Racial and Ethnic Disparities in the Treatment of a Medicaid Population with Schizophrenia

Schizophrenia affects only 0.7 percent of the U.S. population (2 million adults) (Saha et al. 2005), yet because of its early age of onset, chronicity, significant disability, and premature mortality, this severe mental illness is responsible for 5 percent of all burden of disease (Murray and Lopez 1996). Although U.S. community-based prevalence studies have generated little evidence on comparative rates for Latinos and non-Latino whites (Karno et al. 1987; Dassori, Miller, and Saldana 1995;), they suggest that blacks have a higher prevalence of schizophrenia than whites (Robins and Regier 1991; Kendler et al. 1996;). A recent California cohort study conducted in an insured population showed that the incidence of schizophrenia is three times higher among blacks than whites, the association partly mediated by socioeconomic status (Bresnahan et al. 2007). Although these studies employed standardized diagnostic methods, a previously documented tendency to overdiagnose schizophrenia in black adults may have played a role in these epidemiological findings (Williams and Earl 2007). The armamentarium of effective treatments for adults with schizophrenia has grown substantially in the past several decades. Even so, the quality of care typically received by people diagnosed with this severe psychiatric illness in the United States falls short of optimal (Lehman 1999). Moreover, quality of schizophrenia care varies depending on the race and ethnicity of patients. Relative to whites, blacks are more likely to use inpatient and emergency services (Snowden and Holschuh 1992) and less likely to receive outpatient care and a variety of recommended interventions (Wang, Demler, and Kessler 2002; Barrio et al. 2003;). Further, during a period when prevailing norms of good care favored atypical (over conventional) and oral (over long-acting injectable) antipsychotic medications, blacks had lower use rates of atypical antipsychotics and higher use rates of injectable antipsychotics than whites (Kuno and Rothbard 2002; Kreyenbuhl et al. 2003;). The evidence is substantially sparser and less consistent for Latinos (Vega et al. 2007). Despite rising awareness of the significance of disparities, some efforts to eradicate them, and isolated reports of improvements (Trivedi et al. 2005), disparities in health care for blacks and Latinos persist (Brady et al. 2007). For mental health care overall, studies have found either no change (Stockdale et al. 2008) or worsening health care disparities over time (Zuvekas 2005; Cook, McGuire, and Miranda 2007;). However, little is known about the care of minorities with schizophrenia. Daumit et al. (2003) used data on physician office and hospital outpatient department visits from the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey to assess use of atypical antipsychotics by race/ethnicity during the period 1992–2000. Among subjects with psychotic disorders, the minority-white disparities in atypical antipsychotic use narrowed during the period 1992–2000, closing for Latinos yet persisting for blacks (Daumit et al. 2003). In sum, previous research on disparities in schizophrenia care has focused on specific levels of care or specific interventions and little is known about broader patterns of care. Further, little is known about the health care experience of Latinos, or about temporal trends in disparities within the evolving treatment patterns for schizophrenia. The overall purpose of this study was to study disparities among Medicaid recipients with schizophrenia receiving health care in Florida. We focused on Medicaid because most people in the United States with schizophrenia rely on Medicaid (Frank and Glied 2006), and we chose Florida because of its size and racially and ethnically diverse population. Further, availability of 12 years of data enabled us to evaluate trends in health care disparities. Consistent with the definition proposed by the Institute of Medicine, we define disparities as differences in care not explained by differences in health status or need for services (Smedley, Stith, and Nelson 2003). On the basis of past research, we expected to find racial/ethnic disparities. We hypothesized that because minorities are less likely to receive regular care and atypical antipsychotics, their spending on psychotropic drugs would be lower than that of whites. We further hypothesized that as a result of poorer access to high-quality care, minorities would have a higher likelihood of using psychiatric inpatient services, and as a result of nonclinical considerations, minorities would have higher psychiatric inpatient spending with respect to whites. Since these use patterns work in opposing directions we had no expectation on how total mental health and total health spending might differ among groups. Lastly, on the basis of limited research to date, we hypothesized that observed disparities would diminish over time.