Association of Cost Sharing With Mental Health Care Use, Involuntary Commitment, and Acute Care

JAMA Psychiatry. 2017 Sep 1;74(9):932-939. doi: 10.1001/jamapsychiatry.2017.1847.


Importance: A higher out-of-pocket price for mental health care may lead not only to cost savings but also to negative downstream consequences.

Objective: To examine the association of higher patient cost sharing with mental health care use and downstream effects, such as involuntary commitment and acute mental health care use.

Design, setting, and participants: This difference-in-differences study compared changes in mental health care use by adults, who experienced an increase in cost sharing, with changes in youths, who did not experience the increase and thus formed a control group. The study examined all 2 780 558 treatment records opened from January 1, 2010, through December 31, 2012, by 110 organizations that provide specialist mental health care in the Netherlands. Data analysis was performed from January 18, 2016, to May 9, 2017.

Exposures: On January 1, 2012, the Dutch national government increased the out-of-pocket price of mental health services for adults by up to €200 (US$226) per year for outpatient treatment and €150 (US$169) per month for inpatient treatment.

Main outcomes and measures: The number of treatment records opened each day in regular specialist mental health care, involuntary commitment, and acute mental health care, and annual specialist mental health care spending.

Results: This study included 1 448 541 treatment records opened from 2010 to 2012 (mean [SD] age, 41.4 [16.7] years; 712 999 men and 735 542 women). The number of regular mental health care records opened for adults decreased abruptly and persistently by 13.4% (95% CI, -16.0% to -10.8%; P < .001) per day when cost sharing was increased in 2012. The decrease was substantial and significant for severe and mild disorders and larger in low-income than in high-income neighborhoods. Simultaneously, in 2012, daily record openings increased for involuntary commitment by 96.8% (95% CI, 87.7%-105.9%; P < .001) and for acute mental health care by 25.1% (95% CI, 20.8%-29.4%; P < .001). In contrast to our findings for adults, the use of regular care among youths increased slightly and the use of involuntary commitment and acute care decreased slightly after the reform. Overall, the cost-sharing reform was associated with estimated savings of €13.4 million (US$15.1 million). However, for adults with psychotic disorder or bipolar disorder, the additional costs of involuntary commitment and acute mental health care exceeded savings by €25.5 million (US$28.8 million).

Conclusions and relevance: Higher cost sharing for seriously ill and low-income patients could discourage treatment of vulnerable populations and create substantial downstream costs.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adolescent
  • Adult
  • Age Factors
  • Commitment of Mentally Ill / economics*
  • Cost Sharing / economics*
  • Female
  • Health Care Costs / statistics & numerical data
  • Humans
  • Male
  • Mental Health Services / economics
  • Mental Health Services / statistics & numerical data*
  • Netherlands
  • Young Adult