Use of Health Care Services for Mental Health Disorders and Spending Trends

Approximately 1 in 5 adults and 1 in 6 youth experience mental illness each year, and these rates have been rising. Over 20 million Americans have a substance use disorder. The COVID-19 pandemic has exacerbated mental health issues nationally and in the workplace. With increases in both the number of individuals diagnosed with mental health disorders and use of health care services, higher spending is of great concern to plan sponsors of health benefit programs. In this study, we investigate trends in spending on mental health disorders. The study examines how diagnoses are changing and associated changes in use of health care services and spending.

Key findings:

The percentage of the population under age 65 with employment-based health coverage diagnosed with a mental health disorder increased from 14.2 percent in 2013 to 18.5 percent in 2020.
Use of mental health care services increased between 2013 and 2020. Use of outpatient services increased the most — the percentage of enrollees using outpatient services increased from 12 percent to 16 percent, a 32 percent increase. In contrast, use of prescription drugs increased from 19 percent to 21 percent, a 6 percent increase. Use of inpatient services was unchanged at 0.3 percent between 2013 and 2020.
Overall spending on mental health care services as a percentage of total spending increased from 6.8 percent in 2013 to 8.2 percent in 2020. As expected, among diagnosed enrollees, spending on mental health care services as a percentage of total spending was higher — roughly 20 percent between 2013 and 2019, increasing to 20.5 percent in 2020. Enrollees with a mental health disorder also tend to have higher overall health care spending.
Among enrollees with a mental health diagnosis, average annual spending on mental health care services increased from $1,987 to $2,380 between 2013 and 2020. It increased 20 percent, or an average of 3 percent per year, but examining overall trends buries some important findings. Spending on outpatient mental health services increased 37 percent, while spending on prescription drugs for mental health disorders fell 15 percent. In contrast, overall spending on health care services increased 20 percent overall, or 3 percent per year, suggesting that either use of health care services or prices are increasing faster for mental health care services than for other services.
Outpatient mental health care services accounted for two-thirds of total spending in 2020, up from just over one-half in 2013. The share taken by outpatient spending increased in part because spending on prescription drugs fell and because the dollar amount of outpatient spending increased. The decline in the share taken by spending on prescription drugs, from 34 percent to 23 percent of total spending between 2013 and 2020, was due to lower average prices for drugs, which may be due to some medications becoming available in generic form.
Although all ages saw increased prevalence over the study period, prevalence was lower for older ages and increasingly higher among younger adult categories. Overall, the percentage of enrollees with a diagnosis for any mental health disorder fell from 21.5 percent for those ages 18–24 to 16.7 percent for those ages 55–64. Diagnoses for children (enrollees under age 18) were at 14.9 percent, lower than any of the adult categories.
Anxiety diagnoses have been trending up for all ages since 2013. Similarly, diagnoses for major depressive disorder (MDD) have also increased for all groups. In general, diagnosis rates have increased faster among younger enrollees than among older enrollees.
Spending on mental health care services as a percentage of total spending increased for all but the oldest age groups. Such spending increased the most for younger enrollees.
Traditionally, older people use more health care than younger people. As a result, health care spending is not evenly distributed across the population. The same pattern does not hold for spending on mental health care services. The distribution of spending on mental health care services is much closer to the distribution of the enrolled population.

The data presented in this paper for 2020 — the first year of the COVID-19 pandemic — may underrepresent the number of people with mental health disorders if enrollees were unable to receive care because of shortages of mental health providers or because they did not seek or were unable to receive care due to lockdowns. The COVID-19 pandemic appears to also have heightened employers’ awareness and response to employees’ mental health disorders. And policymakers have also been addressing the issue of access to mental health services through various forms of mental health parity legislation. Despite heightened employer awareness and response and public policy efforts to address access, with increases in both the number of individuals diagnosed with mental health disorders and use of health care services, higher spending will continue to be of great concern to plan sponsors. A healthier and more productive work force should be considered as employers seek to manage the cost of treating mental health disorders.

This study was conducted through the EBRI Center for Research on Health Benefits Innovation (EBRI CRHBI), with the funding support of the following organizations: Aon, Blue Cross Blue Shield Association, ICUBA, JP Morgan Chase, Pfizer, and PhRMA.

