title: Rural-urban differences in health care benefits of a community-based sample of at-risk drinkers.
abstract: BACKGROUND
  Different types of health plan cost-containment strategies (eg, gatekeeping, selective contracting, and cost-sharing) may affect the utilization of behavioral health services differently in urban and rural areas.
  
  
  OBJECTIVE
  This research compares the cost-containment strategies used by the health plans of insured at-risk drinkers residing in rural and urban areas.
  
  
  METHODS
  A screening instrument for at-risk drinking was administered by phone to approximately 12,000 residents of 6 southern states; 442 at-risk drinkers completed 4 interviews over a 2-year period and consented to release insurance and medical records. Two thirds of the sample (n=294) were insured during the last 6 months of the study. In 1998, health plan characteristics were successfully collected for 217 (72.3%) of the insured at-risk drinkers, representing 113 different health plans and 206 different policies.
  
  
  RESULTS
  Compared with urban at-risk drinkers, rural at-risk drinkers were significantly less likely to be enrolled in a health plan with gatekeeping policies for both behavioral health (P = .001), and physical health (P = .031). Compared with urban enrollees, rural enrollees were significantly more likely to pay deductibles (P = .042), to pay coinsurance for physical health services (P = .002), and to have limits placed on physical health services use (P = .067), but they were less likely to pay copayments for physical health (P = .046). Rural enrollees were less likely to face higher copayments (P = .007) and higher coinsurance (P = .076) for mental health than for physical health, compared to urban enrollees.
  
  
  CONCLUSIONS
  Because rural residents were more likely to be enrolled in indemnity plans and less likely to be enrolled in health maintenance organizations, rural at-risk drinkers were enrolled in plans that relied less on supply-side cost-containment strategies and more on demand-side cost-containment strategies targeting physical health service use, compared with their urban counterparts. Rural at-risk drinkers were less likely to be enrolled in health plans with greater cost-sharing for mental health than for physical health compared to urban at-risk drinkers.
authors.affiliation: VA HSR&D Center for Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System, USA. fortneyjohnc@uams.edu
authors.forename: John C
authors.initials: JC
authors.lastname: Fortney
authors.forename: Brenda M
authors.initials: BM
authors.lastname: Booth
authors.forename: JoAnn E
authors.initials: JE
authors.lastname: Kirchner
authors.forename: Xiaotong
authors.initials: X
authors.lastname: Han
mesh_terms: D000206:Actuarial Analysis; D000328:Adult; D000437:Alcoholism / Q000191:economics / Q000628:therapy*; D003363:Cost Control / Q000379:methods; D017047:Cost Sharing; D005260:Female; D020793:Gatekeeping; D006297:Health Services Accessibility / Q000191:economics*; D006301:Health Services Needs and Demand; D006801:Humans; D015273:Insurance Selection Bias; D007348:Insurance, Health / Q000145:classification* / Q000191:economics; D008297:Male; D008605:Mental Health Services / Q000191:economics*; D018570:Risk Assessment; D012307:Risk Factors; D019035:Rural Health Services / Q000191:economics*; D014481:United States / Q000453:epidemiology; D019037:Urban Health Services / Q000191:economics*