Study On The Economic Burden Of Mental Disorders And The Influence Of Health Insurance

BackgroundWith the quick pace of life in modern society, the great difference between the rich and poor, more and more work and social pressure, the great gap between people’s expectation and the actual situation and long-term chronic diseases,the number of patients with mental disorders is growing. World Health Organization showed thatthere was one person among 4 people having some kind of mental disorders in the life. Mental health has become a prominent social problem. In 1970s, the prevalence rate of mental disorders was 3.2%-7.2%. In recent years,the prevalence rate of adults has risen to about 17.5%.The number of serious mental disorders reached 16 million, and because of the difficulty of screening, this prevalence rateis far below the actual prevalence rate. Only less than 10% of patients with mental disorders seek treatment currently, the remaining 90% of patients hang out in the society. Inability to pay for treatment costs is the main cause of no treatment. And health expenditure in China is heavily skewed towards physical illness, less than 1% was spent in the field of mental health.Therefore, the government’s health expenditureis not tied to the burden of disease currently. Especially in recent years, due to the rapid development of economy, the serious impact of western thought, the gap bettween the reality of life and the expectation, the prevalence of mental illness is getting higher and higher. Since 21st century, the government has promulgated "Chinese mental health plan (2002-2010)" and the national mental health system development guidelines (2008-2015) ", made the development program of mental health care system. One of the objectives is to popularize the knowledge of psychological health, improve the diagnosis and treatment of mental disorders. In 2009, China began to implement the new health care reform, to achieve universal health coverage and solve the expensive and difficult medical treatment. Meanwhile, mental disorderswereincorporated into the basic public health service project. On October 26,2012, The twenty-ninth session of the Standing Committee of the Eleventh National People’s Congressadopt the "the people’s Republic of mental health law, and it wouldcome into effect on May 1,2013. The mental health law pointed out that the medical costs of patients with mental disorders can be reimbursed by basic medical insurances. But there is no special medical insurance for mental disorders. In a few areas, the deductible was reduced or remitted or reimbursement ratio was increased slightly to promote mental health.But in the field of mental health, due to the thin foundation of mental health, insufficient investment, serious discrimination against patients with mental disorders, the deficiency of mental health professionals and disease monitoring, data availability and related research is very scarce. Although epidemiological surveys of mental disorders have developed since twentieth century, there is still no clear study of the economic burden of family and society on patients with mental illness. With the increased prevalence, growth ofmedical expenses and increased mental health services demand, the economic burden of mental illness will be growing. Therefore, mental health will bring more severe challenges for the national health planning and resources allocation. The study on the economic burden of mental illness will provide an important basis for the allocation of health resources. At present, the basic medical insurance is the most direct and effective economic intervention to alleviate the economic burden of family effectively. Since the reform of medical system, the construction of basic medical insurance system in China has been developed rapidly, for example, the scope of coverage has been expanded and financing has been raised. Although the basic medical insurance has covered the patients with mental disorders, but the differences of financing and compensation among insurances is relatively large.Whether thedifference of compensation of different medical insurances for patients with mental illness exists? Along with the continuous deepening of the reform of the medical insurance, should medical insurance further promote universal coverage or strengthen the structure adjustment of medical insurance? The related research has great significance to the adjustment on the policy of medical insurance reform.MethodsIn this study, we used the prevalence-based, bottom-up economic methods to calculate the family and social economic burden of mental disorders. The direct method was used to calculate the social direct economic burden of mental disorders, and the actual treatment rate of patients with mental disorderwas considered. Human capital method was used to calculate indirect economic burden. Indirect economic burden to the family including wage loss of patients and caregivers due to hospitalization. The per capita wage, and 250 working days a year,8 working hours everyday were used. The economic loss due to disability caused by mental disorders was measured by DALYs (disability adjusted life years).Due to the existence of inflation (or deflation), the economic income, medical expenses in different years need to be discounted in order to compare them.In this