Alex McDowell

Alex McDowell

Assistant Professor, Mongan Institute
Mass General Hospital, Harvard Medical School

Dissertation Title:  "Understanding Mental Health Care Use and Outcomes among Individuals with Reduced Access to Care"Many individuals in the United States do not have access to adequate health care. Reduced access to care contributes to physical and mental health inequities experienced by vulnerable populations. In this thesis, I studied mental health care use and outcomes among individuals with reduced access to care, focusing specifically on individuals who are transgender, gender diverse, or living with serious mental illness.

Chapter one characterized the health status of privately insured gender minority (i.e., transgender or gender diverse) individuals. We created a diagnosis-based algorithm to identify gender minority children and adults in a commercial claims database and found that individuals with gender minority-related diagnosis codes have a markedly higher prevalence of mental health and substance use disorders (50.6% among gender minorities versus 10.3% among non-gender minorities) with even more notable disparities among individuals younger than 18 (71.1% among gender minorities versus 8.9% among non-gender minorities). This is the first study of gender minority individuals in private health insurance claims and it provides critical new knowledge on the wellbeing of the gender minority population in the US.

Chapter two evaluated the effect of state-level nondiscrimination policies on mental health outcomes among privately insured gender minority individuals. Since 2012, more than 20 states have implemented policies banning discrimination based on gender identity among private health insurers, and this is the first study to evaluate the effect of such policies on gender minority health. We used a difference-in-differences design to compare changes in suicidality before and after states implemented nondiscrimination policies and find that such policies were associated with a decrease in suicidality in the first post-implementation year among states that implemented policies in 2014-2016. Among states that implemented policies in 2013, there was no association with suicidality. Given high rates of suicidality among gender minority individuals in the US, health insurance nondiscrimination policies may offer an effective mechanism for reducing barriers to care and mitigating discrimination.

Chapter 3 classified patterns of mental health care use prior to initiation of telemental health services among rural Medicare beneficiaries living with serious mental illness. While telemental health use is growing in the US, increased uptake of telemedicine will be necessary to address the lack of access to adequate mental health treatment, particularly for individuals with serious mental illness who are living in rural areas. Using latent class analysis, we identified five distinct subgroups of enrollees based on their care patterns. By identifying common treatment patterns leading up to telemental health initiation, one can target interventions to increase telemental health use.




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