Article Abstract

Online ISSN: 1099-176X    Print ISSN: 1091-4358
The Journal of Mental Health Policy and Economics
Volume 26, Issue 3, 2023. Pages: 101-108
Published Online: 1 September 2023

Copyright © 2023 ICMPE.

Value-Based Insurance Design: Clinically Nuanced Consumer Cost-Sharing for Mental Health Services

Nicole M. Benson¹*, A. Mark Fendrick²

¹MD,MBI, McLean Hospital, Belmont, MA; Mongan Institute, Massachusetts General Hospital, Boston, MA; Department of Psychiatry, Harvard Medical School, Boston, MA, USA.
²MD, Departments of Internal Medicine, School of Medicine, and Department of Health Management & Policy, School of Public Health, University of Michigan, Ann Arbor, MI, USA

While consumer cost-sharing is a common strategy to mitigate health care spending, studies have demonstrated that even modest levels of out-of-pocket cost are associated with lower use of mental health care, including clinically necessary, high-value services. Clinically informed solutions explicitly balancing the need for appropriate access to essential mental health services with growing fiscal pressures faced by public and private payers are needed. Value-Based Insurance Design (VBID) describes a model where consumer cost-sharing is based on the potential clinical benefit rather than price of a specific service or treatment. Clinically nuanced VBID programs have been implemented in an effort to optimize the use of high-value health services and enhance equity through reduced consumer cost-sharing. Overall, the evidence suggests that VBID has demonstrated success in reducing consumer out-of-pocket costs associated with specific, high value services. However, the impact of VBID on overall mental health care spending and clinical outcomes remains uncertain.

Background: While consumer cost-sharing is a widely used strategy to mitigate health care spending, numerous studies have demonstrated that even modest levels of out-of-pocket cost are associated with lower use of medical care, including clinically necessary, high-value services. Within mental health care, increases in cost-sharing are associated with reductions in use of mental health care and psychotropic medication use. Further, these reductions in mental health services and treatments can lead to downstream consequences including worsening of psychiatric illness and increased need for acute care and psychiatric hospitalization. Thus, there is a need for clinically informed solutions that explicitly balance the need for appropriate access to essential mental health services and treatments with growing fiscal pressures faced by public and private payers. Value-Based Insurance Design (VBID) describes a model where consumer cost-sharing is based on the potential clinical benefit rather than the price of a specific health care service or treatment.

Aims of the Study: Describe value-based insurance design and applications in mental health care.

Results, Discussion and Implications for Health Policies: For over two decades, clinically nuanced VBID programs have been implemented in an effort to optimize the use of high-value health services and enhance equity through reduced consumer cost-sharing. Overall, the evidence suggests that VBID has demonstrated success in reducing consumer out-of-pocket costs associated with specific, high value services. By reducing financial barriers to essential clinical services and medications, VBID has potential to enhance equity. However, the impact of VBID on overall mental health care spending and clinical outcomes remains uncertain.