Having a parent with a behavioral health condition increases the likelihood that a child will develop one too. In the paper “Household dynamics in the prevalence of mental health conditions and substance use disorders,” Milliman’s Stoddard Davenport and Marissa North explore the prevalence of mental health and substance use disorders within commercially insured families in the United States to understand the likelihood of a household being affected by these conditions.
The infographic below illustrates key findings and trends from the paper.
Many social determinants of health have important effects on
behavioral health and can apply to all members of a family. Some research has
found that having a family member with a mental illness decreases family
functioning and is a general stressor for families. With that in mind, payers
and providers may find that the diagnosis of a behavioral health condition in
one family member could signal that it may be worth screening for circumstances
that might affect the entire household. This could provide an opportunity for
earlier diagnosis and intervention with other household members who may be at
heightened risk for similar behavioral health concerns.
In order to shed more light on how behavioral health conditions affect families, Milliman analyzed the prevalence of several conditions among family members in a national, commercially insured population in 2017. In this paper, Milliman’s Stoddard Davenport and Marissa North expand on existing research by analyzing the prevalence of behavioral conditions in parents of children with behavioral conditions versus those without as well as children of parents with behavioral conditions versus those without.
A federal judge recently ruled that a company administering mental health and substance use disorder benefits for ERISA-covered health benefit plans breached its fiduciary duty when it applied its own flawed medical review guidelines in rejecting plan participants’ claims for behavioral health services. ERISA requires fiduciaries to administer benefit plans solely in the interest of participants and beneficiaries and in accordance with plan documents.
Because the case, Wit v. United Behavioral Health (No. 14-cv-02346-JCS [as well as a related case, No. 14-cv-05337-JCS]), was decided by the U.S. District Court in the Northern District of California, it applies only to the parties involved. An appeal is possible, perhaps after the remedy phase of the case is completed and a final judgment is issued.
The court noted that the administrator abused its discretion when it adopted its guidelines in several ways, such as:
- Having a conflict of interest because a large portion of its revenues came via pressure to keep expenses down
- Not insulating the individuals who developed, revised, and approved the guidelines from financial considerations
- Refusing to adopt generally accepted clinical guidelines despite the recommendations from clinicians to do so and against some states’ requirements stipulating standards of care
A key issue raised by the case was the coverage for behavioral and substance use disorders as chronic, rather than acute, conditions. Thus, the plaintiffs argued, the guidelines limited coverage once a patient’s symptoms subsided and did not cover services needed to stabilize his or her condition over a longer term. Furthermore, the court noted that the 2008 Mental Health Parity and Addiction Equity Act requires coverage of depression or addiction no more restrictively than other medical conditions. And yet, in the court’s opinion, the administrator’s guidelines adopted appropriate standards of care for medical conditions but not for the mental health conditions.
Employers that sponsor healthcare coverage should review the implications of the case and discuss any concerns with their behavioral management administrators.
For additional information about the court’s ruling, please contact your Milliman consultant.