Federal parity law associated with increased probability of using out-of-network substance use disorder treatment services

Incident mental health episodes after initiation of gabapentinoids vs. dopamine agonists for early-onset idiopathic restless legs syndrome

Limited long-term safety information exists for gabapentinoid treatment of idiopathic restless legs syndrome (RLS). We estimated incident mental health-related emergency department visits and hospitalizations with a primary mental health diagnosis (primary outcome) among early-onset idiopathic RLS patients following first-line treatment initiation and examined outcome risk with gabapentinoids compared with dopamine agonists (DAs). A retrospective cohort study was conducted using administrative claims data from 2012 to 2019. Adults with early-onset (18-44 years) idiopathic RLS initiating either gabapentinoids or DAs within 60 days of new diagnosis were followed up to two years. Incidence rates were calculated and a log-binomial regression model with propensity score weighting estimated relative risk of the outcome and of substance use disorders (SUDs) as a secondary analysis with gabapentinoids. Among a cohort of 6,672 patients, 4,986 (74.7%) initiated DAs and 1,686 (25.3%) gabapentinoids. Incidence of the primary outcome (49.8 [95% CI 40.8-69.3] per 1,000 person-years) and SUDs (49.5 [95% CI 40.6-59.9] per 1,000 person-years) were higher in the gabapentinoid group compared with the DA group. A statistically significant risk of mental health diagnoses with gabapentinoids was not detected, but SUD risk was significant after covariate adjustment. High-risk mental health comorbidities (i.e., SUDs) should be considered when initiating RLS treatments.

Phantom Networks: Discrepancies Between Reported And Realized Mental Health Care Access In Oregon Medicaid

Understanding the extent to which beneficiaries can "realize" access to reported provider networks is imperative in mental health care, where there are significant unmet needs. We compared listings of providers in network directories against provider networks empirically constructed from administrative claims among members who were ages sixty-four and younger and enrolled in Oregon's Medicaid managed care organizations between January 1 and December 31, 2018. "In-network" providers were those with any medical claims filed for at least five unique Medicaid beneficiaries enrolled in a given health plan. They included primary care providers, specialty mental health prescribers, and nonprescribing mental health clinicians. Overall, 58.2 percent of network directory listings were "phantom" providers who did not see Medicaid patients, including 67.4 percent of mental health prescribers, 59.0 percent of mental health nonprescribers, and 54.0 percent of primary care providers. Significant discrepancies between the providers listed in directories and those whom enrollees can access suggest that provider network monitoring and enforcement may fall short if based on directory information.

Out-of-Network Care in Commercially Insured Pediatric Patients According to Medical Complexity

BACKGROUND

Commercial health plans establish networks and require much higher cost sharing for out-of-network (OON) care. Yet, the adequacy of health plan networks for access to pediatric specialists, especially for children with medical complexity, is largely unknown.

OBJECTIVE

To examine differences in OON care and associated cost-sharing payments for commercially insured children with different levels of medical complexity.

DESIGN

Cross-sectional study using a nationwide commercial claims database.

SUBJECTS

Enrollees 0-18 years old in employer-sponsored insurance plans. The Pediatric Medical Complexity Algorithm was used to classify individuals into 3 levels of medical complexity: children with no chronic disease, children with non-complex chronic diseases, and children with complex chronic diseases.

MAIN OUTCOMES

OON care rates, cost-sharing payments for OON care and in-network care, OON cost sharing as a proportion of total health care spending, and OON cost sharing as a proportion of total cost sharing.

RESULTS

The study sample included 6,399,006 individuals with no chronic disease, 1,674,450 with noncomplex chronic diseases, and 603,237 with complex chronic diseases. Children with noncomplex chronic diseases were more likely to encounter OON care by 6.77 percentage points with higher cost-sharing by $288 for OON care, relative to those with no chronic disease. For those with complex chronic diseases, these differences rose to 16.08 percentage points and $599, respectively. Among children who saw behavioral health providers, rates of OON care were especially high.

