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Finance & Value

The Costs Of Mental Health Parity: Still An Impediment?

Abstract

 
Parity in mental health benefits rectifies unfairness in health insurance coverage and reduces financial risk for those with mental illness. However, increased coverage for mental illness has been seen as creating inefficiencies and increasing total spending, based largely on results from the RAND Health Insurance Experiment conducted in the 1970s. Newer evidence suggests that cost control techniques associated with managed care give health plans alternatives to discriminatory coverage for containing costs. We review both eras of research on mental health insurance and conclude that comprehensive parity implemented in the context of managed care would have little impact on total spending.

Equity-in-access and adverse-selection arguments regarding parity have been articulated for many years, but until recently they have not been on the winning side of the debate. Against parity policies stood both efficiency and cost objections.³ The efficiency argument is well known in mental health services research.⁴ Traditional welfare economics views the demand for mental health care as representing the consumer’s willingness to pay for care. Insurance coverage reduces the price to the consumer, inducing more use; this is labeled "moral hazard." Services used only in the presence of the insurance-reduced price are not worth the cost to the consumer, assuming that the demand curve represents willingness to pay. A large literature has grown around the question of measuring this demand response. Demand response was found to be greater for mental than for physical health care, which implies that a given reduction in price resulting from insurance would create more inefficiency in mental than in physical health care use.⁵ This finding sets up the main efficiency argument against parity: In the interest of consumers, coverage should not be equal for physical and mental care.

It is important to emphasize that these arguments about parity have to do with cost response, not the absolute level of spending. Policymakers and others have often argued that mental health care should not be covered because it is "too costly." Costly and unexpected adverse health events are what insurance should cover. Furthermore, the converse argument—"psychotherapy costs are low, so we should cover them"—is also inconsistent with the principles of insurance. Managed care matters to the economic principles bearing on coverage, as we shall see, but not because it makes coverage less costly.

Managed care alters the efficiency arguments bearing on parity by changing the methods of rationing health and mental health care.⁶ Under managed care, benefit design provisions are only one mechanism that affects the use of mental health care. Because managed care introduces other mechanisms for controlling moral hazard and cost sharing, a health plan need not rely exclusively on such benefit-design features to control costs. Suppose, for purposes of discussion, that these mechanisms reduce a good deal of the "low value" use of health services. Then, consumer cost sharing need no longer trade moral hazard–induced inefficiencies for the loss of financial protection. If moral hazard is better dealt with by other mechanisms, benefits can be designed with a focus on risk protection. Formal analyses of payment systems confirm that benefit-design features can be assigned the task of protecting against financial risk, while policies aimed at affecting providers’ behavior, such as payment arrangements, can contend with moral hazard.⁷

Despite the dramatic changes that have occurred in mental health care delivery during the past fifteen years, some health insurers and employers remain wary of the cost of improving mental health benefits. Skeptics suggest that expanded mental health services will yield few benefits and generate large cost increases. In 2003, Donald Young, then president of the Health Insurance Association of America (now America’s Health Insurance Plans), described federal parity legislation as "a hidden tax" and "a misguided effort to provide additional treatment resources for a wide variety of ill-defined and difficult-to-diagnose mental disorders."⁸ In his message vetoing a bill to expand the Maine parity law delivered 11 April 2002, then governor Angus King said: "As we look for ways to reduce the costs of health care, we must not exacerbate the problem by adding new mandates. When you are in a hole, the first rule is not to dig any deeper."⁹ Fortunately, a rich body of research on response of costs to changing mental health coverage means that policymakers can base coverage decisions on evidence. Here we review this research with an eye toward consolidating an evidence base.

Two Eras Of Economic Research

Top Two Eras Of Economic... Implications NOTES

 
We distinguish two eras in our review of the empirical literature on the effects of mental health insurance. The first era encompasses research on data from the 1970s and 1980s, before managed care. The second era dates forward from the mid-1990s. Because the majority of studies are not randomized controlled trials, we opted against conducting a formal meta-analysis. Rather, we qualitatively compared the entire body of literature with attention to the methodological approaches employed and key evidence amassed in both eras.

The studies conducted in these two periods differ in their primary research aims, methods, and implications for the cost of parity. Early studies focused on estimating the effect of prices on demand for ambulatory mental health care; more recent studies exploited natural experiments to evaluate parity (or near-parity) coverage expansions in the context of shifts to managed care and do not provide direct evidence on price elasticities.¹⁰ Some studies followed an "experimental" group over time and compared changes with those in an investigator-constructed "comparison" group. Some of the managed care–era studies compare people living in states that enacted parity laws with those living in other states. Because of the complexity of these real-world interventions, it is not always possible to isolate a response to price in these studies.

