Did Nationwide Mental Health Insurance Reform in Israel Increase Access to Community-Based Care? : A Population-Based Retrospective Cohort Study.

Abstract

Israel's nationwide mental health reform (July 1, 2015) transferred responsibility and funding for mental healthcare from the Ministry of Health to Israel's four Health Maintenance Organizations (HMOs), aiming to improve access and availability, integrate mental health into general care, and shift delivery toward community-based models. Using electronic health records and administrative data from all four HMOs and the Ministry of Health, we assessed longitudinal trends in mental health service utilization from 2012 to 2019 among continuously insured Israeli residents with any recorded mental health diagnosis, mental health-related service contact, or psychotropic medication dispensing (31% of the national population). Outcomes included annual community-based mental health visits in HMO clinics, outpatient psychiatric visits in hospital clinics, mental health-related emergency department (ED) visits, psychiatric hospitalizations, and psychiatric medication dispensed. Post-reform changes were examined using Poisson regression adjusted for age, sex, social group, and socioeconomic status. Post-reform, community-based visits increased fourfold and hospital outpatient visits increased 3.3-fold. Psychiatric medication dispensing rose by 56% (psychostimulants + 87%; antidepressants + 60%). ED visits without admission increased by 40% while admission rates remained stable; total hospitalizations increased by 10%. Women had higher outpatient and medication use, whereas men had higher ED and inpatient use. Adjusted models indicated a 16% post-reform increase in service utilization (P < .0001). During 2015-2019, we analyzed 265,286 mental health-related ED visits; 77% occurred in psychiatric-hospital EDs and 23% in general-hospital EDs, and most visits did not result in hospitalization (78% in general hospitals; 67% in psychiatric hospitals). Overall, Israel's reform was associated with system-wide expansion and a shift toward community-based care, alongside rising non-admission ED presentations, warranting further research on pathways, clinical need, and follow-up, and on strengthening accessible community-based urgent and crisis alternatives to ED care.