Professional Abstract

Objective

To determine the effect of changing from low- to high-deductible insurance plans on healthcare use and out-of-pocket spending compared with staying on low-deductible plans for people with bipolar disorder

Study Design

Design Element	Description
Design	Observational: cohort study
Population	Insurance claims of 19,654 people ages 12–64 with bipolar disorder and with low- or high-deductible health plans from 2003 to 2014
Interventions/ Comparators	Employer-mandated change from low- to high-deductible health plan No change from low-deductible health plan
Outcomes	Psychiatrist and nonpsychiatrist mental health provider outpatient visit rates, mental health ED and hospitalization rates, bipolar medication median daily dose and associated laboratory monitoring, visit- or medication-associated out-of-pocket spending
Timeframe	1-year follow-up for study outcomes

This retrospective observational cohort study used an interrupted time series with matched comparison design to examine the effect of changing from low- to high-deductible health insurance plans on healthcare use and spending for people with bipolar disorder.

Over two consecutive years, researchers compared people with bipolar disorder who had a low-deductible health plan for at least one year and then had an employer-mandated change to a high-deductible health plan, with people who stayed with a low-deductible plan. To assess healthcare use and spending, researchers reviewed private health insurance claims data. To understand people’s experiences with high-deductible health plans, researchers also interviewed 40 people with bipolar disorder or their family members.

The study included insurance claims from 2003 to 2014 for 19,654 people ages 12–64 with bipolar disorder and low- or high-deductible health plans. The average age was 38, and 62% were female.

People representing bipolar disorder advocacy organizations, insurers, psychiatrists, and patients provided input throughout the study.

Results

Compared with people who continued to have low-deductible health plans, people who changed to high-deductible plans showed a

• 10.9% decrease in visits with nonpsychiatrist mental health providers, such as counselors
• 13.1% increase in out-of-pocket spending for mental health visits overall
• 15.3% increase in out-of-pocket spending for bipolar medication
• 11.3% increase in out-of-pocket spending for other psychotropic medications

These changes were significant (all p<0.05 or lower).

The groups did not differ in the

• Number of visits with psychiatrists
• Number of emergency department (ED) or hospital visits related to mental health
• Average monthly median daily dose of bipolar medication taken by patients over 30 days
• Number of lab tests to monitor medication

In interviews, people reported hardship because of high costs associated with high-deductible plans. They used a range of strategies to cope with these challenges, such as cutting spending in other areas of life or requesting exemptions from insurance restrictions. People reported prioritizing bipolar care over other types of care.

Limitations

The study was observational, and the claims data did not include severity of bipolar disorder. These factors may result in unmeasured confounding.

Conclusions and Relevance

In this study, changing to a high-deductible plan was associated with a reduction in visits to nonpsychiatrist mental health providers and an increase in patient spending for mental health services and medications; it was not associated with differences in other outcomes. Interviews suggested that patients maintain essential services to manage bipolar disorder, using different strategies to cope with challenges related to high-deductible plans.

Future Research Needs

Future research could examine whether reducing visits to nonpsychiatrist mental health providers causes adverse mental health or clinical events.