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PubMed1997

Mental health care use, morbidity, and socioeconomic status in the United States and Ontario.

This study focuses on mental health problems and compares the association of demographic and socioeconomic factors to the use of mental health specialty care and general medical care in the United States and the Canadian province, Ontario. It also examines how lack of insurance coverage in the United States and perceived need for care affects differences between the two countries. We employ a cross-sectional study design using the 1990 U.S. National Comorbidity Survey and the 1990 Mental Health Supplement to the Ontario Health Survey. Overall, 8.8% of Americans report one or more visits to the health sector for a mental health problem, compared to 6.9% of Canadians in Ontario. Americans with the highest incomes and no mental morbidity are much more likely to receive services than their Canadian counterparts. By contrast, Americans with the lowest incomes and high morbidity are much less likely to receive services for mental health problems than a similar group of Canadians. These results suggest that universal and comprehensive coverage, as exists in Ontario, does not necessarily lead to increased use of services with low value. However, the greater prevalence of perceived need for care among Americans with higher socioeconomic status and low mental morbidity suggests that the United States should be cautious in drawing lessons from other countries.

Adult↗
PubMed1997

How expensive is unlimited mental health care coverage under managed care?

OBJECTIVES: To study costs, access, and intensity of mental health care under managed care carve-out plans with generous coverage; compare with assumptions used in policy debates; and simulate the consequences of removing coverage limits for mental health care as required by the Mental Health Parity Act. DESIGN: Claims data from 1995 and 1996 for 24 managed care carve-out plans; all plans offered unlimited mental health coverage with minimal co-payments. OUTCOME MEASURES: Probability of care, intensity of care, and total costs broken down by service type and type of enrollee. RESULTS: Assumptions used in last year's policy debate overstate actual managed care costs by a factor of 4 to 8. In the plans studied, costs are lower owing to reduced hospitalization rates, a relative shift to outpatient care, and reduced payments per service. However, access to mental health specialty care increased (7.0% of enrollees) compared with the preceding fee-for-service plans (6.5%) or free care in the RAND Health Insurance Experiment (5.0%). Removing an annual limit of $25000 for mental health care, which is the average among plans currently imposing limits, will increase insurance payments only by about $1 per enrollee per year. Children are the main beneficiaries of expanded benefits. CONCLUSIONS: Concerns about costs have stifled many health system reform proposals. However, policy decisions were often based on incorrect assumptions and outdated data that led to dramatic overestimates. For mental health care, the cost consequences of improved coverage under managed care, which by now accounts for most private insurance, are relatively minor.

Costs and Cost Analysis↗
PubMed1998

Mental health and substance abuse benefits in carve-out plans and the Mental Health Parity Act of 1996.

Legislation passed in the fall of 1996 required employers and insurers offering mental health benefits to raise dollar coverage limits on mental health services to the level of medical services. We analyze the benefit designs of 4,000 current behavioral health carve-out plans and contrast them to medical benefits. We find that almost 90 percent of all plans are inconsistent with the current legislation and need to be rewritten in the coming year. The restructuring of designs required by the Parity Act provides a unique opportunity because plans often are inconsistent and unnecessarily complex, a legacy of past attempts by employers to contain costs and control adverse selection and moral hazard in an unmanaged fee-for-service environment. Under managed care, the need for deductibles, limits, or other demand-side cost-sharing mechanisms may have diminished and restructuring outdated designs could benefit both enrollees and employers.

Health Benefit Plans, Employee↗
PubMed1993

Use of inpatient services by a national population: do benefits make a difference?

This study describes changes in the use of inpatient mental health services by children and adolescents under age 18. The data were insurance claims from the Blue Cross and Blue Shield Federal Employees Program. The study focused on a cut in inpatient benefits that occurred between 1978 and 1983. The rate of inpatient hospitalization dropped significantly, and the average number of days also decreased significantly from 45.8 to 27.0 days. This study is among the first to demonstrate that the rate and amount of inpatient care provided for children and adolescents is responsive to variations in benefit coverage.

Adolescent Psychiatry↗
PubMed1977

The effects of National Health Insurance on Canadian Psychiatry: the Ontario experience.

After studying psychiatric coverage under national health insurance in Ontario, the author concludes that psychiatric benefits can be provided on the same basis as other medical benefits and that a government system can maintain confidentiality. Costs have been reasonable and in line with the proportion of psychiartists to the total number of physicians, and psychiartists' incomes have increased substantially, even with comparatively low official fees. Despite the existence of NHI, the public mental health system has been maintained in Canada and has been expanded in regard to children's services. There appears to be a continued need for direct public funding of services for certain other groups such as the elderly, chronic patients, ans substance abusers.

Child↗
PubMed2000

Medical necessity and psychiatric managed care.

The concept of medical necessity is a provision of commercial insurance contracts and federal government Medicaid requirements that limits the payment to only those services that are essential for treating a person's sickness, injury, or condition. The concept of medical necessity is one tool used by third-party payers to contain their financial risk in a seemingly nonarbitrary manner. Also, the definitions of medical necessity used by commercial insurers or by the federal government reflect their product's or program's philosophies. Expanding commercial insurance or Medicaid psychiatric coverage would require changing those philosophies. As long as society is faced with a greater demand for health-related service than resources to meet them, such systems of rationing will be used. Even with full parity for psychiatric benefits, mechanisms will be used by payers to limit or control demand, thereby controlling financial risk. The short-term challenge for psychiatric advocates is to secure the most acceptable definitions of medical necessity from third-party payers. The long-term challenge for MH/SA advocates and for all health care advocates, is to develop a system that pays for the greatest number of quality services for the greatest number of people in need, in an affordable manner, regardless of diagnosis.

Behavior Therapy↗