Psychiatric Cost Sharing Linked to Lower Mental Health Care Use, but Large Downstream Costs

According to a recent study, implementing cost-sharing requirements on mental health services produced short-term savings by reducing mental health care use, but resulted in more costly outcomes like involuntary commitments and acute mental health care.

The study, published in JAMA Psychiatry, used medical records to track mental health care utilization in the Netherlands after the government increased the out-of-pocket price for outpatient mental healthcare by €200 ($226) and required a monthly co-pay of €150 ($169) for inpatient care. Before this change went into effect in 2012, the annual deductible for all types of care had been no higher than €170 ($192).

Using a database of nearly 1.5 million mental health records opened from 2010 to 2012, the researchers found that the number of adult treatment records opened per day decreased by 13.4% in 2012, while the number of daily records opened for youths, who were unaffected by the cost sharing changes, slightly increased.

However, the number of daily records opened for involuntary commitment and acute mental health care increased by 96.8% and 25.1%, respectively, among adults in 2012, indicating the downstream effects of the observed reductions in regular mental health treatment. The researchers also found that the declines in demand for regular treatment observed in 2012 were significantly larger in poorer neighborhoods than in richer ones, even though treatment rates in the poorest decile had been 2.7 times higher than in the wealthiest decile before the cost sharing increase.

After calculating the cost savings resulting from reduced treatment, as well as the cost increases due to involuntary commitments and acute care, the researchers determined that the reform saved approximately €13.4 million ($15.1 million) more than it cost. However, net savings were negative for psychotic disorder and bipolar disorder, which were the diagnoses mainly responsible for the increase in involuntary commitment.

According to the study authors, the findings indicated that while some individuals may have reduced their use of low-value care due to the imposition of higher cost-sharing requirements, it seemed that a proportion of patients stopped receiving regular treatment that would be considered high-value, as evidenced by the resulting increases in involuntary commitment and acute mental health care. For certain populations, like patients with psychotic disorder, this ended up increasing total spending rather than cutting costs.

The researchers noted that their findings were relevant to the ongoing debate over behavioral health cost sharing in the United States, and pointed out that “reducing coverage for mental health care can lower mental health care costs overall but may have negative unintended consequences for the seriously ill.”