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M. Christopher Use of HealtDist h Care Se ribution of Pop rvice ulatio s n Figure for and M Healt 8 eh nCare Spe tal Hend alt ing, h Di 2020sorders and Proportion of Total Spending on Mental Health or Substance Abuse, 10 Inpatient Spending Outpati Figure ent Spend14 ing Prescription Drug Spending 20% The HCPCS is a collection of standardized codes that represent medical procedures, supplies, products and services. 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This Issue Brief was written with assistance from the Institute’s A A Am nxi sie ge rnif ic tya ic n Ac da ia ng t noses a num dembye ha r of A v of m e A c A o ttrm ua unt ende errie icof s. (2 d ans Le Le up Use, s s s ssu 02 Tha Tha foff 2) re n 1 n 1 a . rA ll 8 8 D fr m a rom iv gong e es si rm s of 18 18enc – –Th nt 24 24e 20 a os l illne 20 2313 e H 25 25 Usin ss e ( – –a Fi 34 34 or lt gh I ur g a e ns su Men 13 ur 35 35 bst ) – – a. 44 44 nc a ta They mor nc el e P Healt rus e 45 45 m e– – ium 54 54 de h is tor or Su ha Cd ha n d e55 55 rnge e oub – –64 64 bs ac s. h ye le ta W dnc a for ash re , ingt e anr nd oll on, the eeD s unde C COVI : Dr- 19 age 100% We searched medical c laims for the presence of ICD 9/10 diagnosis codes for any mental health disorder, including Population Total Spending Mental Health and Substance Abuse Spending Spending Trends 2013 –2020 18.5% Percentage of Population Under Age 65 Diagnosed With Dep 1ressio 8.4% n, codes are used to facilitate the processing of health insurance claims by Medicare and other insurers. t inc spe halude tnding ha s b ca os . ny e W tes t e n sa m ha foc ent id tus a aa l he r e on b out not aw lt or h d td he k ire is e p rc or s a a tly nde d nd erre m la fe fa ic tll fr e m d cili ont om te o s w rhe ibut 21 it a.5 p h e lting h ca m etrp o r cloy e em nt sm e e nt rfor e vnt a ic l he e t-hose b s, suc aa sed lth ch ah a g he es 18 a s low alle lth cov nge –e 24 rs, it p etr ro a o g d 16 de u o.c .7 p e ts not ivit ey r c a e and nt pp for e m ais r tsed those o b w e or a sh gkow e s 55 da ing ys– . up 64. in Abuse Services, by Type of Health Care Service, Diagnosed Enrollees, r p 18 e asea nde and rm ch a tic hose A m ha nd es e re a icd g a xa it e n Ac or s ce 18 ia ra b l st –d a24 e ta e m , ff dy inc . s A of uc ny re h A a c v is si tie ua su ng we rs e ie fr s.om s. Re xpr The 2.1 p e tss C rie OVI ev d ee rin t D d ce -July 19 nt his Figure tp o r 29 ae4.7 p nde p , or 20 m t 22 19 e a ic rrc , ea e fr p t nt hose om p e for a r s t of enr o tolle he als 17.9% o a eut s und ha hor ves, a ehe r a ight nd ge sh e 65 ne ould , d a nd e m not inc ploy bre ee ar asi s’ sc ng ribfe ro dm to 5 30% substance use, anxiety, attention deficit hyperactivity disorder (ADHD), autism, bipolar and manic disorders, eating 25% Figure 6, Probability of Use of Any Mental Health or Substance Abuse Services, by Type of Health Care Service, All 90% 18% by Age, 2013 –2020 10 20% % All Enrollees Enrollees With a Diagnosis 22% 22% 23% 23% 24% Figure 6 By Paul Fronstin, Ph.D., Employee Benefi Atp R pee ns de ixa F rch igurIns e 1titute, and M. Christopher Roebuck, c laims any Dia m gor noses e tha for n in chil the dr e pn ( aste . nr Ov ole le ra ell, s unde 27% diagnosi r ags e r18 a 2013 te ) sw inc e – re 2020 r ea atsed 14.9 p an a er vc ee rnt ag, elow of e 4.4 r tha pen a rceny nt of per the ye a ard ult be tc w ae te eg n 2013 ories. t 11 he offic ®ers, trusProp tees, or ort ot io he n r of sponsor Total s of Spen EBRI di , ©ng EBRI on -E Men RF, orta the l Healt 16.9% ir staffh . 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Between August 2020 mental health disorder increased from 14.2 percent in 2013 to 18.5 percent in 2020 (Figure 3). Despite the COVID-19 See https://adaa.org/college-aged-adults-face-less-mental-health-stigma. Outpatient MHSA 14% 14% a A rpep r sh oxim own in atelyFi 1 in gure5 a 1. dults and 1 in 6 yout 13% h experienc 13% e mental illness each year, and these r13% ates have be 8.2% e 13% n rising. 12% 12% Ma Figr ur k, e 6% 3% T. L., 12, Pe Lr e 12% cveitnt , K ag . e R., of Va Pop ndivor ulation U t-Wande rren, r A R., ge B65 uc k D, ia J. gno A., sed & C W offe ith Va y, R. rious M. (Me 2011 nta , l He Feba rua lth D ry)is . or Cha denge rs, b s I y n U Age S , Sp 20e 20 ndi .... ng 14 Inpat 10 ie% nte Sp nrolle ending d pop — ula Ht ospit ion. a lization spe139 nding was classified into spending on inpatient care for mental health 15 4% % 7.7% 7.5% Report availability: This report is available on the internet at www.ebri.org p a nd ande Fem br ic ua tT ha rry e t a 20 tst m21 a er nt, tetd he in 202 propor 0, ne tion o arly f a ad ll 7.3% ult the s sh inc ow reing ase sy in m dp ia tg om nosi s of s 7.3% rm ata ejs oc or dceur prre ess d iv be et w die sor en 2013 der (MD and D) 20 or 19 anxi . The ety 7.1% 10% 7.0% 0% 6.8% Over 20 million Americans have a substance use disordeF r.i gThe ure C 1OVID-19 pandemic has exacerbated mental he 9 alth On Mental Health And Substance Abuse Treatment, 1986–2005, And Implications For Policy. Health Affairs, 8% diagnoses and spending on inpatient care for substance use based on Diagnosis-Related Group (DRG) 12.4% Codes. 4% Outp20 at13 ient Evaluatio 20 n 14 2015 2016 2017 AND 2018 2019 2020 Figure 10 13, Percentage of Population Under Age 65 Diagnosed With Anxiety, by Age, 2013–2020 ............................... 15 increased from 36.4 percent to 41.5 percent (Vahratian, Blumberg, Terlizzi, & Schiller 2021). According to the 2021 p revalence of anxiety and MDD accounted for the bulk of the increase in overall mental health disorder prevalence rates 4% 2% 101, 104, 109, 110, The issued s na ata tp iona resent lly a end d in t in t his he p w ap or ek r pfor lac e 20 . W 20it S — h inc a m the p re l e fir a ses D ste y m in ea ob rg ot of ra h th tp he he i c C num s OVI ,* b D by e -19 rY of e p aindiv a rndeidua mic ls — d m iaa gy nosed unde rw re itp h me resent nta tl he he alth 10% 3% 30(2), 284-292. doi:10.1377/hlthaff.2010.0765 Table of Contents and Management by 10.3% 8% 365, 458, 860, 20, b Ee BtRI w/Gr een 2013 eenw Soa u ld rc and e: Re Em20 se plo20 a yer ec Be h Wor (Fi neg fiur t Res e k p e4 ala rc ).c h e Ra In sW ti1 t tue 1 e tes of 3 lln e , s1 tie m 1ss a 4 ate nxi s Sur be astv ey de ojyum n, aone dm pie nis d -tra ha fr tivlf of om e en ro4.4 p w llmo en rt k a e e nrr dcs a ce lant im re s t do a ata t8.6 p .leaste r m ce od nte.r a MD tely D c ra onc tes inc erne 9.7% rd e a ase bou d t 6.7 num Outpb a 5% e tie r of nt p Sp eop ending 6.2 le wit — h m Ce ant tea gl he oriziang lth d out isp or ad tie ernt s if e spennding rollee s w was m ere or una e cbom le tpo lic ra etce ed iv a es it car r ee b qe uir ca eus d e seve of sh ralor dtiff ag ee re s of nt cm od eint ng al d Fiis gor urd e 10 e % 14 rs , aP nd erc us ent e a of ge he of altPh ca opula ret ion U servicnde es, hig r Aghe e r 65 spe Dinding agnosed is of Wg itrh D eate cponc ress eion, rn to p by la An sp ge, 20 onsor 13– 6.1 s of 2020 he ......................... alth benefit 16 MHSA Providers 6.0 5.9 5.8 5.9 5.9 21, 22, 23 2% 5% I ntrod 1% 2% uction ................................ 