The study was paid for by the Mental Health Treatment and Research Institute, part of The Bowman Family Foundation.
Researchers analyzed 2017 medical claims for people ages 2 to 64 with commercial insurance, mostly through an employer. The claims predated the COVID-19 pandemic, so researchers didn't address how the crisis may affect the prevalence of behavioral health conditions and the cost of treatment. Other reports show COVID-19 has led to higher demand for mental health services.
Milliman reported healthcare costs in terms of allowed costs, which include the insurer and patient's costs. Allowed costs represent the maximum amount a plan will pay for a covered service. People were counted as having a behavioral health condition if they had a diagnosis, received behavioral health-specific treatment, including certain prescription drugs, had costs for behavioral health services, or attempted suicide or self-harm.
Across all individuals, total annual healthcare costs were $5,932 per person on average. People with a behavioral health condition had total healthcare costs of $12,272—about 3.5 times the total costs of individuals without a behavioral health condition: $3,552.
Spending on patients' physical health needs dwarfed spending on behavioral health. For patients with a behavioral health condition, treatment for those conditions averaged $965 per patient, or 8% of their total healthcare costs.
Dr. Henry Harbin, former CEO of Magellan Health and an adviser to The Path Forward, said the findings show that to bring down total healthcare costs, payers should ensure people with behavioral health get treatment.
"If you want to do something about your total medical costs, which is a major problem in this country…you better pay attention to this group," he said.
The figures are starker when drilling down to the most expensive 10% of people in the study. Of those 2.1 million high-cost patients, 57% had a behavioral health condition, and they accounted for 44% of total healthcare costs for the entire study population. They had average total healthcare costs of $45,782 per individual, but just $2,620 of that total was for behavioral health treatment. Half of the highest-cost individuals had less than $95 per year of total spending on behavioral health treatment.
People with behavioral health conditions also had higher costs for medical and surgical treatment. Among the most expensive individuals in the study, those with behavioral health conditions had average medical and surgical treatment costs of $43,162 compared, while those without behavioral health conditions had medical and surgical costs of $36,183.
"What we found for people that had behavioral conditions is it exacerbates their medical conditions, so the cost for their medical condition really goes up much more than if they weren't depressed or had a substance use disorder," said Steve Melek, one of the study's authors.
"If you can effectively coordinate treatment for (people's) behavioral and medical conditions, you can end up reducing healthcare costs by a significant amount," he said.
The study didn't touch on why behavioral health treatment accounts for a small percentage of overall costs, but other experts said patients have a hard time accessing services.
"We underinvest in mental health services in part because we have created barriers to people getting those services," said Michael Thompson, president and CEO of the National Alliance of Healthcare Purchaser Coalitions, one of the groups that launched The Path Forward initiative.
Most health insurers cover behavioral health, but studies show they pay behavioral health providers lower rates than Medicare. A 2019 study by the Congressional Budget Office found that average in-network rates for common mental health services in commercial and Medicare Advantage plans in 2014 were 13% to 14% less than fee-for-service rates in traditional Medicare.
Behavioral health providers tend to stay out of network as a result, making treatment more expensive for insured patients, experts said. High specialist copayments and deductibles also deter low-income patients from getting treatment, Harbin said.
A spokeswoman for America's Health Insurance Plans, however, said one of the biggest barriers to behavioral healthcare is a shortage of providers. The increased use of telehealth, particularly during the COVID-19 pandemic, will help increase the availability of providers and care, she said.
Others said primary care providers don't do enough to screen patients for behavioral health issues and intervene early like they do with other chronic illnesses.
"We don't try to detect it," said Andy Keller, CEO of Meadows Mental Health Policy Institute in Dallas. "We don't detect mental illness until the person is suicidal, or until there's a crisis that pushes us to do something."
Keller said providers should implement the collaborative care model, in which primary care clinicians, care managers, and psychiatric consultants work together to care for patients with behavioral health conditions and track their progress. The model has been shown to be effective at treating depression, anxiety and other disorders, and has proven to save costs. Most insurers now reimburse for collaborative care, but health systems haven't caught up, Keller said.