Federal spending on behavioral health accelerated during recession as individuals lost employer insurance.

The 2007-09 recession had a dramatic effect on behavioral health spending, with the effect most prominent for private, state, and local payers. During the recession behavioral health spending increased at a 4.6 percent average annual rate, down from 6.1 percent in 2004-07. Average annual growth in private behavioral health spending during the recession slowed to 2.7 percent from 7.2 percent in 2004-07. State and local behavioral health spending showed negative average annual growth, -1.2 percent, during the recession, compared with 3.7 percent increases in 2004-07. In contrast, federal behavioral health spending growth accelerated to 11.1 percent during the recession, up from 7.2 percent in 2004-07. These behavioral health spending trends were driven largely by increased federal spending in Medicaid, declining private insurance enrollment, and severe state budget constraints. An increased federal Medicaid match reduced the state share of Medicaid spending, which prevented more drastic cuts in state-funded behavioral health programs during the recession. Federal Medicaid served as a critical safety net for people with behavioral health treatment needs during the recession.

Current and future funding sources for specialty mental health and substance abuse treatment providers.

OBJECTIVES: Goals were to describe funding for specialty behavioral health providers in 1986 and 2005 and examine how the recession, parity law, and Affordable Care Act (ACA) may affect future funding. METHODS: Numerous public data sets and actuarial methods were used to estimate spending for services from specialty behavioral health providers (general hospital specialty units; specialty hospitals; psychiatrists; other behavioral health professionals; and specialty mental health and substance abuse treatment centers). RESULTS: Between 1986 and 2005, hospitals-which had received the largest share of behavioral health spending-declined in importance, and spending shares trended away from specialty hospitals that were largely funded by state and local governments. Hospitals' share of funding from private insurance decreased from 25% in 1986 to 12% in 2005, and the Medicaid share increased from 11% to 23%. Office-based specialty providers continued to be largely dependent on private insurance and out-of-pocket payments, with psychiatrists receiving increased Medicaid funding. Specialty centers received increased funding shares from Medicaid (from 11% to 29%), and shares from other state and local government sources fell (from 64% to 46%). CONCLUSIONS: With ACA's full implementation, spending on behavioral health will likely increase under private insurance and Medicaid. Parity in private plans will also push a larger share of payments for office-based professionals from out-of-pocket payments to private insurance. As ACA provides insurance for formerly uninsured individuals, funding by state behavioral health authorities of center-based treatment will likely refocus on recovery and support services. Federal Medicaid rules will increase in importance as more people needing behavioral health treatment become covered.

Hospital readmission among medicaid patients with an index hospitalization for mental and/or substance use disorder.

Hospital readmission rates are increasingly used as a performance indicator. Whether they are a valid, reliable, and actionable measure for behavioral health is unknown. Using the MarketScan Multistate Medicaid Claims Database, this study examined hospital- and patient-level predictors of behavioral health readmission rates. Among hospitals with at least 25 annual admissions, the median behavioral health readmission rate was 11% (10th percentile, 3%; 90th percentile, 18%). Increased follow-up at community mental health centers was associated with lower probabilities of readmission, although follow-up with other types of providers was not significantly associated with hospital readmissions. Hospital average length of stay was positively associated with lower readmission rates; however, the effect size was small. Patients with a prior inpatient stay, a substance use disorder, psychotic illness, and medical comorbidities were more likely to be readmitted. Additional research is needed to further understand how the provision of inpatient services and post-discharge follow-up influence readmissions.

Mental health spending by private insurance: implications for the mental health parity and addiction equity act.

OBJECTIVE: The study developed information on behavioral health spending and utilization that can be used to anticipate, evaluate, and interpret changes in health care spending following implementation of the Mental Health Parity and Addiction Equity Act (MHPAEA). METHODS: Data were from the Thomson Reuters' MarketScan database of insurance claims between 2001 and 2009 from large group health plans sponsored by self-insured employers. Annual rates in growth of total health spending and behavioral health spending and the contribution of behavioral health spending to growth in spending for all diseases were determined. Separate analyses examined behavioral health and total health spending by 135 employers in 2008 and 2009, and simulations were conducted to determine how increases in use of mental health services after implementation of parity would affect overall health care expenditures. RESULTS: Across the nine years examined, behavioral health expenditures contributed .3%, on average, to the total rate of growth in all health expenditures, a contribution that fell to .1%, on average, when prescription drugs were excluded. About 2% of employers experienced an increased contribution by behavioral health spending of more than 1%. More than 90% of enrollees used well below the maximum 30 inpatient days or outpatient visits typical of health insurance plans before parity. Simulations indicated that even large increases in utilization would increase total health care expenditures by less than 1%. CONCLUSIONS: The MHPAEA is unlikely to have a large effect on the growth rate of employers' health care expenditures. The data provide baseline information to further evaluate the implementation effect of the MHPAEA.