Most importantly, research findings from these two eras differ in their implications regarding the cost of parity. Early evidence supported employers’ concern that outpatient parity would "break the bank." In contrast, the managed care studies, despite not always being able to identify price elasticity, indicate that enactment of full parity would not greatly increase total spending and would protect families against financial risks associated with mental illness.

Early evidence on demand response. When the first studies of price of and demand for ambulatory mental health care were initiated in the 1970s and 1980s, it was an open question whether psychotherapy should be covered by health insurance. From the time mental health coverage was first offered as part of major medical contracts in the 1950s, insurers worried that intensive or long-term psychotherapy would drive up premiums. This concern prompted insurers to exclude or impose special limits on coverage for mental health services. These limits were tolerated in part because of the presence of a public safety-net mental health system to care for those disabled by mental illness.

Early studies sought to understand whether and to what extent demand for outpatient mental health care (with a focus on psychotherapy) differed from that for general medical care (Exhibit 1). Price elasticity indicates in percentage terms how much the quantity of mental health services demanded by consumers responds to changes in price. A price elasticity of –0.5, for example, means that for each 1 percent rise in price (such as that resulting from a change in coinsurance), quantity demanded falls by 0.5 percent. At the high end, using a survey of psychiatrists and their patients conducted by the American Psychiatric Association in 1973, Tom McGuire estimated that total demand for mental health services would increase 1 percent in response to a 1 percent increase in insurance. This estimate was somewhat higher than but broadly consistent with the other research cited in Exhibit 1. Where comparisons could be made, demand response to price in mental health was found to exceed demand response in other areas of care. Using data from the National Medical Care Utilization and Expenditure Survey (NMCUES), Carl Taube and colleagues reported estimates for mental health care much greater than those for ambulatory medical care, and Constance Horgan’s estimates showed the elasticities for mental health care as almost three times those for general health care.

A consensus emerged by the end of the 1980s, on the basis of these studies, that validated insurers’ decisions to limit mental health coverage and confirmed policymakers’ concerns about the cost of regulating mental health benefits. The consensus was embodied in the recommendations for mental health during the 1993–94 national health reform debate. The basic benefit package proposed under the Clinton plan would have included thirty days of inpatient and residential care and thirty outpatient psychotherapy visits, with $25 cost sharing for managed care and 50 percent outpatient cost sharing for unmanaged care.¹²

With the research supporting the status quo of differential coverage, mental health benefits, if anything, decayed in relation to benefits for other conditions during the late 1980s into the 1990s. Data from the U.S. Bureau of Labor Statistics (BLS) indicate that private insurers augmented their limits on mental health benefits over this period. In 1981, for example, 41 percent of full-time, privately insured workers were subject to limits on inpatient mental health care, and 83 percent had limits on outpatient care.¹³ By 1995, 89 percent had inpatient mental health limits, and 96 percent had limits on outpatient care.¹⁴ The increased use of day and visit limits was particularly pronounced. Unlike higher deductibles and coinsurance for mental health services, use of such limits is harder to justify on efficiency grounds because when sizable cost sharing is in place, limits offer only modest savings. As a result, the decision to impose these limits has been viewed as motivated largely by incentives to risk-select rather than to address moral hazard. In fact, evidence from the Federal Employees Health Benefits (FEHB) Program suggests that adverse selection worsened over this period. In the 1980s and 1990s, the adverse selection–driven dynamics of coverage offerings in national FEHB plans approached "death spiral" proportions, with plan restrictions leading to an eventual decline in the percentage of total dollar value of claims in behavioral health services (excluding prescription drugs) from 7.8 percent in 1980 to 1.9 percent in 1997.¹⁵ Short-circuiting such market failures had been the economic rationale for state benefit mandates during the 1970s and 1980s.¹⁶ Although these mini-parity laws were popular, they only placed a floor in coverage at a low level, and only for plans subject to state insurance regulation. Furthermore, benefit mandates were often denominated in dollar terms, and medical price inflation eroded their purchasing power.

