This post is not about mental health parity. Although it is a
very important topic, there is no reason for me to write about it.
If you are interesting in the topic, just go read the (open
access) Perspectives column in the current NEJM: Shuffling
toward Parity — Bringing Mental Health Care under the Umbrella.
The column is short enough that there would not be any point in trying
to distill it any further. But I do want to make a couple of points, including a
mild-to-moderate quibble with one of the points mentioned:
Insurers who offer relatively generous coverage for
mental health care will disproportionately attract people with mental
disorders — people who have been shown to incur higher costs for health
care and mental health care than most other enrollees. Being the best
mental health plan in a competitive health insurance market is a losing
financial proposition, so insurers may compete to narrow their benefits
and avoid enrolling people with mental illness.
These assertions are made with no references to empirical data.
Perhaps the references exist, but were not mentioned for the
sake of brevity.
My concern, though, is that the assertions are of the sort that seem so
obviously true, that it might not seem as though they need any actual
data to back them up.
Is there are reason to suspect that intuition might lead one astray,
with regard to these assertions? Yes, there is.
If you are lucky enough to have several insurance plans available to
you, and you have the benefit summaries at hand, you might want to take
a look at what it said about the mental health benefits (assuming there
are such benefits).
It is somewhat likely that they will all look similar, if not
identical. But are they identical? Probably not.
Even though they look the same, it is likely that there are
some important differences. In some cases, the differences
are extremely large.
Look, for example, at the coverage for outpatient mental health
services. You may see that they all cover “up to 20”
outpatient sessions per year. However, if you had some way of
finding out the average number of sessions that are actually approved,
you might find that some routinely give all 20, some might routinely
cover only half that. Some might cover all 20 for the first
two or three years, then declare that the condition is chronic, and
stop covering any.
Some companies might be fairly liberal with outpatient coverage, but
maddeningly stingy with inpatient; others might show the opposite
The fact is, that the little summaries you get when you are selecting a
plan do not tell you much about what will actually happen when you try
to use the benefit. In other words, they are typical
marketing brochures. The truth contained in them is a
“special” kind of truth, to put it charitably.
It does stand to reason that persons who know they might end up in the
hospital would choose a plan that seems to offer better inpatient
coverage. Unless they happen to ask their doctor which plan
they should choose, and are advised to do otherwise, or have a friend
who gives them the real story. But if they do not, and have a
bad experience, they may switch plans for the following year.
By the way, what I’ve said so far is based upon my particular
experience providing care in a particular geographic area, during a
particular time period. Observations made in other areas and
other time periods might reveal similar or dissimilar findings.
The point is that there are many variables that affect the patient
population that ends up being covered by a particular plan.
Those variables may change from year to year. And
it is devilishly difficult for consumers to know the truth about the
plans that are available to them.
I would caution anyone studying this topic to avoid making
assumptions such as the ones in the quote above.
The other point to make, is that the authors do not address the crucial
issue of the medical offset effect. This is the notion that
the provision of mental health benefits may actually save money
overall. Even though the additional benefit may add costs
that go for mental health treatment, it is possible that improved
mental health could lower the expenses incurred for treatment for other
health conditions. Thus, the cost of the mental health
benefit may be offset, by savings in somatic health expenses.
Based upon a quick, informal review of the research, it appears that
the medical offset effect is either beneficial, or neutral.
For example, this
study shows that treatment of anxiety and depression resulted
in no net change in health care expenditures. This
article, similarly, showed that the benefit to employers
offering coverage for substance abuse treatment is similar to the added
cost. That is, the cost of the added benefit was made up for,
by improved productivity. The employers do not actually gain,
but they don’t lose, either. This
article shows a net benefit.
Sometimes, spending more in one area can save you money in the long
run. Unfortunately, this effect tends to be obscured by the
common practice of “carve out.” That is, the mental health
benefits often are allocated and managed separately, with a separate
budget. The people managing the mental health benefits
neither know, nor care, if what they are doing has any effect on
spending for somatic health.
Note that I am not faulting the authors of the NEJM study for leaving
out all of these issues. Their article was meant to be a
brief treatment of an important, complex issue. I am hopeful
that they have raised awareness sufficiently to have an impact on
As a curious aside, this
article ponders why it is, that the people in the military
who have the best mental health, are those who use
the most mental health services:
Paradoxically, the Air Force, the Service with the
highest mental health status on average, had the highest mental health
Note that the study was done during peacetime. The results
might not be the same today.