Mental Health Parity Still Lags for Drug Use Disorders

Spending for treatment stagnates in face of burgeoning opioid abuse

While financing for mental health conditions by private insurers, Medicaid, and Medicare has increased over the past 30 years, funding for substance use disorder treatment remains stagnant, according to a recent study in Health Affairs.

A team of researchers from IBM’s Truven Health Analytics unit analyzed numerous data sets to measure spending on services treating mental health and substance use disorders since 1986.

They found that the share of treatment expenditures for mental health disorders funded by Medicare, Medicaid, and private health insurers increased from 44% in 1986 to 68% in 2014. But the corresponding figure for substance abuse treatment remained unchanged at 44% throughout this period. The rest of funding that is not covered by insurers comes from patients’ pockets or from other state or federal programs.
Additionally, from 2004 to 2013, the percentage of adults using mental health treatment increased from 12.6% to 14.6%. In contrast, only approximately 1.25% of adults received substance use treatment in inpatient, outpatient, or residential settings despite a surge in opioid-related addictions in this period.
The study’s lead author, Tami Mark, PhD, MBA, of Truven Health Analytics, explained to MedPage Today that the paper “counted spending based on which was the primary diagnosis treated in a particular healthcare encounter.” For example, if the outpatient visit primarily addressed substance use, and secondarily mental health illness, it would fall into the substance use disorder-spending bucket.
She emphasized that the study is “more descriptive than evaluative. We focused on the trends in spending by payer and provider type and use of services.” And, she noted, “there isn’t good data to track whether the quality of mental health and substance use disorder treatment is improving.”
Mark identified two key messages in the findings. First, while the share of financing for mental health coming from standard insurance is increasing over time, it hasn’t yet been felt in treatment of substance abuse disorders. This is likely because “mental health disorders are being more mainstreamed in terms of delivery and financing than substance abuse disorders, which are still heavily stigmatized,” she said.

The other key finding is that increases in spending on mental health appear to have been driven heavily by greater use of medications. “This also raises questions about access to non-medication services,” Mark said.
Andrew Kolodny, MD, a psychiatrist who serves as chief medical officer for the addiction treatment chain Phoenix House, commented that the paper “points to a disturbing trend. We are in the middle of a severe epidemic but spending on addiction remains flat.”
According to Kolodny, “Treatment providers are not making the treatment available because the reimbursement is so low from insurers.” This means that people often have to go out of pocket even when covered by insurance, which is not something you see for other conditions. “This is likely because addiction is highly stigmatized, and insurers take advantage of this and provide little reimbursement.”
He also argued that, when treatment is provided, often it’s the wrong kind. “There is a lot of inappropriate prescribing of medications,” he said. For example, providers may prescribe less effective alternatives such as antidepressants to treat substance use disorders than more effective medications such as buprenorphine. Furthermore, he worried “that there is not enough spending on the psychosocial aspects of mental health.”
Mark agreed, noting that funding for substance use disorders may be lagging because “people don’t appreciate the effectiveness of their treatments, including medications such as methadone and buprenorphine.” She added that psychosocial interventions, such as cognitive behavioral therapy, brief motivational interviewing, and intensive outpatient therapy, are “useful and cost-effective [but] unfortunately, psychosocial services may not be utilized as much as they should.”

Jeanmarie Perrone, MD, of the Perelman School of Medicine at the University of Pennsylvania wondered how the data would look if the study authors counted both primary and secondary diagnoses in substance use disorders and mental health, such as depression with substance abuse.
She said she had seen escalation in overall funding for substance abuse treatment, but “it is still challenging to obtain treatment for these patients.”
Mark said several policies now in place may boost mental health/substance abuse funding. These include the Mental Health Parity Act and provisions in the Affordable Care Act that define mental health and substance use disorder treatment as essential benefits.
Furthermore, a new emphasis on using early intervention to slow the progression of mental health and substance use disorder conditions, as well as pharmacological advances in medications to treat addiction, “are likely to further enhance the effectiveness of mental health and substance abuse treatment,” Mark said.
LAST UPDATED 07.01.2016


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