Is Medicare Clearing Better Pathways to Wellness for Men With Depression?

You would expect Medicare to spend about the same for a man with heart, lung, or kidney disease as it does for a woman.  And if you looked at the actual numbers, you would not be surprised.  On average, it does. 

So why does Medicare spend so much more on men when you couple these disease with depression? That is a question that deserves an answer.

The startling numbers, which show just how wide the disparity is, are in the chart accompanying this column.  They are very similar to some others that I shared in my column last week.

They all come from the 2010 CMS Medicare public use data files, the most recent ones available.  The CMS file includes information on all 48 million Medicare recipients. 

Last week, I wrote that men with depression in the 65-69 year old age group enjoyed an 11% Medicare spending advantage over women in the same age group.  (The men were those on Medicare only, not both Medicare and Medicaid.)  I also wrote that the disparity persisted both as they aged and when they were diagnosed as having both depression and dementia.

That column raised at least one troubling question – why are women with depression being undertreated relative to men, when they are two to three times more likely to be diagnosed with it?

I received a number of possible answers to that question, but the most common one was that perhaps men’s needs are more intensive.  Because they are diagnosed less frequently, they may simply be sicker by the time they are, and therefore need more treatment.

The Medicare data do not include a severity measure, so there is no way to tell for sure.  But there is at least some indirect empirical evidence for this. The Medicare spending gap in favor of men is wider for hospital care (Part A) than it is for outpatient treatment of drugs (Parts B/D).

If there were an intensity advantage, however, it should disappear as people get sicker.

But it doesn’t. If anything, it may get a little wider. 

This week, I looked at some groups with greater health needs – Medicare recipients in the 65-69 year old age group who were dually diagnosed with depression plus heart disease, depression plus lung disease, depression plus kidney disease, or depression plus cancer.  In every case, being sicker (i.e., having a second diagnosis of depression on top of the other chronic disease) led to a wider gap in spending.

Three of the examples are captured in the chart.  As expected, there’s very little gender bias in Medicare spending on heart disease (2% more on men), lung disease (1% more on men), or kidney disease (4% more on men).  There is a gender bias in spending on cancer, but it favors women (Medicare pays 26% less on men with cancer).

When you add depression to these conditions, the spending tilts in favor of men again.  

• The 2 percent difference in spending favoring men with heart disease grew to 9 percent when the men and the women had both heart disease and depression. 
• The 1 percent difference in spending on lung disease expanded to 13 percent when both lung disease and depression were present. 
• And the 4 percent difference in spending favoring men with kidney disease ballooned to 30 percent when both kidney disease and depression were present.

And the cancer spending gap dropped from 26 percent down to just 15 percent.

The difference is clearly the depression.

Medicare simply spends less on women with depression, even when they have other serious chronic conditions.  You can decide for yourself about the reason.  Are men underdiagnosed? Are women overdiagnosed?  Are men overtreated? Are women undertreated?

The CMS data set does not answer those questions.

But it does tell us this – Medicare-eligible men and women with depression, at least in this age group, are clearly being treated differently.  For whatever reason, the men are getting more, and the women are getting less.

Today is the start of Mental Health Month.  This year’s theme is “Pathways to Wellness.”  So here’s my question, similar to last week’s.   Is Medicare clearing better pathways to wellness for men with depression than it is for women?

To reach Paul Gionfriddo via email: gionfriddopaul@gmail.com.  Twitter: @pgionfriddo.  Facebook: www.facebook.com/paul.gionfriddo.  LinkedIn:  www.linkedin.com/in/paulgionfriddo/ 

Women and Depression - Stoicism or Neglect?

Are women with depression more stoic than men, or are men just getting preferential treatment?

According to the National Institute on Mental Health, women are 70 percent more likely than men to experience depression during their lifetime.  Depression hits women harder than men in nearly every age group.

But if some fascinating data from the Centers for Medicare and Medicaid Services are any indication, we also spend a lot less on treating them than we do men.   

Are women more stoic, or are we just neglecting their mental health needs?

The data that shed some disturbing light on this subject come from the CMS Chronic Conditions Public Use Files.  These files include data for every 2010 Medicare beneficiary – approximately 48 million people.

In 2010, according to the CMS data, 9296 men between the ages of 65 and 69 who were newly-enrolled in Medicare Part B had depression and no other chronic condition.  And so did many more newly-enrolled women in the same age group - 23953 to be exact.

Medicare spent an average of $4650 (Part A, Part B, and Part D combined) on newly-eligible and enrolled 65-69 year old men with depression.  But it spent an average of only $4010 on women with depression in the same age group. 

In other words, Medicare spent 16 percent more on the men than it did on the women.

It is possible that those first-year data were an anomaly.  After all, they represented an average of just seven months of coverage.  It is possible that the men just got earlier, more aggressive treatment for depression when they first enrolled in Medicare, and that the women caught up later on in the year.

But this wasn’t the case.  When I looked at men and women in the same age group who had a full year of Medicare coverage in 2010, the disparity persisted. 

The numbers were just bigger.  There were around 35,000 men and over 85,000 women enrolled in both Parts A and B, and around half those numbers in Part D.  And we did spend more on women with depression - $5761 on average.  But we spent $6386 – or 11 percent more than that – on men.

The difference could be explained in part because men got more hospital-based care.  Medicare spent almost 50 percent more on Part A services, on average, for men.  But it still spent more on their Part B (physician/community) and Part D (prescription drug) care, too.

And here’s the interesting thing – the disparity seemed to persist as men and women aged.

I looked fifteen years down the road, at the 80-84 year old population.  Because women live longer, there were around three times as many women with depression in this age group as there were men.  But we were still spending more on the men.

Among 80-84 year olds with depression and no other chronic condition, Medicare spent 14 percent more overall on men than it did on women – an average of $7141 versus $6247.

And the disparity in spending also persisted when men and women had depression plus certain other chronic conditions – Alzheimer’s Disease and related disorders, and diabetes.

For example, Medicare paid out 23 percent more in first-year care for a 65-69 year old male with depression plus Alzheimer’s Disease or other dementia than it did for a 65-69 year old woman with the same two diseases.  And the difference over a full year was still 10 percent.

And Medicare paid out 34 percent more in the first-year care for a 65-69 year old male with depression plus diabetes than it did for a 65-69 year old woman with same two diseases.  And while that vast difference narrowed over a full year, it was still 7 percent.

These differences also persisted as people aged.  In the 80-84 age group, Medicare paid 22 percent more for men with depression plus diabetes than it did for women, and 7 percent more for depression plus dementia than it did for women.

This disparity cannot be explained away by suggesting that the men might also have other chronic conditions complicating their cases.  These are equivalent groups – neither the men nor the women had any other diagnoses at the time.

So as we enter another Mental Health Month and strive to strip away the stigma and misconceptions related to mental illnesses, perhaps one question we should be asking ourselves is this. 

Is stoicism or stigma the reason we spend less on mental health care for women with depression?

To reach Paul Gionfriddo via email: gionfriddopaul@gmail.com.  Twitter: @pgionfriddo.  Facebook: www.facebook.com/paul.gionfriddo.  LinkedIn:  www.linkedin.com/in/paulgionfriddo/