The impact of enhanced behavioral health services on total healthcare costs amongst employers in the USA: A meta-analysis of 19 cohort studies

Importance: The return on investment (ROI) of mental healthcare is a critical metric in an era of cost-conscious healthcare decision making. However, selective reporting of positive study results may inflate ROI estimates. Objective: To quantify the mean and variation in employer-level ROI outcomes for a comprehensive behavioral health benefit program. Data Sources: Data were obtained from 19 employer-specific studies conducted between May 2023 and December 2024. Sources included medical claims data spanning 12 months pre- and post-program launch, and program billing records of clinical and non-clinical costs. Study Selection: Studies were included because they were conducted by a single behavioral health benefit where the full sample of studies was known. The population included 19 US employers where employees and dependents received up to 12 free psychotherapy or medication management sessions. All studies used the same inclusion and exclusion criteria, retrospective matched cohort design, and difference-in-differences analysis. Data Extraction and Synthesis: Data were abstracted following PRISMA guidelines. ROI was estimated using a difference-in-differences model to control for baseline medical spending, and pooled using inverse variance weighting with a random effects structure. Main Outcome and Measure: The primary outcome was the ROI multiple, defined as the ratio of gross per-member-per-month savings to total program spending. Results: The meta-analysis included 42,148 participants (14,645 program users and 27,503 matched controls) across a range of employer sizes and industries. The pooled ROI multiple was 2.3 (95% CI, 1.9 to 2.8), corresponding to net savings of $159 PMPM (95% CI, $111 to $207). Significant heterogeneity was observed (I² = 67.8%; t² = 0.646; p < .001). A sensitivity analysis including non-clinical costs yielded a pooled ROI of 1.8. Conclusions and Relevance: This meta-analysis, the largest of its kind, demonstrates that a centralized behavioral health benefit can consistently generate net savings across varied employer settings. These findings provide robust evidence to support the adoption of comprehensive mental health programs as an effective strategy for reducing overall medical spending.