Expanded Insurance: Mental Health Care Admissions Drop

Deborah Brauser

February 24, 2014

Despite concerns that health insurance expansions would boost inpatient admissions for mental health care, it appears the opposite is true ― at least in Massachusetts.

A new study shows that following Massachusetts' 2006 health reform, there was a significant decline in inpatient admissions for any behavioral health disorder, including depression and substance abuse, among young adults.

In addition, the proportion of uninsured individuals aged 19 to 25 years dropped from 26% to 10%. The rate of uninsured behavioral health discharges from hospital care and from emergency departments (EDs) also decreased significantly, especially when compared with other states.

"Recent calls for increased access to mental health services have raised concern that increases in coverage will fuel unsustainable increases in use and spending," write the investigators.

However, the findings show "significant declines in admissions or visits without insurance coverage in both hospital and ED settings," the investigators, led by Ellen Meara, PhD, associate professor at the Dartmouth Institute for Health Policy and Clinical Practice in Lebanon, New Hampshire, write.

They add that the latter could be due to increased coverage through Medicaid, private healthcare insurance, and Commonwealth Care.

"This signifies much lower out of pocket burden for young adults with a behavioral health crisis, as well as less uncompensated care burdening hospitals," the researchers write.

The study was published online February 19 in JAMA Psychiatry.

Sweeping Changes

"There has been a lot of change happening, particularly in health insurance in the US. We're now getting results from newly covered young adults because of the Affordable Care Act dependent coverage, which requires insurers to allow dependents to remain on a parental policy until the age of 26," Dr. Meara told Medscape Medical News.

Dr. Ellen Meara

"But we realized that Massachusetts offered us this chance to understand changing care for young adults after their 2006 reform. Also, this was a group that had very high rates of uninsurance prior to 2006," she added.

The investigators decided to examine effects from the reform by comparing Massachusetts health records before and after 2006 with those from the rest of the country.

They included data for 2,533,307 nationwide hospital inpatient admissions, "representing 12,821,746 weighted admissions across 7 years" from 2003 to 2009. They also assessed 6,817,855 weighted ED visits by those between the ages of 12 and 25 years in Massachusetts and Maryland only.

Primary outcome measures included inhospital admission rates and ED visit rates per 1000 population for any behavioral health disorder. Insurance coverage for behavioral health ED visits and hospital admissions was also measured.

Results showed that inpatient admissions rates for individuals in Massachusetts declined after 2006 an absolute 2 per 1000 for primary diagnoses of any behavioral health disorder when compared with changes observed in comparable age groups in other states (95% confidence interval [CI], 0.95 - 3.2; P < .001).

The rates also declined by 1.3 per 1000 for substance abuse disorders (95% CI, 0.68 - 1.8) and 0.38 for depression (95% CI, 0.18 - 0.58; both, P < .001).

Although ED visits in Massachusetts for any behavioral health diagnosis increased after 2006 (from 33 to 41 per 1000 for 12- to 18-year-olds and from 53 to 72 per 1000 for 19- to 25-year-olds), the rates were lower than those found in Maryland (35 to 42 and 65 to 99 per 1000, respectively).

"Much of this growth was among visits with diagnoses of substance use disorder," the investigators write.

The rate of uninsured 19- to 25-year-olds in Massachusetts was 26% before 2006 and only 10% afterward.

Uninsured behavioral health discharges from hospitals decreased by 5.0 percentage points (95% CI, 3.0 - 7.2), as did those from EDs (95% CI, 1.7 - 7.8), relative to other states.

Financial Protection

"For clinicians, I think the take-away is to let young adults who typically haven't been well insured know that the financial consequences of using effective outpatient settings are different," told Medscape Medical News.

"Plus, clinicians themselves need to know that the care they are providing for behavioral health services is now more likely to be covered, especially in Massachusetts," said Dr. Meara, noting that almost 3 million young adults in the United States have recently gained insurance coverage.

Although expanded insurance coverage did not lead to an increase in inpatient behavioral healthcare, the researchers note "it increased financial protection for young adults…and for the hospitals that care for them."

According to Dr. Meara, there are several potential explanations for the study's findings.

"One is that if we give people insurance coverage, it gives them access to things like outpatient care, which might keep them from needing inpatient or [ED] care," she said.

"But we don't know if this is the reason for the decline in admissions or whether it reflects something else, such as a private behavioral health managed care organization that might place limits on the ability to use services in a hospital setting. Or they might have a triage set up so that you can call and talk to a nurse and arrange to go to an outpatient setting."

She said that overall, there is a need for better information about what is happening in both inpatient and outpatient settings.

"Further studies should examine patterns of care…, particularly as data emerge since implementation of federal parity laws," write the investigators.

The study was supported by grants from the National Institute of Drug Abuse. The study authors have reported no relevant financial relationships.

JAMA Psychiatry. Published online February 19, 2014. Abstract

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