In our paper recently published by The Lancet Psychiatry we describe inequalities by income along the mental health treatment pathway in the Netherlands.
Our results are pivotal in quantifying disparities favourable to patients with a higher income that persist through the different stages of mental health treatment. While calling for a better understanding of the role of social environment and quality of care as complementary mechanisms, these findings highlight the limitations of solely focusing on access to care to reduce the mental health gap
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In our paper published Health Economics we study the effect of becoming eligible to supported housing, a program that provides housing, personal and domestic care, guidance, and daily activities to persons with mental disorders.
Read more on the original open access publication, or find below a short summary!
Summary
We use a leniency design that leverages on the different strictness of the assessors deciding if each applicant is eligible to supported housing or to other forms of long-term care (such as support at own home). Because of variation in assessor leniency, a case that is difficult to assess (at the margin) might be considered eligible if allocated to less strict assessors and non-eligible by more strict assessors. This creates similar eligible and non-eligble subgroups whitin the subset of applicants at the margin, that we compare in our study.
We find that being eligible to supported housing increases the the probability of moving into these structures and decreases the use of home care, resulting in higher total health and social care expenditures. This increase is primarily due to the costs of supported housing, but potentially also higher consumption of outpatient mental health care.
We also study effects on income and employment measures, finding that eligibility to supported housing eligibility reduces the total personal income and income from work. Our results suggest lower participation in the labor market by individuals granted eligibility, but the labor participation of their parents increases in the long-run.
Our study suggests that policy decisions on extending supervised environments should consider the trade-off between effects in the various domains, and weight the different perspectives of the system, the individual and the families. While our findings seem to support some of the usual criticisms towards supported housing - a costly form of care that might undermine patient's social functioning - we are not able to study relevant outcomes such as wellbeing and quality of life, and found positive spillover effects to parental employment.
In our paper published by Social Science & Medicine we use a difference-in-discontinuity design to study increased cost-sharing in youth.
We find that high deductibles led Dutch young adults to reduce the use of mental health services. The deductible increase reduced mental health care use mostly among low-income females.
These findings lead us to conclude that financial barriers increase the mental health care gap at the transition to adulthood. Furthermore, blunt forms of cost-sharing widen inequalities in access to mental health care among youth.
Our paper is open access: read it here!
Summary
We find that the deductible increase of approximately 180 euros between 2011 and 2013 led girls turning 18 to use mental treatment less because they start paying this form of cost-sharing. From 8.1% of young women using mental health services, on average, only 7% did so when the deductible increased. This corresponds to a reduction of 13.6%. We also found that it was mostly young women coming from lower-income households that did not receive treatment anymore.
Our findings highlight that making young adults pay higher amounts of their treatment increases inequalities in access to mental health care in a crucial period of life, with potential long-term consequences on mental health and development.
These effects are concerning because they happen at a time when a lot of adolescents turning into adults would already have their treatment disrupted or stopped. This is the so-called transition gap, often triggered by the change between the mental health care system for children/adolescents and the system for adults. Cost-sharing is therefore contributing to an unequal transition gap in the Netherlands, because the deductible increase impacted lower-income girls the most.
Using an natural experiment and rich administrative data was essential to achieve these conclusions: we study the entire Dutch youth population and compare individuals just before and after turning 18, and between the periods of low (2009-2011) and high deductible (2013-2014). This allows us to perform a causal evaluation of the policy by observing what happened in the real-world.
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Summary (Dutch)
Een onlangs gepubliceerde studie van onderzoekers van het Erasmus Medisch Centrum Rotterdam en de Erasmus Universiteit Rotterdam laat zien hoe een verhoging van het verplicht eigen risico in Nederland leidde tot een afname in zorggebruik van geestelijke gezondheidszorg (GGZ) door jongvolwassenen. Het gaat hierbij om zorggebruik zoals de psycholoog of een psychiatrische behandeling.
Tussen 2011 en 2013 nam het eigen risico toe met zo’n 180 euro. Dit heeft ertoe geleid dat meisjes die op 18-jarige leeftijd eigen risico zijn gaan betalen, minder gebruik van GGZ zijn gaan maken. Van de 8,1% jonge vrouwen die gebruik maakten van de GGZ, deed gemiddeld slechts 7% dat toen het eigen risico toenam. Dit komt overeen met een daling van 13,6%. Deze daling was het meest uitgesproken (20%) voor jonge vrouwen uit huishoudens met lage inkomens.
Deze bevindingen laten zien dat ongelijkheid in de toegang tot de GGZ toeneemt wanneer het eigen risico voor jongvolwassenen stijgt. Verminderde toegang tot de GGZ in deze cruciale periode van het leven heeft mogelijke langdurige gevolgen voor de geestelijke gezondheid en ontwikkeling van jongvolwassenen.
Deze resultaten zijn zorgwekkend omdat ze optreden op het moment dat adolescenten volwassen worden. De behandeling wordt dan regelmatig bewust of onbewust onderbroken of stopgezet omdat er moet overgestapt worden van het zorgsysteem voor kinderen/adolescenten naar het zorgsysteem voor volwassenen. Het verhogen van het verplicht eigen risico in de zorgverzekering draagt bij aan deze zogenaamde transitiekloof, en in het bijzonder onder jonge vrouwen uit lage inkomens huishoudens.
Het gebruik van een natuurlijk experiment en administratieve gegevens was essentieel om de impact van de verhoging van het eigen risico te evalueren. We maakten gebruik van zorgdeclaratie gegevens van de gehele Nederlandse bevolking en vergeleken jongvolwassenen net voor en nadat ze 18 jaar werden. We vergeleken de periodes met lage (2009-2011) en hoge eigen risico (2013- 2014). Dit stelt ons in staat om het beleid causaal te evalueren.
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