Key Points Question Are mental health disorders associated with health care utilization and costs among people with chronic diseases? Findings In this population-based cohort study of 991 445 Canadian adults, including 156 296 with a mental health disorder, 3-year adjusted mean costs were $38 250 for those with a mental health disorder and $22 280 for those without a mental health disorder. Presence of a mental health disorder was associated with higher rates of hospitalization and emergency department visits, including when considering only visits associated with chronic disease and ambulatory care–sensitive conditions. Meaning In this study, mental health disorders were associated with substantially higher resource utilization and health care costs in patients with chronic diseases.

Objective In 2008 the federal Mental Health Parity and Addiction Equity Act (MHPAEA) passed, prohibiting U.S. health plans from subjecting mental health and substance use disorder (behavioral health) coverage to more restrictive limitations than those applied to general medical care. This require d some health plans to make changes in coverage and management of services. The aim of this study was to examine private health plans’ early responses to MHPAEA (after its 2010 implementation), in terms of both the intended and unintended effects. Methods Data were from a nationally representative survey of commercial health plans regarding the 2010 benefit year and the preparity 2009 benefit year (weighted N=8,431 products; 89% response rate). Results Annual limits specific to behavioral health care were virtually eliminated between 2009 and 2010. Prevalence of behavioral health coverage was unchanged, and copayments for both behavioral and general medical services increased slightly. Prior authorization requirements for specialty medical and behavioral health outpatient services continued to decline, and the proportion of products reporting strict continuing review requirements increased slightly. Contrary to expectations, plans did not make significant changes in contracting arrangements for behavioral health services, and 80% reported an increase in size of their behavioral health provider network. Conclusions The law had the intended effect of eliminating quantitative limitations that applied only to behavioral health care without unintended consequences such as eliminating behavioral health coverage. Plan decisions may also reflect other factors, including anticipation of the 2010 regulations and a continuation of trends away from requiring prior authorization.

Background: As the adverse clinical outcomes common in patients with chronic kidney disease (CKD) can be prevented or delayed, information on the cost of care across the spectrum of CKD can inform investments in CKD care. Objectives: To determine the cost of caring for patients with CKD who are not on dialysis or transplant at baseline. Design: Population-based cohort study using administrative health data. Setting: Alberta, Canada. Patients: Cohort of 219 641 adults with CKD categorized by estimated glomerular filtration rate (eGFR) between April 1, 2012, and March 31, 2014, into Kidney Disease: Improving Global Outcomes (KDIGO) CKD categories, excluding patients on dialysis or transplant at baseline. Measurements: The primary outcome was 1-year cumulative unadjusted health care costs, including the cost of drugs, physician visits, emergency department visits, outpatient procedures (including dialysis and other day medicine and surgery procedures), and hospitalizations for the year following each patient’s index date. Methods: Mean 1-year direct medical costs were estimated for the cohort as a whole and for patients in the different KDIGO CKD categories as defined at baseline. Costs were further categorized according to baseline demographic and clinical characteristics, and by type of care (ie, kidney care and cardiovascular care). Results: In 219 641 adults with CKD, the mean unadjusted cumulative 1-year cost of care was Can$14 634 per patient (median = Can$3672; Q1 = Can$1496, Q3 = Can$10 221). Costs were higher for those with more comorbidity, those with lower eGFR, and those with more severe albuminuria. The cost of kidney and cardiovascular care was Can$230 (1.6% of total costs) and Can$720 (4.9% of total costs), respectively, for the cohort overall. These costs increased substantially for patients with lower eGFR, averaging Can$14 169 (32.3% of total costs) and Can$2395 (5.5% of total costs) for kidney and cardiovascular care, respectively, for people with eGFR<15 mL/min/1.73 m 2 at baseline. Limitations: We only have estimates of the cost of health care for people with CKD, and not the costs borne by patients or their families. As we have not included costs for people without CKD in this analysis, we are unable to assess the incremental costs associated with CKD. Conclusions: We identified that patients with CKD, even when not on dialysis at baseline, had high health care costs (more than twice the cost per person in Canada in 2015), with a graded association between severity of CKD and costs. Our findings can inform current and future cost estimates across the spectrum of CKD, including an estimate of potential savings that might result from interventions that slow or prevent kidney disease.

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