Spending trends on substance abuse treatment under private employer-sponsored insurance, 2001-2009.

BACKGROUND: From 1986 to 2003, substance abuse spending covered by private insurance fell in nominal dollars from $2444 million to $2239 million. The present study updated this literature to determine recent spending and utilization trends and provides a baseline for assessing the effects of recent health care policy changes. METHODS: We used insurance claims data from Thomson Reuters MarketScan Commercial Claims and Encounters Database to study approximately 100 large, self-insured employers and millions of enrollees. We examined patterns in substance abuse treatment utilization and spending from 2001 through 2009. RESULTS: The study revealed that substance abuse spending remained a relatively constant share of all health spending, comprising about 0.4% of all health spending in 2009. The share of substance abuse spending on medications increased from 1% to 14%, but remained a small share of all health spending at about $2.45 per-member per-year. CONCLUSIONS: The study has implications for anticipating the effects of the federal parity law, in that the low share of substance abuse treatment means that even large increases in substance abuse utilization and spending are unlikely to have a significant impact on total health care costs.

An analysis of the slowdown in growth of spending for psychiatric drugs, 1986-2008.

OBJECTIVE: This study analyzed recent trends in spending on psychiatric prescription drugs and underlying factors that served as drivers of these changes. METHODS: Data were collected from the MarketScan Commercial Claims and Encounters Database (1997-2008), Substance Abuse and Mental Health Services Administration spending estimates (1986-2005), and the Medical Expenditure Panel Survey (1997-2007). The trends in medication spending derived from the data were decomposed into three categories: percentage of enrollees who used psychiatric medications, days supplied per user, and cost per day supplied. RESULTS: The average annual rate of growth in expenditures per enrollee slowed from 18.5% in 1997-2001 to 6.3% in 2001-2008. A decline in the growth rate of cost per day supplied, from 8% to 2%, accounted for 49% of the overall decline in spending growth, and a decline in the growth of the percentage of enrollees who used medication, from 7% to 2%, contributed 41% to the overall decline. There was a smaller change in days supplied per user, from 3% to 2%, that contributed 10% to the overall decline. The increased entry of generic medications, which constituted 70% of all psychiatric prescriptions by 2008, particularly generic antidepressants, was a key contributor to the slower growth in costs. CONCLUSIONS: Past high growth in psychiatric drug spending arising from growth in utilization of branded medications has declined significantly, which may have implications for access and new product investment.

Type of health insurance and the substance abuse treatment gap.

OBJECTIVE: Most individuals reporting symptoms consistent with substance use disorders do not receive care. This study examines the correlation between type of insurance coverage and receipt of substance abuse treatment, controlling for other observable factors that may influence treatment receipt. METHOD: Descriptive and multivariate analyses are conducted using pooled observations from the 2002-2007 editions of the National Survey on Drug Use and Health. The likelihood of treatment entry is estimated by type of insurance coverage controlling for personal characteristics and characteristics of the individual's substance use disorder. RESULTS: Multivariate analyses that control for type of substance and severity of disorder (dependence vs. abuse) find that those with Civilian Health and Medical Program of the Uniformed Services/Veterans Affairs, Medicaid only, Medicare only, and Medicare and Medicaid (dual eligibles) have 50% to almost 90% greater odds of receiving treatment relative to those with private insurance. CONCLUSIONS: The privately insured population has substantially lower treatment entry rates than those with publicly provided insurance. Additional research is warranted to understand the source of the differences across insurance types so that improvements can be achieved.

Changes In US spending on Mental Health And Substance Abuse Treatment, 1986-2005, and implications for policy.

The United States invests a sizable amount of money on treatments for mental health and substance abuse: $135 billion in 2005, or 1.07 percent of the gross domestic product. We provide treatment spending estimates from the period 1986-2005 to build understanding of past trends and consider future possibilities. We find that the growth rate in spending on mental health medications-a major driver of mental health expenditures in prior years-declined dramatically. As a result, mental health and substance abuse spending grew at a slightly slower rate than gross domestic product in 2004 and 2005, and it continued to shrink as a share of all health spending. Of note, we also find that Medicaid's share of total spending on mental health grew from 17 percent in 1986 to 27 percent in 2002 to 28 percent in 2005. The recent recession, the full implementation of federal parity law, and such health reform-related actions as the planned expansion of Medicaid all have the potential to improve access to mental health and substance abuse treatment and to alter spending patterns further. Our spending estimates provide an important context for evaluating the effect of those policies.

