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Compendium of Research Related to Mental Health (continued)

Intramural Research

Intramural research at AHRQ is focused on studies of the cost and financing of health care, as well as studies of the structure, organization, and behavior of the health care system and providers within it. AHRQ also develops data sets to support policy and behavioral research and analyses.

Much of AHRQ's intramural research on mental health is based on survey data. Since the 1970s, AHRQ and its predecessor agencies have conducted a series of national medical care surveys. These surveys provide information on the health care use, expenses, and insurance coverage of American families. They also provide the possibility for longitudinal analyses. These surveys are:

  1. The National Medical Care Expenditure Survey (NMCES), conducted in 1977.
  2. The National Medical Expenditure Survey (NMES), conducted in 1987.
  3. The Medical Expenditure Panel Survey (MEPS), an ongoing survey conducted since 1996.

This section is generally organized in terms of specific areas of health services research.

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Barriers to children's mental health services. Journal of the American Academy of Child and Adolescent Psychiatry 2002; 41(6), pp. 731-738.
Authors: Owens P, Hoagwood K, Horwitz S, et al.

Description: Researchers examined the characteristics associated with barriers to children's mental health services, focusing on the effect of children's psychosocial problems on parents. Data were derived from a first-grade, prevention-intervention project conducted in Baltimore, Maryland. Analyses were restricted to 116 families who participated in seventh-grade interviews and indicated that their child needed services. The Services Assessment for Children and Adolescents was used to measure barriers to children's receipt of mental health services. Over 35 percent of parents reported a barrier to mental health services. Types of barriers included those related to structural constraints, perceptions of mental health, and perceptions of services (20.7 percent, 23.3 percent and 25.9 percent, respectively). Although parenting difficulties were associated with all barriers (structural: odds ratio=10.63, 95-percent confidence interval: 2.37, 47.64; mental health: odds ratio=8.31, 95-percent confidence interval:1.99, 34.79; services: odds ratio=5.22, 95-percent confidence interval:1.56, 17.51), additional responsibilities related to attendance at meetings were associated only with structural barriers (odds ratio=5.49, 95-percent confidence interval:1.22, 24.59). Researchers and policymakers interested in increasing children's access to mental health services should consider strategies to reduce barriers related to perceptions about mental health problems and services in addition to structural barriers. Particular attention should be given to programs that focus on the needs of families who are most affected by their child's psychosocial problems.

Trends in mental health services use and spending, 1987-1996. Health Affairs Mar./Apr. 2001; 20(2), pp. 215-223.
Author: Zuvekas S.

Description: Using data from the 1987 NMES and the 1996 MEPS, this study found that the population's access to ambulatory mental health and substance abuse services and psychotropic medications greatly increased between 1987 and 1996. However, despite these apparent gains, there is still much unmet need, and wide variations exist among population subgroups. Out-of-pocket expenses for ambulatory mental health, substance abuse, and psychotropic drug treatment remain high for the well-insured portion of the population residing in the community.

Income and employment among homeless people: The role of mental health, health, and substance abuse. The Journal of Mental Health Policy and Economics 2000; 3, pp.153-163.
Authors: Zuvekas S and Hill S.

Description: Income from employment and public programs may be critical to the ability of homeless persons to become domiciled. The focus of this work was on the effects of physical and mental health and substance use disorders on access to income to rent housing. Using panel data from a survey of homeless persons in Alameda County, California, it was found that few homeless persons work sufficient amounts of time to afford a low-rent domicile, and participation in public support programs is low relative to eligibility. Physical health problems and substance use disorders are barriers to higher levels of employment. Substance use disorders are also a barrier to participation in more generous public support programs. Those with greater income through higher work levels and public programs also gain housing and remain in housing for more time. Policies designed to help the homeless become domiciled need to take into account the high rates of health, mental health, and particularly, substance abuse problems among this population. These problems substantially reduce the earnings capacity of homeless persons and their ability to stop being homeless.

