Full parity: steps toward treatment equity for mental and addictive disorders

Federal Parity and Access to Behavioral Health Care in Private Health Plans

OBJECTIVE

The 2008 Mental Health Parity and Addiction Equity Act (MHPAEA) sought to improve access to behavioral health care by regulating health plans' coverage and management of services. Health plans have some discretion in how to achieve compliance with MHPAEA, leaving questions about its likely effects on health plan policies. In this study, the authors' objective was to determine how private health plans' coverage and management of behavioral health treatment changed after the federal parity law's full implementation.

METHODS

A nationally representative survey of commercial health plans was conducted in 60 market areas across the continental United States, achieving response rates of 89% in 2010 (weighted N=8,431) and 80% in 2014 (weighted N=6,974). Senior executives at responding plans were interviewed regarding behavioral health services in each year and (in 2014) regarding changes. Student's t tests were used to examine changes in services covered, cost-sharing, and prior authorization requirements for both behavioral health and general medical care.

RESULTS

In 2014, 68% of insurance products reported having expanded behavioral health coverage since 2010. Exclusion of eating disorder coverage was eliminated between 2010 (23%) and 2014 (0%). However, more products reported excluding autism treatment in 2014 (24%) than 2010 (8%). Most plans reported no change to prior-authorization requirements between 2010 and 2014.

CONCLUSIONS

Implementation of federal parity legislation appears to have been accompanied by continuing improvement in behavioral health coverage. The authors did not find evidence of widespread noncompliance or of unintended effects, such as dropping coverage of behavioral health care altogether.

Visualizing Anomalies in Electronic Health Record Data: The Variability Explorer Tool

As Electronic Health Record (EHR) systems are becoming more prevalent in the U.S. health care domain, the utility of EHR data in translational research and clinical decision-making gains prominence. Leveraging primay· care-based. multi-clinic EHR data, this paper introduces a web-based visualization tool, the Variability Explorer Tool (VET), to assist researchers with profiling variability among diagnosis codes. VET applies a simple statistical method to approximate probability distribution functions for the prevalence of any given diagnosis codes to visualize between-clinic and across-year variability. In a depression diagnoses use case, VET outputs demonstrated substantial variability in code use. Even though data quality research often characterizes variability as an indicator for data quality, variability can also reflect real characteristics of data, such as practice-level, and patient-level issues. Researchers benefit from recognizing variability in early stages of research to improve their research design and ensure validity and generalizability of research findings.

State parity laws and access to treatment for substance use disorder in the United States: implications for federal parity legislation

IMPORTANCE

The passage of the 2008 Mental Health Parity and Addiction Equity Act and the 2010 Affordable Care Act incorporated parity for substance use disorder (SUD) treatment into federal legislation. However, prior research provides us with scant evidence as to whether federal parity legislation will hold the potential for improving access to SUD treatment.

OBJECTIVE

To examine the effect of state-level SUD parity laws on state-aggregate SUD treatment rates and to shed light on the impact of the recent federal SUD parity legislation.

DESIGN, SETTING, AND PARTICIPANTS

We conducted a quasi-experimental study using a 2-way (state and year) fixed-effect method. We included all known specialty SUD treatment facilities in the United States and examined treatment rates from October 1, 2000, through March 31, 2008. Our main source of data was the National Survey of Substance Abuse Treatment Services, which provides facility-level information on specialty SUD treatment.

INTERVENTIONS

State-level SUD parity laws during the study period.

MAIN OUTCOMES AND MEASURES

State-aggregate SUD treatment rates in (1) all specialty SUD treatment facilities and (2) specialty SUD treatment facilities accepting private insurance.

RESULTS

The implementation of any SUD parity law increased the treatment rate by 9% (P < .001) in all specialty SUD treatment facilities and by 15% (P = .02) in facilities accepting private insurance. Full parity and parity only if SUD coverage is offered increased the SUD treatment rate by 13% (P = .02) and 8% (P = .04), respectively, in all facilities and by 21% (P = .03) and 10% (P = .04), respectively, in facilities accepting private insurance.

CONCLUSIONS AND RELEVANCE

We found a positive effect of the implementation of state SUD parity legislation on access to specialty SUD treatment. Furthermore, the positive association is more pronounced in states with more comprehensive parity laws. Our findings suggest that federal parity legislation holds the potential to improve access to SUD treatment.

Mental health and substance abuse insurance parity for federal employees: how did health plans respond?

A fundamental concern with competitive health insurance markets is that they will not supply efficient levels of coverage for treatment of costly, chronic, and predictable illnesses, such as mental illness. Since the inception of employer-based health insurance, coverage for mental health services has been offered on a more limited basis than coverage for general medical services. While mental health advocates view insurance limits as evidence of discrimination, adverse selection and moral hazard can also explain these differences in coverage. The intent of parity regulation is to equalize private insurance coverage for mental and physical illness (an equity concern) and to eliminate wasteful forms of competition due to adverse selection (an efficiency concern). In 2001, a presidential directive requiring comprehensive parity was implemented in the Federal Employees Health Benefits (FEHB) Program. In this study, we examine how health plans responded to the parity directive. Results show that in comparison with a set of unaffected health plans, federal employee plans were significantly more likely to augment managed care through contracts with managed behavioral health "carve-out" firms after parity. This finding helps to explain the absence of an effect of the FEHB Program directive on total spending, and is relevant to the policy debate in Congress over federal parity.

