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The Hay Group Study
Health Care Plan Design and
Cost Trends--1988 through 1997Prepared for:
National Association of Psychiatric Health Systems
Association of Behavioral Group Practices
National Alliance for the Mentally IllMay 1998
Executive Summary
The National Association of Psychiatric Health Systems (NAPHS) asked the Hay Group to analyze trends in the proportion of employer health care dollars spent on behavioral health care. We used the Hay Benefits Reports, from 1988 through 1997, to determine trends in plan design for both general health and behavioral health. Then, using our Mental Health Benefits Value Comparison (MHBVC) model, we determined the value of benefits offered by medium and large employers in the United States for each year.
Since 1987, there has been a dramatic change in the way health care services are managed. Ninety-two percent of employers reported fee-for-service plans as the most prevalent plan type in 1987. By 1997, fee-for-service plans were reported as the most prevalent plan type by only 20 percent of employers. Preferred Provider Organizations were reported as the most prevalent plan type by 34 percent of organizations in 1997. Point of Service and Health Maintenance Organization plans were reported as the most prevalent plan type by 22 percent and 24 percent of organizations, respectively.
This shift towards managed care has helped control health care costs and utilization. From 1988 through 1991, health care costs increased by 16.8 percent per year. From 1994 to 1997, health care costs increased by only 0.7 percent per year.
The total value of employer provided health care benefits, in constant dollars, decreased by 10.2 percent over the last ten years. The value of general health care benefits decreased by 7.4 percent since 1988, while the value of behavioral health care benefits decreased by 54.1 percent. As a proportion of total health care costs, behavioral health care benefits decreased from 6.1 percent in 1988 to 3.1 percent in 1997.
Behavioral health care benefits have become more limited since 1988. In 1988, 38 percent of plans imposed a day limit on inpatient psychiatric care. By 1997, limits were imposed by 57 percent of plans. The most prevalent limit remained at 30 days during this period. The number of plans imposing any limit on inpatient psychiatric care increased from 63 percent in 1990 to 86 percent in 1997.
Outpatient behavioral health care limits have also changed. Twenty-six percent of plans imposed an annual visit limit in 1988. In 1997, such limits were imposed by 48 percent of plans. In addition to an increase in the number of plans imposing a limit, the limit has decreased. In 1988, 46 percent of plans imposing a limit allowed a maximum of 50 visits. In 1997, the most prevalent limit was 20 visits.
In addition to annual visit limits, many plans impose per visit dollar limits and annual dollar limits. In 1988, 45 percent of plans imposed annual dollar limits on outpatient psychiatric care. By 1997, the percentage of plans imposing these limits had decreased to 40 percent. However, the dollar limits imposed by plans have not kept pace with inflation. Most plans imposed a limit of $2,500 or less in 1988 and in 1997. To keep pace with inflation, a limit of $2,500 in 1988 would have to be increased to $4,933 in 1997.
Data from Mutual of Omaha and NAPHS show a decrease in both inpatient and outpatient utilization of behavioral health services and in average lengths of stay. The Mutual of Omaha data show a decrease in outpatient behavioral health utilization of 24.6 percent from 1993 to 1996. On the other hand, these data show an increase in outpatient general health utilization of 27.4 percent from 1991 to 1996. According to the Mutual of Omaha data, inpatient behavioral health admissions declined by 36.4 percent between 1991 and 1996. During the same period, inpatient admissions for general health services declined by 13.2 percent.
It is important to note that the data in this report were collected prior to implementation of the Mental Health Parity Act of 1996. The act requires parity with respect to aggregate lifetime expense limits and annual dollar limits on mental health benefits. The act does not require a plan to provide mental health benefits. The law is effective starting with plan years beginning on or after January 1, 1998.
II. Methodology
The Hay Benefits Report collects data on the typical design of health care benefits provided by medium and large employers in the United States. The data in the 1997 Hay Benefits Report was collected from 1,043 US employers representing a broad industry and geographic mix.
Plan design information for 1988 through 1997 was extracted from the Hay Benefits Report for each year. The benefits for each year were coded into Hay’s Mental Health Benefit Value Comparison (MHBVC) model. MHBVC was developed by the Hay Group for the National Institute of Mental Health (NIMH) to provide estimates of the costs of mental health parity.
