Medicare Advantage and Traditional Medicare Hospitalization Intensity and Readmissions.

Medicare Advantage plans have incentives and tools to optimize patient care. Therefore, Medicare Advantage hospitalizations may have lower cost and higher quality than similar traditional Medicare hospitalizations. We applied a coarsened matching approach to 2013 Healthcare Cost and Utilization Project hospital discharge data from 22 states to compare hospital cost, length of stay, and readmissions for Traditional Medicare and Medicare Advantage. We found that Medicare Advantage hospitalizations were substantially less expensive and shorter for mental health stays but costlier and longer for injury and surgical stays. We found little difference in the cost and length of medical stays and in readmission rates. One explanation is that Medicare Advantage plans use outpatient settings for many patients with behavioral health conditions and for injury and surgical patients with less complex health needs. Alternatively, the observed differences in behavioral health cost and length of stay may represent skimping on appropriate care.

Insurance Financing Increased For Mental Health Conditions But Not For Substance Use Disorders, 1986-2014.

This study updates previous estimates of US spending on mental health and substance use disorders through 2014. The results reveal that the long-term trend of greater insurance financing of mental health care continued in recent years. The share of total mental health treatment expenditures financed by private insurance, Medicare, and Medicaid increased from 44 percent in 1986 to 68 percent in 2014. In contrast, the share of spending for substance use disorder treatment financed by private insurance, Medicare, and Medicaid was 45 percent in 1986 and 46 percent in 2014. From 2004 to 2013, a growing percentage of adults received mental health treatment (12.6 percent and 14.6 percent, respectively), albeit only because of the increased use of psychiatric medications. In the same period, only 1.2-1.3 percent of adults received substance use disorder treatment in inpatient, outpatient, or residential settings, although the use of medications to treat substance use disorders increased rapidly.

Growth in Spending on and Use of Services for Mental and Substance Use Disorders After the Great Recession Among Individuals With Private Insurance.

OBJECTIVE: Recessions are associated with increased prevalence of mental and substance use disorders, but their effect on use of behavioral health services is less clear. This study examined changes in spending per enrollee for behavioral health services compared with general medical services among individuals with private insurance following the Great Recession that began in 2007. METHODS: The National Survey on Drug Use and Health was used to examine the prevalence of behavioral health conditions among persons with private insurance from 2004 to 2013. Truven Health MarketScan Commercial Claims and Encounters data (2004-2012) were used to calculate use of and spending on treatment of behavioral and general medical conditions before and after the recession among individuals with employer-sponsored private health insurance. RESULTS: There was a statistically significant increase in serious psychological distress and episodes of major depression between 2007 and 2010. Between 2004-2009 and 2009-2012, the growth in average annual spending per individual slowed for general medical care (from 6.6% to 3.7%) but accelerated for behavioral health care (from 4.8% to 6.6%). From 2009 to 2012, the percentage of individuals receiving inpatient treatment, outpatient treatment, and prescription drugs for behavioral conditions increased, whereas use of these services for general medical care decreased or remained flat. Out-of-pocket costs increased more slowly for behavioral conditions than for other medical conditions. CONCLUSIONS: The recession was associated with increased need for and use of behavioral health services among individuals with private insurance. The Mental Health Parity and Addiction Equity Act may have also played a role in facilitating increasing use of behavioral health services after 2008.

Growth in spending on substance use disorder treatment services for the privately insured population.

BACKGROUND: Approximately 8% of individuals with private health insurance in the United States have substance use disorders (SUDs), but in 2009 only 0.4% of all private insurance spending was on SUDs. The objective of this study was to determine if changes that occurred between 2009 and 2012 - such as more generous SUD benefits, an epidemic of opioid use disorders, and slow recovery from a recession - were associated with greater use of SUD treatment. METHODS: Data were from the 2004-2012 Truven Health Analytics MarketScan(®) Commercial Claims and Encounters Database. This database is representative of individuals with private insurance in the United States. Per enrollee use of and spending on SUD treatment was determined and compared with spending on all health care services. Trends were examined for inpatient care, outpatient care, and prescription medications. RESULTS: During the 2009-2012 time period, use of and spending on SUD services increased compared with all diagnoses. Two-thirds of the increase was driven by higher growth rates in outpatient use and prices. Despite the high growth rates, SUD treatment penetration rates remained low. As of 2012, only 0.6% of individuals with private insurance used SUD outpatient services, 0.2% filled SUD medication prescriptions, and 0.1% used inpatient SUD services. In 2012, SUD services accounted for less than 0.7% of all private insurance spending. CONCLUSIONS: Despite recent coverage improvements, individuals with private health insurance still may not receive adequate levels of treatment for SUDs, as evidenced by the small proportion of individuals who access treatment.