Defining 'mental illness' in mental health policy

Mental health policy is shaped fundamentally by the definition of mental illness associated with the policy. Changing policies reflect changing definitions. At various times, the definition may be narrow or broad with respect to the scope of conditions covered by a specific policy. The priority accorded to impairment severity is the most crucial and enduring policy issue related to the definition of mental illness and the scope of that definition. This paper explores the role of definitions in framing mental health policy, using examples from the history of policy making over the past half-century.

Making progress in mental health policy in conservative times: one step at a time

Progress in mental health services has been made incrementally in a sequence of policy steps. In recent years, in spite of political conservatism, progressive changes have advanced new principles of service delivery. Reports from the surgeon general and the President's New Freedom Commission on Mental Health advanced these principles, including recovery and evidence-based practices. Both of these high-level reports were influenced by the findings of the Schizophrenia Patient Outcomes Research Team (PORT). The Schizophrenia PORT established the effectiveness of mental health treatments and supports, which provided a scientific foundation for the optimistic focus on recovery and its expectation of improved outcomes for individuals with severe mental disorders. The PORT study also established the gap between treatment recommendations and actual services. Concern about this gap has motivated efforts to transform services by implementing evidence-based practices. Advances in broad mental health and social policy, coupled with continued advances in science, have the potential to improve the care of individuals who experience severe mental disorders, such as schizophrenia.

The effects of state mental health parity legislation on perceived quality of insurance coverage, perceived access to care, and use of mental health specialty care

OBJECTIVE

To assess the impacts of recent state mental health parity legislation on perceived quality of health insurance coverage, perceived access to needed health care, and use of mental health specialty services by individuals with likely need for mental health care.

DATA SOURCES

The study sample came from two waves of a national household survey first fielded in 1997-1998 and then in 2000-2001. The analysis used a subset of the sample.

STUDY DESIGN

The study took the Difference-in-Difference-in-Difference approach to investigate changes in self-perceived quality of health insurance coverage and access to needed health care, and use of mental health specialty care by the group with mental disorders (relative to those without) in states with parity legislation of different comprehensiveness (relative to the nonparity states) in the years after the law (relative to before the law).

PRINCIPAL FINDINGS

Overall, there were no significant or consistent effects of the parity legislation. Descriptive statistics showed significant changes in some (but not all) outcome variables, but these results disappeared in detailed statistical analyses by controlling for important covariates.

CONCLUSIONS

The null findings of the effects of state mental health parity mandates suggest that under ERISA (Employee Retirement Income Security Act), the scope of state parity legislation may have been restricted because of large proportion of self-insured employers. Furthermore, comprehensiveness of state legislation appears to be related to the traditional level of use of mental health specialty care, which becomes another confounder for the potential policy effects.

A test of mental health parity: comparisons of outcomes of hospital concurrent utilization review

The Mental Health Parity Act of 1996 had as its goal the equity of coverage of mental health care and physical health care. The purpose of this study was to examine the outcomes of hospital concurrent utilization review as a measure of the progress toward the equity goal. The study examined 4 years of denials of certification for reimbursement by payers of inpatient care (1998-2001). Psychiatry was first compared to clinical services with a like number of annual admissions and then compared to clinical services with a like number of concurrent reviews. For each year, psychiatry had the highest numbers of cases denied and patient days denied. The most frequent reason for a psychiatric denial was that the inpatient benefit level had been exceeded. There was only one instance, in 4 years, when this reason (benefit limit exceeded) was given for a patient with a physical illness. This study provides evidence of the current inequity of reimbursement for treatment of mental illness.

The current and future state of mental health insurance parity legislation

Health insurance plans typically provide less coverage for mental health and chemical dependency treatment than for general medical services. In 1996 the federal government responded to these inequities by passing the Mental Health Parity Act, requiring equal annual lifetime dollar limits for mental health benefits. However, provisions within the law are easily circumvented, rendering it relatively ineffective as implemented. The Senator Paul Wellstone Mental Health Equitable Treatment Act of 2003 measures (S. 486 & H.R. 953) currently in Congress would expand the language and effectiveness of the Mental Health Parity Act. This paper reviews the limitations of both the 1996 federal law and existing state laws, and explains why federal action to expand the Mental Health Parity Act is so critical to people with mental illnesses.

The impacts of mental health parity and managed care in one large employer group

We examine the impacts of a state mental health parity mandate on a large employer group, which simultaneously introduced a managed behavioral health care carve-out. Overall, we find that mental health/substance abuse (MH/SA) costs dropped 39 percent from the year prior to three years after parity, with managed care offsetting increases in demand induced by parity coverage. Managed care was most effective in reducing very high inpatient use among adolescents and children. The effect of the parity mandate on access was ambiguous: While treatment prevalence rose nearly 50 percent, similar increases were observed for groups not subject to the mandate.

Toward full mental health parity and beyond

The 1996 Mental Health Parity Act (MHPA), which became effective in January 1998, is scheduled to expire in September 2001. This paper examines what the MHPA accomplished and steps toward more comprehensive parity. We explain the strategic and self-reinforcing link of parity with managed behavioral health care and conclude that the current path will be difficult to reverse. The paper ends with a discussion of what might be behind the claims that full parity in mental health benefits is insufficient to achieve true equity and whether additional steps beyond full parity appear realistic or even desirable.