The MHBVC produces a standardized benefits value based on the input of over 125 items describing the benefit design of a health plan. These include deductibles, coinsurance, maximum out-of-pocket and coverage limitations. In behavioral health care, in particular, the model includes over 25 items including day, visit, and dollar limits. The standardized benefits value is equivalent to the average premium for health care for medium and large employers in the United States in 1997.
The BVC approach and the Hay Benefits report have been used extensively by the private sector, NIMH, and the Congressional Research Service (CRS) to analyze the cost and prevalence of benefits in the United States.
III. Findings
Cost Trends
The National Association of Psychiatric Health Systems (NAPHS) asked the Hay Group to analyze trends in the proportion of employer health care dollars spent on behavioral health care. This analysis includes trends in absolute and proportionate expenditures in health care costs and trends in behavioral health care plan design over the last decade. In addition, this report shows specific characteristics of plans regarding the treatment of inpatient and outpatient mental health services and provides statistics on lengths of stay and utilization.
The total value of employer provided health care benefits decreased by 10.2 percent from 1988 through 1997. This decrease in total value is attributed to the shift towards managed care. The value of general health care benefits decreased by 7.4 percent since 1988, while the value of behavioral health care benefits decreased by 54.1 percent. As a proportion of the total value, behavioral health care decreased from 6.1 percent in 1988 to 3.1 percent in 1997.
The table below shows the total benefits value, general health benefits value and behavioral health benefits value for each year from 1988 through 1997. The dollar values shown are per single employee per year. In addition, it shows the behavioral health value as a percent of the total value. (View related charts)
Behavioral Health Care Benefit Costs as a Percent of Total Health Care Benefit Costs
(All Values are in 1997 Dollars)
Year
Total Value
General Health Value
Behavioral Health Value
Behavioral Health as a Percent of Total
1988
$2,478.41
$2,326.87
$151.54
6.1%
1989
$2,480.72
$2,336.19
$144.53
5.8%
1990
$2,455.41
$2,320.35
$135.06
5.5%
1991
$2,443.19
$2,316.14
$127.05
5.2%
1992
$2,423.81
$2,305.08
$118.73
4.9%
1993
$2,374.23
$2,268.61
$105.62
4.4%
1994
$2,338.48
$2,243.74
$94.74
4.1%
1995
$2,292.30
$2,207.50
$84.80
3.7%
1996
$2,237.59
$2,161.66
$75.93
3.4%
1997
$2,225.21
$2,155.60
$69.61
3.1%
% Change 1988 - 1997
-10.2%
-7.4%
-54.1%
Plan Design Trends
Over the last decade, the way health care is managed has changed dramatically. Health care plans can be classified into four types with differing levels of management: fee-for-service plans (FFS), Preferred Provider Organizations (PPO), Point of Service Plans (POS), and Health Maintenance Organizations (HMO).
Fee-for-service plan: A fee-for-service plan allows patients to choose any provider and does not require patients to obtain referrals to see specialists. They are considered loosely managed.
Preferred Provider Organization: A PPO allows patients to receive medical services at a lower cost by obtaining care from network providers. Patients may choose to receive care from a non-network provider; however, out-of-pocket costs for these services are substantially higher than for services provided by network providers. Patients do not need a referral to see a specialist. These plans are considered moderately managed.
Point of Service Plan: A POS plan is similar to a PPO plan, except that patients are required to receive a referral from their primary care physician prior to receiving care from a specialist. These plans are also considered moderately managed.
Health Maintenance Organization: An HMO requires patients to receive care through a system of affiliated providers. Out-of-network services are not available, except in emergencies. Patients must receive a referral from their primary care physician prior to receiving care from another provider. HMOs are considered tightly managed.
Under any of these four arrangements, a carve-out plan can be implemented to provide mental health and substance abuse services. A carve-out plan is a managed care approach that provides uniform care for mental health and substance abuse treatment regardless of what type of plan provides for general health benefits. Carve-out plans are considered tightly managed. Under a carve-out plan, costs are contained by individual case management of the treatment each patient receives. Any treatment for mental health or substance abuse must be pre-approved by a case manager.
