Schizophrenia Treatment Coverage Provided by the Public and Private Health Systems of Chile

Schizophrenia was the only mental health problem included in the original list of 25 GES-covered conditions in 2005. As the number of mandated-coverage conditions progressively increased to 85, another three mental health conditions were added to the list. Schizophrenia was selected because of the severity of the associated psychotic episodes, high potential for causing disability early in life, repercussions for the family of the individual with the disorder, and high cost of treatment. In addition to these considerations, advocacy of professional organizations and families influenced the decision to include schizophrenia in the GES. Furthermore, its inclusion was facilitated by the fact that this condition had been addressed as part of a national mental health plan launched in 2000, and partial measures had already been undertaken to improve care for patients with schizophrenia. The GES for schizophrenia includes four mandates described in the following.

The interventions that insurance plans must cover are detailed in four sections below (copayment amounts are as of December 2019).

The 2005 reform has had enormous significance for the care of people with schizophrenia. The Chilean public health care system is organized geographically, with semiautonomous service systems responsible for the delivery of primary, secondary, and tertiary care services to the population of a specific territory. A key milestone in the history of the Chilean public mental health system was the integration of mental health care services into this extensive public network in 1990. This policy led to the hiring of psychologists as part of the regular staff of primary care centers and to the creation of community mental health centers, day treatment centers, psychosocial rehabilitation programs, and group homes (3). Despite these important steps, access to services and quality of care for people with schizophrenia were strikingly inadequate before the national schizophrenia treatment program was implemented in 2005.

The private mental health care system in Chile consists of services that include solo practitioners, a few outpatient psychiatric centers, and small inpatient psychiatric facilities. Although this system offered a greater availability of psychiatric and psychological services than the public system before the 2005 reform, the access, quality, and continuity of care of the private system were inadequate. Key factors that contributed to these inadequacies were limited coverage of mental health care and high costs due to copayments for psychiatrist and psychologist fees and to high prices for psychotropic medications in private pharmacies. As a result, a significant proportion of people with schizophrenia were not treated before the reform, and many families became impoverished in their attempts to pay for the health care of their family member with this disorder.

Using treated incidence as a measure of access to the Chilean health care system, we note that access to the system has improved since 2005. Assuming comparable ratios of incidence of treatment for schizophrenia to true incidence of this disorder in the beneficiary populations of both systems, we conclude that public plan beneficiaries are significantly more likely to use the schizophrenia GES program than private plan enrollees among all age groups, both sexes, and all regions of the country (Table 1). Both populations had the highest treated incidence among individuals ages 15–24 years and a higher incidence among males than females. Public plan beneficiaries in highly rural regions had a higher incidence of treatment than those in largely nonrural regions, and the inverse was true for private insurance enrollees. The metropolitan region of Chile (including its capital city, Santiago), which has low levels of rurality, had a significantly higher incidence of schizophrenia than other regions among both insured populations.

It is worth noting that the incidence of treatment for schizophrenia for public plan beneficiaries in Chile is within the range typically described in the literature for many other countries (4, 5). This incidence information suggests that the GES program for people with schizophrenia plays an important role in facilitating timely access to care for publicly insured beneficiaries. The high level of coverage in rural regions provided by the public insurer is noteworthy, although the drivers of the higher detected incidence of schizophrenia in these areas are unclear and require further study. Although this program has achieved a significant level of decentralization in both the public and the private systems, incidence of treatment for schizophrenia remains highest in Chile’s metropolitan region. This finding may be attributable to a greater supply of services and concentration of professionals in this area, but we cannot rule out that this may be due to multiple risk factors for schizophrenia associated with large urban areas.

The principle of universal coverage that inspired the GES contributes to improved access to mental health care for the most vulnerable people with schizophrenia. However, it is unknown whether quality of care and patient outcomes have also improved; they have not been comprehensively measured. The cost-effectiveness of GES-covered mental health care also has not been measured. A previous study concluded that in the public sector of Chile’s mental health care system, adherence to treatment guidelines was good for pharmacological treatments but only average for psychosocial treatments (6). The study also found low utilization of symptom scales and diagnostic measures among public-sector providers.

The next iteration of the clinical guidelines for mental health care should include new evidence-based interventions for early nonaffective psychosis, such as coordinated specialty care with multielement interventions, including low doses of antipsychotic medications, cognitive-behavioral therapy, family education and support, and educational and vocational rehabilitation (7–9).

Different nations have proposed and enacted diverse policies and financing to improve mental health care services for people with schizophrenia (10). The novelty of the Chilean model is that its regulations apply to both the public and private mental health care systems, including insurance companies and providers, with provisions to promote parity coverage for general medical health conditions and guaranteed care beyond the first episode of schizophrenia.

Several lessons have been learned from the implementation of the Chilean national schizophrenia treatment program that may be of interest to countries that are considering implementation of a national strategy for the management of schizophrenia. First, the formulation of new health care policies represents an important window of opportunity for mental health care reforms, including the incorporation of mental health care parity strategies. Second, socioeconomic and geographic inequities may be reduced through policies that include regulations and financing mechanisms and resource allocation aimed at both the public and private health care systems. Moreover, a single national policy has the potential to improve access to early schizophrenia care for all, a critical public health care objective given the prognostic implications of reducing the duration of untreated psychosis. Finally, one of the difficulties in implementing the program was not considering a monitoring system for the quality of care and patient outcomes, which is why the Chilean experience underscores the importance of including a system that starts monitoring at the beginning of program implementation.