Expanded Mental Health Benefits and Outpatient Depression Treatment Intensity

1
Expanded Mental Health Benefits and Outpatient
Depression Treatment Intensity

• Anthony T. Lo Sasso
• University of Illinois at Chicago
• Richard C. Lindrooth
• Medical University of South Carolina
• Ithai Z. Lurie
• John S. Lyons
• Northwestern University
• Research supported by NIMH grant R01MH62114

2
Goal of the Research

• To study how a mental health benefit expansion
  affected outpatient depression treatment
  utilization
• Particular emphasis will be placed on examining
  how the benefit change affected the dose of
  outpatient psycho-therapy received by patients
• Initiation ? OP visits ? sufficient of OP visits

3
Setting Benefit Design

• Large Fortune 50 electronics manufacturing
  company
• Between 1995 and 1996, the company initiated a
  new approach in health benefits for mental health
  with three components
• reduced copayments for mental health treatment
• the creation of a network of select mental health
  providers
• de-stigmatize the treatment of mental disorders

4
Details on the Benefit Change

• Selective contracting with mental health
  providers
• High cost sharing utilization limits for
  out-of-network care
• No limits are placed on in-network mental health
  services
• Coinsurance rates on inpatient care were changed
  from 80 to 90,
• 80 coinsurance for outpatient services was
  replaced with a flat 10 copayment

5
Data

• Claims and enrollment data from intervention
  company for years 1995-1998
• for all persons with a mental health diagnosis or
  procedure code suggestive of mental health
  treatment
• Data only for continuously enrolled members of
  the companys self-insured health insurance plan
• Comparison group comprised of random sample of
  employed persons from Medstat Marketscan
  database, 1995-1998

6
Methods

• We compare outpatient treatment in the
  intervention group to the comparison group over
  time
• Outpatient treatment initiation for depression
• Outpatient treatment visits
• An indicator variable for more than 8 visits for
  psychotherapy
• Basic model
• OP Visits a ßPost ?Intervention
  dPostTreatment ?X e

7
Methods II

• By restricting the regression to the
  within-provider type impact, we can isolate the
  impact of the copayment reduction
  destigmatization
• OP Visits a' ß'Post ?'Treatment
  d'PostTreatment ?1 Non-MD Specialist ?2
  MD-Specialist ?'X e
• Where d' represents the remaining effect of the
  benefit change controlling for the effect of
  provider choice

8
Methods III

• Using estimates of the elasticity of demand for
  mental health treatment from published studies,
  we can decompose d' into the expected impact of
  the cost sharing reduction and destigmatization

9
Descriptive Statistics of Depression Treatment
Initiation and Utilization
Intervention Group Intervention Group Intervention Group Control Group Control Group Control Group
Initiation OP visits gt 8 visits Initiation OP visits gt 8 visits
1995 2.2 5.6 28.7 2.5 5.6 21.7
1996 2.6 7.5 41.0 2.3 6.0 25.2
1997 2.7 6.8 38.0 2.0 5.8 27.4
1998 2.7 6.8 37.3 2.1 6.3 26.9
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Regression Results, Basic Specification
Initiation (Logit-OR) OP Visits (OLS) 8 or More Visits (Logit-OR)
Treatment Post (d) 1.33 1.25 1.25
N310,882 for Initiation regression, n7,560 for
other regressions Indicates 0.01ltplt0.05,
indicates plt0.01
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Descriptive Statistics of Specialist Use
Percentage gt 8 Visits
Intervention Group Intervention Group Intervention Group Comparison Group Comparison Group Comparison Group
Generalist Non-MD specialist MD Specialist Generalist Non-MD specialist MD Specialist
1995 511 385 143 157 226 171
          22.5 35.8 31.5 22.9 21.2 21.1
1996 530 765 150 135 198 132
          31.1 46.9 46.5 18.5 27.3 28.8
1997 609 771 124 150 270 142
          36.3 39.4 37.9 16.0 34.1 26.8
1998 647 775 83 118 274 117
          34.9 39.0 39.8 7.6 37.2 22.2
12
Regression Results, Within-Provider Type
OP Visits (OLS) 8 or More Visits (Logit-OR)
Treatment Post (d') 1.03 1.22
N7,560 Indicates 0.01ltplt0.05, indicates
plt0.01
13
Summary of Findings

• Our prior work has shown that the selective
  contracting network was not defined restrictively
  enough to increase distance to providers, but the
  emphasis on specialist access (particularly
  non-MD) had a significant impact on utilization
  1.25-1.03 0.23 visits
• Based on the RAND HIE elasticity of -0.17, we
  calculate the predicted effect of the copayment
  reduction to 0.42 visits
• The remainder then is attributed to
  de-stigmatization 0.6 visits

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Under Different Assumptions

• If instead we use a higher elasticity measure
  from the literature, -0.32, the predicted impact
  of the copayment reduction is 0.79 visits
• Under this assumption, we are left with a
  de-stigmatization effect of 0.23 visits

15
Discussion

• Our empirical results suggest that the
  combination of benefit changes instituted by the
  company was successful in not only encouraging
  more employees to enter depression treatment, but
  also in enabling more patients to stay in
  treatment longer increasing the likelihood that
  they receive the appropriate minimum adequate
  dose of 8 outpatient psychotherapy visits

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Discussion II

• Our results suggest that each aspect of the
  benefit changepromotion of in-network specialty
  providers, reducing copayments, and a
  company-wide effort to reduce the stigma
  associated with mental health treatmentplayed an
  important part in increasing the number of
  outpatient visits per episode of treatment
  conditional upon treatment initiation for
  depression

17
Conclusion

• Starting treatment is not what matters in
  behavioral healthcare
• Engaging in a successful episode of care is a far
  more relevant indicator
• The results point to the potentially important
  role that corporate benefit designers and
  planners can play in improving access to mental
  health care for employees