SAMHSA National Expenditures on Mental Health Services and Substance Abuse Treatment, 1991 - 2001

1. SAMHSA National Expenditures on Mental Health Services and Substance Abuse Treatment, 1991 - 2001 • Spending by type of provider and payer • 10-year trends • MH/SA compared to all health expenditures • Improvements each round  Revised trends • SAMHSA Researchers: • The MEDSTAT Group • Actuarial Research Corporation • The Lewin Group U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Substance Abuse and Mental Health Services Administration www.samhsa.gov

2. Methods -- Overview • Approach: • Econometric and actuarial techniques • Data Sources: • National Health Accounts of CMS – the control totals • SAMHSA provider surveys (NSSATS and SMHO) • National client-level survey and claims data sets (10)– to parse MH & SA spending by provider and payer • Technical expert review

3. General Sector • Client-level data by diagnosis and payer • 10 data sources, include: NHA, NAMCS, NNHS, NHHHCS, IMS, HCUP-NIS, NMES, MEPS, Rebate • use, charges, and payments (including cost sharing and discounts) • National Health Accounts Control Totals Specialty Sector Methods • Aggregate data from providers/facility surveys by diagnosis and payer • Impute missing values, non-response adjust, smoothing • SAMHSA Data: IMHO (1986 -1994) & UFDS/ADSS

4. Scope of Study • Excludes prevention • Excludes all dementias • Only national level, cannot report by state • Excluded non-treatment costs (e.g, productivity, crime) • Excluded illness partially a consequence of MHAOD (e.g., cirrhosis of liver)

5. Steps for Estimating Community Hospital Inpatient Expenditures METHOD EXPENDITURES DATA A: Establish utilization distribution 1 NHDS by payer and MHAOD diagnosis B: Establish per diem charges 2 HCUP-NIS distribution by payer and MHAOD diagnoses Medicare Program Data C: Establish payment rates (i.e., cost sharing and discounts) MarketScan 3 distribution by payer and MHAOD diagnoses NMES 4 Calculate by payer the percent of total expenditures by diagnosis, by taking the product of A x B x C 5 NHA: 6 7 Apply percents to NHA contol Output: Estimates of MHAOD Control totals totals for hospital inpatient services spending in community hospital by payer by payer inpatient settings

6. Separate single and multi “type-of care” providers Single Calculate annual revenue per client Impute annual revenue for missings Impute annual revenue by “type of care” Distribute revenue by payer and “type of care” Distribute revenue by payer Combine by payer and “typeof care” Expenditures by payer and type of provider Steps for Estimating Specialty Sector Expenditures METHODS DATA EXPENDITURES IMHO UFDS Multi

7. MH/SA Treatment is 7.5 Percent of Total Health Care Expenditures, 2001 SA = 1.3% SA = $ 18.3 billion MH = 6.2% MH = $ 85.4 billion All Health, 2001 All Health = $1,372.5 B MH/SA = 7.5 $104 billion U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Substance Abuse and Mental Health Services Administration www.samhsa.gov

8. Mental Health Dominates MH/SA Expenditures SA 18% MH 82% MH/SA = $104 B

9. The Proportion of Public Spending in SA Treatment Grew between 1991 and 2001 All SA, 2001: Public, 76% All Health Public, 45% All SA, 1991: Public, 62% All SA = $11.4 B Public = $7.1 B Private = $4.3 B All Health = $1,373 B Public = $613 B Private = $759 B All SA = $18.3 B Public = $13.8 B Private = $4.5 B

10. Private and Public Average Annual Growth Rate, 1991 - 2001 Average Annual Growth Rate

11. Public Payments to SA Grew Faster: Annual Growth Rates, 1991 to 2001 Overall SA Growth Rate: 4.8

12. Spending Shifts by Payer for Substance Abuse Treatment, 1991 - 2001 * Medicaid includes Federal and State Dollars ** Other Federal includes VA, DOD, Block Grant etc

13. Private Insurance Expenditures for SA Declines in real Dollars from 1991 to 2001 Total 1991 = 2.5 Billion Total 2001 = 2.7 Billion Ave Annual Growth Rate = negative 1.1% In Millions of Dollars

14. SA Versus MH Expenditures for All Payers, 2001 * Medicaid includes Federal and State Dollars ** Other Federal includes VA, DOD, Block Grant etc 22.3%

15. State & Counties Design and Administer 63% of SA Spending in 2001

16. Medicaid Portion of SA Spending Growing, But SA Remains Small Part of Total Medicaid $ Of All SUD Tx Spending: Medicaid Portion Total Medicaid Spending: Medicaid SUD Tx as Portion of All Medicaid $: 19% SA $: 1.5% MH Svc $ 10% All SA TX $ 18.3 Billion All Medicaid $ 225.5 B

17. Care Continues to Shift Away from Inpatient to Outpatient for SA Spending Residential 46% Residential Inpatient Inpatient Outpatient Outpatient 2001 SA = $18.3 billion 1991 SA = $11.4 billion

18. SA Spending by Provider, 2001: Specialty SA Center Largest Single Provider

19. Specialty SA Centers: Largest Single Provider and Fastest Growing Note: Excludes Insurance Administration: 91 – 5%, 2001 – 6% Note: Retail drugs excluded as 0.4% of Total

20. 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% NH + HH + Drugs, 3% Contribution to the SA Expenditure Change: 1991 & 2001 by Type of Provider & Insurance Administration Insurance Admin., 7% Physician + Other Prof., 7% Specialty Hospitals, 9% General Hospitals, 12% MSMHOs, 12% Percent Contribution to SA Expenditure Change SSACs, 51%

21. Who is the Payer of Least Resistance? • Decline in Private Insurance Coverage • Large Role for States • Golden Era of Medicaid-izing Ended Future of SAMHSA Spending Estimates: • SEP every 1 to 2 years • Projections