43 Income inequalities beyond access to mental health care APPENDIX A INSTITUTIONAL CONTEXT Mental health care in the Netherlands Mental health care in the Netherlands consists of three levels. General practitioners (GP) and mental health nurses working in GP practices are responsible for firstlevel services and provide short-term support for mental distress and mild complaints. These primary care providers act as gatekeepers for the two additional, and more intensive, levels of services that constitute the mental health care sector (Geestelijke gezondheidszorg; GGZ). The second level consists of care provided in outpatient settings, mostly by psychologists, psychotherapists, and geriatric specialists (designated first-line until 2013 and as basic care from 2014 onwards). The third level, and the focus of our study, is specialist care which is provided by clinical psychologists, psychiatrists, and multidisciplinary teams in both outpatient and/or inpatient settings, often within large mental health care providers (designated second-line until 2013 and specialist care from 2014 onwards). The change in denominations in 2014 resulted of a reorganization of these levels of care, described in the section below. All levels of mental health care are covered by the mandatory standard insurance benefit package. While there are zero out of pocket costs for the patients using primary care, services provided by the mental health care sector (second and third levels) fall under a health care-wide annual deductible. The deductible ranged from 170€ to 385€ per year in the study period study and applies not only to mental health services but to most other health care such as other specialist (physical) services and medicines. Most mental health care treatments are covered by the standard insurance benefit package with some exceptions for specific treatments such as neurofeedback and gestalt therapy, or care provided for adaptation disorders and relationship problems (coverage removed in 2012) [1]. Specialist mental health care treatment records At the third level of care – the focus of our study – providers of specialist mental health care are reimbursed under a case-mix system; ‘diagnosis treatment combinations’ (Diagnose Behandeling Combinatie; DBCs), which provides the ground for our data. For everyone accessing specialist care, the provider must open a treatment record that can at most have a duration of 364 days. The treatment record can only be created by a mental health professional with certain professional qualifications – the main practitioner - who becomes responsible for the treatment course. The main practitioner identifies the primary diagnosis and is also responsible for accurately completing information on the treatment record. The record opening should coincide with the first direct or indirect patient-related activity. A first treatment record will usually start with pre-intake and intake and diagnosis activities, followed by therapeutic activities. Alternatively other activities provided include guidance, nursing care and crisis care. While pre-intake consists of administrative procedures to get the patient onboard, the intake and diagnosis phase 2
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