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Health care use and costs for children with attention-deficit/hyperactivity disorder. Archives of Pediatric Adolescent Medicine May 2002; 156(5), pp. 504-511.
Authors: Chan E, Zhan C, and Cherkin D.

Description: Data from the 1996 MEPS were used to compare the health care costs and use of children with attention deficit-hyperactivity disorder (ADHD), children with asthma, and the general pediatric population. A sample of 5,439 children ages 5-20 (representing 62 million children nationwide) who had ADHD, asthma, or neither were identified from ICD-9 codes and prescription records. For each group, researchers determined mean health care use (outpatient visits, emergency department [ED] visits, hospital discharges, home health visit days, and prescriptions) and total as well as component expenditures (outpatient, ED, prescription, out of pocket, and other). Differences between means were compared among the three groups, both with and without adjusting for sociodemographic characteristics and access-to-care variables. Overall, costs of care for children with ADHD were comparable to costs for children with asthma and significantly greater than costs for the general pediatric population. Specific types of health care use and the sources of expenditures differ between children with ADHD and children with asthma. Because much ADHD-related care occurs within school and mental health settings and might not be captured by MEPS, these figures likely underestimate the true costs of caring for children with this condition.

Use and expenditures for the treatment of mental health problems. NMES Research Findings 22. AHCPR Pub. No. 94-0085. Rockville, MD: Agency for Health Care Policy and Research. July 1994.
Authors: Freiman M, Cunningham P, and Cornelius L.

Description: This report used the 1987 NMES to provide national estimates of health care use and expenditures for the treatment of mental problems. Just over 18 million persons, or 7.6 percent of the U. S. civilian noninstitutionalized population covered by NMES, had some type of health care use for a mental problem during 1987. This use resulted in personal health care expenditures of 18.2 billion, with an average of just under $1,000 per user. These expenditures comprised 5.0 percent of all personal health care expenditures. The rate of use for males (5.8 percent) was much lower than the rate for females (9.3 percent). Socioeconomic status also appeared to play an important role in the use of mental health care. There were 111 million ambulatory mental health visits in 1987, which cost a total of $6.5 billion. Hospitalization for the treatment of mental illness was a relatively rare event, but the high expense of such hospitalization made it a major component of mental health costs. Prescription medicines were also a large source of expenditure. These findings exclude a sizable portion of the expenditures for the treatment of the severely mentally ill. In particular, only a small percentage of the expenditures for State and county mental hospitals are included here. This report also does not include mental health expenditures for persons in nursing homes.

Personal characteristics and contextual factors associated with residential expenditures for individuals with mental retardation. Mental Retardation Apr. 2001; 39(2), pp. 114-129.
Authors: Rhoades J and Altman B.

Description: This study demonstrated that severity of disability, facility characteristics, and community resources are associated with the long-term care costs for people with mental retardation. The mean daily expense was significantly greater for those with severe or profound mental retardation. Younger residents (under 22 years) and those with greater daily needs for assistance (limited to two or more activities of daily living) had greater daily expenses, and expenses were higher for minority residents than white. Expenses in larger facilities, with 16 or more beds, were higher than in those that had 3 to 15 beds. Nonprofit or government facilities, facilities with a higher number of services included in the basic charge, and facilities that routinely provide more additional services had higher daily expenditures. Finally, facilities located in the Northeast or Midwest had higher daily expenditures than facilities in other regions of the country. The level of community affluence (per capita income)—but not generosity of State programs—influenced daily expenses for residents. After analyzing the interaction of these factors, the researchers conclude that moving people with borderline, mild, moderate, or severe mental retardation to smaller facilities could result in cost savings or at least no additional cost.

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Institutional Care

Elderly persons with developmental disabilities in long-term care facilities. NMES Research Findings 25. AHCPR Pub. No. 95-0084. Rockville, MD: Agency for Health Care Policy and Research. 1995.
Author: Altman B.

