Results Summary
What was the research about?
People with bipolar disorder have severe changes in mood, energy, and activity levels. To feel and function well, they need regular medical care.
Some people with bipolar disorder are enrolled in high-deductible health plans, or HDHPs. HDHPs require people to pay more toward the cost of their healthcare services than low-deductible health plans. If people face high out-of-pocket costs, they may have trouble paying for treatment and avoid getting care.
In this study, the research team compared use of health services for people with bipolar disorder who had to switch to an HDHP with those on a low-deductible health plan.
What were the results?
Compared with people who had low-deductible health plans, people who switched to HDHPs had an
- 11 percent decrease in mental health visits with nonpsychiatrist providers, such as counselors
- 15 percent increase in out-of-pocket costs for bipolar medicine
- 11 percent increase in out-of-pocket costs for other mental health medicines
- 13 percent increase in out-of-pocket costs for mental health visits overall
The groups didn’t differ in
- Number of visits with psychiatrists
- Number of emergency room or hospital visits related to mental health
- Amount of bipolar medicine patients took, on average, over 30 days
- Number of lab tests to monitor medicine
In interviews, people with HDHPs reported hardship due to their increased costs for treatment. They coped in different ways. Some cut back on costs in other areas of life. Others asked for exemptions from insurance restrictions. People prioritized their bipolar care over other types of care.
Who was in the study?
The study included insurance claims from 19,654 people ages 12–64 with bipolar disorder. The average age was 38, and 62 percent were women. The claims were from 2003 to 2014. The research team also interviewed 40 people with bipolar disorder who had experience with an HDHP.
What did the research team do?
The research team reviewed insurance claims for people with bipolar disorder and identified two groups of people. In one group, people had a low-deductible health plan for at least one year, and then their employers switched them to an HDHP. In the other group, people had a low-deductible plan for two years in a row. The team compared patients’ out-of-pocket costs for treatment, use of medicine, and number of mental health visits. The team also interviewed 40 people about their experiences with HDHPs and bipolar disorder.
Bipolar disorder advocacy groups, insurers, psychiatrists, and people with bipolar disorder gave input to the research team and reviewed study results.
What were the limits of the study?
The research team didn’t assign patients to each group by chance, so they can’t be sure that the results were entirely due to the change in insurance. The team also didn’t know how severe patients’ bipolar disorder was in either group.
Future research could see if decreases in nonpsychiatrist mental health visits affect patient mental health.
How can people use the results?
Employers can use the results when considering the types of health plans they offer employees. People with bipolar disorder can use the results when considering types of insurance.
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 |
|
| 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 |
| 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.
Final Research Report
View this project's final research report.
More About This Research
Peer-Review Summary
Peer review of PCORI-funded research helps make sure the report presents complete, balanced, and useful information about the research. It also assesses how the project addressed PCORI’s Methodology Standards. During peer review, experts read a draft report of the research and provide comments about the report. These experts may include a scientist focused on the research topic, a specialist in research methods, a patient or caregiver, and a healthcare professional. These reviewers cannot have conflicts of interest with the study.
The peer reviewers point out where the draft report may need revision. For example, they may suggest ways to improve descriptions of the conduct of the study or to clarify the connection between results and conclusions. Sometimes, awardees revise their draft reports twice or more to address all of the reviewers’ comments.
Peer reviewers commented and the researchers made changes or provided responses. Those comments and responses included the following:
- The reviewers expressed concern that the study might have excluded people with more severe forms of bipolar disorder. The researchers responded that their only restriction on participants was that they had spent at least one year in a low-deductible health plan followed by at least one year in a high-deductible health plan that an employer had mandated. The researchers said these criteria captured people with all severity levels of bipolar disorder. They illustrated this statement by showing that among the patients included, 29 to 30 percent had emergency department visits and 13 to14 percent had hospitalizations in the baseline year.
- The reviewers wondered if the relatively minor consequences observed in this study of switching to high-deductible plans would be true for people with very high deductibles. The researchers agreed that patients with very high deductibles are an important group to study but said such deductible levels are not common, so results of such an analysis would not be generalizable. The researchers noted that only 5 percent of patients in their study had deductibles of $2500 or higher. They added comments to the report stating that the small number of patients with very high deductibles precluded their ability to analyze results separately for this group. The researchers commented that as rates of high-deductible plans rise, future research should focus on this question.
