A Reduction in Health Care Expenditures Linked to Mental Health Service Use Among Adults With Chronic Physical Conditions
Abstract
Objective:
The aim was to examine the impact of receipt of mental health services on health care expenditures for U.S. adults with major chronic physical conditions.
Methods:
Medical Expenditure Panel Survey data for 2004–2014 were analyzed for adults ages ≥18 with at least one of six chronic physical conditions (cardiovascular diseases, cancer, diabetes, emphysema, asthma, and arthritis) who were followed up for 2 years (N=33,419). Outcomes included overall health care spending and expenditure by service type (inpatient services, outpatient services, emergency department visits, office-based physician visits, and prescribed medication). A difference-in-differences model compared a change in health care costs in the subsequent year for those who did and did not receive mental health services in the preceding year.
Results:
On average, the increase in overall health care expenditure in the subsequent year among adults receiving mental health services in the preceding year was smaller by 12.6 percentage points (p<0.05) than for those who did not receive such services. The difference was equivalent to $1,146 in 2014 constant U.S. dollars (p=0.05). Medication treatment alone did not have a meaningful effect on overall costs. The combination of psychotherapy and medication was associated with a per-capita reduction in overall health care expenditure of 21.7 percentage points, or $2,690 (p<0.01). The combination was also associated with reduced costs for office-based visits (p<0.05) and medication (p<0.05).
Conclusions:
Receipt of mental health services was associated with a reduction in overall health care costs, particularly for office-based visits and prescribed medication, among adults with chronic physical conditions.
HIGHLIGHTS
•
Among adults with at least one of six major chronic physical conditions (cardiovascular disease, cancer, diabetes, emphysema, asthma, or arthritis), those who received any mental health services in the preceding year had a smaller increase in overall health care expenditure in the subsequent year.
•
Receipt of both psychotherapy and medication treatment was associated with a greater reduction in health care costs, compared with receipt of only one of the services.
•
Receipt of mental health services in the preceding year led to a reduction in health care expenditures for office-based visits and prescribed medication in the subsequent year.
Cardiovascular disease (CVD), cancer, diabetes, chronic lower-respiratory diseases, and arthritis are among the leading causes of mortality and disability among American adults (1, 2). These conditions have posed a significant financial burden of hundreds of billions of U.S. dollars each year to both patients and the health care system (3–7). Among individuals with these chronic physical conditions, mental disorders, such as affective disorders and anxiety, are also prevalent as a result of coping with physical symptoms (8–15). The co-occurrence of mental health problems among patients with these chronic physical conditions could reduce adherence to treatment, decrease quality of life (16–19), and increase health care costs (20, 21).
The vast literature on how mental health service use influences health care expenditures of individuals with physical conditions focuses on how depression treatment is associated with medical costs of people with concurrent depression. Some found that total health care expenditure was reduced by treatment with antidepressants and psychotherapy (22, 23), yet others showed that receiving depression treatment was associated with increased costs (24) or no differences in costs (25). Furthermore, mental health conditions are often underdiagnosed and overlooked among individuals with complex chronic physical conditions (26, 27). A recent study of U.S. adults ages 18 and older found that having adverse physical health events altered demand for mental health services (28), which could have implications on overall health care utilization and cost over time.
To our knowledge, little research has quantified the impact of receipt of mental health services on health care expenditures in a large population sample of people with chronic physical conditions that are often comorbid with various mental health conditions. Our primary objective was to examine how the utilization of mental health services in the preceding year was associated with the change in overall health care expenditure in the subsequent year among individuals with at least one of six chronic physical conditions: CVD, cancer, diabetes, emphysema, asthma, and arthritis. We also analyzed the relationship between receipt of each type of mental health service and overall health care expenditure. Moreover, we examined the impact of mental health service use on service-level costs, including inpatient services, outpatient services, emergency department (ED) visits, office-based physician visits, and prescribed medication.
Methods
Data and Sample
We used data from the Household Component of the Medical Expenditure Panel Survey (MEPS) for years 2004 to 2014 (29). MEPS is a large-scale survey of a nationally representative sample of the noninstitutionalized population in the United States (29). The panel design of the MEPS allowed us to follow each individual in each of the 10 panels (2004–2014) for 2 calendar years and thus to examine how receipt of mental health services in the preceding year was associated with health care expenditures in the subsequent year.