Description: This report from the Institutional Population Component of the 1987 NMES provides national estimates of the functional, behavioral, and health characteristics of the population with developmental disabilities living in residential facilities, including nursing homes. Developmental disabilities are defined as conditions that occur at birth or sometime else before the age of 22 and that limit or slow an individual's intellectual or physical development. The most prevalent disability among this institutionalized population is mental retardation; others are autism, cerebral palsy, spina bifida, and epilepsy. The inclusion of nursing home residents in estimates of persons with mental retardation and other developmental disabilities who live in long-term care facilities indicates that there is a larger proportion over age 50 in this population than previously reported. A total of 19.2 percent were age 65 or over, and another 16.7 percent were ages 50-64. As in the general population, there is a decline in health among the elderly with developmental disabilities. The estimates indicate, however, that the highest level of functional disability among those age 65 and over was comparable to that in the age group from birth to 24, who often have multiple diagnoses, multiple limitations, and fragile health. While the causes of the need for services differ among these two age groups, their functional care needs are very similar, suggesting the usefulness of intergenerational service models that could accommodate the integration of both groups. (An earlier version of this paper was presented at the 1993 Meetings of the American Association on Mental Retardation.)

The dynamic process of movement in residential settings. Journal of Mental Retardation 1993; 98(2), pp. 304-316.
Authors: Altman B and Cunningham P.

Description: Findings from the 1987 NMES show that almost 16 percent of the persons who spent some time in a residential facility during 1987 moved into other living arrangements within the system or outside of it during the survey year. A smaller number of persons had multiple moves during that period. Most of the movement occurred between residential facilities of the same type (e.g., group home to group home), and this movement did not result in significant changes in the total residential population between the beginning and end of 1987. Persons moving into the residential system from outside were more likely to end the year once again outside the system. Those living in institutions were the least likely to move at all. These findings suggest that there is considerably more mobility among the mentally retarded residential population than can be observed by examining annual rates of change in residential populations. (An earlier version of this paper was presented at the 1990 meeting of the American Association on Mental Retardation.)

Characteristics of facilities for the mentally retarded. NMES Data Summary 6. AHCPR Pub. No. 92-0067. Rockville, MD: Agency for Health Care Policy and Research. 1992.
Authors: Beauregard K and Potter D.

Description: Over the last 20 years there has been a steady trend toward the deinstitutionalization and integration of persons with mental retardation/developmental disabilities into the community. As this transition has occurred, large State institutions have been downsized and smaller community-based group homes have proliferated. This Data Summary presents national estimates of facilities for the mentally retarded based on data collected in the Institutional Population Component of the 1987 NMES. Estimates include the number of facilities, beds, and residents; geographic distribution; type of ownership; certification; and service provision. The percent of current residents who were mentally retarded is identified. Special emphasis is given to small residential facilities.

Sample design of the institutional population component. NMES Methods 6. AHCPR Pub. No. 94-0017. Rockville, MD: Agency for Health Care Policy and Research. 1993.
Authors: Cohen S, Potter D, and Flyer P.

Description: This report describes the sample design of the Institutional Population Component (IPC) of the 1987 NMES. The IPC was established to provide an assessment of the utilization, costs, sources of payment, and health status of the U.S. population in nursing and personal care homes and in facilities for the mentally retarded for calendar year 1987. The IPC sample consisted of two distinct selections of 1987 institutional users: a sample of institutional residents as of January 1, 1987, and an independent sample of admissions over the course of 1987. Particular attention is given to the estimation strategy specified to correct for the multiple chances of selection in the IPC through the year and the problems of dual representation in the independent sampling frames of January 1, 1987, residents and 1987 admissions. The report also provides a summary of sample yields for the facility interview and subsequent interviews for the sample of residents and admissions. Detailed specifications for the derivation of NMES sampling weights are provided. These sampling weights are employed to yield national estimates of health care parameters at both the facility and person levels. The specifications include adjustments to correct for survey nonresponse at each level of sample selection in addition to the poststratification adjustments. Appropriate methods of variance estimation that take into account survey design complexities are suggested. Copies of the report (AHCPR Publication No. 94-0017) are available from AHRQ.