CONCLUSIONS

Commercially insured children with medical complexity experience higher rates of OON care with higher OON cost-sharing payments compared with those with no chronic disease.

Impact of Mental Health Insurance Legislation on Mental Health Treatment in a Longitudinal Sample of Adolescents

BACKGROUND

Mental health insurance laws are intended to improve access to needed treatments and prevent discrimination in coverage for mental health conditions and other medical conditions.

OBJECTIVES

The aim was to estimate the impact of these policies on mental health treatment utilization in a nationally representative longitudinal sample of youth followed through adulthood.

METHODS

We used data from the 1997 National Longitudinal Survey of Youth and the Mental Health Insurance Laws data set. We specified a zero-inflated negative binomial regression model to estimate the relationship between mental health treatment utilization and law exposure while controlling for other explanatory variables.

RESULTS

We found that the number of mental health treatment visits declined as cumulative exposure to mental health insurance legislation increased; a 10 unit (or 10.3%) increase in the law exposure strength resulted in a 4% decline in the number of mental health visits. We also found that state mental health insurance laws are associated with reducing mental health treatments and disparities within at-risk subgroups.

CONCLUSIONS

Prolonged exposure to comprehensive mental health laws across a person's childhood and adolescence may reduce the demand for mental health visitations in adulthood, hence, reducing the burden on the payors and consumers. Further, as the exposure to the mental health law strengthened, the gap between at-risk subgroups was narrowed or eliminated at the highest policy exposure levels.

Insurance expansions and adolescent use of substance use disorder treatment

OBJECTIVE

To provide evidence on the effects of expansions to private and public insurance programs on adolescent specialty substance use disorder (SUD) treatment use.

DATA SOURCE/STUDY SETTING

The Treatment Episodes Data Set (TEDS), 1996 to 2017.

STUDY DESIGN

A quasi-experimental difference-in-differences design using observational data.

DATA COLLECTION

The TEDS provides administrative data on admissions to specialty SUD treatment.

PRINCIPAL FINDINGS

Expansions of laws that compel private insurers to cover SUD treatment services at parity with general health care increase adolescent admissions by 26% (P < .05). These increases are driven by nonintensive outpatient admissions, the most common treatment episodes, which rise by 30% (P < .05) postparity law. In contrast, increases in income eligibility for public insurance targeting those 6-18 years old are not statistically associated with SUD treatment.

CONCLUSIONS

Private insurance expansions allow more adolescents to receive SUD treatment, while public insurance income eligibility expansions do not appear to influence adolescent SUD treatment.

Do expansions in adolescent access to public insurance affect the decisions of substance use disorder treatment providers?

We apply a mixed-payer economy model to study the effects of changes in the generosity of children's public health insurance programs - measured by Medicaid and Children's Health Insurance Program income thresholds - on substance use disorder (SUD) treatment provider behavior. Using government data on specialty SUD treatment providers over the period 1997-2011 combined with a two-way fixed-effects model and local event study, we show that increases in the generosity of children's public health insurance induce providers to participate in some, but not all, public markets. Our effects appear to be driven by non-profit and government providers. Non-profit providers also appear to increase treatment quantity slightly in response to coverage expansions.

Psychiatrist Participation in Private Health Insurance Markets: Paucity in the Land of Plenty

OBJECTIVE

Access to specialty mental health care may be poor because many psychiatrists do not accept health insurance reimbursement, whereas many patients rely on insurance to help pay for care. The objective of this study was to examine the extent of participation in private insurance by licensed psychiatrists.

METHODS

Using 2013 Massachusetts licensing data and the All-Payer Claims Database (APCD), the authors performed a cross-sectional analysis of licensed psychiatrists in Massachusetts. The fraction of psychiatrists who filed insurance claims, number of unique patients with insurance claims per psychiatrist, and physician characteristics associated with insurance participation were evaluated.

