Insurance benefits can have a large effect on whether one is able to access health care services.1 Mental health and substance abuse (MHSA) insurance coverage has typically been less generous than for general health services. Unlike general health services, MHSA benefits often limit the number of days of inpatient care and outpatient visits, and often have separate limits on the total dollar amount reimbursed for inpatient and outpatient services. When insurance covers more limited expenditures, more must be paid out-of-pocket by the insured and there is less incentive to use services and more financial risk. The goal of this paper is to measure the change in value of mental health (MH) insurance coverage over time by simulating the out-of-pocket expenditures required under typical benefit packages offered in 1987 and 1996. This is done by examining trends in the number of insurance policies that set specific types of limits on coverage and then by simulating reimbursed and un-reimbursed expenses submitted to private insurance plans given typical insurance benefits in 1987 and 1996. This paper used data on MH benefits collected by the Agency for Health Care Research and Quality. Before presenting that data, it is useful to review what other surveys have shown about trends in health insurance benefits. The Department of Labor (DOL) employee benefits surveys of medium and large employers show that almost all employees with health particularly of inpatient care, experienced a decline in coverage while those with less intensive needs may have experienced a slight increase. Implications for Health Policies: Out-of-pocket spending in both years of the study was substantial suggesting that improved health care coverage, such as that mandated in parity legislation, could improve access to care for persons needing mental health treatment. Implication for Further Research: Additional research is needed to understand how trends in out-of-pocket spending and insurance benefits have influenced access to care.

Full report: Trends in mental health insurance benefits and out-of-pocket spending.pdf (39.83 kb)

Age is one of the most revealing lenses through which one can examine spending on mental health and substance abuse (MH/SA) treatment. There are several reasons why. The epidemiology of MH disorders and SA is strongly related to age and presents distinct challenges for treatment of various age groups. Furthermore, public policy on health financing is often linked to the age of the beneficiaries. For example, the elderly and young (along with the severely disabled) have been the primary recipients of public financing of health services: about 90% of Medicare population is age 65 and older, and over 50% of the Medicaid population is younger than 18 years.

This study is one of the first to analyze the age distribution of national spending on MH/SA services and is the first to look at the full age spectrum of MH/SA clients. The study builds on the comprehensive MH/SA spending estimates developed under Substance Abuse Mental Health Services Administration (SAMHSA) Spending Estimates Project, which calculated spending on MH treatment at $73.4 billion and on SA treatment at $11.9 billion for 1997.11 That study found that between 1987 and 1997, MH/SA spending had increased 3.7% annually, versus 5% for all personal health care and public health spending.* MH spending grew slightly faster, at 4%, compared to 3.4% for SA spending. Public payers reimbursed a disproportionate share of MH/SA treatment costs compared to costs for treatment of other health problems; 9.9% of public payer health spending was for MH/SA, compared to 6% of private spending. Only one other published study was found that examined MH/SA expenditures by age. Ringel and Sturm2 estimated treatment expenditures for children aged 1–17 for the year 1998. They used many of the same data sources used in the SAMHSA Spending Estimates Project, as well as additional survey data. Use of the Medical Expenditure Panel Survey (MEPS), which was not available when the SAMHSA estimates were developed, allowed them to allocate spending not only by age and type of service but also by type of payer. They put total MH/SA spending for children aged 1–17 at $11.68 billion in 1998. Adolescents (aged 12–17) accounted for 60% of the total and had the highest expenditures per child, children aged 6–11 accounted for 34% of the total, while children aged 1–5 accounted for 6% of the total. They also learned that in 1998, private insurance covered the largest proportion of spending on these youth (46%), while Medicaid (at 24%) and State and local payers (at 21%) covered comparably sized shares of expenditures for children 0–17 years of age.

Full report (PDF): National Spending on Mental Health and Substance Abuse Treatment by Age of Clients, 1997.pdf (209.89 kb)

More than 18 million people who use alcohol and almost 5 million who use illicit drugs need substance abuse treatment, while, overall, less than one fourth of those needing treatment actually get it. Substance abuse treatment usually proceeds in three stages: acute intervention (including emergency treatment and detoxification), rehabilitation (outpatient, residential or inpatient primary and extended care), and maintenance (aftercare, relapse prevention, or domicile care).

Each year at least 300,000 patients obtain inpatient detoxification in general hospitals and additional numbers obtain detoxification in other settings. Detoxification is the medical management or monitoring of acute alcohol or illicit drug intoxication and withdrawal. While detoxification may offer a gateway for patients into a substance abuse treatment program, detoxification alone will not lead to lasting improvements. The receipt of continuing treatment/rehabilitation services following substance abuse detoxification is considered to be essential for successful recovery. Research has shown that patients who receive such services after detoxification have better outcomes in terms of drug abstinence and re-admission rates than those who do not enter treatment.

Because the need for detoxification identifies persons who are substance dependent, detoxification presents an opportunity to link such persons to continuing substance abuse treatment services so that they may be able to attain sobriety and recover.

This paper starts with the premise that persons receiving inpatient detoxification, alone or with inpatient rehabilitation, should receive continuing rehabilitation treatment services after they are discharged. Data from both efficacy and effectiveness studies have shown that patients who participate in continuing specialized outpatient substance abuse treatment after being discharged from treatment for substance abuse tend to have better long-term outcomes

Full report: Factors Associated With The Receipt Of Treatment Following Detoxification.pdf (68.19 kb)

This article presents an analysis of Medicaid utilization and expenditures for ten Medicaid programs from 1993 including behavioral health and behavioral healthcare patients (including general healthcare costs) as a percentage of Medicaid expenditures.   

Authors: Sherry A. Glied, Richard G. Frank.

*Note: The New England Journal of Medicine (NEJM) policies preclude us from providing an article abstract or linking to the NEJM website; however, this article is available via the NEJM website.