study, data in 2013as a benchmark, the data in other years were adjusted according to the consumer price index (CPI) to exclude the impact of price to facilitate the longitudinal comparison.Methods of statistical analysis used in the study mainly conclude:(1)Q-Q figure and Shapiro Wilk test showed the cost and utilizationdata distribution was skewed, so this study on main results reportedmean value, standard deviation, and the median.The frequency, mean, median, and percentage were used to describe sociodemographic and clinical characteristics, health service utilization and economic burden of patients with mental disorders. (2) this studywas divided into different levels based on sociodemographic and clinical characteristics to exclude the interference of confounding factors, and Mann Whitney U test (two groups) and Kruskal Wallis test (more than two groups) were used to analysethe difference of mental service utilization. (3)generalized linear regression was used to analyse the influencing factors of the direct medical cost of inpatients with mental disorders. (4) sensitivity analysis was used to identify the effect of uncertain factors to the social economic burden.Uncertain factors included in the sensitivity analysis were:prevalence, direct medical cost, and treatment rate. (5) rate andpercentage were used to analyse the reimbursement results of different insurances, including interior camparition among health insurances, patients withinsurance and patients without insurance. Mann Whitney U test (two groups comparison) and Kruskal Wallis test (more than two groupscomparison) were used to campare the difference among different characters of patients. (6) least square methodwas used to analysethe effect of different health insurances on mental service utilization and medical cost when the other factors (gender, age, marital status, occupations, living area, admission diagnosis)were controlled. (7) overall economic risk, absolute economic risk, relative economic risk, economic risk changes, indirect standardization of health services and concentration index were used to evaluate the equity of compensation for patients with mental disorders.Results1. In the utilization of mental health service, the utilization rate of mental health services in China was relatively low with two-week consultation rate around 0.7‰ and hospitalization rate 0.2‰-0.5‰. However, the utilization rate of mental health service in urban areas was slightly higher than that in rural areas.In Shandong province, outpatient frenquency of 97.9% of patients was 1 time.There was significant difference in outpatient frenquency among different living regions and occupations of patients with mental disorders. Hospitalization frenquncy of 60% of inpatients was 1 time, and LOS wasless than 30 days, but the utilizationamong different patients(genders,age,marital status,occupations,living regions, diagnosis, discharge time and income)was not same statistically (p<0.05).2.The economic burden of family caused by mental disordersincreased form 7938.02RMB in 2005 to 22105.41RMB in 2013. The economic burden of women, 18-39 years-old patients,urban patients and schizophrenia was higher than that of men, >55 years old patients,rural patients and other diagnoses, respectively.The proportion of direct economic burden of family was higher (more than 50%). The proportion of direct medical economic burden in urban areas accounting for per capita disposable income was 50%-80%.In rural areas, the proportion of direct medical economic burdens accounting for per capita disposable incomewas more than 130%, eventhough it declined in 2012 and 2013, but it was still above 80%.3.In general, the social economic burden increased from 100.76 billion yuan in 2005 to 312.77 billion yuan in 2013, and the proportion ofthe social economic burden accounting for GDP of Shandong province was between 0.5%-0.7%. The economic burden of women,18-39 years-old patients,rural patients and mood disorders was higher than that of men, more than55 years old patients, urban patients and other diagnoses, respectively.From sensitivity analysis,the prevalence rates had the largest effect on economic burden of mental disorders. With the prevalence of 11.9%, social economic burden decreasedfrom 312.77 yuan to 212.68 billion yuan in 2013.The economic costs decreased to 248.17yuan in 2013with 2.08% treatment rate.4.Generalized linear regression analysis showed that the time of hospitalization, LOS, hospitalization frenquncy and medical insurance patients had significance (P<0.05) and hospital costs of insured patients was higher than that of uninsured patients.5.In the hospital costs, costs of insured patients was higher than that of uninsured patients, but OOP of insured patients was significantly lower than that of uninsured patients.There were significant differences among hospital cost and OOP of patients with different characteristics. The compensation amount and compensation rate of UEBMI was the highest and those of NRCMI was the lowest among basic insurances. With the increase of reimbursement rate, the compensation amount would increase.The differences of reimbursement amount of patients with different marital status and income levels weresignificant.6.The regression model showed that:medical insurance can reduce OOP(-0.268). Basic medical insurance