Psychiatric discharges in community hospitals with and without psychiatric units: how many and for whom?

OBJECTIVE: This study sought to describe the extent to which community hospitals, in a sample of states, are caring for patients with psychiatric disorders in medical-surgical beds (scatter beds) and to compare the characteristics of patients treated in scatter beds with those of patients treated in psychiatric units in community hospitals. METHODS: Information on hospital discharges in 12 states for patients with a principal psychiatric diagnosis was gathered from the Healthcare Cost and Utilization Project State Inpatient Databases. Discharges of patients who were treated in community hospital psychiatric units (N=370,984) were compared with those of patients who were treated in scatter beds (N=26,969). RESULTS: Overall, only 6.8% of discharges were from scatter beds. The rate of total psychiatric discharges per 10,000 total state population ranged from a high of 62.3 in one study state to a low of 9.6 in another. The average rate of scatter bed discharges per 10,000 state population ranged from 1.6 to 5.8, whereas the average rate of psychiatric unit discharges ranged from 7.4 to 58.9. A comparison of discharges of patients treated in scatter beds with discharges of patients treated in psychiatric units indicated that patients in scatter beds were more likely to have somatic conditions and were half as likely to have an accompanying substance use disorder. Discharge codes indicated that almost 40% of patients from scatter beds had a diagnosis of schizophrenia, episodic mood disorder, or depression; about two-thirds were admitted from emergency rooms; and about one-fifth were transferred to another facility. CONCLUSIONS: More research is needed to determine the optimal supply of psychiatric unit beds across regions and whether and how scatter beds should be used to address the lack of psychiatric beds.

Evidence for substance abuse services and policy research: a systematic review of national databases.

We reviewed 39 national government- and nongovernment-sponsored data sets related to substance addiction policy. These data sets describe patients with substance use disorders (SUDs), treatment providers and the services they offer, and/or expenditures on treatment. Findings indicate the availability of reliable data on the prevalence of SUD and the characteristics of specialty treatment facilities, but meager data on financing and services. Gaps in information might be filled through agency collaboration to redesign, coordinate, and augment existing substance abuse and general health surveys. Despite noted gaps, these data sets represent an unusually rich set of resources for health services and policy research.

Alcohol and opioid dependence medications: prescription trends, overall and by physician specialty.

Over the past decade, advances in addiction neurobiology have led to the approval of new medications to treat alcohol and opioid dependence. This study examined data from the IMS National Prescription Audit (NPA) Plus database of retail pharmacy transactions to evaluate trends in U.S. retail sales and prescriptions of FDA-approved medications to treat substance use disorders. Data reveal that prescriptions for alcoholism medications grew from 393,000 in 2003 ($30 million in sales) to an estimated 720,000 ($78 million in sales) in 2007. The growth was largely driven by the introduction of acamprosate in 2005, which soon became the market leader ($35 million in sales). Prescriptions for the two buprenorphine formulations increased from 48,000 prescriptions ($5 million in sales) in the year of their introduction (2003) to 1.9 million prescriptions ($327 million in sales) in 2007. While acamprosate and buprenorphine grew rapidly after market entry, overall substance abuse retail medication sales remain small relative to the size of the population that could benefit from treatment and relative to sales for other medications, such as antidepressants. The extent to which substance dependence medications will be adopted by physicians and patients, and marketed by industry, remains uncertain.

Transforming mental health and substance abuse data systems in the United States.

State efforts to improve mental health and substance abuse service systems cannot overlook the fragmented data systems that reinforce the historical separateness of systems of care. These separate systems have discrete approaches to treatment, and there are distinct funding streams for state mental health, substance abuse, and Medicaid agencies. Transforming mental health and substance abuse services in the United States depends on resolving issues that underlie separate treatment systems--access barriers, uneven quality, disjointed coordination, and information silos across agencies and providers. This article discusses one aspect of transformation--the need for interoperable information systems. It describes current federal and state initiatives for improving data interoperability and the special issue of confidentiality associated with mental health and substance abuse treatment data. Some achievable steps for states to consider in reforming their behavioral health data systems are outlined. The steps include collecting encounter-level data; using coding that is compliant with the Health Insurance Portability and Accountability Act, including national provider identifiers; forging linkages with other state data systems and developing unique client identifiers among systems; investing in flexible and adaptable data systems and business processes; and finding innovative solutions to the difficult confidentiality restrictions on use of behavioral health data. Changing data systems will not in itself transform the delivery of care; however, it will enable agencies to exchange information about shared clients, to understand coordination problems better, and to track successes and failures of policy decisions.

