Dataset Information

Cost-Sharing Disparities for Out-of-Network Care for Adults With Behavioral Health Conditions.

ABSTRACT:

Importance

Individuals in the United States with mental illnesses and substance use disorders can face major access barriers from limited provider (eg, clinicians and facilities) networks in health insurance plans.

Objective

To evaluate the cost-sharing payments for out-of-network (OON) care for private insurance plan enrollees with mental health conditions, alcohol use disorders, or drug use disorders compared with those with congestive heart failure (CHF) or diabetes.

Design, setting, and participants

This cross-sectional study used data from a large commercial claims database from 2012 to 2017. The study included adults with mental health conditions, with alcohol use disorders, with drug use disorders, with CHF, and with diabetes who were aged 18 to 64 years and enrolled in employer-sponsored insurance plans.

Main outcomes and measures

Main outcomes included OON care during hospitalization, OON care during outpatient care, cost-sharing payments with OON care, OON cost sharing as a proportion of total health care spending, and OON cost sharing as a proportion of total cost sharing.

Results

The study sample included 3?209?929 enrollees with mental health conditions (mean [SD] age, 45.9 [12.6] years; 64.8% women), 294?550 with alcohol use disorders (mean [SD] age, 42.8 [13.4] years; 60.9% men), 321?535 with drug use disorders (mean [SD] age, 41.1 [13.9] years; 59.1% men), 178?701 with CHF (mean [SD] age, 53.8 [8.9] years; 62.6% men), and 1?383?398 with diabetes (mean [SD] age, 52.5 [9.0] years; 58.9% men). Enrollees with behavioral conditions were more likely to encounter OON clinicians in inpatient and outpatient settings. For instance, those with drug use disorders were 12.9 percentage points (95% CI, 12.5-13.2 percentage points; P?Conclusions and relevanceIn this cross-sectional study of enrollees in commercial insurance plans, cost sharing for OON care among those with behavioral health conditions was significantly higher than those with chronic physical conditions. These disparities may be indicative of limited in-network availability for behavioral health care.

SUBMITTER: Xu WY

PROVIDER: S-EPMC6865267 | biostudies-literature | 2019 Nov

REPOSITORIES: biostudies-literature

ACCESS DATA

Publications

Cost-Sharing Disparities for Out-of-Network Care for Adults With Behavioral Health Conditions.

Xu Wendy Yi WY Song Chi C Li Yiting Y Retchin Sheldon Michael SM

JAMA network open 20191101 11

<h4>Importance</h4>Individuals in the United States with mental illnesses and substance use disorders can face major access barriers from limited provider (eg, clinicians and facilities) networks in health insurance plans.<h4>Objective</h4>To evaluate the cost-sharing payments for out-of-network (OON) care for private insurance plan enrollees with mental health conditions, alcohol use disorders, or drug use disorders compared with those with congestive heart failure (CHF) or diabetes.<h4>Design, ...[more]

PMID: 31693122

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Project description:ImportanceA higher out-of-pocket price for mental health care may lead not only to cost savings but also to negative downstream consequences.ObjectiveTo examine the association of higher patient cost sharing with mental health care use and downstream effects, such as involuntary commitment and acute mental health care use.Design, setting, and participantsThis difference-in-differences study compared changes in mental health care use by adults, who experienced an increase in cost sharing, with changes in youths, who did not experience the increase and thus formed a control group. The study examined all 2 780 558 treatment records opened from January 1, 2010, through December 31, 2012, by 110 organizations that provide specialist mental health care in the Netherlands. Data analysis was performed from January 18, 2016, to May 9, 2017.ExposuresOn January 1, 2012, the Dutch national government increased the out-of-pocket price of mental health services for adults by up to €200 (US$226) per year for outpatient treatment and €150 (US$169) per month for inpatient treatment.Main outcomes and measuresThe number of treatment records opened each day in regular specialist mental health care, involuntary commitment, and acute mental health care, and annual specialist mental health care spending.ResultsThis study included 1 448 541 treatment records opened from 2010 to 2012 (mean [SD] age, 41.4 [16.7] years; 712 999 men and 735 542 women). The number of regular mental health care records opened for adults decreased abruptly and persistently by 13.4% (95% CI, -16.0% to -10.8%; P < .001) per day when cost sharing was increased in 2012. The decrease was substantial and significant for severe and mild disorders and larger in low-income than in high-income neighborhoods. Simultaneously, in 2012, 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 contrast to our findings for adults, the use of regular care among youths increased slightly and the use of involuntary commitment and acute care decreased slightly after the reform. Overall, the cost-sharing reform was associated with estimated savings of €13.4 million (US$15.1 million). However, for adults with psychotic disorder or bipolar disorder, the additional costs of involuntary commitment and acute mental health care exceeded savings by €25.5 million (US$28.8 million).Conclusions and relevanceHigher cost sharing for seriously ill and low-income patients could discourage treatment of vulnerable populations and create substantial downstream costs.