The effects of sociodemographic and contextual factors on employment of persons with mental retardation living in residential facilities. Journal of Developmental and Physical Disabilities 1993; 5(4), pp. 28l-296.
Authors: Cunningham P and Altman B.

Description: Data from a 1987 national sample of persons in residential facilities were used to assess the effects of sociodemographic and contextual factors on rates of paid employment among this population. The results showed that age, race, facility type, and U.S. Census Region had significant effects on the likelihood of any type of paid employment, even when controlling for the individual's functional limitations, level of retardation, and Supplemental Security Income status. Sex and county unemployment rate had independent effects on the likelihood of being employed in supported or competitive employment. As more persons with mental retardation move into competitive employment arrangements, those concerned with increasing access to employment should give some consideration to factors not directly associated with physical and intellectual functioning. (An earlier version of this paper was presented at the 1990 Annual Meeting of the American Association for Mental Retardation.)

Characteristics of residents in facilities for the mentally retarded. NMES Research Findings 6. DHHS Pub. No. (PHS) 90-3468. Rockville, MD: Agency for Health Care Policy and Research. 1990.
Authors: Cunningham P and Mueller C.

Description: The concept of deinstitutionalization has guided policies concerning the provision of residential services to the mentally retarded. The success of these policies depends on matching client needs and facility resources. Data from NMES, which provides national estimates of residents of facilities for the mentally retarded in the United States, are used to compare clients residing in large public facilities with residents of community-based facilities. Findings indicate that residents of State institutions are more severely retarded and are more likely to have other disabilities and functional impairments than residents of community facilities. Nevertheless, the latter often also have significant impairments, and evidence suggests that they do not receive certain services routinely provided in larger State institutions. Additional research is needed on services received in community-based facilities and on whether needs match community resources. (An earlier version of this paper was presented at the 1988 annual meeting of the American Public Health Association.)

Questionnaires and data collection methods for the Institutional Population Component. NMES Methods 1. DHHS Pub. No. (PHS) 89-3440. Rockville, MD: National Center for Health Services Research and Health Care Technology Assessment. 1989.
Authors: Edwards W and Edwards B.

Description: This report from the 1987 NMES describes the operational design and instruments of the Institutional Population Component. This component comprises a set of surveys that collected information for calendar year 1987 on demographic characteristics, health and functional status, use of medical and other health care services, and related expenditures by individuals residing in nursing and personal care homes and facilities for the mentally retarded at some time during 1987. Information on both facility characteristics and residents was collected from facility administrators and caregivers in four rounds of interviews at the facility site. Personal and background information on the residents was collected from next of kin or other knowledgeable respondents over the course of the year in four or five interviews, depending on the time of selection into the sample. The report discusses in detail instrument design and data collection procedures, and it includes extensive exhibits illustrating the scope and focus of the various data collection instruments.

Nursing home reform and the mentally ill. Health Affairs Winter 1990; 9(4), pp. 47-60.
Authors: Freiman M, Arons B, Goldman H, and Burns B.

Description: Researchers calculated several estimates of the number of persons who might be eligible for placement out of nursing homes as a result of the 1987 Omnibus Budget Reconciliation Act (OBRA) nursing home reform, although greater weight was attached to estimates that utilized a lower measure of more severe mental illness. These rough estimates indicate that approximately 40 to 50 thousand nursing home residents, or between 3 and 4 percent, might be faced with out-placement. The effects of the OBRA provisions regarding prospective residents of nursing homes who would be turned away as a result of the regulations were not calculated. The estimates make several important empirical points about the overall number of persons potentially identified for alternative placement, the magnitude of the screening process, and the implied costs of identifying the population that is the focus of the regulations. Results indicate that the majority of mentally ill residents are appropriately placed with regard to nursing needs.

