Behavioral health cases doubled over a decade

Behavioral health diagnoses ballooned over the past decade as more youths cope with mental health and substance abuse issues, according to a new analysis of private health insurance claims.

Behavioral health cases increased 108% from 2007 to 2017, rising from 1.3% to 2.7% of all medical claim lines, the not-for-profit Fair Health's analysis of 28 billion claims found. The share of claims for those age 22 or younger with major depressive disorder, the most common diagnosis, increased from 15% to 23% over that span.

"Sadly, something that took our attention was the disproportionate increases of behavioral health cases with those 22 and younger," said Robin Gelburd, president of Fair Health. "Both in terms of major depressive disorder and adjustment disorder as well as generalized anxiety disorder, they were all notable in their increases."

Generalized anxiety disorder claims became much more common from 2007 to 2017, rising from 12% to 22% of total mental health cases. Among the college-age population, anxiety rose by 441% from 0.62% to 3.16% of all claims while anxiety for high-school age individuals rose 389%. Adjustment disorders, which are emotional or behavioral disturbances induced by stress, for individuals age 11 to 18 rose 54% from 0.57% to 0.89% of all medical claim lines for that age cohort.

The prevalence of several eating disorders also grew, particularly anorexia with an increase of 156%, from 0.007% to 0.02% of all medical claims, a large proportion of which involved those age 11 to 18.

"It would be interesting how these data points align with the growing use of social media and online interaction as well as the increasing pressure with getting into a university," Gelburd said. The silver lining though is that more people are getting treated, she added.

Many of those pediatric patients with mental health issues have ended up in the emergency department as was the case at Seattle Children's Hospital, where utilization increased steadily from 2010 to 2016, the organization said. While there was a slight decrease in outpatient pediatric behavioral health admissions from 2017 to 2018, visits to the ED for pediatric behavioral health increased "alarmingly" from 2,324 in 2016 to 3,298 in 2018.

Southfield, Mich.-based Beaumont Health is seeing a similar trend in ED utilization, said Lee Ann Odom, president of shared services for Beaumont.

Health systems are trying to get mental health patients out of the ED where appropriate, but behavioral health services are often few and far between and if there are some available, patients often don't know, experts said.

"We are seeing more children and adolescents in our emergency departments who are in crisis and parents who are not familiar with community or school-based resources," she wrote in an email.

Health systems like Seattle Children's and Beaumont are building out their behavioral health capacity, particularly for the younger demographic. But efforts are in the early stages. Providers that position themselves well could reap financial benefits, especially since treating behavioral health issues on the front end is far less expensive.

Although reimbursement for mental health treatment, substance abuse and telehealth have traditionally been on the lower end, that dynamic is shifting slowly aided by the Mental Health Parity Act, which required a plan's coverage for behavioral health treatment to be on par with its coverage for medical-surgical treatment. As mental health awareness grows and the stigma fades, mergers and affiliations like Hackensack Meridian Health and Carrier Clinic's combination are poised to bolster addiction treatment and better integrate behavioral healthcare into the continuum.

"As we see telehealth claims trend upward, my sense is that there would not be those increases if organizations didn't make an individual judgment as to whether entering or expanding this type of care is worthwhile a from public policy perspective as well as a financial one." Mental health is among the top uses of telehealth, Fair Health found in another paper.

Opioid dependence diagnoses overtook alcohol abuse as the largest among those with a substance use disorder over that 2007 to 2017 span, although opioid dependence cases trailed from 2015 to 2017.

Opioid dependence claims increased 1,180% from 0.016% of all medical claim lines in 2007 to 0.252% in 2017. But they fell 50% from 0.479% in 2015.

Meanwhile, stimulants other than cocaine rose from 0.001% of all claims to 0.03%. Individuals 18 years old or younger had a higher share than any other age group of cannabis abuse claim lines at 32% in 2017.