Journal of Mental Health Policy and Economics最新文献

Background: For decades, insurance plans in the United States have applied more restrictive treatment limits and higher cost-sharing burdens for mental health and substance use treatments compared to physical health treatments. The Mental Health Parity and Addiction Equity Act (MHPAEA) required health plans that offer mental health and substance use benefits to offer them at parity with physical health benefits starting in January 2010.

Aims of the study: To determine the effect of MHPAEA on out-of-pocket spending and utilization of outpatient specialty behavioral health services.

Methods: The proportion of individuals with at least one outpatient specialty behavioral health visit, the average number of visits among those with any behavioral health visit, and the proportion of behavioral health spending paid out-of-pocket were obtained from the nationally-representative Medical Expenditure Panel Survey (MEPS) for the years 2006 to 2013. Difference-in-differences models were estimated comparing individuals with employer-sponsored insurance to those with Medicaid, Medicare, or who were uninsured.

Results: Out-of-pocket share of spending was lowest among Medicaid (2.0%) and highest among the uninsured (22%), followed by the employer group (13%). Individuals in Medicaid had the highest proportion of any behavioral health visit (11%) and the uninsured had the lowest (2.4%). Among those with any behavioral health visits, the average number of visits was similar across groups. Our primary and sensitivity analyses suggest MHPAEA did not lead to changes in utilization or spending on specialty outpatient behavioral visits for individuals with employer-sponsored insurance compared to other groups.

Discussion: Potential reasons for MHPAEA's apparent lack of effect are that health plans were already at parity before the law's passage, that many health plans continue to be out of compliance with the law, that concurrent changes in plans' cost-sharing blunted the law's effects, and that other barriers to behavioral health service use continue to limit utilization. While our study cannot provide direct evidence of these mechanisms, we review existing evidence in support of each of them. Our study had several limitations. We cannot test definitively whether the difference-in-differences assumption was violated or fully control for time-varying differences between groups. We attempt to address this by using multiple control groups and presenting evidence of parallel trends before MHPAEA implementation. Second, because our data do not have state identifiers, we cannot control for which states had existing mental health parity laws. Third, a nationally representative analysis may mask substantial heterogeneity for affected subgroups.

Implications for health policies: We find no evidence MHPAEA substantially affected behavioral health

Background: Schizophrenia spectrum disorders exert a large and disproportionate economic impact. Early intervention services may be able to alleviate the burden of schizophrenia spectrum disorders on diagnosed individuals, caregivers, and society at large. Economic analyses of observational studies have supported investments in specialized team-based care for early psychosis; however, questions remain regarding the economic viability of first-episode services in the fragmented U.S. healthcare system. The clinic for Specialized Treatment Early in Psychosis (STEP) was established in 2006, to explicitly model a nationally-relevant U.S. public-sector early intervention service. The purpose of this study was to conduct an economic evaluation of STEP, a Coordinated Specialty Care service (CSC) based in a U.S. State-funded community mental health center, relative to usual treatment (UT).

Methods: Eligible patients were within 5 years of psychosis onset and had no more than 12 weeks of lifetime antipsychotic exposure. Participants were randomized to STEP or UT. The annual per-patient cost of the STEP intervention per se was estimated assuming a steady-state caseload of 30 patients. A cost-offset analysis was conducted to estimate the net value of STEP from a third-party payer perspective. Participant healthcare service utilization was evaluated at 6 months and over the entire 12 months post randomization. Generalized linear model multivariable regressions were used to estimate the effect of STEP on healthcare costs over time, and generate predicted mean costs, which were combined with the per-patient cost of STEP.

Results: The annual per-patient cost of STEP was $1,984. STEP participants were significantly less likely to have any inpatient or ED visits; among individuals who did use such services in a given period, the associated costs were significantly lower for STEP participants at month 12. We did not observe a similar effect with regard to other healthcare services. The predicted average total costs were lower for STEP than UT, indicating a net benefit for STEP of $1,029 at month 6 and $2,991 at month 12; however, the differences were not statistically significant.

Conclusions: Our findings are promising with regard to the value of STEP to third-party payers.

Objective: Two separate changes in insurance regulation have altered mental health delivery to Americans: (i) the Mental Health Parity and Addiction Equity Act (MHPA 2008) and (ii) the Patient Protection and Affordable Care Act (ACA 2010). This study aims to model and provide estimates for the costs and effects of depression that are impacted by these regulations.

Method: Literature exists on the effectiveness of insurance coverage in reducing the prevalence, the costs of treatment and lost productivity time, as well as the health related quality of life (HRQL) associated with depression. Data from this literature is employed in a Markov model to obtain costs and effects associated with depression under both the MHPA and the ACA regulations as compared to without either one.

Results: The implementation of these regulations may reduce the per capita lifetime costs of depression treatment and lost productivity by USD 215 and enhance life expectancy by 0.01 Quality Adjusted Life Years (QALY) per capita.

Conclusions: If the savings of these regulations are expanded over the entire cohort of Americans adults, the potential cost savings from treated depression are estimated at USD 47.30 billion in addition to 2.2 million QALYs saved.

Background: Child labor has been usually claimed to produce negative effects on health. However, most of the studies that investigated this hypothesis examined only its impact on child laborers' physical health. This study formulates the hypothesis that child labor may have an impact on the mental health of these individuals.

