Ringel Jeanne S., Sturm Roland
The RAND Graduate School, Santa Monica, CA, 1700 Main Street, Santa Monica, CA 90407,USA, Tel.: +1-310-393 0411 ext. 6626, Fax: +1-310-451 7025,
J Ment Health Policy Econ. 2001 Sep 1;4(3):141-150.
Mental health benefits have traditionally been much less generous than benefits for physical health care, with separate deductibles, higher copayments or coinsurance, and lower limits on covered services, a trend that continues despite a recent wave of 'parity' legislation. In spite of the current policy debates on mental health insurance reforms, little is known about the burden of mental health out-of-pocket expenditures. AIMS OF THE STUDY: This study examines differences in out-of-pocket expenditures and their burden across different populations, stratified by insurance status, age, ethnicity, and socioeconomic groups. METHODS: This study uses the 1998 HealthCare for Communities household survey, the latest national survey data that are currently available, to measure the burden of out-of-pocket mental health expenditures. We use several measures of burden such as total out-of-pocket expenditures, their share of total treatment costs, and their share of family income. To address the methodological issues that arise in the calculation of the relative measures of burden (e.g. outliers, measurement error, systematic underreporting) we consider three different approaches that have been suggested in the literature and discuss their relative advantages given the type of data typically available. RESULTS: Although there is a common perception that out-of-pocket expenditures for mental health services represent a significant burden for service users, the estimates suggest that this is not the case. In fact, across the three measures of out-of-pocket expenditures as a share of income the estimates are under 10 percent for most groups. However, there is some variation in burden across groups with people who are older, uninsured, or minority spending a larger share of their income out-of-pocket. Since many insurance plans have limits on the number of visits covered and on the total amount that the insurer will pay for mental health services, the share of total mental health expenditures that are paid by individuals is another important measure of the burden faced by people with mental health service needs. We estimate that the mean out-of-pocket share of total expenditures for the group as a whole is 25 percent. In addition, we find that the burden varies across groups with older, more educated, or privately insured individuals paying a larger share of expenditures out-of-pocket. DISCUSSION: Although the overall picture regarding the burden of out-of-pocket costs relative to income is encouraging, it is also important to keep in mind that individuals make treatment decisions based on their available income. The fact that the burden of actual out-of-pocket payments is relatively low may also reflect decisions to forego potentially valuable care. Nevertheless, the results for mental health do not suggest that out-of-pocket costs are currently a major burden for most users. This situation may reflect a major change from the past given the recent shifts towards managed care, however there are no comparable data available to test this hypothesis empirically. IMPLICATIONS FOR HEALTH POLICY FORMULATION AND FURTHER RESEARCH: It may be tempting to attribute the low estimates of out-of-pocket expenditures as a share of income in this paper to recent parity legislation. However, recent research shows that parity legislation has not led to significant changes in benefit design. In fact the high ratio of out-of-pocket payments relative to total mental health care expenditures presented in this paper are consistent with a limited role of parity legislation. Another possible explanation for the observed results is the growth of managed care and the shift in treatment style towards greater use of medications, which are comprehensively covered in most private insurance plans, has reduced total treatment costs and consequently the size of out-of-pocket payments.
传统上，心理健康福利远不如身体健康护理福利慷慨，有单独的免赔额、更高的共付额或 coinsurance（此处可能是指“共保率”，但不太确定，按照原文翻译），以及对承保服务的更低限额，尽管最近有一波“平价”立法，但这种趋势仍在持续。尽管当前存在关于心理健康保险改革的政策辩论，但对于心理健康自付费用的负担却知之甚少。
本研究考察了不同人群在自付费用及其负担方面的差异，这些人群按保险状况、年龄、种族和社会经济群体进行分层。
本研究使用 1998 年社区医疗保健家庭调查，这是目前可获得的最新全国性调查数据，来衡量心理健康自付费用的负担。我们使用了几种负担衡量指标，如自付费用总额、其在总治疗成本中的份额以及其在家庭收入中的份额。为了解决在计算负担相对指标时出现的方法学问题（例如异常值、测量误差、系统性低报），我们考虑了文献中提出的三种不同方法，并根据通常可获得的数据类型讨论了它们的相对优势。
尽管人们普遍认为心理健康服务的自付费用对服务使用者来说是一项重大负担，但估计结果表明并非如此。事实上，在自付费用占收入份额的三项衡量指标中，大多数群体的估计值都低于 10%。然而，不同群体之间在负担方面存在一些差异，年龄较大、未参保或少数族裔人群自付的收入份额更大。由于许多保险计划对承保的就诊次数和保险公司为心理健康服务支付的总金额有限制，个人支付的心理健康总支出份额是有心理健康服务需求者所面临负担的另一项重要衡量指标。我们估计，整个群体的总支出平均自付份额为 25%。此外，我们发现不同群体之间负担有所不同，年龄较大、受教育程度较高或有私人保险的个人自付的支出份额更大。
尽管相对于收入而言，自付费用负担的总体情况令人鼓舞，但同样重要的是要记住，个人会根据其可支配收入做出治疗决策。实际自付费用负担相对较低这一事实也可能反映了放弃潜在有价值治疗的决策。然而，心理健康方面的结果并不表明自付费用目前对大多数使用者来说是一项重大负担。鉴于最近向管理式医疗的转变，这种情况可能反映了与过去的重大变化，但没有可比数据来实证检验这一假设。
可能会倾向于将本文中自付费用占收入的低估计值归因于最近的平价立法。然而，最近的研究表明，平价立法并未导致福利设计发生重大变化。事实上，本文中呈现的自付费用相对于心理健康总护理支出的高比例与平价立法的有限作用是一致的。对观察到的结果的另一种可能解释是管理式医疗的增长以及治疗方式向更多使用药物的转变，而大多数私人保险计划对药物有全面覆盖，这降低了总治疗成本，从而减少了自付费用的规模。