RESULTS

In 2013, Massachusetts had 2,348 licensed psychiatrists. Overall, 79% (N=1,843) had at least one paid claim for an outpatient visit in the APCD, but only 6% (N=151) had claims for at least 300 patients per year (a full caseload). Psychiatrists had a median of 18 patients with claims (mean=73). Compared with psychiatrists 30-39 years since medical school graduation, those within 19 years since graduation were less likely to bill for an outpatient (7-19 years, odds ratio [OR]=0.67, 95% confidence interval [CI]=0.47-0.94) and less likely to have claims for ≥300 patients per year (7-19 years, OR=0.49, 95% CI=0.29-0.83). Participation varied across insurance types (93% for group commercial plans versus 33% for Medicaid managed care plans).

CONCLUSIONS

Among Massachusetts psychiatrists, participation in the private insurance market appears to be limited. Older psychiatrists are more likely to participate, and patients' access to psychiatrists who accept insurance could worsen as these psychiatrists retire.

Prices And Cost Sharing For Psychotherapy In Network Versus Out Of Network In The United States

Patients in the US are more likely to receive out-of-network behavioral health care, including treatment for mental health or substance use disorders, than they are to receive other medical and surgical services out of network. To date, out-of-network and in-network trends in the prices and use of ambulatory behavioral health care have been seldom described. Here we compare levels and growth of insurer-negotiated prices (allowed amounts), patient cost sharing, and use of psychotherapy services in network and out of network in a large, commercially insured US population during 2007-17. For both adult and child psychotherapy, prices and cost sharing were substantially higher out of network than they were in network. These gaps widened during the eleven-year period. Prices and cost sharing for in-network psychotherapy decreased during this period, whereas prices and cost sharing for out-of-network psychotherapy increased. Use of adult and child psychotherapy increased during this period, driven by growth of in-network rather than out-of-network use. The increasing gap in prices and cost sharing between out-of-network and in-network psychotherapy, viewed in the context of a shortage of behavioral health providers who accept insurance, may limit access to ambulatory behavioral health care.

Changes in Medicaid Acceptance by Substance Abuse Treatment Facilities After Implementation of Federal Parity

BACKGROUND

Adequate access for mental illness and substance use disorder (SUD) treatment, particularly for Medicaid enrollees, is challenging. Policy efforts, including the Mental Health Parity and Addiction Equity Act (MHPAEA), have targeted expanded access to care. With MHPAEA, more Medicaid plans were required to increase their coverage of SUD treatment, which may impact provider acceptance of Medicaid.

OBJECTIVES

To identify changes in Medicaid acceptance by SUD treatment facilities after the implementation of MHPAEA (parity).

RESEARCH DESIGN

Observational study using an interrupted time series design.

SUBJECTS

2002-2013 data from the National Survey of Substance Abuse Treatment Services (N-SSATS) for all SUD treatment facilities was combined with state-level characteristics.

MEASURES

Primary outcome is whether a SUD treatment facility reported accepting Medicaid insurance.

RESULTS

Implementation of MHPAEA was associated with a 4.6 percentage point increase in the probability of an SUD treatment facility accepting Medicaid (P<0.001), independent of facility and state characteristics, time trends, and key characteristics of state Medicaid programs.

CONCLUSIONS

After parity, more SUD treatment facilities accepted Medicaid payments, which may ultimately increase access to care for individuals with SUD. The findings underscore how parity laws are critical policy tools for creating contexts that enable historically vulnerable and underserved populations with SUD to access needed health care.

Cost-Sharing Disparities for Out-of-Network Care for Adults With Behavioral Health Conditions

IMPORTANCE

Individuals in the United States with mental illnesses and substance use disorders can face major access barriers from limited provider (eg, clinicians and facilities) networks in health insurance plans.

OBJECTIVE

To evaluate the cost-sharing payments for out-of-network (OON) care for private insurance plan enrollees with mental health conditions, alcohol use disorders, or drug use disorders compared with those with congestive heart failure (CHF) or diabetes.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study used data from a large commercial claims database from 2012 to 2017. The study included adults with mental health conditions, with alcohol use disorders, with drug use disorders, with CHF, and with diabetes who were aged 18 to 64 years and enrolled in employer-sponsored insurance plans.

