Association Between Out-of-Pocket Insurance Costs and Psychotherapy Utilization Among Commercially Insured Birthing Individuals

Abstract

Background

Perinatal mood and anxiety disorders (PMADs) are common, burdensome, and costly pregnancy complications, yet few receive treatment. Out-of-pocket costs (OOPCs) may represent a significant barrier to PMAD treatment.

Objectives

In a population of commercially insured enrollees with a documented live birth, we sought to determine whether commercial insurance plans with above-median OOPCs had lower rates and amounts of psychotherapy utilization than plans with below-median OOPCs and whether utilization differed by income or mental health status.

Methods

This serial, cross-sectional study used Optum's de-identified Clinformatics® Data Mart Database (2016–2020). We tested associations using logistic regression predicting psychotherapy utilization. Our sample included 219,043 unique births from 199,022 enrollees in 38,512 insurance plans. We categorized all enrollees as having low or high OOPCs, income below 400% of the federal poverty level or at or above 400% federal poverty level, and claims indicating a PMAD or not.

Results

The median OOPC for psychotherapy rose from $49 in 2016 to $54 in 2020. Enrollees in low OOPC plans were 1.12 (95% confidence interval [1.10, 1.15]) times more likely to utilize psychotherapy than those in high OOPC plans. Lower-income enrollees with PMADs attended the same number of psychotherapy visits regardless of OOPC level (five visits for low and high OOPC plans). Higher-income enrollees attended more psychotherapy by OOPC plan level (seven visits for low OOPC plans vs. six visits for high OOPC plans).

Discussion

Higher OOPCs were associated with lower psychotherapy utilization among higher-income enrollees, whereas lower-income enrollees used less psychotherapy regardless of OOPC level. Reducing or eliminating cost sharing for PMADs may improve access and enhance equity.