At this time, there is uncertainty about the degree to which carve-out plans that achieve substantial cost savings are used by medium and large employers. For this study, we have arbitrarily assumed 20 percent of plans utilize a carve-out approach for behavioral health care services in 1997.
Over the last 11 years, fee-for-service medical plans have become significantly less prevalent as the primary medical plan (plan type covering most employees) while managed care plans continue to gain in prevalence. The chart below shows the shift in health care delivery systems from 1987 through 1997. Unless otherwise noted, data presented in this report are from the Hay Benefits Report.
The last decade has also seen a shift in the way behavioral health care services are managed. Specifically, there have been shifts in the way limits are imposed on both inpatient and outpatient psychiatric health care.
The data in this report were collected prior to implementation of the Mental Health Parity Act of 1996 (MHPA). The MHPA requires parity in certain aspects of provision of mental health and medical/surgical benefits under a plan that provides both benefits. Specifically, it requires parity with respect to aggregate lifetime expense limits and annual dollar limits on mental health benefits. In other words, if a plan imposes an aggregate lifetime expense limit or an annual dollar limit on medical/surgical benefits, the limit on mental health benefits cannot be less. The law does not require a plan to provide mental health benefits. In addition, the MHPA allows plans to adopt higher copayments and deductibles and, to impose limits on the number of visits or days. The requirements of the MHPA do not apply to substance abuse benefits.
Inpatient Psychiatric Care - Day Limits
In 1988, 38 percent of plans imposed a day limit on inpatient psychiatric care. By 1997, day limits were imposed by 57 percent of plans. While more plans are imposing limits, the limit has remained stable. Of the plans imposing a day limit, 59 percent imposed a limit of 30 days in 1988. In 1997, 57 percent of plans imposed a limit of 30 days.
Psychiatric Care Room and Board - Level of Coverage
The level of coverage for inpatient psychiatric care is measured by the percentage covered, as well as any maximums imposed on the amount of coverage (day limits, for example). The percentage of plans covering inpatient psychiatric care at the same maximum as other confinements (total of rows 1 and 3 in the table below) decreased from 37 percent in 1990 to 14 percent in 1997. The percentage of plans covering inpatient psychiatric care at 100 percent of reasonable and customary (total of rows 1 and 2 in the table below) has remained relatively stable over the years. In 1988, 46 percent of plans covered inpatient psychiatric care at 100 percent of reasonable and customary. In 1997, 47 percent of plans covered inpatient psychiatric care at 100 percent of reasonable and customary.
1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 100% of R&C Same Maximum as Other Confinements
22%
22%
14%
10%
7%
7%
4%
5%
6%
7%
100% of R&C Separate Maximum
24%
21%
33%
30%
32%
40%
38%
40%
40%
40%
Less than 100% of R&C (Same Maximum) 23%
16%
12%
9%
9%
8%
7%
7%
Less than 100% of R&C (Separate Maximum) 54%*
57%*
30%
44%
49%
44%
49%
47%
47%
46%
* In 1988 & 1989, these amounts were reported as "Less than 100% of R&C - Same or Separate Maximum."
In Hospital Psychiatric Care - Limits
The number of plans imposing a limit on inpatient psychiatric care increased from 63 percent in 1990 to 86 percent in 1997. Also, the number of plans that impose more than one limit increased from 16 percent in 1988 to 28 percent in 1997. The first row of the table below shows the percentage of plans that impose a limit. The remaining rows show the type of limits and the percentage of plans with limits that impose each type. For example, in 1997, 86 percent of plans impose a limit and, of these, 47 percent impose a limit on the number of days of inpatient care that are covered.
1990 1991 1992 1993 1994 1995 1996 1997 Plans with limits 63%
74%
81%
84%
87%
87%
87%
86%
Have a Maximum Number of Days Only 59%
46%
42%
41%
42%
47%
47%
47%
Have an Annual Dollar Limit Only 7%
5%
5%
5%
5%
4%
4%
4%
Have a Lifetime Dollar Limit Only 18%
25%
25%
24%
23%
21%
21%
21%
Have a Combination of Limits 16%
24%
28%
30%
30%
28%
28%
28%
(data for 1988 & 1989 are unavailable)
Maximum Number of Visits Per Year for Outpatient Psychiatric Care
Outpatient psychiatric care limits have also changed. In 1988, 26 percent of plans imposed an annual visit limit. In 1997, 48 percent of plans imposed such a limit. In addition to an increase in the number of plans imposing a limit, the number of visits allowed has decreased. In 1988, 46 percent of plans that imposed a limit allowed a maximum of 50 visits. In 1997, the most prevalent limit was 20 visits.