3 .......................................................................................................................... 5 their emotional well-being. Most companies think they have a responsibility to make sure employees are mentally from 3.8 percent to 5.3 percent, and ADHD rates increased from 2.3 percent to 2.7 percent. Substance use disorders Mark, T. L., Levit, K. R., Yee, T., & Chow, C. M. (2014, August). Spending On Mental And Substance Use Disorders 2013 2020 he sc p rhe og altm rh p a 2% e m s, so rs. ov Iide n th me rs o tis im st re b s in udy, w ecacus om e e b inv the ina e yt 7.2% st ion. diga id tnot W e e t r see e m nds ad k eor in spe us w ee of rnding e tuna he b Ma on ler tk m o ee trSc nt eca a el he n® ive a c plt a rh d rop e rd is ie uor tea d r ty o e rP loc s.r oc The kd eow dur st ns e udy e .G The roup xaC m v OVI ine aria D s how b-l19 e, w hich 6% AND 5 Fi M ge urnt e 15 al , H Pee rcalt enth Diag age of Pop no ula ste ion U s by E nder nr Ago e ll 65 e W e itA h An get idepressant Drug Fill, by Age, 2013–2020 ....................... 17 Outpatient Evaluation inc hea re lta hy sed and from em ot 2.2 p iona elly rce w nte ll to (C 2.6 p opela ernd cent 20 . 21). Data and Methods ................................................................................................................................5 ................. .4 6 Projected To Gr G oe w n d Mor er e Slowly Than All Healt5 h Sp .0 ending Thr 5.1 ough 20205.1 . Health Affair 5.1 s, 33(8), 1407-1415. p ass ande emm ble ics m app ae ny ar spe s to ca ifils co , yha etv si e m he ila ight r, p erne ocd e deur me ps int loyeo rs’ maor we a rg ee ne ne ss ra a l c nd a tr ee gsponse 5.4% ories. H te o ae ltm h p Cloy are e 2 e C 9 som 0 ’ .m xx m e –nt on 31a 9l he P .xrxoc /Fx ae ltd xh d .ure is or Coddeing rs. diagnoses 0% 0% 0% are changing and associated cha5.3% nges in use of health care services and spending. 4.7 4.5 4.4 5% and Management by 101, 104, 109, 110, 4.4% The prevalenc20 e 20 20 13 13 13 of mental he 20 20 20a 14 14 14 lth diagnoses 20 20 2015 15 15tended to 20 20 20 d16 16 16 ecrease wit20 20 20 h a 17 17 17ge (Figure 20 20 20 12 18 18 18). The per 20 20 20 ce 19 19 19 ntage of e20 20 20 nr20 20 20 ollees with a 4% 5% 10 1% Male 49% 50% xx doi:10.1377/hlthaff.2014.0163 Figure 16, Average Annual Number of Antidepressant Drug Fills, Among Those With a Drug Fill, by Age, 2013–2020 .. 17 A Sy nd ste pm olic (H ym CP aC kS) er s ha code ve s, als po rov beide en a r td yd pree, ss aing nd ItC he D 9/ is10 sue c od of e as w ccee ss re t o als m o eut ntili al he zeda . lt Ah se tota rv l o icf 10 c es thra oug tegh va ories w rious er e fo rms of Mental Health and Substance Use Disorders ........................................................................................................ 7 Other Providers for 113, 114 Figure 13 0% The COVID-19 pandemic appears to have heightened employers’ awareness and response to employee’s mental health 2.6% diagnosi 0% s for any mental health disorder ranged from 21.5 percent for those ages 18–24 to 16.7 pAND ercent for those ages Key findin So gus rc:e : Employee BeneF fit e Res ma elae rch Institute estimates based on administrative enrollment and cla51% ims data. 50% Sourc Le e: sEm s Tha ploy n 1 ee 8 Benefit Research18 In– s24 titute estimates ba 1.8% sed 25 on – a34 dministrative enrollmen 35 t a– n44 d claims data. 45–54 55–64 c m onst enta ru l he c 0tea d M lt a h p Hs Ssh A a rD ow itiy a g n in le no gsis eA la sptp ion. endix DeFi spit gur e e he 1ight . ened employer awareness and response and public policy efforts to Source: Employee Benefit Research Institute estimates based on administrative enrollment and claims data. 2013 Percent 20 ag 14e of Pop 20 ul 15ation Un 20 de 16r Age 65 20Diag 17 nosed 20 18 With Anx 20 iet 19y, by 2020 Figure 2% 17, Percentage of Population Under Age 65 With Psychotherapy Visit, by Age, 2013 0.9% –2020 ............................. 18 disC or la dss erifi s.c a The tion o ava f He ilaba ili ltth C y of arte e le Cm ost ed s ic ................................ ine benefits, which ar................................ e often used to provide ................................ mental he 0.8% alth servic...................... es, was already 7 0% 2013 0.5% 2014 2015 2016 2017 2018 no 20 t 19 classified ab20 ov20 e 55 Me– le 64. k, S., The De axc vee npo ption rt, S., to t& his G a ra gy e, -r T. J elat. e(d 20 p19 att)e . rA n is dd ic tha tion t daia nd gnoses Me 0.4% ntaw l He erea low lth vs est . P for hy si chil cad l He ren ( alt eh: Wide nrollees unde ning Dris a pg ae r it18 ies in ) at 0.3% 0.3% 0.3% 0.3% 0.3% 0.3% 0.3% address acc Sourc ess, e: w Emp ith inc loyee Bene r 0e .3a % fises t Resea in b rch ot Insh th titute es e tinum mates b bae sr ed of on ad indi mini vsidua trative ls en rol dia lmg ennosed t and clai m w sit da h me ta. ntal health disorders and use of Age, 2013 –2020 4 2013 2014 2015 2016 2017 2018 2019 2020 trending 0% upward prior to the pandemic, and by 2021, nearly all employers offered a telemedicine program. • The Psp ye ch rc iaetnt rica D gie a gof nos the tic population under age 65 with employment-based health coverage diagnosed with a Figure 2 14.9 p 0% erceSourc nt. W e: Emp e sa loyw ee t Bene he fisa t Rm esea e rc p h a In ts tti e tu rte n w estihe matn es e baxa sedm on ini adng minia stra nxi tive een tyrol d lm is en or t an de d r cs a laimsnd da taMD . D. However, when we examined Classifi Nce attw ion o ork f He Use aalt nd A h C g e Pa ,r ov r Ye e ide a Uti rsrliz Raetim ionb ................................ ursement. Milliman. ................................ 32.5 ................................ 33.2 ................ 7 Prescription Drug Spending — Six prescription drug categories were created using the proprietary American Hospital Figure 18, Average Annual Number of Psy 124 chotherapy Visits, Among Those With a Visit, by Age, 2013–2020 .............. 18 Source: Employee Benefit Research Institute estimates based on administrative enrollment and claims data. health ca 0% re services, higher spending will continue to be of great concern to plan sponsors. A healthier and more 2013 2014 2015 2016 2017 2018 2019 2020 S Soe urrc viec : e Em s ployee Benefit Resea Le rcs hs In Tha stitun 1 te e 8stimates 18 bas –e 24 d on admin25 istra –34 tive enrollm 35 en –t 44 and claims45 da– ta 54 . 55–64 Furthermore, among employers already offering telemedicine, they made several changes to enhance the program, mental healtPercent h disordeag r inc e rof ea sed Pop frul om at 14 io.2 p n Un erc de ent r in 201 Age 65 3 to Diag 18.5 p no esed rcent W in 202 ith V 0. ariou s 11 A DHD, we found 2013that enrolle L20 ese 14 ss unde than 1r 8 ag20 e 15 18 were the 20 16 most likely 20 ag 17 e group 26% to 20 ha 18ve suc 24% h a 20 dia 19gnosis, whic 2020 h is to be Formulary Service (AHFS) Pharmacologic-Therapeutic Classification® system, as shown in Appendix Figure 2. P revalence of Mental Health Disorders .................................................................................................................... 8 productive work force should be considered as employers seek to manage the cost of treating mental health disorders. Speech & Hearing 5 Figure 19, Proportion of Total Spending on Mental Health or Substance Abuse, by Age, 2013–2020 .......................... 19 Vahratian, A So., urcB e: lum Empb loe yer eg Be , n S. efit J Res ., Te earcrhliz Inzi, E. P stitute estim ., ate & s bSc ase hil d ole n r a, dmJ. in isS. trati( v20 e en21 roll, me A np t arnil) d c. laSy imsm dap tat.oms of Anxiety or Depressive Disorder ranging from reducing or eliminating cost149 Mental sharing tHealth o increa si Disorders, ng communic 2020 ation of telemedicine resources. 18–24 12% 12% expected as ADHD is usually first diagnosed when a person is in school. There is a question as to whether diagnosis Source: Employee Benefit Research Institute estimates based on administrative enrollment and claims data. 12% Therapy Figure Figure Figure 16 18 4 -5% Figure 10 Use • of Me Use nta of l He ma elt nt h C al he area lt Sh ca ervicre es se ................................ rvices increased betw ................................ een 2013 and 2020. ................................ Use of outpatient serv....................... ices increased t he 10 and Use of Mental Health Care Among Adults During the COVID-19 Pandemic — United States, August 2020– Dis cussion For each spending categor25–34 y, we calculated the average annual enrollee out 13% -of-pocket cost 14% (deductible, coinsurance, rates fall with age because enrollees no longer have mental health disorders or because they are less likely to seek Figure 20, D Dris ut gr ibut Testion o ing f Population and 302 Health Care Spending, 2020 ..................................................................... 20 AA verage vPercent erage AA nag nu nnu e al of al Nu Nu Pop mm be ul be r at r of io of n Psy A Un nt ch de ide ot r pre he Age rssan ap 65 y V t Diag isit Drug s, no A Fi sed m lls, ong W Aith m Th o V ng os ariou e Th W os s ith e a Anxiety Disorders Total Annual Spending on Mental Health Disorders per Diagnosed 8.6% P olicymakers have also been addressing the issue of access to mental health services through various forms of mental most — the percentage of enrollees using outpatient services increased from 12 percent to 16 percent, a 32 February 2021. MMWR and Morbidity and Mortality Weekly Report, 70, 490-494. a nd/or copayment), plan p35–44 aid amount, and total allowed amount. We also 17% calculated the 17% percentage of all health care I Sp trte is e anding tim me pnt or on taas t nt Me he to nt yunde a gl He et old ra st lta e h C nd r. Iatn cont r he e S unde errvaic st re ly sting o ................................ anxi face tor ty s d disror ivd ing er, the MD ................................ inc D, raen ad se AD in HtD he , d num iagnoses be................................ r of for pe op sub lest d aia nc ge nose used .............. d w isit or h a den rs d 12 Mental Health W or Subst ith a Drug Visit, by ance Fill, Age, Aby bu 2013 se Age, Disorders, –2013 2020 –2020 2013 and 2020 Enrolle Fi e, gu 20 re 13 7 –2020 J1230, J2315, A he pa plt eh p ndix arFi ity g ur lee g is 1la , tOut ion. p a For tie n etxa Sp m ep nding le, the C a Me tent gor al He ization alth ................................ Parity Act of 1996 (MH ................................ PA) provided that la.......................... rge group health 22 S pending on Mental Health Care Services percent inc Ma re joa r Depres se. In cont sive Disr orde astr, use of prescription drugs increased from 19 percent to 21 percent, a 6 percent doi:10.15585/mmwr.mm7013e2 5.3% 45–54 20% 18% spending T 10 h % is st rep urd ey sent wa esd co byn td he use ctead m th ount rou s.g Fi hna thlly e E , in a BRd I d C iten ion te to r fro ep r or Res ting ea on rch a on ll indivi Hea dua lth ls Ben in ag efits greg I an ten , o w ve a ti als oo n present seeking treatment for mental health disorders. Use of mental health services may be increasing because more people tend -10 to %increase slightly with age. J0592, Q9991, Probability of Le Le s sUse s s Tha Than 1 n 1 of 8 8 Any18 18 Men – –24 24 tal 20Healt 25 25 13 – –34 3420h 20or Su 35 35– –44 44 bsta 45 45 nc – –54 54 e Abus 55 55– –e 64 64Services, Mental Health Diagnoses by Enrollee Age .............................................................................................................. 