Recent evidence under managed care. A second generation of research in the late 1990s studied mental health coverage in the context of managed care. These studies were more heterogeneous in their central research aims, methodological approaches, and outcomes of interest. Instead of focusing exclusively on estimating demand response to price, research addressed such questions as how total mental health spending and consumers’ out-of-pocket spending changed in response to parity-like coverage expansions. This virtue was born of necessity: The natural experiments under study were multifaceted changes, with improvements in benefit design often coupled with introduction of managed care. With the emergence of a federal debate over parity in Congress in the early and mid-1990s, this period also included debate over competing actuarial reports estimating how parity would likely affect health insurance premiums.

Renewed interest in the effects of mental health benefit changes on costs was prompted in part by emerging evidence of managed care’s role in controlling overall health care spending. The nature and extent of managed care varies tremendously across health plans and over time, which makes measuring its effects difficult. (These measurement problems are exacerbated by risk segmentation if managed care plan enrollees differ from those in conventional insurance.) Evidence on the effects of managed care suggests that they have been instrumental in reducing inpatient admissions, inpatient lengths-of-stay, and total spending on inpatient care, with a concomitant increase in outpatient visit rates across the health sector.¹⁷ In the mental health context, managed care contracts often take the form of risk-sharing arrangements negotiated by employers or insurers with specialized managed behavioral health care "carve-out" firms having expertise in establishing specialty provider networks, negotiating payment rates, and managing use to affect the supply of mental health services. The carve-out industry has grown rapidly: In 2002, 164 million people were covered, compared with 70 million in 1993.¹⁸ One stated goal of second-generation mental health coverage studies was to examine whether managed care, largely done by carve-out companies, would enable more-affordable implementation of parity.

In contrast with those of the earlier era, these second-generation studies did not find large mental health spending increases attributable to parity, and all studies that addressed risk protection identified sizable decreases in consumers’ out-of-pocket mental health care spending (Exhibit 2). All five studies examined here are natural experiments structured to examine the effects of mental health/substance abuse (MH/SA) benefit changes, using the period before the change as a benchmark for comparison. The challenge of such before/after comparisons is that the study population can change during the time period. These studies used various techniques to control for secular trends. Three selected only those enrollees who were continuously covered for the entire study period for analysis, and two addressed case-mix considerations by studying outcomes in an affected population in contrast to a comparable unaffected group. The outcomes of interest differ across the studies, but most examined how parity affects mental health spending, and some also considered its effects on consumer financial protection.

Although the studies by William Goldman and colleagues and by Yuhua Bao and Roland Sturm did not examine out-of-pocket costs, their total cost and use results are similar to the broader literature in direction and significance. Goldman and colleagues examined the simultaneous introduction of an expansion in MH/SA benefits and introduction of a carve-out contract by a private employer. They identified a sizable reduction in MH/SA costs following these changes, resulting from fewer outpatient visits per user, a reduction in the probability of inpatient admissions, reduced lengths-of-stay, and lower costs per unit of service. They also detected an increase in the probability of using any mental health care over this time period. Using a difference-in-difference econometric approach to estimate the effect of parity laws enacted at the state level, Bao and Sturm found no significant difference in perceived access to care among those with differing mental health care needs in states with and without these policies.¹⁹

A key challenge in interpreting the findings from these studies involves separating the effects due to initiation of MH/SA benefit changes from those due to simultaneously occurring shifts in managed mental health care. Because supply-side rationing through managed care is inherently less transparent than control through benefit limits, we know relatively little about how various managed care tools contribute to changes in use and spending. Some studies cannot directly identify managed care changes; this is true for all multistate studies comparing people living in states with and without parity laws. Although researchers in four of the five studies were aware of shifts to carve-out contracts concurrent with MH/SA benefit changes, these research settings offer limited opportunity to peer inside the "black box" of a carve-out contract to identify how various managed care mechanisms affect outcomes. Although evidence is sparse, network incentives appear to exert subtle but powerful control over the quantity of services used. Network incentives arise from the cooperation that a plan can expect from providers who value being included "in network." Ma and McGuire attempted to decompose the quantity reductions identified among Massachusetts state employees that were directly attributable to managed care (Exhibit 2). They found that network incentives under managed care accounted for most of the MH/SA cost reductions observed. In the case of parity in the FEHB, the Office of Personnel Management (OPM) explicitly allowed plans to establish higher cost sharing and special day/visit limits for out-of-network MH/SA services, implicitly recognizing the moral-hazard problem.²⁰ All fee-for-service plans took advantage of this option.²¹ To the extent possible, Exhibit 2 includes available information on managed care changes to signal that these findings should not be interpreted as the pure effect of insurance changes.