1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 Plans with Visit Limit 26% 28% 33% 35% 34% 39% 40% 43% 47% 48% Fewer than 20 7% 6% 5% 4% 4% 4% 4% 5% 20 16% 22% 25% 28% 31% 34% 39% 38% 21 - 29 5% 3% 4% 4% 4% 3% 4% 5% 30 29%* 34%* 11% 12% 14% 17% 16% 17% 16% 17% 31 - 49 4% 3% 7% 8% 8% 9% 9% 7% 8% 8% 50 46% 42% 36% 35% 30% 25% 25% 23% 20% 17% 51 - 75 16% 18% 15% 13% 13% 12% 10% 11% 8% 9% More than 75 5% 3% 3% 1% 1% 1% 1% 1% 1% 1% * In 1988 and 1989, the data are shown for 30 visits and less
Outpatient Psychiatric Care - Maximum Benefit Per Visit
In addition to annual visit limits, plans impose per visit dollar limits and annual dollar limits on outpatient psychiatric care. The table below shows the percentage of plans imposing a per visit dollar limit and the limits imposed by these plans. The amounts shown are not adjusted for inflation. Based on the overall trend in health care costs, a limit of $50 in 1988 is equal to a limit of $98.65 in 1997. Therefore, even though fewer plans are imposing per visit dollar limits, the amount of the average limit is more restrictive than in 1988.
1990 1991 1992 1993 1994 1995 1996 1997 Plans with Per Visit Dollar Limit 27% 26% 25% 23% 21% 19% 17% 17% Less than $20 3% 9% 5% 4% 3% 2% 2% 0% $20 - $29 13% 25% 27% 24% 22% 24% 19% 23% $30 - $39 7% 20% 18% 17% 17% 18% 13% 18% $40 - $49 18% 19% 19% 16% 14% 13% 15% 13% $50 - $59 24% 14% 14% 21% 23% 26% 26% 23% $60 - $69 13% 7% 6% 5% 5% 5% 7% 8% $70 or greater 22% 6% 11% 13% 16% 12% 18% 15% Annual Dollar Maximum for Outpatient Psychiatric Care
In 1988, 45 percent of plans imposed annual dollar limits on outpatient psychiatric care. Of these, 34 percent imposed limits of $751 to $1,000; 21 percent imposed limits of $1,001 to $1,999; and, 15 percent imposed limits of $2,000 to $2,500. By 1997, the percentage of plans imposing limits had decreased to 40 percent. Of these, 16 percent imposed a limit of $1,000; 23 percent imposed limits of $1,500 to $1,999; 20 percent imposed limits of $2,000 to $2,499. Fourteen percent of plans imposed limits greater than or equal to $5,000. Again these numbers are not adjusted for inflation. Therefore, a limit of $1,000 in 1988 is equal to a limit of $1,973 in 1997.
Outpatient Psychiatric Care Coverage
There is a growing trend of providing outpatient psychiatric care with a separate per visit copayment as opposed to providing these benefits under the general medical plan deductible. The percentage of plans that do not cover psychiatric care has remained stable.
1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 Provided Subject to Medical Plan Deductible 85% 85% 79% 74% 72% 64% 58% 49% 41% 38% Provided Subject to Separate Per Visit Copay/Deductible 6% 6% 10% 13% 14% 18% 21% 26% 32% 35% Provided and Not Subject to Deductible 7% 8% 10% 12% 13% 17% 20% 24% 26% 26% Not Covered
2% 1% 1% 1% 1% 1% 1% 1% 1% 1% Percentage of Reasonable and Customary Charges Paid for Outpatient Psychiatric Care
The typical percentage of reasonable and customary charges paid for outpatient psychiatric care varies from 50 percent to 100 percent. Payment of 100 percent of reasonable and customary is increasing in popularity while both 50 percent and 80 percent of reasonable and customary coverage are declining. It is important to remember that coinsurance is not the only measure of the amount of coverage provided. The use of other limits (such as per visit or annual dollar limits and limits on the number of visits) decrease the actual amount of charges that a plan covers.