14 plans cannot impose annual or lifetime dollar limits on mental health benefits that are less favorable than any such incM re ea dse. icat iUse on-A s of sisinp teda tient services was unchanged at 0.3 percent between 2013 and 2020. Overall spending on menta55–64 l health care services as a percentage of total sp 12% ending increa 15% sed between 2013 and 2020 Attention Deficit Hyperactivity Disorder -10.4% these averages by age group. (EBRI CRHBI), with the funding support of the following organizations: Aon, Blue Cross Blue Shield A ha pv pe e ndix mentFi ag l he urea lt 2, h d Pris eor scd ripti ers t on ha Dn in rug tSp hee nding past. IC t ais te p goss oriza Q ible 9t 9ion 9 2 tha , ................................ J2 t 3d 1ia 0,g noses are more................................ accurate, like with ot................ her medica l 22 by Type of Health Care Service, All Diagn 2.7% osed Enrollees, 2013 –2020 Trends in Use of Mental Health Care Services and Spending by Enrollee Age Treatment ((M AD eHD) dical- Figure 12 20% lim its imposed on medical/surgical benefits. The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Tr ends in Diagnoses by Enrollee Age..................................................................................................................... 15 (Figure 9). In 2013, 6.8 percent of health care spending was attributable to mental health care services. By 2020, it 9% 14 12 G0128, J0570, Association, ICUBA, JP Morgan Chase, Pfizer, and PhRMA. $2,380 conditions. However, if diagnosis rates are increasing, an important question to ask is what is driving the underlying 8.6% Increase Adjudicated) Inpatient Stays Outpatient Visits Prescrip$2,317 tion Drug Fills • Overall spending Percent on m ag ent e a of l he Pop alth ca ulat reio sen rvUn ices a des a r A pge erc e 65 ntaDiag ge of no totsed al sp e W nding ith V inc ariou reased s from 6.8 percent Following the upw Sa ub rs dtan trce ends Abuse D in a isorder nxiesty and depression, use of 2.6% health mental care ser $2,295 vices increased commensurate Equity Act of 2008 (MHPAEA) prevents group health plaJ n0s a 571 nd , J0 he 57a 2lt , h insurance issuers that provide mental health or 8% Geographic Region was 8.2 -15%percent, a 20 percent increase over 2013 spending. Am $2 ong ,260 diagnosed enrollees, spending on mental health Classification of Health Care Utilization 100% g Tr row ends th?in U One se m of ayMe sunt rm al He ise ta hlt ah C t the ar est Se ress rve icse s a assnd ocia Sp teed ndin witg h th bye E C nr OVI olleD e- 19 Ag-e r e................................ lated pandemic are to ........................... blame. Yet, we 16 $2,206 Any Mental Health Anxiety DisordeMental rs Major De Health pressive Disorders, Attention Deficitby S u A bs ge, tance2020 Abuse Bipolar and Manic Post-Traumatic in 2013 to 8.2 percent in 2020. As expected, J0 a5 m 73 ong , J0 5 d7ia 4,g J n0ose 575d enrollees, spending on mental health care with the 8% various age groups. For example, all age groups experienced an increase in the percentage with an su bstance use disorder benefits from imposing less favorable benefit limitations on those benefits than on Northeast 17% 14% c are services as a percentage of total spe$2,108 nding was much higher — roughly 20 percent between 2013 and 2019, or Substanc Bipo e A la bu r and se Manic Disorders Di0.6% sorder Hyperactivity Disorders Disorders Stress Disorder found that most of the growth in diagnoses occurred between 2013 and 2019. Access issues during the pandemic may In addition to costs, use of health care services was also examined. For inpatient, outpatient, and prescription drug 2512 % Endnotes Spending on Mental Health Care Services vs. Other Health Care Services................................................................. 19 90%services as a percentage of total spending was higher — roughly 20 percent between 2013 and 20 87% 19, a ntidep 10ressant Di d so rru dg er fill (Fig Mur ide w e15 st). Fu Lersts he Tha rm n 1 or 8e, inc 18–r 24 eaD sie s25 o s w r– d34 ere (r AD e 35 H highe D –)44 r 45 for – 21% 54 young 55–e 64 r age24% s. Similarly, the number of medical/surgical bene $1,987 fits. MHPAE $1,988 A preserved the MHPA p 86%rotections and added new protections, such as extending the 86% 86% 86% 86% 86% 2986% 0.xx–319.xx/Fxx. increasing to 20.5 percent in 2020. This increase might have been due to reductions in use of other health care services Spending on Mental Health Care Services vs. Other Health Care Services have artificially reduced the growth rate in mental health diagnoses between 2019 and 2020, even while the availability service 7% s, we derived the proportion of individuals using any of the service (i.e., the extensive margin) and the average Total Spent Post-Traumatic Stress Disorder 0.5% 6% increasing to 20.5 percent in 2020. Enrollees with a mental health disorder also tend to have higher overall drug fills for antidepressant Ss ou inc th reased for each age group (Figure 16). Whil 40% e they increa 42% sed the most xx for younger age p arity requiO re th m ere O nt us t tpa o tie su ntb fst or ance use disorders. The Patient Protection and Affordable Care Act (ACA) of 2010 built on Discussion ................................ 21.5% ........................................................................................................................... 20 as a result of the COVID-19 pandemic. on Mental Health I of t is te c le om mem do icn know ine w 21.0% as inc ledgr ee taha sing t old . er people use more health care than younger people. As a result, health care spending use (i.e 80% ., d Soa uy rcs, v e: Emis plit oys, or ee Ben fil efit ls Res ) of earcthhe Ins tiser tute v esic tim ea te ut s ili baze sedd o nc a ond dminit isi tra ona tive l o enron llmus ent ing and ca lany ims ser data.vice (i.e., the intensive margin). Note 1 20.7% AND MHSA Diagnoses Nationalhe As as lto h ca ciation re spe of Me nding W nta es l. tIllness. See https://www.nami.org/mhstats. 