Projected Spending on Psychotropic Medications 2013-2020.

Spending on psychotropic medications has grown rapidly in recent decades. Using national data on drug expenditures, patent expirations, future drug development and expert interviews, we project that spending will grow more slowly over the period 2012-2020. The average annual increase is projected to be just 3.0 % per year, continuing the steady deceleration in recent years. The main drivers of this expected deceleration include slower development of new drugs, upcoming patent expirations which will lower prices, and payers' growing ability to manage utilization and promote generic use. The slowdown will relieve some cost pressures on payers, particularly Medicare and Medicaid.

The diminished pipeline for medications to treat mental health and substance use disorders.

OBJECTIVE: Psychotropic drug development is perceived to be lagging behind other pharmaceutical development, even though there is a need for more effective psychotropic medications. This study examined the state of the current psychotropic drug pipeline and potential barriers to psychotropic drug development. METHODS: The authors scanned the recent academic and "grey" literature to evaluate psychotropic drug development and to identify experts in the fields of psychiatry and substance use disorder treatment and psychotropic drug development. On the basis of that preliminary research, the authors interviewed six experts and analyzed drugs being studied for treatment of major psychiatric disorders in phase III clinical trials. RESULTS: Interviews and review of clinical trials of drugs in phase III of development confirmed that the psychotropic pipeline is slim and that a majority of the drugs in phase III trials are not very innovative. Among the barriers to development are incentives that encourage firms to focus on incremental innovation rather than take risks on radically new approaches. Other barriers include human brain complexity, failure of animal trials to translate well to human trials, and a drug approval threshold that is perceived as so high that it discourages development. CONCLUSIONS: Drivers of innovation in psychotropic drug development largely parallel those for other drugs, yet crucial distinctions have led to slowing psychotropic development after a period of innovation and growth. Various factors have acted to dry up the pipeline for psychotropic drugs, with expert opinion suggesting that in the near term, this trend is likely to continue.

Spending on mental and substance use disorders projected to grow more slowly than all health spending through 2020.

Spending on mental and substance use disorders will likely grow more slowly than all health spending through 2020. We project that spending on mental and substance use disorders, as a share of all health spending, will fall from 7.4 percent in 2009 ($172 billion out of $2.3 trillion) to 6.5 percent in 2020 ($281 billion out of $4.3 trillion). This trend is the projected result of reduced spending on mental health drugs because of patent expirations, the low likelihood of innovative drugs entering the market, and a slowdown in spending growth for hospital treatment. By 2020 the expansion of coverage to previously uninsured Americans under the Affordable Care Act (ACA), combined with the projected slowdown in Medicare provider payment rates under the ACA and the Budget Control Act of 2011, are expected to add 2.7 percent to behavioral health spending, compared to spending without these changes.

Estimating inpatient hospital prices from state administrative data and hospital financial reports.

OBJECTIVE: To develop a tool for estimating hospital-specific inpatient prices for major payers. DATA SOURCES: AHRQ Healthcare Cost and Utilization Project State Inpatient Databases and complete hospital financial reporting of revenues mandated in 10 states for 2006. STUDY DESIGN: Hospital discharge records and hospital financial information were merged to estimate revenue per stay by payer. Estimated prices were validated against other data sources. PRINCIPAL FINDINGS: Hospital prices can be reasonably estimated for 10 geographically diverse states. All-payer price-to-charge ratios, an intermediate step in estimating prices, compare favorably to cost-to-charge ratios. Estimated prices also compare well with Medicare, MarketScan private insurance, and the Medical Expenditure Panel Survey prices for major payers, given limitations of each dataset. CONCLUSIONS: Public reporting of prices is a consumer resource in making decisions about health care treatment; for self-pay patients, they can provide leverage in negotiating discounts off of charges. Researchers can also use prices to increase understanding of the level and causes of price differentials among geographic areas. Prices by payer expand investigational tools available to study the interaction of inpatient hospital price setting among public and private payers--an important asset as the payer mix changes with the implementation of the Affordable Care Act.

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.

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.

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.

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 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.