The study population consisted of adults ages 18 and older who reported diagnoses of any of six physical conditions: CVD (i.e., heart disease and stroke), cancer, diabetes, emphysema, asthma, and arthritis. We derived our sample on the basis of the MEPS questions about whether an individual had ever been diagnosed as having each of the six physical conditions either before or during the first year of follow-up (30). Among 36,480 individuals who met the criteria, we excluded 3,061 persons (8.4%) who reported zero overall health care spending during a year, which is uncommon among adults with these physical conditions. Having zero health care spending may be due to self-report bias, or these persons may have had different characteristics compared with others in the sample. The analytic sample included 33,419 adults with any of the six physical conditions, of whom 7,929 had a diagnosis of co-occurring mental disorders, such as anxiety, mood disorders, adjustment disorders, schizophrenia, and other psychotic disorders.
Outcome Variable
Our primary outcome was overall health care expenditure, which captured the overall payment from all sources for health care services used within a year. We also analyzed service-level costs, separately for inpatient services, outpatient services, ED visits, office-based physician visits, and prescribed medication. Health care expenditures were adjusted for inflation by the Personal Healthcare (overall and component) Price Indices and Consumer Price Index (for medication) (31) and expressed in 2014 constant dollars.
Outpatient Mental Health Services
Mental health services included psychotherapy and medication treatment. Psychotherapy was defined as seeing a psychologist or as receipt of psychotherapy or mental health counseling during an office-based physician visit, outpatient visit, or ED visit. Medication treatment for mental health was identified by purchases of prescription drugs associated with psychiatric conditions. Information on type of provider (i.e., psychologist) and visit category (i.e., psychotherapy or mental health counseling) in MEPS medical event files was used to determine psychotherapy use. We used clinical classification codes 650 (adjustment disorders), 651 (anxiety disorders), 657 (mood disorders), and 659 (schizophrenia and other psychotic disorders) to identify prescription drug purchases associated with mental disorders (a table with a complete list of ICD-9-CM codes associated with the clinical classification codes is included in an online supplement to this article). Most common medications associated with these clinical classification codes included selective serotonin reuptake inhibitors, selective serotonin and norepinephrine reuptake inhibitors, antidepressants, antipsychotics, and anxiolytic or sedative drugs.
Covariates
Individual demographic and socioeconomic characteristics included age, sex, race-ethnicity, marital status, census region, metropolitan residence, income, education, and insurance status. Because the utilization of mental health services could depend on the severity of physical illness as well as the need for mental health care, we controlled for perceived physical and mental health status as proxy for the severity of physical and mental health conditions, respectively. Our measures included physical component summary and mental component summary scores that were computed with information from the 12-item Short-Form Health Survey (32). Co-occurrence of mental disorders and alcohol or drug use disorders was identified with clinical classification codes from the MEPS household condition files.
Analytic Model
The identification of the effect of receiving mental health services on subsequent health care expenditures hinged on a difference-in-differences (DID) framework. We compared an average change in health care expenditures from the preceding year to the subsequent year among individuals with the chronic conditions who utilized mental health services in the preceding year to an average change in health care expenditures among those who did not.
Although overall health care expenditure did not have zero value, it was distributed highly right-skewed with individuals who had extremely high cost. To obtain more consistent parameter estimates, we employed a generalized linear model (GLM) with the log link function and the gamma distribution (33). We included interaction terms for the indicators of receipt of mental health services in the preceding year and the indicator of the subsequent year in our models. The coefficients on the interaction terms measured the percentage point changes in health care expenditure in the subsequent year attributed to receipt of mental health services in the preceding year.
We then examined the effects on health care expenditures of receiving mental health services by type of service using two-part DID models (33 –35), because service-level costs may be right-skewed and could also have many zeros (e.g., patients who did not have any hospital admissions or ED visits). In this approach, the first part estimated the impact of receiving mental health services on the probability of incurring any cost by using logistic regression and the second part modeled the change in expenditures among those who had nonzero costs by using GLM.
All models controlled for annual individual demographic and socioeconomic characteristics, perceived health status, co-occurrence of mental disorders and alcohol or drug use disorders, and time trend. We computed the average marginal effects of the interaction terms in terms of dollar amounts to estimate the change in health care expenditures associated with use of mental health services. Bootstrapped standard errors of the marginal interaction effects were obtained based on 1,000 repetitions.