22% 19% groups, t 10 he differences were as pronounced as they were for the percentage of enrollees with such a drug fill. MHPAE and S A by ubstanc requiring e coverage of mental health and substance use disorder services as 1 of 10 essential health Phobic Anxiety Disorders 0.4% 6% is not evenly distributed across the population. For example, individuals under age 18 accounted for 24 percent of the Conclusion .......................................................................................................................................................... 21 that 20 the % product of these two averages represents the average number of units utilized across the full sa 37m % p le. As with Abuse 8 (MHSA) not classified above $1,597 18.7% Among enrollees with a mental healt5.3% h diagnosis, average annual spending on mental health care services increased benefits categories. Most recently, the Consolidated Appropriations Act (CAA) of 2021 amended MHPAEA to require 2 70% $1,534 $1,543 The increase may be attributable to lower stigma associated with mental health disorders. Many people In cre wit as h me e ntal Substance Abuse and Mental Health Services Administration. 66% See https://www.samhsa.gov. 66% enrolled population, but only 12 percent of total spending (Figur $1e ,4 20 91 ). In contrast, individuals ages 55–64 accounted spending 4% , we present these averages by age65% group, in addition to reporting on all indi 65% viduals in a 65% ggregate. Not all • Among enrollees w Auti itsh a m Di 64% m sore dn ertal hea 0.4% lth diagnosis, average annual spending on mental health care serv 65% ices The likelihood of having an outpatient psychotherapy visit increased for nearly all age groups and increased the most 63% Relationship to Policyholder $1,456 Appendix ............................................................................................................................................................ 22 5% fr om $1,987 to $2,380 between 2013 and 2020 (Figure 10). It increased 20 percent, or an average of 3 percent per plans and issuers to provid 16.7% e comparative analyses of their non-quantitative treatment limitations (NQTLs) to the ill ness do not receive help for their disorder because of the stigma. They may be in fear of their employer finding out 8 4.4% for 15 percent of the enrolled population, but they accounted for 27 percent of health care spending. 3 findings a inc rer e pa re sed sent fre om d in t $1he ,987 pa tpo er $2 . ,380 $1,336 between 2013 and 2020. It increased 20 percent, or an average of 3 percent for Se y eoung https e:r/ /a w gw ew g.reoup bri.o s ( rgFi /d S go e uc lfrse/ d17 efaul ). E tnr -so olle urce es a /wb gse/s 55 wws– -202 64 w 1/e 2021 re the -w o erk xcpela pct44% e ion. -we They sa llness-shw o46% rt a- re slp ight ort. p dd efc.r ease in the Use 60 o % f Mental Health Care Services year, but examining overall trends buries some important findings. Spending on outpatient mental health services Secretary of tO he bs es Tr se iva e-C su om rypu , ltshe ive Di Se sorder cretsary of 0.3% Labor, and the Secretary of HHS (collectively, the Secretaries) upon request Reference 14.9% s .......................................................................................................................................................... 23 and losing their job. Or they may be in fear of how their friends and colleagues may react. A recent survey found that $1,224 3.8% 15% 6 4% per year, but examining overall trends burA iep s som pende ix im Fip gor urte a nt 2 findings. Spending on outpatient mental health percentage with a p$1,169 sychothe Spo ra up se y visit. The number of psychotherapy visits in 19% creased as w 18% ell, and the increases 4 C inc om rem ased ens ur 37 a tp ee w rcit eh th nt, w e hil inc er spe ease nding in d ia on gnosi pres scrra ipti tes on , us de rug of s for ment m ae l he ntaa l he lth a clt ah d re ser isor vd iceers inc s fell 15 p reased e rb ce ent tw.e Ien cont n 2013 ra a stn, d and to authorize the Secretaries to determine whether those NQTLs comply with MHPAEA. NQTLs include plan See Figure 13.3 in https://www.kff.org/report-section/ehbs-2021-section-13-employer-practices-telehealth-and-employer- The m entsa al he me apltah st tterigma n doe is s not a m hold ajor cfor ha lle spe nge nding in t he on w mo ernt kp ala l he ce.a lt Only h ca a re b out ser vone ices. -ha The lf of dis wtorribut kers a ion o re f spe comfor nding tab le on ta m lkeing nta l On a fin 2%al note, in addition to reporting all of these spending and utilization averages based on the sample of all Eating Disorders 50% 0.2% Endnotes ............................................................................................................................................................ 23 6 Prescription Drug Spending Categorization ser Outpat vice ien s inc t reasedC 37 hild p /oe tr hc ee r n dt e, pw enhil dee n tspending on prescription drugs 37% for mental he 36% alth disorders fell 15 percent. generally followed the previously observed age pattern — younger enrollees experienced a greater increase than older 20 ove 20 ra ll spe (Figur nding e 6). Use on he of alt out h ca parte ie se nt rser vice vs inc ices inc rearsed eased 20 tp he er c m eost nt ov —e rta he ll, o pe r r3 p cent er acgeent of pe er n ryolle eare , s us suging gestout ing pta ha tie tnt eit ser her v 14 ic us ee s p re rs ov po is nions ses- to su -the ch a -p s d and et ee mic rm/ina . tions of prior authorization and medical necessity, as well as network adequacy. health care services is much closer to the distribution o 2.7% f the enrolled population. For instance, individuals under age 18 about 3% theM irH m SA ental health at work, and about one-third are worried about their job if they seek mental health care. To enrollees, in some cases, we pre11.1% sent them among enrollees diagnosed 2.6% with a mental health or substance use disorder 11.2% In contrast, overall spending on health care services increased 20 percent overall, or 3 percent per year, e nrollees in use of p Ssy chc izhot ophrhe enir a Di apsy order vissits (Fi 10.7% gure 18 2.3% ). 