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The European Journal of Health Economics
Published in: The European Journal of Health Economics 6/2018

Open Access 01-07-2018 | Original Paper

The impact of copayments on mental healthcare utilization: a natural experiment

Authors: Timo R. Lambregts, René C. J. A. van Vliet

Published in: The European Journal of Health Economics | Issue 6/2018

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Abstract

Empirical evidence suggests that people are fairly sensitive to cost sharing arrangements in ambulatory mental healthcare. However, pure cost sharing effects are typically hard to measure due to the presence of adverse selection effects. In this paper, we examine the impact of cost sharing on mental healthcare utilization in the context of mandatory health insurance where adverse selection is absent. Using a large proprietary dataset of a Dutch private health insurer, we examine to what extent a new copayment scheme for adult mental healthcare changed healthcare utilization. We exploit the fact that non-adults are exempted from copayments. First, we compare changes in utilization among adults and non-adults using t tests and a difference-in-difference analysis. Second, we highlight differential changes in mental healthcare utilization by treatment (duration and type of mental illness) and individual characteristics (gender and socioeconomic status). Third, we evaluate to what extent anticipatory behavior occurred pending the introduction and subsequent repeal of the new copayment scheme. Our results show a strong and significant (p < 0.01) decrease in outpatient secondary mental healthcare utilization among adults following the introduction of copayments, which is absent among non-adults. This decrease is concentrated among treatments for less severe mental illnesses. Furthermore, the utilization patterns suggest the presence of anticipatory behavior.
Appendix
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Footnotes
1
Long-term mental healthcare treatments include psychiatric institutionalizations of at least 1 year in duration (at least 3 years in duration as of January 1, 2015).
 
2
Exemptions were made for crisis treatments, treatments of involuntarily hospitalization and treatments started after so-called interference care, in which social workers try to persuade worrisome healthcare avoiders to obtain the healthcare services they need.
 
3
These aggregated neighborhood SES scores are based on four neighborhood characteristics: average income, percentage of inhabitants with a low income (less than €9250 annually converted to Dutch price levels of 2000), percentage of low-educated inhabitants [highest level of completed education is primary education, pre-vocational education (VMBO) or lower vocational education (MBO-1)] and percentage of inhabitants without a job. The SES scores reflect deviations from the national average over the years 1998–2014.
 
4
Dutch zip codes consist of four numbers and two letters (e.g., 1000 AA) in which the numbers indicate a neighborhood or village and the letters indicate one or sometimes multiple streets within this area.
 
5
For a more detailed overview of the system of DTC codes, see [19].
 
6
It is important to consider that relying on data provided by healthcare providers has two consequences. First, around 66% of all patients with a mental condition do not receive any treatment [20]. This group is not included in such data. Second, to an extent healthcare providers have opportunities for upcoding, hence the DTC codes can moderately deviate from the actual situation [21].
 
7
In the period studied, treatment duration was not reported directly. Ranges of total duration of the diagnosis and treatment could be inferred from the reported tariffs. For example, a fee of 3297 euros could be matched to a treatment duration between 1800 and 3000 min.
 
8
Levene’s tests [22] have been performed alongside all t tests and found no heteroscedasticity between any pair unless stated differently.
 
9
‘Group rest diagnoses’ include DSM-IV diagnoses that have not been assigned separate diagnosis codes such as disorders of impulse control, dissociative disorders, and sexual and gender identity disorders.
 
10
Exclusion of ‘adjustment disorders’ from the overall analyses summarized in Tables 2 and 3 did not alter the interpretation of our findings.
 
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Metadata
Title
The impact of copayments on mental healthcare utilization: a natural experiment
Authors
Timo R. Lambregts
René C. J. A. van Vliet
Publication date
01-07-2018
Publisher
Springer Berlin Heidelberg
Published in
The European Journal of Health Economics / Issue 6/2018
Print ISSN: 1618-7598
Electronic ISSN: 1618-7601
DOI
https://doi.org/10.1007/s10198-017-0921-7

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