Mental health coverage cuts result in extra costs

(Reuters Health) - An effort by the Netherlands to save money on mental health care by raising patient co-pays produced $15 million in short-term savings but ended up adding $29 million to the costs of treating bipolar and psychotic disorders, researchers say.

“If you zoom in on these two disorders, which are the most serious disorders, it actually cost more money than it saved,” chief author Bastian Ravesteijn, a research fellow in the Department of Health Care Policy at Harvard Medical School in Boston, told Reuters Health in a telephone interview.

The increase in patient cost-sharing led to fewer people seeking regular mental treatment and a simultaneous rise in acute care and involuntary commitments, according to the analysis in JAMA Psychiatry, July 19.

The added copayment program, which only survived for a year because it was unpopular, increased each patient’s share of adult mental health services by $226 per year for outpatient care and $169 per month for inpatient care.

The result: a 13.4 percent decline in the number of new mental health care records opened, particularly in low-income neighborhoods. Meanwhile, the rate of involuntary commitment nearly doubled, increasing by 97 percent, and cases of people seeking acute mental health care rose by 25 percent.

“The findings are troubling,” Dr. Benjamin Druss of Emory University in Atlanta writes in a commentary accompanying the study. “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.”

The work highlights the complexity of trying to save money by requiring patients to pay more for their health care. The debate is whether higher copays or deductibles will prompt patients to avoid short-term treatments that prevent more-expensive care further down the road.

The Dutch case provided a natural experiment, with the extra costs applied only to adults and not children. The analysis included 1.4 million treatment records in the Netherlands. Children under 15 were excluded.

Prior to 2012, patients only had to pay $192 per year for all types of specialist care. That amount was raised to $248 at the same time the additional mental health copays were implemented.

While the demand for mental health services had been growing by 5.6 percent per year from 2004 to 2010, the demand dropped by 14.8 percent when the new payments were required. The rate of regular treatment among youths did not change.

Requests for treatment among people diagnosed with psychotic disorder dropped by 10.6 percent. For depressive disorder, the decline was 13.8 percent. With anxiety disorder, it was 13.1 percent.

Because of the copayment changes, the researchers estimate, regular care costs dropped by $79.4 million but the costs of acute care and commitment rose by $64.3 million for a net savings of $15.1 million.

But costs for psychotic disorder and bipolar disorder - required because too many people stopped receiving regular care - skyrocketed, with acute and commitment costs increasing by $44.0 million on a savings of just $15.3 million. In short, with a system that discouraged regular treatment for these diagnoses, the system had to pay out an extra $28.7 million.

The lesson here: “Make sure that the people with serious mental illness are at least covered,” Ravesteijn writes.

The savings were biggest for people with depressive disorder ($17.3 million) and anxiety disorder ($11.1 million).

In the poorest 10 percent of the population, the number of cases treated in 2012 declined by 16.3 percent. In the richest 10 percent, the decline was 11.3 percent.