Return on Investment of Enhanced Behavioral Health Services

Abstract

Importance: Employer-sponsored benefit programs aim to increase access to behavioral health care, which may help contain health care costs. However, research has either focused solely on clinical outcomes or demonstrated reductions in medical claims without accounting for the costs of behavioral health services, leaving the financial return on investment unknown.

Objective: To determine whether a clinically effective employer-sponsored behavioral health benefit is associated with net medical cost savings.

Design, setting, and participants: This retrospective cohort study included participants eligible for an employer-sponsored behavioral health benefit between November 1, 2019, and May 31, 2023. Eligibility criteria included having a behavioral health diagnosis and, in the program group, attending at least 1 behavioral health appointment. Program users were matched to nonusers on medical risk scores, behavioral health diagnoses, date of diagnosis, age, sex, and employer. Participants were followed up for 1 year before and after the benefit launch.

Exposure: A digital platform screened individuals for common behavioral health conditions and provided access to video and in-person psychotherapy, medication management, care navigation, and self-guided digital content.

Main outcomes and measures: Primary outcomes were per member per month (PMPM) medical spending, inclusive of all medical claims and program costs. A difference-in-differences analysis was used to compare changes in net medical spending between groups from the year before and up to 1 year after an index mental health diagnosis.

Results: This study included 13 990 participants: 4907 of 4949 (99.1%) eligible program group members were matched to 9083 control participants. Their mean (SD) age was 37 (13.2) years, and most participants (65.5%) were female. Costs decreased in the program group relative to the control group, with a net difference-in-differences of -$164 PMPM (95% CI, -$228 to -$100 PMPM), corresponding to savings of $1070 per participant in the first program year and a return on investment of 1.9 times the costs (ie, every $100 invested reduced medical claims costs by $190). Behavioral health costs in the program group increased relative to the control group but were more than offset by decreases in physical health care costs. Savings were larger for participants with higher medical risk.

Conclusions and relevance: In this cohort study, every $100 invested in an employer-sponsored behavioral health program with fast access to psychotherapy and medication management was associated with a reduction in medical claims costs by $190. These findings suggest that expanding access to behavioral health care may be a financially viable cost-reduction strategy for health care buyers.

Figure 1.. Behavioral Health Care Use Rates in the Year Before and After Program Launch

A, The vertical dashed line represents the program launch; the horizontal dashed line represents the mean prelaunch use. B, Error bars denote 95% CIs.

Figure 2.. Changes in Medical Spending After a Behavioral Health Diagnosis

Monthly spending increases were $164 less per member per month (PMPM) (95% CI, −$228 to −$100 PMPM) for program group members than for control group members in the year following a mental health diagnosis.

Figure 3.. Medical Spending in the Year Following a Behavioral Health (BH) Diagnosis

BH costs and physical health costs are presented overall (A and C) and by service category (B and D). In panel C, BH specialist care could occur in any setting; other categories represent care occurring in those settings from a non-BH specialist. PMPM indicates per member per month.

Figure 4.. Medical Spending Differences by Medical Risk Score and High-Cost Condition

A and B, Pre to post changes in total cost of care are presented by medical risk (A) and high-cost condition (B). The gray markers at the bottom of panel A represent the distribution of risk scores. The distance between regression lines represents the difference-in-differences at a given risk score. C, High-cost condition savings estimates are plotted at the average risk level for members with that condition. The downward slope of the dashed line, labeled “risk-based savings estimate,” shows how program savings increased for participants with higher medical risk scores. Chronic pain, gastrointestinal (GI) conditions, and hypertension fell substantially below the risk-based savings line, suggesting that spending on these conditions is more responsive to behavioral health treatment than would be expected from overall medical risk alone. COPD indicates chronic obstructive pulmonary disease; HHS-HCC, Health and Human Services Hierarchical Condition Categories; PMPM, per member per month.