The technology of treating mental illness also was transformed during this period. Treatment innovations and associated spending increases were most notable in psychopharmacology.²² The amount of spending on psychotropic drugs as a proportion of overall mental health spending rose from 8 percent in 1987 to 21 percent in 2001.²³ Along with the increased availability of effective medications, growth in psychotropic drug use is attributable to its comparatively generous coverage.

The absence of quantity increases attributable to parity across these studies is consistent with more recent actuarial estimates of the effect of parity on premiums. Actuarial estimates are calculated as the expected change in total premium as a result of parity. Studies conducted in the early and mid-1990s produced widely disparate estimates, ranging from a 1 percent to an 11 percent increase in total premiums due to parity, with the Congressional Budget Office (CBO) estimating a 4 percent increase.²⁴ (Some of these analyses were commissioned by interest groups such as the ERISA Industry Committee, the Association of Private Pension and Welfare Plans, and mental health provider groups.) Lack of uniformity in estimated effect on premiums due to parity led to an effort to incorporate managed care effects into actuarial models using more recent cost data from the FEHB, state parity experiences, the managed behavioral health care industry, and private employers.²⁵ After updating its estimation methods to incorporate managed care effects, the CBO scored comprehensive parity as raising group health insurance premiums by an average of 0.9 percent.²⁶ CBO analysts also forecast a net 0.4 percent increase in total premiums after accounting for the offsetting impact of behavioral responses by health plans, employers, and workers.

Implications

Top Two Eras Of Economic... Implications NOTES

 
A comprehensive parity bill, the Paul Wellstone Mental Health Equitable Treatment Act, is pending in Congress. In the mold of the FEHB parity policy, this legislation would prohibit higher cost sharing and deductibles or separate inpatient and outpatient service limits for in-network private mental health insurance coverage. The main argument against enacting a comprehensive federal parity law of this kind is that generous coverage would drive up mental health spending, increase premiums, and expand the number of people unable to afford coverage. Old ideas about the cost of parity die hard. In our view, the relevant research implies that parity implemented in the context of managed care would have little impact on mental health spending and would increase risk protection.

Some non-cost-related objections to parity laws have been raised over the years. Parity opponents often raise philosophical objections to government mandates not limited to parity mandates. Some argue that insurance regulation is a state, not a federal, function. Doubts about the effectiveness of the treatments for mental disorders paid for under parity might also influence perceptions about the value of the legislation, although one authoritative recent review by the U.S. surgeon general addresses these concerns.²⁷ Even if quantity of use is unchanged, an improvement in coverage would shift costs from the beneficiary to the insurer. Employers and insurers might oppose parity policies because of these shifts, even if there is no welfare loss. The bottom line is that while reasons for opposing parity might remain in the managed care era, opposition to parity on the basis of increased total spending no longer constitutes an evidence-based objection.

Full parity will not cure all ills in the mental health care system.²⁸ The very mechanisms that have weakened the traditional cost control argument against parity imply that competitive insurance markets might continue to supply inefficiently low levels of mental health care even in the presence of parity laws. Managed care tactics substitute for demand-side cost sharing. Thus, parity laws regulate one dimension of cost and access control (benefit design) and leave others (utilization review, network design, physician incentives) open for use by plans to discourage enrollment by people with mental illnesses. As David Mechanic and Donna McAlpine put it, "Parity in benefit structures means little if ADM [alcohol, drug, and mental health] care is managed more stringently than other types of health care."²⁹ One could take comfort in the observation that parity fixes at least one problem related to equitable access to mental health treatment (benefit design). But this fallback position has problems. A plan will presumably react by tightening elsewhere if regulators force it to make demand-side cost-sharing provisions more generous. One thing is clear: Parity leads to more financial protection. More research is needed to better determine how increased financial protections due to parity might differentially affect those with more or less severe mental health conditions. However, it is important to remember that under parity, the traditional incentives to avoid enrolling people with high expected costs remain at least as strong as in the past, while the mechanisms available to health plans for affecting selection have expanded with managed care.³⁰

A sizable majority of people with mental disorders, even among the insured, do not receive treatment in a given year.³¹ Remarkable scientific advances have led to the availability of various effective treatments for most mental health disorders; however, there is an urgent need to improve dissemination of evidence-based treatment into real-world practice settings. Expanding benefits under parity might help, but it does not solve the problem of unmet need or ensure use of evidence-based medicine in mental health care. Other private and governmental initiatives are better suited to advancing public policy in these areas. Passage of comprehensive parity would allow policymakers, health care managers, and clinicians to shift attention away from benefit design and toward figuring out how to get effective treatment for people who would benefit.

