45 Income inequalities beyond access to mental health care hours are not considered towards the registration of treatment minutes by themselves, but the therapeutic activities from the categories above provided during inpatient stays are registered as treatment minutes. With regards to the recording of treatment minutes for group activities the total time spent by professionals should be equally divided by the total number of patients taking part. An exception is when the practitioner specifically provides therapy to one of the patients only – and the remainder are watching – in which case minutes are allocated to that patient . A last but important part of a treatment record relates to its closure, which happens under the responsibility of the main practitioner and is an essential step before the health insurer reimburses the care provided. Policy changes to mental health care during the study period We have identified two relevant changes in the Dutch mental health care system during our study period. We describe them over the next paragraphs, even though our estimation strategy accounts for these changes through the inclusion of year fixed effects in the models. First, the introduction of co-payments specific for specialist mental health services (third level) in 2012, with the objective of curbing the expenditure growth in specialist care. These included a co-payment of 100 euros to open a specialist outpatient treatment record and additional 100 euros if the outpatient care exceeded the total of 100 minutes during that record; and a monthly co-payment of 145 euros for specialist inpatient care. These co-payments were abolished from January 2013 onwards, due to its controversial potential impact on access to care. For the second level of care a copayment of 10 to 20 euros per therapy/counselling session was in place for most of the study period, being abolished from January 2014 onwards. Furthermore, the number of sessions reimbursed had a cap that ranged from 5 to 8 sessions [5]. A second change happened in 2014 and consisted of a reform aimed at reorganizing the different levels of care. This reform had the objective of shifting patients to lower levels of care [5], given that the large majority of patients using mental health services was in the specialist setting (third level). Stricter criteria on patients to be treated in each one of the levels of care were introduced: specialist care should in principle be reserved to treat the most severe and complex patients with mental health disorders, while basic care would treat patients who suffer from moderate mental health disorders [5]. There was also a strengthening of the GP role, both as gatekeepers and in terms of support provided to mild complaints, mostly through mental health nurses. 2
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