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Cost sharing a slippery slope in mental health care

Higher cost sharing was associated with decreased openings of mental health care records, particularly among individuals with serious mental illness or from low-income neighborhoods, but increases in openings for involuntary commitment and acute mental health care.

“Patient cost sharing lowers health care spending because individuals tend to use fewer health services when they are required to pay a portion of the cost compared with full insurance. It has been argued in the health insurance literature that, if demand for certain health services is highly responsive to price changes, patients do not derive high value from those service,” Bastian Ravesteijn, PhD, of Harvard Medical School, Boston, and colleagues wrote. “Because the demand for mental health services is highly responsive to price changes, some researchers have argued that there is an efficiency rationale for higher cost sharing for mental health care.”

To assess the association of higher patient cost sharing with mental health care use and downstream effects, including involuntary commitment and acute mental health care use, researchers conducted a difference-in-differences study of 2,780,558 treatment records opened from January 2010 through December 2012 by 110 organizations providing specialist mental health care in the Netherlands.

From 2010 to 2012, there were 1,448,541 treatment records opened among individuals with a mean age of 41.4 years.

When cost sharing increased in 2012, the number of regular mental health care records opened for adults “abruptly and persistently” decreased by 13.4% (95% CI, –16 to –10.8; P < .001) per day.

This decrease was significant for severe and mild disorders and was greater in low-income neighborhoods vs. high-income neighborhoods.

At the same time, daily record openings increased for involuntary commitment by 96.8% (95% CI, 87.7-105.9; P < .001) and for acute mental health care by 25.1% (95% CI, 20.8-29.4; P < .001) in 2012.

Contrary to findings in adults, regular care use among youths slightly increased and use of involuntary commitment and acute care slightly decreased after reform in 2012.

Overall, cost-sharing reform was associated with an estimated savings of $15.1 million. However, additional costs of involuntary commitment and acute mental health care among adults with psychotic disorder or bipolar disorder exceeded savings by $28.8 million.

“In the United States, cost sharing in the form of health savings accounts and high-deductible plans has garnered renewed interest among insurance plans and in market-based health care reform proposals. These approaches seek to increase choice and reduce costs by providing patients with more ‘skin in the game,’” Benjamin G. Druss, MD, MPH, of Emory University, wrote in an accompanying editorial. “The Dutch experience suggests that copayments can reduce access to mental health care and increase costs, particularly among vulnerable and high-need populations. Without careful planning and oversight, mental health care cost-sharing programs may exact a steep price.” – by Amanda Oldt

Disclosure: The researchers report no relevant financial disclosures.