Editor's Notes

 
Colleen Barry (colleen.barry{at}yale.edu) is an assistant professor in the Department of Epidemiology and Public Health, Division of Health Policy and Administration, at the Yale University School of Medicine in New Haven, Connecticut. Richard Frank is the Margaret T. Morris Professor of Health Economics in the Department of Health Care Policy at Harvard University in Cambridge, Massachusetts. Tom McGuire is a professor of health economics in that department.

Colleen Barry acknowledges support from the Robert Wood Johnson Foundation through the Changes in Health Care Financing and Organization (HCFO) Initiative. Richard Frank and Tom McGuire received support through National Institute on Drug Abuse (NIDA) Grant no. DA10233-06. Frank also acknowledges support from the John D. and Catherine T. MacArthur Foundation. The authors thank Don Metz, Howard Goldman, and two anonymous reviewers for constructive comments on an earlier draft of this paper.

NOTES

Top Two Eras Of Economic... Implications NOTES

 

1. L. Reed, E. Myers, and P. Scheidemandel, Health Insurance and Psychiatric Care: Utilization and Cost (Washington: American Psychiatric Association, 1972).
2. T.G. McGuire, Financing Psychotherapy: Cost, Effects, and Public Policy (Cambridge: Ballinger Press, 1981).
3. There have also been equity arguments advanced against parity, based on the historical correlation of high income with use of outpatient psychotherapy. We do not discuss these arguments here, although we expect managed care to have had a "levelizing" effect over income groups.
4. R.G. Frank and T.G. McGuire, "Economics and Mental Health," in Handbook of Health Economics, ed. A.J. Culyer and J.P. Newhouse (North Holland: Elsevier, 2000), 893–954.
5. Ibid.; and J.P. Newhouse and the Insurance Experiment Group, Free for All? Lessons from the RAND Health Insurance Experiment (Cambridge, Mass.: Harvard University Press, 1993).
6. S. Glied, "Managed Care," in Handbook of Health Economics, ed. Culyer and Newhouse, 707–753.
7. C.A. Ma and T.G. McGuire, "Optimal Health Insurance and Provider Payment," American Economic Review 87, no. 4 (1997): 685–704[Web of Science]; and R.P. Ellis and T.G. McGuire, "Supply-Side and Demand-Side Cost Sharing in Health Care," Journal of Economic Perspectives 7, no. 4 (1993): 135–151.[Web of Science][Medline]
8. G. Gately, "Wanted: Insurance Parity for Mental Illness," 15 May 2003, http://www.personalmd.com/hs/news/512667.html (accessed 17 March 2006).
9. A. King, Gubernatorial Veto Message to the Maine Legislature, 11 April 2002.
10. It is worth noting that the presence of nonprice rationing such as that found in managed care makes it difficult to "identify" the demand function empirically, thereby making comparison of elasticities across eras more difficult. It also makes the comparison somewhat less relevant for policy.
11. Newhouse et al., Free for All?
12. B.S. Arons et al., "Mental Health and Substance Abuse Coverage under Health Reform," Health Affairs 13, no. 1 (1994): 192–205.[Abstract]
13. U.S. Bureau of Labor Statistics, National Compensation Survey: Employee Benefits in Medium and Large Size Firms, 1981, Bulletin no. 2140 (Washington: BLS, 1982).
14. BLS, National Compensation Survey: Employee Benefits in Medium and Large Size Firms, 1995, Bulletin no. 2496 (Washington: BLS, 1998).
15. S.M. Foote and S.B. Jones, "Consumer-Choice Markets: Lessons from FEHBP Mental Health Coverage," Health Affairs 18, no. 5 (1999): 125–130[Medline]; and D.K. Padgett et al., "The Effect of Insurance Benefit Changes on Use of Child and Adolescent Outpatient Mental Health Services," Medical Care 31, no. 2 (1993): 96–110.[CrossRef][Web of Science][Medline]
16. R.G. Frank, "Regulatory Policy and Information Deficiencies in the Market for Mental Health Services," Journal of Health Politics, Policy and Law 14, no. 3 (1989): 477–501.[Medline]