Risk of behavior problems among nursing home residents in the United States. Journal of Aging and Health Nov. 1997; 9(4), pp. 451-472.
Authors: Jackson M, Spector W, and Rabins P.

Description: In 1987, over half (54 percent) of U.S. nursing home residents had some type of behavior problem. This study has concluded that certain mental and physical disabilities, as well as personal characteristics, increase the likelihood that a nursing home resident will have behavioral problems. Using the Institutional Population Component of the 1987 NMES, this team analyzed the data to identify which factors correlated with four types of behaviors: delusions/hallucinations, aggressive behaviors, collecting behaviors (hoarding and stealing), and wandering or inability to avoid dangers. Cognitive impairment; dependencies in activities of daily living, or ADLs (e.g., eating, dressing, bathing, using the toilet); incontinence; a history of psychiatric problems; difficulty understanding oral communications; and vision problems were associated with a higher likelihood of exhibiting disruptive behaviors. Being unable to walk decreased the likelihood of behavior problems, presumably because of increased isolation. The patterns of association varied by type of disruptive behavior. Men were found to be more at risk for aggressive behaviors than women, who were more at risk for delusions and hallucinations. Generally, cognitive impairment, schizophrenia, and other psychoses had a greater impact for almost all behavior types. Impairment in receptive communication (understanding what is said) was a risk factor for all behaviors but had a more moderate impact. Incontinence and ADL dependencies, in general, had less impact and affected fewer behaviors.

Mental illness and the impact of nursing home reform: Estimates from the 1987 National Medical Expenditure Survey. Gerontological Society of America Annual Meeting, 1989.
Authors: Lair T, Arons B, Freiman M, et al.

Description: The Omnibus Budget Reconciliation Act of 1987 (OBRA) contains provisions that affect mentally ill residents of and admissions to nursing homes, and regulations are being revised to implement these provisions. States are required to review residents and screen potential new admissions in Medicaid-certified facilities for mental illness or mental retardation. If such individuals do not need nursing services or require more acute care, then it may be necessary to find other locations for them. Individuals with a primary diagnosis of dementia are excluded from screening, and residents of nursing facilities for at least 30 continuous months may choose to remain. This paper, using detailed simulations of these regulations, examines the potential size and composition of the population affected by the OBRA provisions for current residents of nursing homes. The data are from the 1987 NMES. Findings suggest that while a substantial percentage of residents would need to be thoroughly assessed, only a very small percentage of those would be identified for possible outplacement. The paper explores the implications of these results with regard to nursing home revenues, screening costs, and the availability of alternative facilities.

Mental health and functional status of residents of nursing and personal care homes. NMES Research Findings 7. DHHS Pub. No. (PHS) 90-3470. Rockville, MD: Agency for Health Care Policy and Research. 1990.
Authors: Lair T and Lefkowitz D.

Description: The Institutional Population Component of the 1987 NMES includes a nationally representative sample of current residents of and new admissions to nursing and personal care homes. This report uses the current resident sample to describe the mental health and functional status of people living in nursing and personal care homes in the United States on January 1, 1987. National estimates of resident characteristics, including age, sex, marital status, and race, are presented. This report also provides estimates of cognitive impairment, mental disorders, emotional/behavioral problems, psychiatric symptoms, and the extent and nature of functional limitations in this population. Finally, selected measures of functional and mental status of the resident population are considered as they relate to various facility characteristics, such as certification, bed size, and facility type.

Availability of special nursing home programs for Alzheimer's disease patients. American Journal of Alzheimer's Care and Related Disorders Research Jan./Feb. 1991; pp. 2-11.
Authors: Leon J, Potter D, and Cunningham P.