Although our models included different sociodemographic characteristics and time trend, selection bias might still be present because of potential unobserved person heterogeneity. To mitigate this concern, we adjusted our estimates with inverse-probability weights to better balance baseline characteristics of the two comparison groups (i.e., those who used mental health services and those who did not). A properly reweighted inverse-probability–weighted estimator is largely used in treatment effect estimation as a tool for causal inference to adjust for measured confounders (36, 37). Further, an inverse-probability–weighted DID estimator has a doubly robust property because it adjusts estimates for both observed and unobserved selection (38, 39). We obtained inverse-probability weights by fitting a logistic regression of the indicator of receipt of any mental health services on all the covariates above, as well as smoking status and year dummies. Our analyses used Stata software, version 13.1 (40). Because we used publicly available MEPS data sets, review by an institutional review board was waived.
For a sensitivity analysis, we estimated linear regression models with and without a log-transformation of expenditures to check the robustness of our results. We also applied survey weights in MEPS and excluded outlier observations.
Results
Characteristics of the Study Population
Table 1 summarizes characteristics of the study sample in the preceding year, for the entire sample and by use of mental health services. The mean overall health care expenditure in the preceding year among individuals with at least one of the six physical conditions was $9,067. Among the 33,419 persons in the overall sample, 20.1% received mental health services. The second and third columns present characteristics of two groups without inverse-probability weighting. Among those who used mental health services, 8.5% received psychotherapy only, 71.5% received medication treatment only, and 20% received a combination of both. The mean overall health care expenditure among individuals who received any mental health services was $13,141, which was higher than the average cost of $8,043 among those who did not use mental health services.
| Received mental health care (unweighted) | Received mental health care (weighted) | ||||
|---|---|---|---|---|---|
| Variable | Total sample (N=33,419) | Yes (N=6,715) | No (N=26,704) | Yes | No |
| Outcome: overall health care expenditure (M±SD) | $9,067.3±$17,548.7 | $13,141.0±$21,320.3 | $8,042.9±$16,306.0 | $14,823.5±$21,813.2 | $8,505.2±$13,354.3 |
| Explanatory | |||||
| Any mental health service use in the preceding yearb | 20.1 | 100.0 | 0 | 100.0 | 0 |
| Psychotherapy only | 1.7 | 8.5 | 0 | 3.0 | 0 |
| Medication treatment only | 14.4 | 71.5 | 0 | 61.7 | 0 |
| Psychotherapy plus medication treatment | 4.0 | 20.0 | 0 | 20.3 | 0 |
| Control | |||||
| Health status | |||||
| Physical component summary score (M±SD)c | 42.5±12.4 | 39.3±12.9 | 43.2±12.1 | 36.1±12.7 | 39.9±13.3 |
| Mental component summary score (M±SD)c | 48.9±11.2 | 41.6±12.3 | 50.7±10.1 | 38.0±12.6 | 40.8±12.1 |
| Chronic physical condition | |||||
| Cardiovascular disease | 34.9 | 39.0 | 33.8 | 41.3 | 38.7 |
| Cancer | 18.3 | 18.6 | 18.3 | 20.0 | 17.8 |
| Diabetes | 27.1 | 25.1 | 27.6 | 25.1 | 23.5 |
| Emphysema or asthma | 24.9 | 32.1 | 23.1 | 35.3 | 34.6 |
| Arthritis | 58.5 | 67.3 | 56.3 | 75.3 | 64.9 |
| Mental disorder | 23.7 | 95.0 | 5.8 | 100.0 | 94.9 |
| Alcohol or drug use disorder | .8 | 1.9 | .5 | 2.5 | 1.9 |
| Age (M±SD) | 56.9±16.1 | 55.0±14.9 | 57.4±16.4 | 55.5±13.3 | 53.5±14.8 |
| Female | 60.8 | 71.7 | 58.0 | 76.1 | 73.0 |
