagnosis of mental illness when compared to white men or African American men. However, there is no race difference in the overall rate of psychiatric disorder among men. African American women have the highest rates of diagnosis of dementia--significantly higher than the other three race-gender groupings. Dementia is also significantly more prevalent among white women than among white men.

Diagnoses of schizophrenia and organic psychosis are also more prevalent among African American women compared to white women and white men. Further, African American men are significantly more likely to have a diagnosis of organic psychosis than are white men. Diagnoses of mood and anxiety disorders are significantly more prevalent among white women than in the other three race-gender groups. African American men are significantly less likely to be diagnosed with anxiety disorders than are white men or African American women.

Our examination of race and gender differences in the prevalence and type of psychiatric diagnosis has implications for health service utilization and costs. Overall, rates of disorder are highest among white women, however this is largely because of higher rates of mood and anxiety disorders. In contrast, African Americans have higher rates of more debilitating mental illnesses: dementia, schizophrenia, and organic psychosis. By taking into account the influence of these diagnoses, we will be able to uncover differences in service utilization and costs that are not attributable primarily to these devastating forms of psychiatric morbidity but instead to other factors associated with race, gender, and psychiatric morbidity.

Race, Gender, Psychiatric Diagnoses and Service Utilization and Costs

Exhibit 2 presents the health care service utilization and costs by service type for the four race/gender groupings and by psychiatric morbidity in each group. We present adjusted means controlling for age, rural residence, SES, multiple psychiatric comorbidity, and particular mental health diagnosis (schizophrenia, dementia, and/or organic psychosis). Comparing these adjusted means across race-gender categories is statistically equivalent to an assessment of a race-gender interaction in Ordinary Least Squares (OLS) regression, but rather than presenting slope differences we present the actual utilization rates and costs for the eight groups.

First, it is notable that on every indicator of health service utilization and healthcare costs, individuals with a psychiatric diagnosis have significantly higher levels of service utilization and significantly higher costs when compared to race-gender peers who have no psychiatric diagnosis. White women with a psychiatric diagnosis spend nearly two more days in the hospital than white women with no diagnosis, while African American men with a psychiatric disorder spend almost three and a half days more in inpatient care. Among white men and white women, having a psychiatric diagnosis doubles the number of visits to an emergency room net of other factors, and mental illness significantly increases emergency service utilization among African American men and women as wen--even after controls for the presence of hard to manage diagnoses like dementia, schizophrenia, and organic psychosis. Psychiatric morbidity is also significantly predictive of higher levels of outpatient utilization and higher numbers of physician visits for all four race-gender groups.

Higher rates of service utilization among those with psychiatric disorders also translate into higher healthcare costs. Overall healthcare costs for those with a mental disorder are significantly higher in every race-gender grouping. For white women, having a mental disorder increases total costs by $3,811, while for African American women the difference is $3,416 net of other factors. The effects of mental illness on costs are somewhat higher for men, and particularly for African American men. Having a psychiatric diagnosis increases costs by $4,049 for white men, while for African American men the figure is significantly higher at $4,756. Clearly the influence of psychiatric morbidity on costs varies by race and gender.

Importantly, Exhibit 2 also shows significant race and gender differences in health care service utilization and costs. Men, and especially African American men, have significantly higher rates of utilization of inpatient care and emergency services when compared to white women and African American women. Further, African American men have lower rates of visiting a physician--suggesting that they may avoid preventive care, and not have access to early detection of disease or adequate control over chronic conditions. Controlling for other factors, African American men also utilize outpatient care less often.

Exhibit 2 also shows that higher levels of utilization of inpatient care and emergency services yields significantly higher inpatient care costs for white men, and especially for African American men. Indeed, African American men have inpatient costs significantly higher than those of white men. African American women and white women do not differ significantly in their inpatient care costs. Turning to the total costs, we find that African American women and men have significantly higher healthcare costs than their white counterparts. Further, costs are higher for men in both racial groups. The race-gender differences are even greater among those who have psychiatric morbidity.

SUMMARY AND DISCUSSION

Our study examined how race, gender, and mental health interact to influence healthcare service utilization and costs. Our study showed that elderly African Americans are more likely to be diagnosed with dementia, organic psychosis, and schizophrenia, while white women have significantly higher rates of mood and anxiety disorders. We used this information to guide our modeling of the influence of race, gender, and psychiatric morbidity on healthcare service utilization and costs. Race and gender differences in health service utilization and costs were not simply a function of the rate or form of psychiatric morbidity, and neither was the impact of psychiatric morbidity attributable to specific costly conditions such as dementia, schizophrenia, and organic psychosis. Our findings shed light on how both race and gender influenced health care service choices among elderly people psychiatric diagnoses, and suggest how these patterns of service utilization lead to differential outcomes in health care costs--which are an important indicator of overall health.

Our study revealed clear gender and race differences in patterns of health service utilization, with males, and especially African American males avoiding physician visits, spending more nights in the hospital, and having more admissions to emergency rooms. To a lesser extent, African American females were also more prone to need inpatient care. Psychiatric diagnosis increased rates of all forms of health service utilization in every race-gender grouping. Patterns of health service utilization translated directly into health care costs, and costs were substantially higher for men, and particularly African American men. Cost differences became even greater when psychiatric morbidity was added to the race-gender difference. Indeed, total costs for African American men with a psychiatric diagnosis were more than double those for white women with no psychiatric morbidity--even after controlling for multiple psychiatric diagnoses and diagnoses of dementia, schizophrenia, and organic psychosis.

