Despite the high cost and prevalence of depression, it is often either undiagnosed or not diagnosed in a timely manner, and diagnosis does not always lead to treatment. While the costs of depression after the diagnosis of the condition have been widely studied, literature on the healthcare costs and absence-from-work costs during the period between initial disease onset and subsequent diagnosis and treatment is not as robust.
The purpose of this research is to estimate the excess healthcare costs and absence-from-work costs during the two-year period prior to the initial diagnosis of depression. We estimate that the total excess healthcare costs and absence-from-work costs for persons with undiagnosed depression over the two-year period leading up to the depression diagnosis/treatment is approximately $3,386 per undiagnosed depressed individual (in 2009 dollars).
To see the full results, including data sources, study methodology, and a discussion of what these findings mean for employers and insurers, click here.
Depression is a prevalent and costly disorder. Existing research has shown that many patients suffering from behavioral health conditions, including depression, receive inadequate or no treatment for these disorders. Inadequate treatment often occurs when patients discontinue their prescribed courses of treatment.
The purpose of this research report is to attempt to quantify the impact of depression treatment persistence on post-treatment healthcare costs. Is persistent treatment associated with future healthcare cost savings? Do patients who receive more depression treatment or continue treatment have lower total healthcare cost growth post-treatment than those who received less treatment or discontinued treatment? We conducted a study from a large national medical claims database and compared the relative change in total healthcare costs from the pre-treatment period to the post-treatment period by cohort.
Our results suggest that there is a relationship between persistent treatment for depression and future healthcare cost trend reductions for certain treatment paths and patient cohorts. We conclude with a discussion of the results and of suggestions for future research on this topic.
Risk adjustment is commonly used by health insurers to increase the accuracy of cost models by taking into account the risk characteristics of different populations, usually by providing a risk score for each individual. Milliman consultants are commonly asked to perform risk adjustment and are always looking to advance its analytical utility. In a recent paper, Milliman consultant Ksenia Draaghtel demonstrates that
…segregating risk by service category better represents the differences in utilization and cost within each component, and is an important aspect in actuarial pricing. Inpatient, outpatient, physician, and pharmaceutical services possess different characteristics with respect to the utilization frequency, cost severity, speed of claim payment, and underlying trends.
The simulations used in the paper show how these techniques can increase profitability.
Risk adjustment has become more newsworthy recently with the resurgence of interest in provider cost-sharing as a mechanism of healthcare cost control. Two recent Milliman papers discuss the issue. The first, “Risk adjustment and its applications in global payments to providers” by Rong Yi, Jon Shreve, and Bill Bluhm, is a great place to start if you are new to the topic. It starts with a rationale for using risk adjustment in this field. Take two patients, one healthy, one with chronic diseases, each patient being treated by different providers. Assume that healthcare payments are determined by patient age and gender. Without risk adjustment, the provider with the sicker patient would appear overpaid and inefficient and would miss out on efficiency-based performance bonuses. The paper goes on to discuss risk adjustment methodologies, concurrent and prospective models, data issues, and other important considerations.
Michael Leyburn Halford and Stephen Melek, speakers from Milliman Inc., Seattle, gave an MHPAEA update presentation in Boston, at the Society of Actuaries’ SOA2011 Health Meeting.
Like an earlier 1996 federal mental health parity law, the MHPAEA, which was enacted in 2008, affects only employers that choose to offer behavioral benefits, and requires those employers to offer parity between the benefits rules for the behavioral conditions they choose to cover and the benefits rules for “subtantially all” of the general medical conditions they cover. Unlike the earlier law, the MHPAEA imposes tough, detailed coverage parity rules. A plan must offer parity for each classification of benefit.
If, for example, a plan provides unlimited coverage for medically necessary inpatient care for heart attacks, and the plan chooses to cover treatment for depression, the plan must offer unlimited coverage for medically necessary inpatient care for depression.
Plans that violate the MHPAEA parity requirements could face fines of up to $100 per enrollee per day, Halford and Melek report in a written copy of their presentation posted on the SOA website, at http://www.soa.org.
Co-payment levels, coinsurance levels, deductibles, annual visit limits and episode visit limits must be the same for any behavioral health benefits provided as they are for substantially all of the general medical benefits provided, Halford and Melek say.
Milliman has found that plan non-compliance rates for mental illnesses known to be biologically based range from 0% for deductibles for in-network inpatient care to 7% for co-payments for in-network outpatient care.
For other types of behavioral health problems, non-compliance rates range close to 9% for day limits and visit limits, according to Milliman data.
More than a year after the enactment of the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA), the Departments of Labor, Health and Human Services, and Treasury issued interim final rules (IFR) prohibiting group health plans and insurance from applying more restrictions on mental health or substance use disorder benefits than they do for medical/surgical benefits. In the absence of formal guidance until the publication of the IFR and with the MHPAEA requiring compliance for plan years starting on or after October 3, 2009, many group health plans have been operating under a good-faith compliance standard. The IFR from the federal agencies provides significant guidance in some areas, and several of the requirements will necessitate additional steps to ensure compliance. Understanding how the IFR may affect the business of behavioral healthcare and the decisions that follow will be of great importance to all interested parties, including health insurance companies, health plans, employers, providers, and consumers of behavioral healthcare. This new health reform briefing paper by Steve Melek explores these implications.
…the employer also determined that many employees were not taking full advantage of the resources available to them, due to a lack of integration between the two vendors. In this case, the EAP was responsible for the first seven days of mental health care, with the health plan covering services after that. The employer had the two vendors develop detailed transition plans to ensure that employees would continue to have assistance when the EAP’s services ceased and the health plan’s responsibility began.
Employers are trying to mimimize any cost impact from parity. Here is an excerpt from the WSJ article:
It’s unclear just how costly mental-health parity will be for companies to provide. A 2007 actuarial analysis conducted by consulting firm Milliman Inc. suggested that costs under parity for employers may increase 0.6%, or $2.40 a month for each employee in 2008 dollars. A 2007 Congressional Budget Office study estimated that premiums would rise by an average of 0.4%.
Isn’t this a great opportunity to change for the better? An investment in more effective behavioral healthcare treatment is an opportunity to improve not only mental health but also physical health in our insured populations. Such health improvements can lead not only to lower healthcare costs, but improved productivity among employees.
A report out of Texas indicates that nine patients in the Austin area accounted for 2678 emergency room visits at a cost of $3 million during the past six years. The causes were not always certain, though seven of the nine have a mental health diagnosis. One doctor at least thinks these diagnoses explain some of the ER visits.
Dr. Christopher Ziebell of University Medical Center at Brackenridge sees many people in the ER who aren’t having emergencies. With mental illness, he said, ‘a lot of anxiety manifests as chest pain.’