for urban workers and residents were also able to reduce OOP in patients with mental illness (-0.385 and -0.226). Although the new rural cooperative medical insurance showed the trend of reducing OOP, it had no statistical significance.7. In the equity of compensation, economic risk of disease increased with the increase of hospital cost.More than 30% of patients of economic risk of diseasewas higher than 1; from the point of the changes of economic risk, economic risk of patients with low cost and high cost decreased, which implied that medical insurance decreased the economic burden of patients with low and high hospital costs.The economic risk of urban patients was relatively high, but after adjustment with income, the disease economic risk of rural patients was higher than that of urban patients; after the compensation of medical insurances,the economic risk of urban patients decreased and the economic risk of rural patients increased, which implied that medical insurance did not reduce the economic burden of rural patients. From the point of economic risk of patients with different medical insurances, the economic risk of NRCMI was higher than that of UEBMI and URBMI. Medical insurance reduced the economic burden of patients with UEBMI rather than URBMI and NRCMI.From the measurement of equity of reimbursement, standardizationinsurance costs of UEBMI was the highest (14783.01 RMB), and the fariness level of NRCMI was lower (CI=0.189), and concentration index was postive of three basic medical insurances, which indicated that medical insurances all exist the phenomenon that the rich benefit.Conclusions and Policy Implications1. the utilization of mental health services is low. It is well known that mental disordersare chronic diseases,treatment and rehabilitation need a long time, and the condition is easily repeated,which show the utilization of mental health service shoud be high. But the results concluded that two week visiting rate, hospitalization rate, lenth of stay and frenquency were not high. Therefore, in order to improve the utilization rate of patients with mental disorders, we should first take measures to reduce the social discrimination against mental disorders, strengthen the propaganda and education of mental health knowledge, encourage patients to recevie early treatment, early rehabilitation. Second, the government should actively take measures to increase mental health resources, increase mental health expenditure reasonably, guide more young people learn mental heath and related majors, train a group of professional mental health practitioners, community mental health physician and related mental health service personnel to support treatment and rehabilitation of patients with mental disorders.2.the economic burden of mental illness to the family and society is heavy and has showed a rising trend during 2005-2013.This study showed that the economic burden of mental disorders to family and society has been increasing in 2005-2013, but the economic burden of patients with different characteristics was not uniform. In order to reduce the heavy economic burden of mental disorders to the family, the government needs to increase expenditure in the prevention and treatment of mental disorders, especially to strengthen the care and subsidies of vulnerable groups, adjustthe policy of health insurance, improve reimbursement rate of patients with mental disorders, incorporate more psychiatric drugs into the basic health insurance reimbursement directory. But in order to improve the quality of life of patients with mental disorders and family, the establishment of a sustainable mental health care system to meet the needs of the population growth, reduce economic costs of mental disordersis urgentin China. The key is to integrate mental health care reform and primary health care reform and establish a community management system for mental disorders, as well as to strengthen primary care systems and community support, and to establish an effective and continuous dual referral mechanism between hospitals and primary health care.3. the impact of health insurance on medical costs.Significant differences exsit in the cost of hospitalization, and the total hospital cost of insured patients was significantly higher than the total hospital cost of uninsured patients. Health insurance reducedOOP of insured patients effectively.In the interior of health insurances, the reimbursement rate of patients with basic medical insurance for urban worker was the highest, followed by patients with basic medical insurance for urban residents and patients with new rural cooperative medical insurance. Therefore, the government shoud investigate the situation of uninsured people to understand the reasons, then to encourage them to have health insurance and give economic support. At the same time,it is important to increase the reimbursement rate of patients according to the severity of the disease, but also consider the compensation equity between different types of insurance. After merging basic medical insurance for urban residents and new rural cooperative medical insurance in every regions, then it is important to gradually achieve the unity of all kinds of medical insurance to narrow the gap of different medical insurance system, reflecting the equity of medical insurance system.