Our results indicate that black homeless adults with severe mental illnesses experience a disparity in intensity of utilization of psychiatric outpatient services. The evidence is that blacks had a lower mean number of psychiatric outpatient visits than whites on state-stratified disparities analyses of self-reported service utilization data collected at baseline by the ACCESS study. Although the difference of 0.5 visits is modest in absolute terms, it is quite substantial relative to the unadjusted mean of 4 visits for the previous 60 days. We did not find disparities in intensity of utilization for Latinos. To the contrary, our only significant finding for white/Latino comparisons was the higher Latino utilization of case management services. Here too, although the difference of 0.5 visits appears modest in absolute terms, it is significant given that the unadjusted mean number of case management visits for the previous 60 days ranged between 2.5 and 3.9 for the 3 groups. We did not find access disparities for either comparison.
Consistent with evidence generated by previous research (9
), we found that our sample had low intensity of utilization of services of critical importance to their well-being. This finding may have been influenced by the ACCESS study exclusion of individuals receiving mental health care at study enrollment. However, the notoriously tenuous connections of homeless adults with severe mental illnesses to the health care system (7
) make it unlikely that our utilization figures represent a substantial underestimate. Low levels of insurance coverage, social marginalization, and distrust of the system are among the many barriers to care faced by this vulnerable population (26
Our finding of variable service utilization across states mirrors findings from other areas of health care (27
). Possible contributors include state differences in availability of resources for homeless people and the characteristics of the social welfare apparatus, including ease of access to public insurance programs.
Ours is the first study of this population to have assessed disparities separately for blacks and Latinos. A previous study that compared services used by Latinos and whites was based on an incomplete ACCESS data set that focused on utilization during the course and not prior to the study (28
Our finding of a disparity in intensity of utilization of psychiatric outpatient services for blacks is not consistent with available evidence. A study of homeless mentally ill and/or substance-abusing veterans receiving Veterans Health Affairs (VHA) care found that blacks and whites had comparable service utilization (29
). Further, a cost-effectiveness study based on data from a randomized trial of assertive community treatment versus usual care for homeless people with severe mental illnesses found that blacks and whites in the usual care arm had comparable utilization of outpatient mental health services (30
). However, neither study aimed to systematically evaluate racial/ethnic service disparities. Further, whereas the VHA study may have obscured potential disparities by adjusting for socioeconomic status, the cost-effectiveness study did not adjust for potential need differences between the groups.
Possible contributors to our disparity finding include individual characteristics such as socioeconomic status (32
) and characteristics of the service system and the policy environment (1
That our disparity finding dissipated upon controlling for education suggests that blacks’ lower educational level relative to whites played an important role in this disparity. We were unable to evaluate the role of insurance in this finding because our data lacked insurance information. However, it is unlikely that insurance differences played a major role because we did not find access disparities. Although our state-stratified analyses controlled for state-specific policies that may contribute to disparities, we may not have fully accounted for geographic variations in access and quality of critical services for this population. For example, because we did not control for study site, if the racial/ethnic groups gravitated to different geographic areas served by providers of varying quality (34
) or cultural and linguistic competency (36
), such differences may have influenced our results.
Racial/ethnic differences in service utilization may also result from stigma and negative attitudes toward treatment (37
). However, we were unable to assess the role played by these factors in our finding.
That we did not find white-black disparities in intensity of utilization of housing or case management services may point to a smaller effect of education on utilization of these services relative to psychiatric outpatient services, or to a smaller quality gap across providers of non-medical services relative to psychiatric providers.
Our finding that severely mentally ill Latinos who are homeless have higher intensity of case management utilization than whites is new to a literature that even for the larger severely mentally ill population, is sparse in evidence with regard to this ethnic group. Two previous studies that have assessed differences in case management utilization between mentally ill whites and Latinos differed from ours not only in that their samples contained largely domiciled people but also in that they adjusted by socioeconomic status. While one study found that Latino adults with schizophrenia had lower
access to these services (38
), the second study found comparable
access for Latino and white children and adults with schizophrenia and other mental illnesses (39
Socioeconomic differences between whites and Latinos may have contributed to this unexpected finding as evidenced by the fact that the difference disappeared when we controlled for education. Although we do not have an explanation for either finding, it is possible that the excess of case management services received by Latinos may have been targeted to people whose educational deficits encumber their ability to navigate the welfare system. It is unlikely that insurance differences or the presence of Spanish-only speakers explain our finding because both dynamics would likely act in the opposite direction (38
Little is known about whether the magnitude and direction of disparities findings are sensitive to the type of outcome measure used –that is, access versus intensity of utilization. Two studies evaluated mental health disparities with measures of access and measures of quality constructed with data on intensity of utilization. While one study found racial disparities regardless of the measure used (32
), disparities findings for the second study were measure-sensitive (41
This study had several limitations. First, despite propensity score adjustment, we were unable to achieve optimal comparability between whites and Latinos. This imbalance means, however, that our Latino group had greater severity of psychotic symptoms than whites, a fact that may underlie the higher intensity of case management utilization among Latinos (38
). Second, because people receiving mental health care at study enrollment were excluded, our findings may not be representative of the typical experience of homeless adults with severe mental illnesses. However, because of the tenuous treatment connections of this population (7
), psychiatric outpatient and case management utilization may not have been substantially higher in the absence of this exclusion criterion. Furthermore, that despite this exclusion criterion utilization of these 2 services was larger than zero for many participants indicates that a substantial fraction of people had been in treatment in the previous 60 days but had dropped out prior to enrolling in the study. Third, although concerns may be raised about our outcomes reflecting self-reported utilization, evidence exists that adults with severe mental illnesses provide reliable utilization data (42
). Lastly, we were not able to assess the effect of language because of the relatively small Latino group in our sample.