0.1% inc of he rea ased lth ca from re se 12 rv ic pe ers or cent p tro ice 16 s a pre er c inc ent re , aasi 32 ng p fa est rce ernt for inc m re ea nt se. al he In cont alth ca rarst e, ser use v ic of es t prha esc n for ripti on othe drrugs serinc vicr ee s. a sed from 40% 4 2.2% a the cc ount degred ee for tha 24 t t he perrec e isnt le of ss tst he igma pop a ula round tion a m nd ent 25 al illne percss en, t m of orm ee p nt eo ap l he le w alt ill h ca seerk e c spe aren for ding. the Sim heila lp rtly he , y indiv nee idua d. The ls ag fa ec s t 5 as previously defined (e.g., ICD9: 290.xx–319.xx; ICD10: Fxx.xx). American Hospital Formulary 10% See Figure 13.6 in httpsH :/ e/a w ltw hw P.lk aff n. o Trg yp /re e port-section/ehbs-2021-section-13-employer-6practices-telehealth-and-employer- 9.0% suggesting that either use of health care services or prices are increasing faster for mental health care services Employers and workers spent nearly $77 billion on mental health disorders in 2020. Employers are looking for ways to 2% 19 pe0% rc4ent to 21 percent, a 6 percent increase. In fact, use of prescription drugs reached 21 percent in 2019, before Figures CatDi egor ssocy iative Disorders Service (AHFS) Therapeutic 55 tha –t64 dia ag cnosi count s r ed at e for s a 15 re inc per rc ee ant sing of for the y p oung 0.03% opula indiv tion a idua nd ls 11 m p ae yr c su ent pp or of tm the ent d aiff l he ere ant lth ca vier w es on spending stigma . . Recent research 7.7% Sp rese pnding onses -on to-the me-nt pa and l he emic alth ca /H . MO re /E se PO rvices as a percentage of total spending 16% increased for15% all but the oldest age groups 30%than for 2013 other serv20 ic14 es. 2015 7.2% 2016 2017 2018 2019 2020 a Out ddp re ass tie tnt he m m ee nt nt aa l he l he aa ltlt h ca h ne ree d ser s of vicw es a orkcecrount s giveedn th fore t w cur o-rt6.5% e hir ntd e s of conomi totac l sp clie m nding ate. A in 202 nd the 0, up y are fr eom spe c jus ially t ov int ere rone este -ha d in lf in falling to 20 percent.$547 Use of inpatient services was a constant 0.3 percent between 20 Cl13 ass and 2020 15 . Limitations — There are several limitations with our analysis. First, we are unable to examine racial disparities in use of 6.2% 15% has found that college-aged adult $511 s have more accepting views of mental health than older adults. (Figure 19). Spending on m Pe Pnt O/a Pl he OSalth ca$483 re services increased the most for 69% enrollees unde 52%r age 18, increasing from 12 1% 5.8% Delusional Disorders 0.02% 0.6% $466 Fi 6 gure 1, Sample Demographics, by Year ................................ $447 ................................ 0.6% ................................................ 6 2013 (Figure 11). The share taken by outpatient spending increased in par$443 t because sp $439 ending on preD sc ec ripti rease on drugs fell addressing mental he Antia dlt eh ne presse ad ns b ts ecause of the connection betw $431 een MDD and produc 28t :1 iv 6it .0 y losses (Goetzel e 0.5t% al. 2018). Unpub 2lished author estimates. 5.1% 4.9% mental hea So ltuh se rce: Em rv pic loye es e Be as t nefihe t Res re e a 4is rc .7h % no Institu dte a t ea sti m for ate sr a bac se ed/e ont hni admc init istra y tiin t ve ehe nrol lm Ma ent r ak ne d t cSc laima sn® data. database. Prior work has found that 202 % 0.2% HRA 8% 15% • 5% Outpatient mental health care services accounted for two-thirds of total spending in 2020, up from just over percent of Rx tot Ma Hl sp SA ending in 2013 to 18 percent in 2020, a 55 percent increase. For enrollees ages 18–24, spending 3.9% 3.9% 3.5% A a Ta nd m kong ing bec re a enr us sponsibilit olle e the es w dA olla it y nh a tfor ip r sa y m w m ch e or ount o ntk tic a es l he r sof ’ m a out lt eh d nt pa aia l he tie gnt nosi a lt spe h ma s, nding the y not p rinc op only e re ns ased it ry e d t. o uc The u ese spe dm ending c elin nte a l he in t on 28 a he .he lt 1h se 6sh a .0 lt 8 a h ca ,r r v e 2ic 8 t:r e a 2e s w 8 k e bn ut ab s m m y a spe ost y inc nding ly run eac se ha on w nge ork de r 0% 1% 2% 3% 4% 5% 6% 7% 3.2% 3.4% 8% 9% The various mental health parity laws that have taken effect since the mid-1990s may have also contributed to 7 p Fie gop urle e 2, of P ce olor rce nt araeg m e or of eP lik ope uly la ttion U o neende d m re A nt ga el he 65 a Dltia h ca gnos ree ser d W vit ich Va es, arrious e le ss Me lik ntealy l He to aalt ch D cess is or the de m rs, 202 , and 18 a 0r % .................... e more likely 8 0% 2.8% ICD-9-CM = International C Hla SA ss -e ific liga ib tion le he oaf ltDis h pe laa ns es, 9th Revision, Clinical Mod6% ification, and 17% ICD-10-CM = International one-half in 2013. The share taken by outpatient spending increased in part because spending 2.9% on prescription increased from 16 percent to 18 percent, a 15 perce2.5% nt increase. Those ages 25–34 experienced a 50 percent increase 2.1% p frrom esc r 2013 iption –2d 02 rugs 0 (, Fi Afr m gom ur phe e t34 7 am ). ip n Use e er sc a eof n nt d out S to tim p 23 u alt aie p ne tnt s rc e ser ntv of icets in otal sp crea esed nding $338 from be t86 we p e 2 $341 n 2013 e 8r :2 c0 e.nt 04 , t a o 2nd 887 :20 20 .p 3e 2 20 r , c2 , e 8m nt :2a .0 y .Use 8 0 ha vof Ie n cre be pras e en sc e rdipti ueon to productivity.A I nx t iet ha y D s b isor ede en e rs stim Ma a 12 jtoe r d Depres thats im veental he Attea ntilt oh co n Defindit cit ions S ub co sst tan c e em Ap buloy se ers ov Bipo elr a r20 and 0 Ma mnill icion los Post-tT rw aum ora kti cd S atry es s e s ach 10% $314 $317 inc reased use of mental health services. Despite these $304 