Utilization and Spending on Mental Health Services Among Children and Youths With Commercial Insurance

This cross-sectional study examines telehealth, in-person, and overall pediatric mental health service utilization and spending rates from January 2019 through August 2022 among a US pediatric population with commercial insurance.


Introduction
The COVID-19 pandemic severely tested the mental health of children and youths due to unprecedented school closures, social isolation and distancing, and COVID-19-related mortality among family. 1,2In response, health systems offered telehealth to increase access to pediatric mental health care. 3However, the extent to which telehealth availability led to greater pediatric mental health service utilization and spending is largely unknown.In this study, we examined telehealth, in-person, and overall pediatric mental health service utilization and spending rates from January 2019 through August 2022.

Methods
In this cross-sectional study among children and youths (aged <19 years) receiving services for the most common pediatric mental health diagnoses (anxiety disorders, adjustment disorder, attentiondeficit/hyperactivity disorder [ADHD], major depressive disorder, and conduct disorder), we quantified diagnosis-specific and overall trends and changes in monthly utilization (mental health diagnosis codes used as proxy) and spending rates between 3 phases related to SARS-CoV-2:

Results
Among approximately 1.9 million claims for children and youths with commercial insurance, utilization and spending trends were generally consistent across pediatric mental health diagnoses (Figure ), allowing for collapsing of estimates.Compared with prepandemic, in-person pediatric mental health services declined by 42% during the pandemic's acute phase, while pediatric telehealth services increased 30-fold (3027%), representing a 13% relative increase in overall utilization.By August 2022, in-person services returned to 75% of prepandemic levels and tele-

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Discussion
After comparing mental health care service utilization and spending rates for children and youths with commercial insurance across 3 periods, we found differences between periods as well as different rates of change within each period for both visit types, even after accounting for state and patient sex.Utilization and spending increased over the entire timeframe.ADHD, anxiety disorders, and adjustment disorder accounted for most visits and spending in all phases.
The study has limitations.The figure is a stacked line graph, conveying cumulative visit rates and spend rates across mental health diagnoses.

( 1 )
prepandemic, before the national public health emergency declaration (January 1, 2019, to March 12, 2020); (2) acute, before vaccine availability (March 13 to December 17, 2020); and (3) postacute (December 18, 2020, to August 31, 2022).Monthly medical claims data (categorized by International Statistical Classification of Diseases and Related Health Problems, Tenth Revision [ICD-10] diagnostic codes 4 ) provided by Castlight Health were used to measure trends in utilization per 1000 beneficiaries and spending (accounting for inflation by indexing 2020 to 2022 rates to 2019) per 10 000 beneficiaries among approximately 1.9 million children and youths with commercial insurance throughout the US (eAppendix in Supplement 1).The RAND institutional review board deemed this study exempt and waived informed consent because deidentified claims data were used.We followed the STROBE reporting guideline.We estimated longitudinal, fixed-effects regressions segmented by each period for each diagnosis and overall.Fixed effects were included for US state and patient biological sex to account for associated variability.Standard errors were clustered at the state level to account for multiple facilities within each state.Precision estimates were reported using 2-sided 95% CIs.Analyses were conducted with Stata version 16.0 (StataCorp) from April to May 2023.

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Utilization and Spending on Mental Health Services Among Children and Youths With Commercial Insurance Table.Changes in Pediatric In-Person and Telehealth Utilization and Spending Between January 2019 and August 2022 aUtilization and Spending on Mental Health Services Among Children and Youths With Commercial Insurance This is an open access article distributed under the terms of the CC-BY License.© 2023 Kalmin MM et al.JAMA Network Open.Table.Changes in Pediatric In-Person and Telehealth Utilization and Spending Between January 2019 and August 2022 a (continued) Each column and row combination is a separate longitudinal fixed-effects regression model controlling for US state and sex of the patient.Standard errors were clustered at the state level.Intercept terms indicate change in utilization and/or spending from the previous period, whereas slopes indicate rate of change within each period.Spending rates in 2020 to 2022 were indexed to 2019 to account for inflation.Segment points coincided with the date cutoffs for the 3 periods: prepandemic phase (January 1, 2019, to March 12, 2020), acute phase (March 13 to December 17, 2020), and postacute phase (December 18, 2020, to August 31, 2022).