Psychiatric morbidity is a common problem among the elderly, and these mental health problems spill over into health-related behaviors and help seeking behaviors (Unutzer et aL, 2000). Both race and gender can further hinder those with a psychiatric disorder from seeking effective and timely treatment, and our study shows that race and gender differences are exacerbated by psychiatric diagnoses. Future studies should examine how specific psychiatric diagnoses influence service utilization, and how these health care choices influence health outcomes and costs. Indeed, it seems likely that certain psychiatric diagnoses may be especially problematic if combined with particular physical health problem (e.g. dementia and diabetes). Given the well-established race and gender differences in physical and mental health diagnoses, this would be a fruitful area for future research. Establishing these complex links between race, gender, and mental and physical health diagnoses will better enable researchers and policy analysts to target areas of need. Race, gender, and diagnosis specific programs will be required to help reduce health disparities.

EXHIBIT 1
MENTAL HEALTH DIAGNOSTIC RATES PER 1,000 BY RACE AND GENDER

                          White         White
                          Female        Male

Psychiatric Disorder       179.1       129.1 (a)
Dementia                    45.8        29.7 (a)
Schizophrenia               31.8        30.1
Organic Psychosis           29.6        25.1 (a)
Mood Disorder               49.2        26.8 (a)
Anxiety Disorder            71.3        40.1 (a)
n                       18,216      11,865

                        African American    African American
                             Female               Male

Psychiatric Disorder      161.0 (a b)          134.5 (a c)
Dementia                   57.1 (a b)           38.1 (c)
Schizophrenia              41.6 (a b)           29.9
Organic Psychosis          42.5 (a b)           35.1 (b)
Mood Disorder              28.7 (a)             16.4 (a)
Anxiety Disorder           45.1 (a)             19.4 (a b c)
n                       2,261                1,338

(a) difference from white female significant at the 0.05 level.

(b) difference from white male significant at the 0.05 level.

(c) difference from African American female significant at
the 0.05 level.

EXHIBIT 2
ADJUSTED MEAN HEALTHCARE SERVICE UTILIZATION AND COSTS BY
RACE, GENDER AND PSYCHIATRIC DISORDER *

                          White          White
                          Female          Male
                       (W/disorder)   (W/disorder)

Inpatient days               2.7             3.4 (a)
                            (4.6)           (5.8) (a)

Emergency Visits             0.6             0.7 (a)
                            (1.2)           (1.4) (a)

Outpatient Visits            1.8             1.7 (a)
                            (2.9)           (2.6) (a)

Physician Visits            14.0            14.0
                           (21.3)          (20.9)

Inpatient Costs          3,393          $4,937 (a)
                       ($5,576)        ($7,615) (a)

Outpatient Costs           708            $784 (a)
                       ($1,108)        ($1,082)

Physician Costs          1,129          $1,313 (a)
                       ($1,617)        ($1,781) (a)

Total Cost               6,268          $7,903 (a)
                      ($10,079)       ($11,952) (a)

n                       14,953          10,333
                        (3,263)         (1,532)

                       African American    African American
                            Female               Male
                         (W/disorder)        (W/disorder)

Inpatient days              3.1 (a)              4.3 (a b c)
                           (6.0) (a)            (7.7) (a)

Emergency Visits            0.7                  0.9 (a b c)
                           (1.1) (b)            (1.5) (a c)

Outpatient Visits           2.0 (b)              1.8
                           (2.7)                (2.1) (a b c)

Physician Visits           13.7                 13.1 (a b)
                          (20.1)               (19.3) (a)

Inpatient Costs        $3,700 (b)           $5,830 (a b c)
                      ($5,913) (b)         ($9,376) (a c)

Outpatient Costs          768                  793
                      ($1,023)             ($1,059)

Physician Costs        $1,172 (a)           $1,334 (a)
                      ($1,953) (a b)       ($1,734)

Total Cost             $7,083 (a)           $9,007 (a b c)
                     ($10,499)            ($13,763) (a C)

n                       1,897                1,158
                         (364)                (180)

* Adjusted mean controlling for age, rural residence, SES,
multiple psychiatric comorbidity, and diagnosis of schizophrenia,
dementia, and/or organic psychosis. All within-cell (e.g. among
white females) differences between recipients with psychiatric
disorder and those with no disorder are significant at the 0.05 level.

(a) difference from white female significant at the 0.05 level.

(b) difference from white male significant at the 0.05 level.

(c) difference from African American female significant at
the 0.05 level.

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Baqar A. Husaini
Tennessee State University (USA)

Darren E. Sherkat
Southern Illinois University (USA)

Robert Levine
Meharry Medical College (USA)

Charles Holzer
University of Texas Medical Branch (USA)

Van Cain
Tennessee State University (USA)

Clinton Craun
Tennessee State University (USA)

Pamela Hull
Tennessee State University (USA)

This paper was presented at the 7th Annual International Symposium & Workshop 2001, of the International Society for Research in Healthcare Financial Management, and was supported by grants from-the Health Care Financing Administration (HCFA20-C90705, NIH/MBRS 2S06GM08092, NIMH R24MH59748) made to Tennessee State University, Baqar A. Husaini, Principal Investigator.

Address for correspondence: Baqar A. Husaini, Box 9580, Center for Health Research, Tennessee State University, Nashville, TN 37209-1561 USA, bahusaini@earthlink, net.