Columns do not total 100%. Some plans offer coinsurance rates that are not shown in this table.
1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 50% 68% 63% 55% 52% 50% 43% 42% 37% 32% 31% 80% 23% 23% 23% 22% 20% 20% 16% 16% 90% 4% 5% 6% 8% 7% 7% 8% 9% 100% 13% 13% 15% 22% 23% 30% 36% 38% *Data for 1988 & 1989 were not reported in this manner.
Summary of Maximum on Outpatient Psychiatric Care
The table on the following page shows a summary of the changes in maximums on outpatient psychiatric care. The dollar values shown in this table have not been adjusted for inflation. Therefore, a limit of $1,000 in 1988 is equal to a limit of $1,573 in 1992 and $1,973 in 1997.
Maximums on Outpatient Psychiatric Care
1988
1992
1997
Of 628 respondents, 25% have no dollar maximum other than the overall major medical plan maximum
Of those plans that have a maximum,
63% have an annual maximum only
10% have a lifetime maximum only
27% have a combination of both annual and lifetime maximums
Of 977 respondents, 33% have no dollar maximum other than the overall comprehensive medical plan maximum
Of those plans that have a maximum,
39% have an annual maximum only
20% have a lifetime maximum only
41% have a combination of both annual and lifetime maximums
Of 1,004 respondents, 33% have no dollar maximum other than the overall comprehensive medical plan maximum
Of those plans that have a maximum,
34% have an annual maximum only
41% have a lifetime maximum only
25% have a combination of both annual and lifetime maximums.
For the 48 plans with a separate dollar maximum per lifetime for outpatient psychiatric coverage, the common maximums are: $5,000 and less (11%)
$7,000 to $10,000 (27%)
$20,000 to $29,999 (25%)
$50,000 and Greater (33%)
For the 69 plans with a separate dollar maximum per lifetime for outpatient psychiatric coverage, the common maximums are: less than $10,000 (17%)
$10,000 (38%)
$25,000 (12%)
$50,000 (16%)
For the 85 plans with a separate dollar maximum per lifetime for outpatient psychiatric coverage, the common maximums are: less than $10,000 (14%)
$10,000 (24%)
$20,001 to $29,999 (14%)
$50,000 (28%)
Comparable data not collected in 1988.
364 plans had a combination inpatient/outpatient maximum; of these, 24% are $25,000
41% are $50,000
12% are greater than $50,000
355 plans have a combination inpatient/outpatient maximum; of these, 23% are $20,001 to $29,999
41% are $50,000
14% are greater than $50,000
Of the 295 plans with separate annual maximums for outpatient psychiatric care, the most common maximums are: $500 and less (14%)
$751 - $1,000 (34%)
$1,001 - $1,999 (21%)
$2,000 - $2,500 (15%)
$3,000 - $4,999 (5%)
$5,000 or greater (5%)
Of the 406 plans with separate annual maximums for outpatient psychiatric care, the most common maximums are: Less than $1,000 (10%)
$1,000 (22%)
$1,500 - $1,999 (22%)
$2,000 - $2,499 (18%)
$2,500 - $2,999 (7%)
$3,000 - $4,999 (9%)
$5,000 or greater (9%)
Of the 396 plans with separate annual maximums for outpatient psychiatric care, the most common maximums are: Less than $1,000 (6%)
$1,000 (16%)
$1,500 - $1,999 (23%)
$2,000 - $2,499 (20%)
$2,500 - $2,999 ( 11%)
$3,000 - $4,999 (8%)
$5,000 or greater (14%)
Data From Other Sources
Mutual of Omaha - Current Trends Data - National Average
Each year, Mutual of Omaha produces a report entitled, "Current Trends In Health Care Costs and Utilization." The reports are based on a sample of Mutual of Omaha’s group business and the actual experience of their policyholders. The policies included in the study represent a mixture of groups with and without managed care features.
Hay has found that the Mutual of Omaha reports reflect national trends. The advantage of the reports is that they provide detailed consistent information on use of specific components of health care for a large insured base over a period of years.
Office Psych Encounters and Average Claims
An "encounter" is defined as a patient/service date combination. A patient who visits more than one physician in a day will have only one visit counted for the day.