| Race-ethnicity | |||||
| White | 77.1 | 69.3 | 56.1 | 80.7 | 70.3 |
| Asian | 4.0 | 1.5 | 4.7 | .6 | 1.6 |
| Black | 2.0 | 14.5 | 21.7 | 8.8 | 13.9 |
| Other | 1.3 | 1.3 | 1.3 | 1.1 | 1.2 |
| Hispanic | 15.6 | 13.4 | 16.2 | 8.8 | 13.0 |
| Marital status | |||||
| Single | 14.5 | 34.9 | 14.2 | 13.7 | 18.0 |
| Married | 53.3 | 46.0 | 55.1 | 46.4 | 42.4 |
| Widowed | 13.1 | 12.0 | 13.4 | 10.9 | 12.0 |
| Divorced | 15.5 | 2.1 | 14.1 | 24.7 | 22.6 |
| Separated | 3.6 | 5.0 | 3.2 | 4.3 | 5.0 |
| Family income | |||||
| Poor | 18.2 | 24.4 | 16.8 | 25.4 | 25.9 |
| Near poor | 6.3 | 7.4 | 6.0 | 8.8 | 6.4 |
| Low income | 15.9 | 15.9 | 15.9 | 16.3 | 15.5 |
| Middle income | 28.8 | 26.8 | 29.2 | 25.4 | 27.1 |
| High income | 30.8 | 25.5 | 32.1 | 24.1 | 25.1 |
| Census region | |||||
| West | 57.8 | 20.7 | 23.1 | 16.7 | 23.3 |
| South | 3.9 | 39.2 | 39.0 | 44.7 | 36.2 |
| Midwest | 22.0 | 23.3 | 21.7 | 19.6 | 23.9 |
| Northeast | 16.3 | 16.8 | 16.2 | 19.0 | 16.6 |
| Metropolitan | 72.4 | 69.9 | 73.0 | 68.3 | 71.8 |
| Employed | 46.2 | 37.7 | 48.3 | 27.9 | 40.0 |
| Education | |||||
| Less than high school | 23.7 | 23.3 | 23.8 | 23.0 | 21.0 |
| High school | 31.2 | 32.1 | 31.0 | 31.2 | 30.1 |
| College | 36.5 | 37.0 | 36.4 | 38.5 | 40.3 |
| Graduate school | 8.6 | 7.6 | 8.8 | 7.3 | 8.6 |
| Insurance coverage | |||||
| Private | 58.6 | 52.3 | 60.2 | 48.9 | 53.4 |
| Public | 32.6 | 40.1 | 30.7 | 46.8 | 38.3 |
| Uninsured | 8.8 | 6.3 | 6.9 | 3.8 | 7.1 |
a
Values are percentages unless otherwise indicated. Inverse-probability weights were estimated from a logistic regression for the indicator of receiving any mental health services as a function of all covariates, smoking status, and year dummies.
b
Psychotherapy was defined as seeing a psychologist or as receipt of psychotherapy or mental health counseling during an office-based physician visit, outpatient visit, or emergency department visit. Medication treatment for mental health was identified by purchases of prescription drugs associated with psychiatric conditions (i.e., adjustment disorders, anxiety, mood disorders, schizophrenia, and other psychotic disorders).
c
Possible physical and mental component summary scores range from 0 to 100, with higher scores indicating better self-perceived health status.
In the sample, 35% had CVD and 18% had cancer. The proportions of individuals who had diabetes or who had emphysema or asthma were 27% and 25%, respectively; 59% had arthritis. A total of 7,929 individuals (23.7%) reported that they had been diagnosed as having a mental disorder. As measured by the physical component summary score, those who received mental health services had poorer self-perceived health status, compared with those who did not receive mental health services. Among those who received mental health services, 95% reported that they had mental disorders. Six percent of those who did not receive mental health services reported that they had mental disorders. Compared with those who did not receive mental health services, those who received services had a higher proportion of co-occurring alcohol or drug use disorders (1.9% versus 0.5%). Compared with those who did not receive mental health services, those who did were more likely to be female, White, and poor and less likely to be married and employed.
The fourth and fifth columns of Table 1 present characteristics of the two groups with use of inverse-probability weights. After weighting, the two groups became more balanced in observed characteristics, especially perceived mental health status (mental component summary score), co-occurrence of mental and alcohol or drug use disorders, marital status, and family income.