- The reviewers similarly wondered if the results were generally equivocal because the difference between low-deductible plans and high-deductible plans could be as little as $500, which might not be enough of a difference to change patients’ treatment behavior. The researchers pointed out that $500 would be the minimum difference in deductibles so the average difference was much higher. However, the researchers also noted that they did not have a sufficient sample with very high deductibles to be able to compare treatment behaviors in just this subgroup to the low-deductible group.
- The reviewers noted that the one-year follow-up for the study was too short to fully assess the consequences of reduced use of preventative care. In particular, the reviewers noted that the substantial decrease in non-psychiatric medical visits was worrying and wondered if differences in health outcomes would emerge over time. The researchers agreed that differences in measures like emergency department visits and hospitalizations could emerge over time and said their study design could examine such outcomes. However, they said much larger sample sizes would be needed, e.g., 100,000 people, compared with the fewer than 6500 people in their study, to assess differences in long-term adverse events such as heart attacks and strokes.
- The reviewers asked why the study included adolescents over age 12, since the bipolar diagnosis is not stable in adolescents, there is little evidence that interventions used in adults benefit children and adolescents, and adolescents do not pay for their own health care. The researchers replied that any measurement error resulting from including children and adolescents would be the same across study groups and therefore, not a source of bias. They also stated that changing to a high-deductible plan would still affect these young people’s ability to access care, even if the change in insurance coverage was due to caregiver rather than patient actions.
Conflict of Interest Disclosures
View the COI disclosure form.
Journal Citations
Results of This Project
Related Journal Citations
Peer-Review Summary
Peer review of PCORI-funded research helps make sure the report presents complete, balanced, and useful information about the research. It also assesses how the project addressed PCORI’s Methodology Standards. During peer review, experts read a draft report of the research and provide comments about the report. These experts may include a scientist focused on the research topic, a specialist in research methods, a patient or caregiver, and a healthcare professional. These reviewers cannot have conflicts of interest with the study.
The peer reviewers point out where the draft report may need revision. For example, they may suggest ways to improve descriptions of the conduct of the study or to clarify the connection between results and conclusions. Sometimes, awardees revise their draft reports twice or more to address all of the reviewers’ comments.
Peer reviewers commented and the researchers made changes or provided responses. Those comments and responses included the following:
- The reviewers expressed concern that the study might have excluded people with more severe forms of bipolar disorder. The researchers responded that their only restriction on participants was that they had spent at least one year in a low-deductible health plan followed by at least one year in a high-deductible health plan that an employer had mandated. The researchers said these criteria captured people with all severity levels of bipolar disorder. They illustrated this statement by showing that among the patients included, 29 to 30 percent had emergency department visits and 13 to14 percent had hospitalizations in the baseline year.
- The reviewers wondered if the relatively minor consequences observed in this study of switching to high-deductible plans would be true for people with very high deductibles. The researchers agreed that patients with very high deductibles are an important group to study but said such deductible levels are not common, so results of such an analysis would not be generalizable. The researchers noted that only 5 percent of patients in their study had deductibles of $2500 or higher. They added comments to the report stating that the small number of patients with very high deductibles precluded their ability to analyze results separately for this group. The researchers commented that as rates of high-deductible plans rise, future research should focus on this question.
- The reviewers similarly wondered if the results were generally equivocal because the difference between low-deductible plans and high-deductible plans could be as little as $500, which might not be enough of a difference to change patients’ treatment behavior. The researchers pointed out that $500 would be the minimum difference in deductibles so the average difference was much higher. However, the researchers also noted that they did not have a sufficient sample with very high deductibles to be able to compare treatment behaviors in just this subgroup to the low-deductible group.
- The reviewers noted that the one-year follow-up for the study was too short to fully assess the consequences of reduced use of preventative care. In particular, the reviewers noted that the substantial decrease in non-psychiatric medical visits was worrying and wondered if differences in health outcomes would emerge over time. The researchers agreed that differences in measures like emergency department visits and hospitalizations could emerge over time and said their study design could examine such outcomes. However, they said much larger sample sizes would be needed, e.g., 100,000 people, compared with the fewer than 6500 people in their study, to assess differences in long-term adverse events such as heart attacks and strokes.
- The reviewers asked why the study included adolescents over age 12, since the bipolar diagnosis is not stable in adolescents, there is little evidence that interventions used in adults benefit children and adolescents, and adolescents do not pay for their own health care. The researchers replied that any measurement error resulting from including children and adolescents would be the same across study groups and therefore, not a source of bias. They also stated that changing to a high-deductible plan would still affect these young people’s ability to access care, even if the change in insurance coverage was due to caregiver rather than patient actions.