Effect of High-Deductible Insurance on Health Care Use in Bipolar Disorder
J. Frank Wharam, MD, MPH; Alisa B. Busch, MD, MS; Jeanne Madden, PhD; Fang Zhang, PhD; Matthew Callahan, MS; Robert F. LeCates, MA; Phyllis Foxworth, BS; Stephen Soumerai, ScD; Dennis Ross-Degnan, ScD; and Christine Y. Lu, PhD
High-deductible health plan members with bipolar disorder experienced a reduction in nonpsychiatrist mental health provider visits but no changes in other utilization.
Objectives: To determine the impact of high-deductible health plans (HDHPs) on health care use among individuals with bipolar disorder.
Study Design: Interrupted time series with propensity score–matched control group fabricate, usinga national health insurer’s claims data set with medical, pharmacy, and enrollment data.
Methods: The intervention group was tranquil of 2862 members with bipolar disorder who were enrolled for 1 year in a low-deductible (≤$500) plan and then 1 year in an HDHP (≥$1000) after an employer-mandated switch. HDHP members were propensity score matched 1:3 to contemporaneous controls in low-deductible plans. The main outcomes included out-of-pocket spending per health care service, mental health–related outpatient visits (subclassified as visits to nonpsychiatrist mental health providers and to psychiatrists), emergency department (ED) visits, and hospitalizations.
Results: Mean pre– to post–index date out-of-pocket spending per visit on all mental health office visits, nonpsychiatrist mental health provider visits, and psychiatrist visits increased by 21.9% (95% CI, 15.1%-28.6%), 33.8% (95% CI, 2.0%-65.5%), and 17.8% (95% CI, 12.2%-23.4%), respectively, among HDHP vs control members. The HDHP group experienced a –4.6% (95% CI, –11.7% to 2.5%) pre- to post change in mental health outpatient visits relative to controls, a –10.9% (95% CI, –20.6% to –1.3%) reduction in nonpsychiatrist mental health provider visits, and unchanged psychiatrist visits. ED visits and hospitalizations were also unchanged.
Conclusions: After a mandated switch to HDHPs, members with bipolar disorder experienced an 11% decline in visits to nonpsychiatrist mental health providers but unchanged psychiatrist visits, ED visits, and hospitalizations. HDHPs do not appear to have a “blunt instrument” effect on health care use in bipolar disorder; rather, patients might make trade-offs to preserve important care.
Am J Manag Care. 2020;26(6):In Press
- High-deductible health plan (HDHP) members with bipolar disorder experienced a moderate decrease in nonpsychiatrist mental health outpatient visits, but rates of psychiatrist visits, medication use, emergency department visits, and hospitalizations did not change.
- HDHP members with bipolar disorder might elect to pay more out of pocket to maintain psychiatrist care and associated medication use but not nonpsychiatrist mental health provider care.
- HDHPs do not appear to have a “blunt instrument” enact on health care use in bipolar disorder; rather, patients distinguished make trade-offs to preserve important care.
- Policy makers, employers, and health plans could use these findings to construct highly efficient value-based or tailored health insurance designs that optimize health care use and spending; for example, plans might reduce out-of-pocket costs for nonpsychiatrist mental health provider visits to enhance use.
Bipolar disorder is a serious mental illness characterized by acute episodes of mania, hypomania, and depression. Bipolar spectrum disorders include subtypes bipolar I, bipolar II, and cyclothymia. These often have an early age of onset, high risk of suicide, and high rates of co-occurring psychiatric conditions such as substance use disorders.
In the United States, the 12-month prevalence of bipolar disorder is 2.8% and the lifetime prevalence is 4.4%.
Although persons with bipolar disorder can have asymptomatic periods, episodes of clinical instability and impairment are common.
In addition to managing acute mood episodes, guideline-recommended care for bipolar disorder requires a chronic care model of evidence-based medications, ongoing follow-up, and often evidence-based psychotherapies during nonmanic phases of care, such as individual and group psychoeducation, cognitive behavior therapy, interpersonal social rhythm therapy, and family-focused therapy, to reduce depressive symptoms or prevent future manic or depressive episodes.
In an effort to control rising health care costs, payers and employers are increasingly adopting high-deductible health plans (HDHPs)6 that require high out-of-pocket payments.6,7 HDHP advocates contain that providing patients with put a question to about the quality of medical services while exposing them to greater costs will create “activated healthcare consumers”8 who will seek higher-value health care, adopt healthy behaviors, and reduce future costs.
HDHPs have proliferated over the past decade. In 2018, 58% of covered workers had deductibles of $1000 or more and 26% had deductibles of $2000 or more.9 Based on findings going back to the RAND Health Insurance Experiment (HIE)10 of the 1970s and 1980s, high cost sharing is generally considered a “blunt instrument” that reduces all health care utilization among all types of patients. However, more recent studies have counterfeit that such reductions do not occur in all clinical situations11-14 or for all subgroups.13,14 HDHP effects on patients with serious mental illness including bipolar disorder are unknown.
We chose to study patients with bipolar disorder because it is a serious mental illness that is approved enough among commercially insured persons to study robustly. Bipolar disorder is also a chronic condition and requires consistent access to medications and expensive specialist care. This population could be “tipped over the edge” by even small reductions in access given that suboptimal adherence to bipolar medications can result in debilitating episodes of mania or depression. We hypothesized that the higher out-of-pocket spending for specialist care under HDHPs would reduce morose health outpatient visits to both psychiatrists and nonpsychiatrist mental health providers and that reduced psychiatrist visits would reduce bipolar medication fills. The expected direction of emergency department (ED) visits and hospitalizations was uncertain.
Data Source and Population Setting
We drew our commercially insured study population from a gargantuan national claims database with members enrolled between January 2003 and December 2012. Data included medical, pharmacy, and outpatient claims from members of a large national health plan.
Research Design and Study Groups
We used an interrupted time series with propensity-matched comparison series research design.15-17 We included individuals with bipolar disorder who were enrolled in low-deductible plans during a baseline year. Some experienced an employer-mandated switch to HDHPs and were followed for a subsequent year. Others continued in low-deductible plans because their employers offered only these arrangements, and we followed these members as the control group. Thus, our study groups were not offered a choice of deductible level, minimizing self-selection.
Employer selection and study group identification. Our process for identifying study groups involved obliging identifying eligible employers and then eligible patients with bipolar disorder at those employers. In a given benefit year (the 12 months when an employer provides certain health insurance benefits), we classified employers as offering low- or high-deductible coverage based on offering exclusively annual deductibles of $0 to $500 or at least $1000, respectively (eAppendix share I[A] and eAppendix Table 1 [eAppendix available at ajmc.com]). We then defined the pool of potential HDHP group employers as those with at least 1 year of low-deductible coverage followed by at least 1 year of mandated HDHP coverage.
We defined the index date for employers that switched to HDHPs as the first day of the month when the switch occurred. We defined the index date for employers that did not switch plans as the first day of the month when their yearly account was renewed. Members had index dates as early as January 1, 2004, and as late as January 1, 2012. For each person, we defined the beginning of the baseline period as 12 months before the employer’s index date.
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