laws, unlike the recent past, spending on mental health services $289 1.3% to have poor clinical outcomes. Second, our estimates for 2020 — the first year of the COVID-19 pandemic — may $270 Cl assification of Diseases, 10th Revision, Clinical Modification. Source: Employee Benefit Resea $253 rc Di h sIn or sd tier tute estimates Hy ba pe sred ac ti on v ity ad Di mini so sr tra de tirve enrollmDi en st o an rdd ers claims data. Disorders Disorder drugs fell and because the dollar amount of outpatient spending increased. The decline in the share taken by in spending, increasing from 7 percent to 10 percent. Enrollees ages 45–54 experienced a 3 perc 13 ent increase in Figure 3, Percentage of S Po op urc ue la : tE ion U mploy nde ee r B e Ang ee fi t65 Re s Deia arg cnos h Ine std it uW teit e h An stima yt e Me s bnt asael He d ona a ltd h o minri sSubst t0.7% rativea nce Abuse Disorder, 0 0 0.3% 2% Benzodia 2% zepines 2% 2% 2% 2% 28:12.1 2% y som de rugs are ( L m inc ee op r de ic old aa sed t ions 20 fr 01 om ha ). v Me 63 ing nt pm e arl ov che ee nt d a lt toff p h d o 65 isa or p te e d nt re c re a s c nt nd .ont A bnd e inu com us e e ing to of ba einpa v a atila tthe b iele nt for a ser s eg fr v eont ic ne es r ic of r ed m m rug e ad ine ia eq dcuiv ov at a e2 p le rant gee s r c .aes nt Thi w fr es sa ll om a2% nd m 2013 ea re– oft 2020 en . EBRI Issue Brief is registered in the U.S. Patent and Trademark Office. ISSN: 0887 –137X/90 0887 –137X/90 $ .50+.50 (ADHD) declined as a share of total health care spending between 1986 and 2005 (Mark, Levit, Vandivort-Warren, Buck, and underrepresent the number of people with symptoms of anxiety and depression if enrollees were unable to receive care Inpatient 20 2013 13 20 2014 14 20 2015 15 20 2016 16 20 2017 17 20 2018 18 20 2019 19 20 2020 20 0% spending on pre en sc rorlipti lmeon nt ad nrdu c gls, fr aimsom da t34 a. percent to 23 percent of total spending between 2013 and 2020, was spe 8 nding, while those ages 55–64 experienced a 5 percent decrease when looking at spending on mental health care 0% 2013–2020 .............................................................................................................................................. 9 Other Anxiolytics, Sedatives, and Hypnotics 28:24:00 We included the following ICD-9 and ICD-10 codes: ICD9: 290.xx–319.xx; ICD10: Fxx.xx. phenomenon o MHSAccurred between 2002 and 2005 (Mark, Levit, Vandivort-Warren, Buck, and Coffey 2011). Spending on connected with other popular policy topics such as gun control, homelessness, incarceration, veterans, and abortion. Any Mental Health or Anxiety Disorders Major Depressive Disorder Attention Deficit Substance Abuse Disorders Coffey 2011). More r20 ec 13 ently, inc 20 re 14 ased dem 20a 15nd for m 20 e16 ntal healt20 h ca 17 re serv 20 ic18 es is expe 20c 19 ted to pla 20y 20 a larger-than- Source: Employee Benefit Research Institute estimates based on administrative enrollment and claims data. because of shor 20 ta 13 ges of men 20 ta 14 l health pr2 ov 01ide 5 rs or be20 ca 16 use they did 201not 7 seek or 2 0w 18 ere unable2 0t1 o 9receive ca 2r 0e 20 due to Source: Employee Benefit Research Institute estimates based on administrative enrollment and claims data. due © t2o 02 low 2, e Erm aplo very aee ge B penef rices f it or Resea drurc gs, w h In hic stit h ma ute –yE b du e ca due tio tn o a som nd Resea e medrc ica h F tion un s b d. eAll r comiig ng hta s vre aila ser bv leed in g . eneric ser In cont vices a rast s a S, uba sp m tan eong r cc ee Ant bu ea nr se D golle ei sof order es tot waho l he aa cc lte h ca ssed re m spe ent nadl he ing.a lth care, utilization inc Hype re raa csed tivity Di ov so err der the study period. These Source: Employee Be *H nM efiO t Res = eh ae rca hl t In hs tim tua tei n es te tim na ate ns c b ea s o erd g o a nn a iz dm at in io isn tra . tiE veP eO nro = llm e ex nt caln ud s c iv la e im p sr d oav ta id .er organization. Medication-Assisted Treatment (Pharmacy-Adjudicated) 28:10, 28:08.12 inpatient services was in the 12 to 14 percent range, and neither trended upward or downward. 9 Fi his gtur oreic 4, al r Pole erc e wnt he an it ge of com Pop es t ula o tion U premnde iumr inc Agre e a 65 ses Dia in g2023 nosed ( A W m ite h Va rican A rious ca d Me em nt ya of l He Ac atlt ua h o rie r s 202 Subst2) anc . e Abuse Disorders, loc DR kd Gs ow ans re .a Tr sta ea tis tm tical ent se yst ste im m atus es a ed rto e a cls lao ssunde ify inp rr ae tie por nt te sta d y to s into the d gro egup res e fo tha r p t urp enr oolle s (e AD se HD) o s a f praey me using nt. W out e -us ofe -ne d DR twG or sk 876 -887 Source: Employee Benefit Research Institute estimates based on administrative enrollment and claims data. form. PPO = preferred provider organization. POS = point-of-service plan. HRA = health enrollees used an average of 5.4 prescription drugs, 6.7 outpatient visits, and 21.6 inpatient stays (per 100 patients) in With prevalence rates rising, we would expect use of mental health care services and spending to rise as well. One Source: Employee Benefit Research Institute estimates based on administrative enrollment and claims data. 20 So 13 urc ea : nd Empl20 oye20 e Be ................................ nefit Research Institute estimates................................ based on administrative enrollme................................ nt and claims data. ........................................ 9 for mental health diagnoses and DRGs 894-897 for substance abuse diagnoses. providers, where the health care claim is not being submitted for adjudication. A recent report found that enrollees reimbursement arrangement. HSA = health savings account. 2020 (Figure 8). Use of prescription drugs trended up between 2013 and 2020, increasing from 4.4 fills to 5.4 fills. In question however is whether spending on mental health care services is rising on a per-diagnosed-member basis. 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