Aims of study: The aim of this study was to investigate the risk of child laborers to develop symptoms of depression in adulthood and to examine the role of physical and mental health of the family members on their risk of developing depression.

Data and methods: We used the 2008 National Household Sample Survey (PNAD, Pesquisa Nacional por Amostra de Domicilios) and its special supplements to estimate probit models.

Results: Individuals who started working between the age group of 15-17 have about 0.6 percentage points lesser risk of developing depression as compared to those who started working between the age group of 10-14. Further reduction of this risk was observed for the age groups of 18-19 and 20-24. No statistical evidence was found regarding older age groups. Individuals with a mother with depression have about 3.2 percentage points higher risk of presenting symptoms of depression. Chronic physical illness in mothers increases the risk of depression in child laborers by 0.3 percentage points.

Discussion and conclusion: Our study supports the hypothesis that work during childhood increases the risk of developing depression in adulthood. Family mental health status and chronic physical illness play a substantial role in the risk that child laborers have to develop depression.

Implications for health policies: The results of the study indicate the need of basic mental health services aimed to the assessment and care for child laborers who withdraw from work, with the aim of reducing the risk of depression in adulthood. The results underline also the importance of mental health assessment and care for those children with a family member with depression or chronic physical illness.

Background: Somatoform disorders are highly prevalent mental disorders causing impairment and large economic burden. In order to improve the diagnosis and management of affected patients, a health care network for somatoform disorders (Sofu-Net) was implemented in primary care.

Aims of the study: The aim of the study was to determine the cost-effectiveness of a stepped, collaborative and coordinated health care network for somatoform and functional disorders (Sofu-Net) compared with regular primary care physician (PCP) practices in German primary care from a societal perspective.

Methods: This study was part of a 6-month controlled, prospective, non-randomized, observer-blinded cluster cohort trial. Participants were recruited from 33 PCP practices in Hamburg, Germany. The health care network was a collaboration of PCPs, psychotherapists, inpatient clinics and a specialized outpatient clinic. Participants in the control group received usual care. A cost-effectiveness analysis, using treatment response as measure of effectiveness, was performed. Uncertainty in cost-effectiveness was analyzed using cost-effectiveness acceptability curves.

Results: In total, n=218 patients (n=119 patients in the intervention group and n=99 patients in the control group) were included in the study. At 6 months, patients within the Sofu-Net group did not differ significantly from the control group with regard to costs (533; standard error 941) and treatment response (--10.3%). For Sofu-Net, the probability of being cost-effective at a willingness-to-pay (WTP) of 10,000 per additional response to treatment was only 31%.

Discussion: Sofu-Net is unlikely to be cost-effective. Even for high WTP, the probability of cost-effectiveness was low. The results were robust to variation of costs included in the analysis as well as when only complete cases were included in the analysis. The most important limitations of the study were that randomization could not be established at patient level and at practice level and that the study design did not allow measurement of costs at baseline.

Conclusion: Patients with severe somatic symptoms did not benefit from the health care network. Sofu-Net might have reduced costs in patients with moderate somatic symptoms.

Implications for further research: Owing to the limitations and due to a short follow-up of this study, further cost-effectiveness analyses with high methodological quality and a follow-up of at least one year are needed in order to produce results that are more reliable.

Background: Measures of efficiency in healthcare delivery, particularly between different parts of the healthcare system could potentially improve health resource utilization. We use a typology adapted from the Agency for Healthcare Research and Quality to characterize current measures described in the literature by stakeholder perspective (payer, provider, patient, policy-maker), type of output (reduced utilization or improved outcomes) and input (physical, financial or both).

Aims of the study: To systematically describe measures of healthcare efficiency at the interface of behavioral and physical healthcare and identify gaps in the literature base that could form the basis for further measure development.

Methods: We searched the Medline database for studies published in English in the last ten years with the terms 'efficiency', 'inefficiency', 'productivity', 'cost' or 'QALY' and 'mental' or 'behavioral' in the title or abstract. Studies on healthcare resource utilization, costs of care, or broader healthcare benefits to society, related to the provision of behavioral health care in physical health care settings or to people with physical health conditions or vice versa were included.

Results: 85 of 6,454 studies met inclusion criteria. These 85 studies described 126 measures of efficiency. 100 of these measured efficiency according to the perspective of the purchaser or provider, whilst 13 each considered efficiency from the perspective of society or the consumer. Most measures counted physical resources (such as numbers of therapy sessions) rather than the costs of these resources as inputs. Three times as many measures (95) considered service outputs as did quality outcomes (31).

Discussion: Measuring efficiency at the interface of behavioral and physical care is particularly difficult due to the number of relevant stakeholders involved, ambiguity over the definition of efficiency and the complexity of providing care for people with multimorbidity. Current measures at this interface concentrate on a limited range of outcomes.

Limitations: We only searched one database and did not review the gray literature, nor solicit a call for relevant but unpublished work. We did not assess the methodological quality of the studies identified.

Implication for health care provision and use: Most measures of healthcare efficiency are currently viewed from the perspective of payers and providers, with very few studies addressing the benefits of healthcare to society or the individual interest of the consumer. One way this imbalance could be addressed is through much stronger involvement of consumers in measurement-development, for example, by an expansion in patient-reported outcome measures in assessing quality of care.

Implications for health policies: Integrating behavioral