Future funding for mental health and substance abuse: increasing burdens for the public sector.

Spending on mental health (MH) and substance abuse (SA) treatment is expected to double between 2003 and 2014, to $239 billion, and is anticipated to continue falling as a share of all health spending. By 2014, our projections of SA spending show increasing responsibility for state and local governments (45 percent); deteriorating shares financed by private insurance (7 percent); and 42 percent of SA spending going to specialty SA centers. For MH, Medicaid is forecasted to fund an increasingly larger share of treatment costs (27 percent), and prescription medications are expected to capture 30 percent of MH spending by 2014.

Mental health and substance abuse spending by age, 2003.

This article presents national estimates of mental health and substance abuse (MHSA) spending in 2003 by age groups. Overall, $121 billion was spent on MHSA treatment across all age groups in 2003. Of the total $100 billion spent on MH treatment, about 17% was spent on children and adolescents, 68% on young and mid-age adults, and 15% on older adults. MH spending per capita by age was $232 per youth, $376 per young and mid-age adult, and $419 per older adult. Of the total $21 billion spent on SA treatment, about 9% was spent on children and adolescents, 86% on adults ages 18 through 64, and 5% on older adults age 65 and older. SA spending per capita by age was $26 per youth, $98 per mid-age adult, and $28 per older adult.

Mental health treatment expenditure trends, 1986-2003.

OBJECTIVE: This study determined spending on mental health treatment in the United States over time by provider and payer relative to all health spending. METHODS: Estimates were developed to be consistent with the National Health Expenditure Accounts. Numerous public data sources were used. RESULTS: Mental health treatment expenditures grew from $33 billion in 1986 to $100 billion in 2003. In real 2003 dollars, spending per capita on mental health treatment rose from $205 to $345. The average annual nominal total mental health growth rate was 6.7%. In comparison, total health care expenditures increased by 8.0%. As a result of the slower growth rate of mental health expenditures compared with all health spending, mental health fell from 8% of all health expenditures in 1986 to 6% in 2003. Total national health spending increased by approximately $1.175 trillion from 1986 to 2003; of this, 6% is attributed to an increase in mental health spending. The mix of services has changed, with more care being provided through prescription drugs and in outpatient settings and less in inpatient settings. Payer mix has also shifted, with Medicaid taking a more prominent role. CONCLUSIONS: Spending on mental health treatment has increased over the past decade, reflecting increases in the number of individuals receiving mental health treatment, particularly prescription drugs and outpatient treatment. Changes in payer and provider mix raise new challenges for ensuring quality and access.

Trends in spending for substance abuse treatment, 1986-2003.

Since 1987, public and private investment in substance abuse (SA) treatment has not kept pace with other health spending. SA treatment spending in the United States grew from $9.3 billion in 1986 to $20.7 billion in 2003. The average annual total growth rate was 4.8 percent. In comparison, total U.S. health care spending grew by 8.0 percent. As a result of the slower growth of SA spending compared to that for all health care, SA spending fell as a share of all health spending from 2.1 percent in 1986 to 1.3 percent in 2003.

Substance abuse benefits: still limited after all these years.

Using data from a special supplement to the 2006 Kaiser/HRET Employer Health Benefits Survey, this study examines the state of employer-sponsored insurance substance abuse benefits in 2006 and how benefits compare to coverage for medical-surgical services. In 2006, 88 percent of insured workers had some coverage for substance abuse services. Current substance abuse benefits, however, do not provide the same protection afforded under medical-surgical benefits. Instead, substance abuse benefits are characterized by higher cost sharing and annual limits and lifetime limits on inpatient and outpatient care. These limits generally do not exist for other medical conditions and have increased since 1990.

Factors affecting detoxification readmission: analysis of public sector data from three states.

The objective of this study was to understand the rate of detoxification readmissions and the factors associated with readmission within a public sector population. The study sample was drawn from an integrated database that includes Medicaid and state mental health and substance abuse agency data from three states (Delaware, Oklahoma, and Washington) for 1996-1998. Clients with at least one state agency-sponsored detoxification event in 1996 or 1997 were included in the study. Twenty-seven percent of the sample was readmitted for detoxification within 1 year of their index detoxification. Clients who received two or more substance-abuse-related services within 30 days of their index detoxification were less likely to be readmitted and had a longer time until their second detoxification admission. Detoxification readmission is common in the public sector. Engaging patients in treatment following detoxification may reduce readmission rates and time to readmission.