The table below shows the change in outpatient psychiatric encounters and average charge per encounter from 1991 through 1996. During this period, the number of outpatient psychiatric encounters decreased by 8.9 percent. After adjusting for inflation, the average charge per encounter decreased by 7.0 percent.
1991 1992 1993 1994 1995 1996 % Change 1991 - 1996
Encounters per 1,000 people 313 346 378 360 339 285 -8.9% Average Charge Per Encounter $81 $83 $84 $85 $87 $92 13.6% Average Charge per Encounter in 1997 Dollars $100 $92 $86 $85 $86 $93 -7.0% The number of encounters per 1,000 people increased between 1991 and 1993 by 20.8 percent. After 1993, the number of encounters per 1,000 began to decline. The decrease from 1993 to 1996 is 24.6 percent.
General Office Visit Encounters and Average Claims
The table below shows the change in general office visit encounters and average charge per encounter from 1991 through 1996. The number of general office visit encounters increased by 27.4 percent and the average charge per encounter increased by 5.9 percent, after adjusting for inflation.
1991 1992 1993 1994 1995 1996 % Change 1991 - 1996
Encounters per 1,000 people 1638 1747 1928 1956 2023 2087 27.4% Average Charge Per Encounter $41 $43 $46 $48 $51 $54 31.7% Average Charge per Encounter in 1997 Dollars $51 $48 $47 $48 $50 $54 5.9% Inpatient Utilization - Mental and Behavioral
The tables below show the trends in inpatient utilization for mental and behavioral diagnoses and all diagnoses. Inpatient utilization has decreased across all categories of care. However, the decrease has been more dramatic for mental and behavioral health care. From 1991 through 1996, the number of inpatient admissions per 1,000 people declined by 36.4 percent for mental and behavioral diagnoses. For all diagnoses, the decline was only 13.2 percent.
Similarly, lengths of stay have decreased across all categories of care. Again, the decrease is more dramatic for mental and behavioral diagnoses than for all diagnoses (50 percent compared to 18.3 percent).
1991 1992 1993 1994 1995 1996 % Change 1991 - 1996
Inpatient Admissions per 1,000 people 5.5 5.2 4.7 4.3 4.4 3.5 -36.4% Average Length of Stay 17.0 14.6 13.3 12.3 10.4 8.5 -50.0% Inpatient Days per 1,000 people 93 76 62 53 46 29 -68.8%
Inpatient Utilization - All Diagnoses (including mental & behavioral)
1991 1992 1993 1994 1995 1996 % Change 1991 - 1996
Inpatient Admissions per 1,000 people 69.7 68.6 66.2 62.3 63.2 60.5 -13.2% Average Length of Stay 6.0 5.8 5.7 5.6 5.1 4.9 -18.3% Inpatient Days per 1,000 people 416 396 378 347 322 294 -29.3%
Inpatient Utilization - General Health Diagnoses (excluding mental & behavioral)
1991 1992 1993 1994 1995 1996 % Change 1991 - 1996
Inpatient Admissions per 1,000 people 64.2 63.4 61.5 58.0 58.8 57.0 -11.2% Inpatient Days per 1,000 people 323 320 316 294 276 265 -18.0% Separating general health diagnoses shows greater disparity between the decline in mental health and general health inpatient utilization. Inpatient admissions per 1,000 people for mental and behavioral diagnoses declined by 36.4 percent between 1991 and 1996. During the same period, inpatient admissions per 1,000 people for general health diagnoses declined by 11.2 percent. Also, inpatient days per 1,000 people declined by 18.0 percent for general health diagnoses and by 68.8 percent for mental and behavioral diagnoses.
The results of the Mutual of Omaha survey confirm the trends shown in the Hay Benefits Report regarding plan design and management. While utilization has decreased across all categories of care, mental and behavioral utilization has declined at a faster pace.
National Association of Psychiatric Health Systems Annual Survey Reports
Each year NAPHS surveys its members to examine various aspects of the behavioral health delivery system. The data reported in the NAPHS surveys show a decrease in average lengths of stay from 1993 to 1996 of 29 percent. (View charts)
Also see: APPENDIX A, Typical Plan Design 1988 and 1997
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