Department of Health Policy and Management (Schilling, Eisenberg, Kennedy-Hendricks, Stuart, Meiselbach, Barry), Johns Hopkins Center for Mental Health and Addiction Policy (Schilling, Kennedy-Hendricks, Barry), and Department of Mental Health (Stuart), Johns Hopkins Bloomberg School of Public Health, Baltimore; OptumLabs Visiting Fellow, OptumLabs, Eden Prairie, Minnesota (Eisenberg); Department of Health Care Policy, Harvard Medical School, Boston (Busch, Huskamp); McLean Hospital, Belmont, Massachusetts (Busch).
Psychiatr Serv. 2022 May;73(5):518-525. doi: 10.1176/appi.ps.202000914. Epub 2021 Sep 30.
High-deductible health plans (HDHPs) are increasingly common in the U.S. health insurance market and are intended to reduce the use of low-value services, but evidence suggests that HDHP enrollees also reduce the use of high-value services. This study examined the effects of HDHPs on enrollees with mental health conditions, a population with high levels of unmet treatment need, often because of financial barriers. Enrollees with a co-occurring substance use disorder have greater treatment needs and unique barriers to care, perhaps changing their response to an HDHP.
Commercial health insurance claims data in a difference-in-differences design was used to evaluate the effect of an employer's offer of an HDHP on 6,627,128 enrollee-years among enrollees with mental health conditions, stratified by having a co-occurring substance use disorder or not.
Among enrollees without a co-occurring substance use disorder, an HDHP offer was associated with a 4.8% (95% confidence interval [CI]=2.4%-7.2%) reduction in overall spending on mental health care, despite an 11.3% (95% CI=1.0%-21.6%) increase in spending on mental health-related emergency department visits. Among enrollees with a co-occurring substance use disorder, no significant changes attributable to an HDHP offer were found in most categories of spending on combined mental health and substance use disorder care, apart from a 4.5% (95% CI=1.9%-7.2%) reduction in spending on psychotropic medications.
HDHPs may reduce use of necessary care among enrollees with mental health conditions, which could exacerbate undertreatment in this population and result in adverse health outcomes.
高免赔额健康计划（HDHPs）在美国健康保险市场中越来越普遍，旨在减少低价值服务的使用，但有证据表明，HDHP 参保人也减少了高价值服务的使用。本研究考察了 HDHPs 对有心理健康状况的参保人的影响，这是一个治疗需求未得到满足程度较高的人群，通常是由于经济障碍。同时患有物质使用障碍的参保人有更大的治疗需求和独特的护理障碍，这可能会改变他们对 HDHP 的反应。
采用差异中的差异设计，使用商业健康保险索赔数据，评估雇主提供 HDHP 对有心理健康状况的 6627128 参保人年的影响，按是否同时患有物质使用障碍进行分层。
在没有同时患有物质使用障碍的参保人中，尽管心理健康相关急诊就诊支出增加了 11.3%（95%置信区间[CI]=1.0%-21.6%），但 HDHP 提供与心理健康护理总支出减少 4.8%（95% CI=2.4%-7.2%）相关。在同时患有物质使用障碍的参保人中，除了精神药物支出减少 4.5%（95% CI=1.9%-7.2%）外，大多数与心理健康和物质使用障碍联合护理支出相关的类别中，没有发现归因于 HDHP 提供的显著变化。
HDHPs 可能会减少有心理健康状况的参保人对必要护理的使用，这可能会加剧该人群的治疗不足，并导致不良健康后果。
