The findings highlight what the authors say is ongoing discrimination in payer coverage for substance abuse care, in contrast with other mental health conditions.
A new study tracking US spending on mental health and substance use disorder services for more than 20 years finds that there is more complete payer coverage, but it’s not uniform: substance abuse coverage has lagged behind other conditions.
The share of total mental health treatment spending financed by private insurance, Medicare, and Medicaid increased from 44% in 1986 to 68% in 2014. However, the share of spending for substance use disorder treatment financed by private insurance, Medicare, and Medicaid was 45% in 1986, and remains nearly the same (46%) in 2014.
The study, by Tami Mark, PhD, MBA, of Truven Health Analytics, and colleagues also found that from 2004 to 2013, a growing percentage of adults received mental health treatment (12.6% and 14.6%, respectively), but this largely meant an increased use of psychiatric medications. In the same time period only 1.2% to 1.3% of adults received treatment for substance use disorder in inpatient, outpatient, or residential settings, even though the use of medications to treat substance use disorders increased rapidly. The findings were published in the June 2016 issue of Health Affairs.
The investigators used the large and representative Substance Abuse and Mental Health Services Administration (SAMHSA) National Survey on Drug Use and Health for 2004 to 2013 as the primary data source for their analysis. They found that in 2014 behavioral health treatment expenditures totaled $220 billion, with mental health treatment spending accounting for 6.4% of all health spending, and substance use disorder treatment spending accounting for 1.2% of spending. From 1986 to 2014 all health spending growth exceeded behavioral health spending growth. But for 2009 to 2014, mental health and substance use disorder spending growth (5.1% and 6.2%, respectively) surpassed all health spending growth (4.3%).
The authors describe an important trend in behavioral health financing: the shift from a system in which the majority of funding came from state and local governments or individuals’ out-of-pocket spending to a system that is financed largely by Medicaid, Medicare, and private insurance. The shift to insurance-based financing of treatment has been slower for substance use disorders than for mental health. Spending by private health insurance accounted for 28% of total mental health spending in 2014, an increase from 20% in 1986. It accounted for 18% of total substance use disorder spending in 2014. Private insurance spending represented 35% of all healthcare spending in 2014.
As seen in other studies, the shift in financing brought about the integration of behavioral health treatment into general medical settings. Thus, mental health services are expanding from specialty behavioral health systems to primary care physicians’ offices and general hospitals, they say. And services are shifting away from psychosocial therapies toward treatment with prescription medications that are usually prescribed by primary care physicians and nonpsychiatric specialists. The recent proposal from CMS for the 2017 Physician Fee Schedule calls for funding the collaborative care model in Medicare, which is designed to foster this integration.
In contrast, in 2014 substance use disorder treatment continued to be financed primarily by federal block grants and state and local general revenues. This may be due in part tthe fact that medications to treat substance use disorders have lagged behind medications to treat mental health disorders in terms of development and use, the authors hypothesize.
“Discrimination against people with substance use disorders appears to have remained more robust than stigmas associated with mental health disorders,” the authors note. “These negative views may curb individuals’ willingness to seek treatment, as well as public support for investment in and insurance coverage of substance use disorder treatment programs.”
Mark TL, Yee T, Levit KR, Camacho-Cook J, Cutler E, Carroll CD. Insurance financing increased for mental health conditions but not for substance use disorders, 1986-2014. Health Aff. 2016; 35:6957-6965. doi: 10.1377/hlthaff.2016.0002