Table 2 reports mean health care expenditures, total and by type of service. The increase in overall expenditure was greater among individuals who did not use mental health services (an increase from $8,043 to $8,624), compared with the increase in expenditure of those receiving mental health services (an increase from $13,141 to $13,295). Similar patterns were observed for inpatient expenditure and prescribed medication cost. Average ED expenditure slightly decreased in both groups. Office-based provider cost and outpatient cost slightly decreased among those using mental health services, but these costs increased among individuals who did not use mental health services.
| Received mental health care | ||||||
|---|---|---|---|---|---|---|
| Total sample (N=33,419) | Yes (N=6,715) | No (N=26,704) | ||||
| Expenditure type and year | M | SD | M | SD | M | SD |
| Overall | ||||||
| 1st year | 9,067.3 | 19,562.7 | 13,141.0 | 21,320.3 | 8,042.9 | 16,306.0 |
| 2nd year | 9,562.6 | 18,224.0 | 13,294.7 | 20,597.1 | 8,624.1 | 17,452.3 |
| Inpatient services | ||||||
| 1st year | 2,663.1 | 12,808.9 | 3,535.5 | 15,162.8 | 2,443.7 | 12,135.9 |
| 2nd year | 2,861.4 | 12,787.1 | 3,660.7 | 14,268.7 | 2,660.4 | 12,378.9 |
| Emergency department visits | ||||||
| 1st year | 307.2 | 1,480.4 | 391.2 | 1,554.8 | 286.1 | 1,460.4 |
| 2nd year | 292.2 | 1,245.1 | 376.9 | 1,424.5 | 270.9 | 1,194.8 |
| Office-based physician visits | ||||||
| 1st year | 2,072.4 | 5,518.4 | 2,886.5 | 5,712.0 | 1,867.7 | 5,449.6 |
| 2nd year | 2,134.6 | 5,483.5 | 2,836.5 | 5,795.4 | 1,958.1 | 5,388.0 |
| Outpatient services | ||||||
| 1st year | 784.0 | 3,599.8 | 1,063.9 | 4,112.7 | 713.5 | 3,455.4 |
| 2nd year | 790.1 | 3,988.7 | 946.7 | 3,387.2 | 750.7 | 4,125.3 |
| Prescribed medication | ||||||
| 1st year | 2,338.6 | 4,840.6 | 4,007.9 | 7,546.6 | 1,918.8 | 3,758.6 |
| 2nd year | 2,550.3 | 5,095.9 | 4,156.1 | 6,756.1 | 2,146.6 | 4,495.6 |
Table 3 presents coefficient estimates from our GLM models for overall health care expenditure. Model 1 estimated change in overall cost associated with receiving any mental health services, and model 2 estimated change in overall cost associated with types of mental health services. In model 1, the increase in expenditure in the subsequent year among individuals who received any mental health services was smaller than the increase in expenditure among those who did not receive these services—by 12.6 percentage points (p<0.05). Model 2 suggests that receiving a combination of psychotherapy and medication treatment reduced the increase in subsequent overall cost by 21.7 percentage points (p<0.01).
| Model 1 | Model 2 | |||
|---|---|---|---|---|
| Variable | Coefficient | SE | Coefficient | SE |
| Explanatory | ||||
| Receipt of mental health care in the preceding year (reference: no receipt)b | ||||
| Any mental health services | .456*** | .045 | na | na |
| Psychotherapy only | na | na | .303*** | .091 |
| Medication treatment only | na | na | .366*** | .046 |
| Psychotherapy plus medication treatment | na | na | .724*** | .058 |
| Subsequent year | .111 | .057 | .112 | .058 |
| Interaction term of receipt of mental health care and subsequent year | ||||
| Any mental health services × subsequent year | –.126* | .062 | na | na |
| Psychotherapy × subsequent year | na | na | –.231 | .132 |
| Medication treatment × subsequent year | na | na | –.077 | .064 |
| Psychotherapy plus medication treatment × subsequent year | na | na | –.217** | .076 |
| Control | ||||
| Health status | ||||
| Physical component summary score | –.031*** | .001 | –.031*** | .001 |
| Mental component summary score | –.006*** | .001 | –.004*** | .001 |
| Chronic physical condition (reference: no indicated condition) | ||||
| Cardiovascular diseases | .216*** | .026 | .231*** | .026 |
| Cancer | .235*** | .031 | .236*** | .031 |
| Diabetes | .298*** | .027 | .296*** | .027 |
| Emphysema or asthma | .068* | .026 | .061* | .026 |
| Arthritis | .007** | .029 | .004 | .029 |
| Mental disorder (reference: no disorder) | –.101** | .032 | –.085** | .032 |
| Alcohol or drug use disorder (reference: no disorder) | .423*** | .079 | .384*** | .078 |
| Age | .005*** | .001 | .006*** | .001 |
| Female (reference: male) | .013 | .027 | .008 | .027 |
| Race-ethnicity (reference: White) | ||||
| Asian | –.208 | .122 | –.179 | .128 |
| Black | .146*** | .038 | .153*** | .039 |
| Other race | .257* | .115 | .273* | .115 |
| Hispanic | –.007 | .040 | –.003 | .040 |
| Marital status (reference: single) | ||||
| Married | –.162*** | .041 | –.142*** | .042 |
| Widowed | –.163** | .051 | –.152** | .052 |
| Divorced | –.119** | .043 | –.118** | .043 |
| Separated | –.134* | .065 | –.132* | .066 |
| Family income (reference: poor) | ||||