17. R.H. Miller and H.S. Luft, "HMO Plan Performance Update: An Analysis of the Literature, 1997–2001," Health Affairs 21, no. 4 (2002): 63–86.[Abstract/Free Full Text]
18. M. Oss et al., Open Minds Yearbook of Managed Behavioral Health and Employee Assistance Program Market Share in the U.S., 2002–2003 (Gettysburg, Pa.: Open Minds, 2003).
19. Within the broader multistate literature on effects of state parity policies, none detected increased use of services, and one study that examined consumer spending found evidence of risk-protection benefits. This latter study was C.L. Barry and S.B. Busch, "Effects of State Parity Laws on Children with Mental Health Care Needs" (Working Paper, Yale School of Medicine, 2006).
20. U.S. Office of Personnel Management, "Call Letter for Contract Year 2001—Policy Guidance," published as FEHB Program Carrier Letter no. 2000-17 (Washington: OPM, 2000).
21. C.B. Barry and M.S. Ridgely, "Health Plan Response to Regulation of Mental Health Coverage for Federal Employees" (Working Paper, Yale School of Medicine, 2006).
22. R.G. Frank, R.M. Conti, and H.H. Goldman, "Mental Health Policy and Psychotropic Drugs," Milbank Quarterly 83, no. 2 (2005): 271–298.
23. T.L. Mark et a1., "U.S. Spending for Mental Health and Substance Abuse Treatment, 1991–2001," Health Affairs 24 (2005): w133–w142 (published online 29 March 2005; 10.1377/hlthaff.w5.133)[CrossRef]; and R.M. Coffey et al., National Estimates of Expenditures for Mental Health and Substance Abuse Treatment (Rockville, Md.: U.S. Department of Health and Human Services, 2000).
24. U.S. Congressional Budget Office, CBO’s Estimates of the Impact on Employers of the Mental Health Parity Amendment in H.R. 3101 (Washington: CBO, 13 May 1996); J. Rodgers, "Analysis of the Mental Health Parity Provision of S. 1028" (Washington: Price Waterhouse, 1996); M. Sing, "The Costs and Effects of Parity for Mental Health and Substance Abuse Insurance Benefits" (Washington: DHHS, 1998); Watson Wyatt Worldwide, "The Costs of Uniform Plan Provisions for Medical and Mental Health Services: An Analysis of S. 298, the ‘Equitable Health Care for Severe Mental Illness Act’ " (Bethesda, Md.: Watson Wyatt Worldwide, 1996); and R.E. Bachman, "An Actuarial Analysis of the Domenici-Wellstone Amendment to S.1028 ‘Health Insurance Reform Act’ to Provide Parity for Mental Health Benefits under Group and Individual Insurance Plans" (Atlanta: Coopers and Lybrand, 1996).
25. R.G. Frank et al., Estimating the Costs of Parity for Mental Health: Methods and Evidence (Princeton, N.J.: Robert Wood Johnson Foundation, 2001).
26. CBO, "Cost Estimate: S543 Mental Health Equitable Treatment Act of 2001" (Washington: CBO, 2001).
27. DHHS, Mental Health: A Report of the Surgeon General (Rockville, Md.: DHHS, 1999).
28. R.G. Frank, H.H. Goldman, and T.G. McGuire, "Will Parity in Coverage Result in Better Mental Health Care?" New England Journal of Medicine 345, no. 23 (2001): 1701–1704.[Free Full Text]
29. D. Mechanic and D.D. McAlpine, "Mission Unfulfilled: Potholes on the Road to Mental Health Parity," Health Affairs 18, no. 5 (1999): 7.[Abstract]
30. Z. Cao and T.G. McGuire, "Service-Level Selection by HMOs in Medicare," Journal of Health Economics 22, no. 6 (2003): 915–931.[Medline]
31. D.A. Regier et al., "The de facto U.S. Mental and Addictive Disorders Service System: Epidemiologic Catchment Area Prospective One-Year Prevalence Rates of Disorders and Services," Archives of General Psychiatry 50, no. 2 (1993): 85–94[Abstract/Free Full Text]; R.C. Kessler et al., "Lifetime and Twelve-Month Prevalence of DSM-III-R Psychiatric Disorders in the United States: Results from the National Comorbidity Survey," Archives of General Psychiatry 51, no. 1 (1994): 8–19[Abstract/Free Full Text]; and P.S. Wang et al., "Twelve-Month Use of Mental Health Services in the United States: Results from the National Comorbidity Survey Replication," Archives of General Psychiatry 62, no. 6 (2005): 629–640.[Abstract/Free Full Text]

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