Description: While still controversial, there is a growing belief that Alzheimer's disease patients require special programs across the service continuum. There is also a growing concern that nursing home facilities are not providing the programs required. Using data from the 1987 NMES, national estimates are presented on the number of nursing facilities that have special units or programs directed towards the specific needs of the cognitively impaired elderly—primarily patients with Alzheimer's disease. The findings represent the first national estimates on special nursing home programs and units for Alzheimer's disease patients based on a nationally representative sample of nursing facilities. The survey included 759 facilities and is weighted to be representative of all nursing facilities serving the elderly in 1987. The numbers of facilities with Alzheimer's disease programs, the patient capacities of these programs, the characteristics of the facilities, the future plans of facilities to either expand present programs or develop new ones, the availability of specialized training for staff of these programs, and the respite care these programs offer to nonresidents are examined. The discussion centers on the implications these analyses hold for the further development of long-term care policies and program provisions regarding Alzheimer's disease patients.

Current and projected availability of special nursing home programs for Alzheimer's disease patients. NMES Data Summary 1. DHHS Pub. No. (PHS) 90-3463. Rockville, MD: Agency for Health Care Policy and Research. 1990.
Authors: Leon J, Potter D, and Cunningham P.

Description: In 1987, there were approximately 53,800 nursing home beds—just over 3 percent of the Nation's supply at the time—for patients with Alzheimer's disease or related dementias. According to this study, the beds were located in 1,668 nursing facilities (just under 8 percent of all nursing homes) with special units for such patients. The study provides the first national estimates of the number and bed capacity of nursing facilities with special units or programs for patients with cognitive disorders related to Alzheimer's disease and other dementias. While the benefits of special units in either reducing costs or improving patient care are still in question, it is clear that the present number of specialty beds falls short of the potential demand. Unpublished NMES data show that in 1987 an estimated 640,000 nursing home patients suffered from dementias—almost 12 times the supply of special unit beds at that time. While not every nursing home resident with Alzheimer's disease or a related dementia may need care in a specialized unit, the researchers conclude that the potential demand clearly exceeds the supply by a substantial margin. The study also found that nearly 70 percent of the special unit beds for Alzheimer's disease patients were in for-profit nursing homes. The West had the highest percentage of Alzheimer's disease beds, followed in descending order by the South, Northeast, and Midwest. Less than 6 percent of all nursing homes provided specialized staff training for care of patients with Alzheimer's disease and other dementias. Even among nursing homes with special units, roughly a quarter of the facilities did not offer such training. (An earlier version of this paper was presented at the 1989 Annual Meeting of the Gerontological Society of America.)

Correlates of disruptive behaviors in nursing homes. Journal of Aging and Health May 1994; 6(2), pp. 173-184.
Authors: Spector W and Jackson M.

Description: Some nursing home residents are disruptive because of their wandering, abusive behavior, and noisiness, as well as less common behaviors such as disrobing and stealing. Residents most likely to be disruptive are severely cognitively impaired; are unable to perform a number of activities of daily living (ADLs), such as feeding and walking; or are incontinent. Immobile patients are less likely to be disruptive and women are less likely to be abusive than men. Correlates of disruptive behaviors were analyzed in a representative sample of 3,351 residents in 103 nursing homes in Rhode Island in 1985. It was found that more cognitively disabled individuals were more likely to wander. Being female did not affect the likelihood of being disruptive in general, but women were less likely to be verbally or physically abusive. Residents with higher levels of ADL dysfunction were most likely to be abusive or noisy. The loss of independence in toileting and feeding, for example, further increased the likelihood of being disruptive, independent of mobility status. The researchers suggest that the loss of control of bodily functions results in frustration and increases "acting out" behaviors as a way of coping. On the other hand, immobility may isolate residents and reduce the number of potentially frustrating situations that they encounter. This may be why immobile patients were not only less likely to wander, but were also less verbally or physically abusive.