| Near poor | .128** | .044 | .132** | .044 |
| Low income | .045 | .043 | .048 | .043 |
| Middle income | .115** | .040 | .124** | .039 |
| High income | .220*** | .045 | .225*** | .045 |
| Census region (reference: West) | ||||
| South | –.091* | .036 | –.075* | .035 |
| Midwest | .013 | .037 | .015 | .037 |
| Northeast | .050 | .041 | .030 | .040 |
| Metropolitan (reference: not metropolitan) | .064* | .028 | .058* | .028 |
| Employed (reference: not employed) | –.123*** | .034 | –.101** | .033 |
| Education (reference: less than or some middle school) | ||||
| High school | .015 | .034 | .014 | .034 |
| College | .119*** | .036 | .099** | .036 |
| Graduate school | .298*** | .055 | .238*** | .053 |
| Insurance coverage (reference: uninsured) | ||||
| Private | .753*** | .060 | .760*** | .058 |
| Public | .579*** | .059 | .579*** | .057 |
| Constant | 9.352*** | .128 | 9.228*** | .129 |
a
All estimates were adjusted for year dummies and inverse-probability weights. Model 1 estimated change in overall cost associated with receiving any mental health services, and model 2 estimated change in overall cost associated with types of mental health services (na, not applicable).
b
Psychotherapy was defined as seeing a psychologist or as receipt of psychotherapy or mental health counseling during an office-based physician visit, outpatient visit, or emergency department visit. Medication treatment for mental health was identified by purchases of prescription drugs associated with psychiatric conditions (i.e., adjustment disorders, anxiety, mood disorders, schizophrenia, and other psychotic disorders).
*
p<.05, **p<.01, ***p<.001.
Table 4 presents results from two-part DID models used to estimate the impact of mental health service use on service-level costs. We did not find a statistically significant relationship of mental health service use and subsequent inpatient cost, ED cost, or outpatient cost. Although use of mental health services did not reduce the probabilities of incurring costs for office-based visits and prescribed medication, it was associated with a reduction in costs. Utilization of any mental health services lowered the subsequent cost increase for office-based visits by 15.7 percentage points (p<0.05) and for prescribed medication by 17.7 percentage points (p<0.05). Receiving a combination of both psychotherapy and medication treatment lowered the cost increase for office-based visits and prescribed medication by 33.3 percentage points (p<0.001) and 22.7 percentage points (p<0.05), respectively.
| Change in health care expenditures (%)b | ||||||||
|---|---|---|---|---|---|---|---|---|
| Any mental health services | Psychotherapy only | Medication treatment only | Psychotherapy plus medication treatment | |||||
| Service type | Coefficient | SE | Coefficient | SE | Coefficient | SE | Coefficient | SE |
| Inpatient services | ||||||||
| Change in probability of incurring cost | –1.26 | .016 | –.15 | .036 | –.99 | .016 | –2.30 | .021 |
| Change in cost among those with nonzero cost | 4.92 | .123 | –12.0 | .276 | 7.16 | .126 | –1.75 | .161 |
| Emergency department visits | ||||||||
| Change in probability of incurring cost | .03 | .017 | –4.87 | .042 | .83 | .018 | –1.65 | .021 |
| Change in cost among those with nonzero cost | 13.20 | .129 | –29.0 | .277 | 10.70 | .137 | 25.30 | .155 |
| Office-based visits | ||||||||
| Change in probability of incurring cost | –3.74*** | .011 | –6.20*** | .019 | –3.48** | .012 | –3.84*** | .011 |
| Change in cost among those with nonzero cost | –15.70* | .079 | –42.20* | .175 | –5.60 | .082 | –33.30*** | .093 |
| Outpatient services | ||||||||
| Change in probability of incurring cost | –.39 | .021 | 1.75 | .05 | .14 | .021 | –2.38 | .028 |
| Change in cost among those with nonzero cost | –7.16 | .142 | –30.30 | .422 | –3.54 | .143 | –12.80 | .195 |
| Prescribed medication | ||||||||
| Change in probability of incurring cost | –1.89* | .009 | –.02 | .022 | –2.28* | .009 | –1.62 | .01 |
| Change in cost among those with nonzero cost | –17.70* | .077 | –2.65 | .20 | –15.80* | .077 | –22.70* | .09 |
a
Reference group, adults who did not use mental health services. Two-part difference-in-differences models were used to estimate changes in service-level costs (i.e., inpatient services, emergency department visits, office-based visits, outpatient services, and prescribed medication). Changes in probability of incurring any cost are marginal effects estimated from logistic regression in the first part with bootstrapped SEs from 1,000 repetitions. Changes in cost among those with nonzero cost are coefficients from the generalized linear model in the second part that applied to a subsample of patients who had incurred any expenditure.