Project description:Importance:Cardiovascular disease is a major cause of death among homeless adults, with mortality rates that are substantially higher than in the general population. It is unknown whether differences in hospitalization-related care contribute to these disparities in cardiovascular outcomes. Objective:To evaluate differences in intensity of care and mortality between homeless and nonhomeless individuals hospitalized for cardiovascular conditions (ie, acute myocardial infarction, stroke, cardiac arrest, or heart failure). Design, Setting, and Participants:This retrospective cross-sectional study included all hospitalizations for cardiovascular conditions among homeless adults (n?=?24?890) and nonhomeless adults (n?=?1?827?900) 18 years or older in New York, Massachusetts, and Florida from January 1, 2010, to September 30, 2015. Statistical analysis was performed from February 6 to July 16, 2019. Main Outcomes and Measures:Risk-standardized diagnostic and therapeutic procedure rates and in-hospital mortality rates. Results:Of the 1?852?790 total hospitalizations for cardiovascular conditions across 525 hospitals, 24?890 occurred among patients who were homeless (11?452 women and 13?438 men; mean [SD] age, 65.1 [14.8] years) and 1?827?900 occurred among patients who were not homeless (850?660 women and 977?240 men; mean [SD] age, 72.1 [14.6] years). Most hospitalizations among homeless individuals were primarily concentrated among 11 hospitals. Homeless adults were more likely than nonhomeless adults to be black (38.6% vs 15.6%) and insured by Medicaid (49.3% vs 8.5%). After accounting for differences in demographics (age, sex, and race/ethnicity), insurance payer, and clinical comorbidities, homeless adults hospitalized for acute myocardial infarction were less likely to undergo coronary angiography compared with nonhomeless adults (39.5% vs 70.9%; P?<?.001), percutaneous coronary intervention (24.8% vs 47.4%; P?<?.001), and coronary artery bypass graft (2.5% vs 7.0%; P?<?.001). Among adults hospitalized with stroke, those who were homeless were less likely than nonhomeless individuals to undergo cerebral angiography (2.9% vs 9.5%; P?<?.001) but were as likely to receive thrombolytic therapy (4.8% vs 5.2%; P?=?.28). In the cardiac arrest cohort, homeless adults were less likely than nonhomeless adults to undergo coronary angiography (10.1% vs 17.6%; P?<?.001) and percutaneous coronary intervention (0.0% vs 4.7%; P?<?.001). Risk-standardized mortality was higher for homeless persons with ST-elevation myocardial infarction compared with nonhomeless persons (8.3% vs 6.2%; P?=?.04). Mortality rates were also higher for homeless persons than for nonhomeless persons hospitalized with stroke (8.9% vs 6.3%; P?<?.001) or cardiac arrest (76.1% vs 57.4%; P?<?.001) but did not differ for heart failure (1.6% vs 1.6%; P?=?.83). Conclusions and Relevance:There are significant disparities in in-hospital care and mortality between homeless and nonhomeless adults with cardiovascular conditions. There is a need for public health and policy efforts to support hospitals that care for homeless persons to reduce disparities in hospital-based care and improve health outcomes for this population.

Dataset Information

Cost-Sharing Disparities for Out-of-Network Care for Adults With Behavioral Health Conditions.

Importance

Objective

Design, setting, and participants

Main outcomes and measures

Results

Publications

Cost-Sharing Disparities for Out-of-Network Care for Adults With Behavioral Health Conditions.

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