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Drug use, drug abuse, and labor market outcomes. Health Economics May 1998; 7(3), pp. 229-245.
Authors: Buchmueller T and Zuvekas S.

Description: This paper examines the relationship between illicit drug use and labor market success, and in doing so addresses two major shortcomings of the previous literature. First, unlike many previous analyses, this work accounts for differences between moderate and pathological drug use using clinically based measures. Second, while recent studies focus only on young adults, this study analyzes a prime-age (30 to 45 years old) sample as well. Results indicate that these differences are important. It was found that pathological use is negatively associated with income among both young and prime-age men. The positive association between moderate drug use and income among younger men, found both in this study and in previous studies, disappears among prime-age men. No significant association between either moderate or pathological use and employment among younger men was found, but a negative relationship between pathological use and employment among prime-age men was identified. The effects of illegal drug use on productivity are one justification for employer drug-testing policies and government policies designed to eliminate the consumption of illegal drugs.

Measuring functioning in daily activities for persons with dementia. Alzheimer Disease and Associated Disorders 1997; 11(6), pp. 81-90.
Author: Spector W.

Description: This study reviews the measurement of functional disability for persons with dementia; emphasizes the concepts of validity, measurement bias, and scaling properties; and questions if dementia-specific scales measure the disability consequences of cognitive impairment or actual cognitive impairments.

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The impacts of mental health parity and managed care in one large employer group. Health Affairs May 2002; 21(3), pp. 148-159.
Authors: Zuvekas S, Regier D, Rae D, et al.

Description: This study examined the impact of a State's mental health parity mandate on a large employer group that simultaneously implemented a managed care "carve-out" for its mental health and substance abuse benefits. The researchers compared plan costs, use patterns, and access in the year prior to the changes with those in the 3 years following the changes. Because of confidentiality issues, the name of the large employer group, the State in which it is located, and the specific years of the study cannot be provided. Although the number of people treated for mental health problems increased nearly 50 percent, the costs to the plan for mental health services declined by almost 40 percent over the 4-year study period. Costs for employees and spouses together remained flat over the study period, while costs for children and adolescents declined by 64 percent. Most of this decline was due to reducing the lengths of stay for inpatient mental health treatment. Managed care did not limit access to outpatient treatment. There was nearly a 50-percent increase in the number of people using outpatient treatment with no change in the average number of visits.

How would mental health parity affect the marginal price of care? Health Services Research Feb. 2001; 35(6), pp.1207-1227.
Authors: Zuvekas S, Banthin J, and Selden T.

Description: Using the MEDSIM health care microsimulation model developed by researchers at AHRQ, this team computed marginal out-of-pocket costs from the cost-sharing benefits described by policy booklets under current coverage and under parity for various mental health treatment expenditure levels. Results show that as of 1995, parity coverage would substantially reduce the share of mental health expenditures that consumers would pay at the margin under their existing plan's cost-sharing provisions, with larger changes for outpatient care than for inpatient care.

Mental health parity: What are the gaps in coverage? The Journal of Mental Health Policy and Economics 1998;1, pp.135-146.
Authors: Zuvekas S, Banthin J, and Selden T.

Description: This study compared the out-of-pocket spending for hypothetical episodes of mental health treatment as considered under a person's current insurance plan and when applied to a reform policy of full mental health parity. The data analyzed were actual health plan benefits using a nationally representative sample of the privately insured population under age 65 from the 1987 NMES. Findings showed that existing benefits in this population are quite inadequate and people are at risk for high out-of-pocket expenses should they develop serious mental illness. However, under simulated full parity coverage, significantly lower out-of-pocket costs were found. It was also found that persons with less generous mental health coverage usually had less generous physical health coverage too.

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Page last reviewed January 2003
Internet Citation: Compendium of Research Related to Mental Health (continued). January 2003. Agency for Healthcare Research and Quality, Rockville, MD.