b
Psychotherapy was defined as seeing a psychologist or as receipt of psychotherapy or mental health counseling during an office-based physician visit, outpatient visit, or emergency department visit. Medication treatment for mental health was identified by purchases of prescription drugs associated with psychiatric conditions (i.e., adjustment disorders, anxiety, mood disorders, schizophrenia, and other psychotic disorders).
*
p<.05, **p<.01, ***p<.001.
Table 5 presents changes in health care expenditures associated with use of mental health services in terms of dollar amounts (2014 constant dollars). On average, adults who received any mental health services had a cost saving in the subsequent year of $1,146, compared with those who did not use mental health services. Receipt of both psychotherapy and medication treatment was associated with savings in overall cost, office-based visit cost, and prescribed medication cost of $2,690, $1,056, and $577, respectively.
| Overall expenditure | Inpatient services | Emergency department services | Office-based visits | Outpatient services | Prescribed medication | |||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Service typeb | ME | 95% CI | ME | 95% CI | ME | 95% CI | ME | 95% CI | ME | 95% CI | ME | 95% CI |
| Any mental health services | –1,146.3 | –2,327.3, 34.6 | –81.3 | –1,031.7, 869.0 | 43.2 | –49.8, 136.2 | –371.0* | –691.4, –50.7 | –85.4 | –361.2, 190.3 | –335.6 | –698.8, 27.6 |
| Psychotherapy only | –2,238.0 | –4,838.9, 362.8 | –327.5 | –2,247.6, 1,592.5 | –160.1 | –401.5, 81.4 | –1,371.3* | –2,484.8, –257.8 | –278.2 | –1,237.5, 681.2 | 21.7 | –984.9, 1,028.2 |
| Medication treatment only | –560.9 | –1,794.1, 672.2 | 55.4 | –978.9, 1,089.7 | 48.3 | –50.6, 147.4 | –126.0 | –464.5, 212.5 | –30.4 | –302.5, 241.8 | –271.1 | –658.7, 116.5 |
| Psychotherapy plus medication treatment | –2,690.1** | –4,600.9, –779.3 | –486.6 | –1,823.0, 849.7 | 54.7 | –58.6, 168.0 | –1,055.8*** | –1,614.3, –497.3 | –234.2 | –747.6, 279.3 | –577.4 | –1,330.4, 175.7 |
a
Reference group, adults who did not use mental health services. Changes in overall expenditures are marginal effects (ME) estimated from generalized linear models. For service-level costs (inpatient services, emergency department services, office-based physician visits, outpatient services, and prescribed medication), changes in expenditures are marginal effects estimated by combining results from two parts of the two-part difference-in-differences models. Bootstrapped 95% CI based on 1,000 repetitions.
b
Psychotherapy was defined as seeing a psychologist or as receipt of psychotherapy or mental health counseling during an office-based physician visit, outpatient visit, or emergency department visit. Medication treatment for mental health was identified by purchases of prescription drugs associated with psychiatric conditions (i.e., adjustment disorders, anxiety, mood disorders, schizophrenia, and other psychotic disorders).
*
p<.05, **p<.01, ***p<.001.
Sensitivity analyses using linear regression models with and without log-transformed expenditures, with exclusion of outliers, or adjusting the estimates with survey weights yielded consistent results.
