The Effects of Three Kinds of Insurance Benefit Design Features on Specialty Mental Health Care Use in Managed Care.

backgroundInsurance benefit features play a role in determining access to specialty mental health care. Previous research, primarily examining the effects of copayments, coinsurance, and deductibles in a fee-for-service setting, has concluded that specialty mental health use is highly sensitive to changes in financial requirements. Less is known about the effects of other benefit features and the effects of all of these features in a managed care environment. AIMS OF THE STUDY: Determine whether increased generosity of three types of benefit features was associated with increases in specialty mental health use and expenditures in a managed care setting. Secondary analyses investigated whether these associations varied by income level.

methodsA first-differences design used linked claims, enrollment, and benefit data for 1,242,949 non-elderly adults (aged 18-64) with employer-sponsored insurance, before (2009) and after (2011) national behavioral health parity implementation. The data were provided by a large national managed behavioral health organization. Benefit design features included combined cost sharing from copayment and coinsurance, deductibles, the presence of annual use limits, cost sharing penalties associated with services used without getting required prior-authorization, and provider network. Outcomes included visits/days, total expenditures and patient out-of-pocket expenditures for individual psychotherapy and inpatient use, with separate values for in-network and out-of-network (OON) service use. Ordinary least squares regression was performed on change scores (2011 minus 2009 values) of all outcomes to implement the first-differences study design and normalize distributions of otherwise heavily skewed (towards zero) variables. Regressions stratified by higher income (>=USD75,000) and net worth (>=USD100,000) and lower income/net worth were also conducted.

resultsFor in-network individual psychotherapy, larger increases in cost sharing from copayment and coinsurance were modestly associated with larger decreases in use and total expenditures (beta_visits=--0.00008, p-value=0.030; beta_total expenditures=USD--0.00629, p-value=0.011), and elimination of treatment limits was associated with larger increases in use (beta=0.09637, p-value=0.002) and total expenditures (beta=USD6.57506, p-value=0.001). These results were observed among all enrollees of plans that covered in-network and out-of-network plans and among a sub-set of these enrollees who did not change plans between 2009 and 2011. Benefit features had fewer associations with inpatient care and OON services. DISCUSSION: Elimination of limits was associated with small average increases in in-network individual psychotherapy utilization and expenditures. Cost sharing sensitivities of individual psychotherapy visits to financial requirements reported here were small, and resembled previous findings based in a managed care setting, which were smaller than findings based on the fee-for-service settings. Cost sharing may not pose a practical barrier to specialty behavioral health for non-elderly adults with employer-sponsored managed care plans. However, the influence of cost sharing may vary by specific healthcare needs, something that should be explored in further research.