Abstract
BackgroundIn 2015, mental health services were added to the Israeli National Health Insurance package of services. As such, these services are financed by the budget which is allocated to the Health Plans according to a risk adjustment scheme. An inter-ministerial team suggested a formula by which the mental health budget should be allocated among the Health Plans. Our objective in this study was to develop alternative rates based on individual data, and to evaluate the ones suggested.MethodsThe derivation of the new formula is based on our previous study of all psychiatric inpatients in Israel in the years 2012–2013 (n = 27,446), as well as outpatients in one psychiatric clinic in the same period (n = 6115). Based on Ministry of Health and clinic data we identified predictors of mental health services consumption. Age, gender, marital status and diagnosis were used as risk adjusters to calculate the capitation rates for outpatient care and inpatient care, respectively. All prices of services were obtained from the Ministry of Health tariffs. These rates were modified to include non-users using restricted models.ResultsThe mental health capitation scales are typically “humped” with regard to age. The rates for ambulatory care varied from a minimum 0.19 of the average consumption for males above the age of 85 to a maximum of 1.93 times the average for females between the ages of 45–54. For inpatient services the highest rate was 409.25 times the average for single, male patients with schizophrenia spectrum diagnoses, aged 45–54. The overall mental health scale ranges from 2.347 times the average for men aged 45–54, to 0.191 for women aged 85+. The modified scale for the entire post-reform package of benefits (including both mental health care and physical health care) is increasing with age to 4.094 times the average in men aged over 85. The scale is flatter than the pre-reform scale.ConclusionsThe risk adjustment rates calculated for outpatient care are substantially different from the ones suggested by the inter-ministerial team. The inpatient rates are new, and indicate that for patients with schizophrenia, a separate risk-sharing arrangement might be desirable. Adopting the rates developed in this analysis would decrease the budget shares of Clalit and Leumit with their relatively older populations, and increase Maccabi and Meuhedet’s shares. Future research should develop a risk-adjustment scheme which covers directly both mental and physical care provided by the Israeli Health Plans, using their data.
Highlights
Mental health services in Israel are included in the third addendum to the National Health Insurance Law (1994) [1], along with other services that until the law came into effect were provided by the state
The risk adjustment rates calculated for outpatient care are substantially different from the ones suggested by the inter-ministerial team
The goal of this study is to propose a risk adjustment scheme for mental health based on expected cost of patients classified by age, gender, marital status and diagnosis, to derive overall post-reform risk adjustment rates based on age and gender, and to examine how a formula based on these rates would effect the allocation of the budget among the Health Plans
Summary
Mental health services in Israel are included in the third addendum to the National Health Insurance Law (1994) [1], along with other services that until the law came into effect were provided by the state. Most ambulatory and hospitalization services were provided in the past by government operated mental health clinics and hospitals, rather than by the Health Plans. This dichotomy of separation of psychiatric and other mental health services from the rest of health care is undesirable in the opinion of the majority of those concerned, primarily with regarding patients who suffer from psychiatric disorders. In 2015, mental health services were added to the Israeli National Health Insurance package of services As such, these services are financed by the budget which is allocated to the Health Plans according to a risk adjustment scheme. Our objective in this study was to develop alternative rates based on individual data, and to evaluate the ones suggested
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