Discussion
Our findings suggest that receipt of mental health services may subsequently lead to savings in overall health care cost among adults with any of six prevalent chronic physical conditions, i.e., CVD, cancer, diabetes, emphysema, asthma, or arthritis. Use of mental health services in the preceding year was significantly associated with a reduction in subsequent overall health care expenditure by 12.6 percentage points. The average saving was estimated to be $1,146 dollars (2014 constant U.S. dollars) per individual. The estimated saving was equivalent to 8.7% of overall health care expenditure in the preceding year of individuals receiving any mental health services ($13,141). Compared with the average cost of mental health services in the preceding year, which was $5,098 (i.e., the difference in average overall expenditures between individuals who used mental health services and those who did not), the estimated saving of $1,146 dollars was about 22.5% of the cost incurred for mental health care. Because mental health problems are common among adults with chronic physical conditions but often go unrecognized and thus left untreated, our study suggests a potential impact on health care expenditures of integrating mental health services for these individuals.
Adding to the current literature, our results also imply a greater financial benefit of providing a combination of psychotherapy and medication treatment for individuals with chronic physical conditions. The combination of psychotherapy and medication treatment subsequently lowered the increase of overall health care cost by 21.7 percentage points or $2,690 dollars for these adults. Previous studies have also found that the combination of psychotherapy and antidepressants was associated with a decrease in total health care expenditure among diabetes patients (22, 23, 41, 42) or was cost-effective for CVD patients (25).
We did not find a statistically significant impact of mental health service use on costs for inpatient services, outpatient services, and ED visits, which might be attributable to a short follow-up time. Some studies have suggested that cost reduction related to mental health care could result in a longer follow-up time (23, 25). Nevertheless, we found subsequent cost savings for office-based visits and prescribed medication among adults who used mental health services. Some studies suggested that cost containment associated with mental health services could be attributable to either reduction of future cost related to mental health conditions (43) or a decrease in future health care use resulting from improved chronic physical conditions (44).
Our findings may also speak to potential cost savings from health care delivery transformations rapidly expanding nationwide that integrate general medical and mental health care. Some health care delivery models with such integration have been shown to improve management of chronic illnesses, depression screening, and follow-up (45) while controlling cost growth (46, 47). Although our results suggest that providing mental health services, especially psychotherapy, may reduce overall costs for people with costly chronic physical conditions, they do not exclude the possibility that covering mental health services for the entire insured population will also in the long run reduce overall costs and increase quality of life. Future research is needed to investigate how state and federal policies that encourage behavioral health integration through delivery system reforms affect health care costs and health outcomes.
Our study had some limitations. First, given the nature of the MEPS, we were not able to investigate the impact on health care expenditures of receipt of mental health care in a longer follow-up time. Second, the data did not allow for separation of expenditures for physical conditions and mental health conditions. Also, because of the high prevalence of comorbidities in the study population, it was not possible to examine the impact of mental health services utilization separately for each chronic physical condition. Further studies may benefit from examining how mental health care influences costs for patients with chronic physical illnesses in the long-term, as well as examining separate costs for each physical condition and mental health conditions. Third, this was an observational study with 2 years of follow-up, and our estimates might be biased because of different trends in health care costs between the two groups (those who used mental health services and those who did not) during the pre-period. Although matching two groups by using inverse-probability weights could mitigate this concern by minimizing observed differences between the groups, and the application of the quasi-experimental DID approach possibly captured unobservable group differences, potential selection bias might not be completely ruled out with observational data. Finally, demand for mental health services could depend on prices and availability of services. Because of data limitations, we could not control for some state-level characteristics, such as state policy regarding mental health treatment or prices of mental health services.
Conclusions
Utilization of mental health services was associated with reduced overall health care expenditure among adults with major chronic physical conditions, including CVD, cancer, diabetes, emphysema, asthma, and arthritis. Psychotherapy alone had a larger effect on cost containment than did medication treatment alone—indeed the latter did not appear to have a meaningful effect on overall costs. The combination of the two, however, yielded a modestly larger effect than did psychotherapy alone. Future research should evaluate whether emerging health care delivery models that integrate general medical and mental health care are cost-effective.
Footnote
The contents, views, and opinions expressed in this article are those of the authors and do not necessarily reflect official policy or position of the Uniformed Services University of the Health Sciences, the Department of Defense, or Departments of the Army, Navy, or Air Force.
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Information & Authors
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Received: 12 March 2020
Revision received: 28 September 2020
Accepted: 29 September 2020
Published online: 4 May 2021
Published in print: July 01, 2021
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The authors report no financial relationships with commercial interests.
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