MAIN OUTCOMES AND MEASURES

Main outcomes included OON care during hospitalization, OON care during outpatient care, cost-sharing payments with OON care, OON cost sharing as a proportion of total health care spending, and OON cost sharing as a proportion of total cost sharing.

RESULTS

The study sample included 3 209 929 enrollees with mental health conditions (mean [SD] age, 45.9 [12.6] years; 64.8% women), 294 550 with alcohol use disorders (mean [SD] age, 42.8 [13.4] years; 60.9% men), 321 535 with drug use disorders (mean [SD] age, 41.1 [13.9] years; 59.1% men), 178 701 with CHF (mean [SD] age, 53.8 [8.9] years; 62.6% men), and 1 383 398 with diabetes (mean [SD] age, 52.5 [9.0] years; 58.9% men). Enrollees with behavioral conditions were more likely to encounter OON clinicians in inpatient and outpatient settings. For instance, those with drug use disorders were 12.9 percentage points (95% CI, 12.5-13.2 percentage points; P < .001) more likely to have inpatient OON care than those with CHF and 15.3 percentage points (95% CI, 15.1-15.6 percentage points; P < .001) more likely to receive outpatient OON care. Behavioral conditions also had higher cost sharing for OON care. For example, individuals with mental health conditions had cost-sharing payments for OON care $341 (95% CI, $331-$351) higher than those with diabetes (P < .001), individuals with drug use disorders had cost-sharing payments for OON care $1242 (95% CI, $1209-$1276) higher than those with diabetes (P < .001), and individuals with alcohol use disorders had cost-sharing payments for OON care $1138 (95% CI, $1101-$1174) higher than those with diabetes (P < .001). The OON care rates and cost-sharing payments were much higher when enrollees sought care from behavioral clinicians and facilities.

CONCLUSIONS AND RELEVANCE

In this cross-sectional study of enrollees in commercial insurance plans, cost sharing for OON care among those with behavioral health conditions was significantly higher than those with chronic physical conditions. These disparities may be indicative of limited in-network availability for behavioral health care.

U.S. alcohol treatment admissions after the Mental Health Parity and Addiction Equity Act: Do state parity laws and race/ethnicity make a difference?

BACKGROUND

The U.S. Mental Health Parity and Addiction Equity Act (MHPAEA) was a landmark federal policy aimed at increasing access to substance use treatment, yet studies have found relatively weak impacts on treatment utilization. The present study considers whether there may be moderating effects of pre-existing state parity laws and differential changes in treatment rates across racial/ethnic groups.

METHODS

We analyzed data from SAMHSA'S Treatment Episode Data Set (TEDS) from 1999 to 2013, assessing changes in alcohol treatment admission rates across states with heterogeneous, pre-existing parity laws. NIAAA's Alcohol Policy Information System data were used to code states into five groups based on the presence and strength of states' pre-MHPAEA mandates for insurance coverage of alcohol treatment and parity (weak; coverage no parity; partial parity if coverage offered; coverage and partial parity; strong). Regression models included state fixed effects and a cubic time trend adjusting for state- and year-level covariates, and assessed MHPAEA main effects and interactions with state parity laws in the overall sample and racial/ethnic subgroups.

RESULTS

While we found no significant main effects of federal parity on alcohol treatment rates, there was a significantly greater increase in treatment rates in states requiring health plans to cover alcohol treatment and having some pre-existing parity. This was seen overall and in all three racial/ethnic groups (increasing by 25% in whites, 26% in blacks, and 42% in Hispanics above the expected treatment rate for these groups). Post-MHPAEA, the alcohol treatment admissions rate in these states rose to the level of states with the strongest pre-existing parity laws.

CONCLUSION

The MHPAEA was associated with increased alcohol treatment rates for diverse racial/ethnic groups in states with both alcohol treatment coverage mandates and some prior parity protections. This suggests the importance of the local policy context in understanding early effects of the MHPAEA.

Mental Health Parity and Addiction Equity Act and the Use of Outpatient Behavioral Health Services in the United States, 2005-2016

Objectives. To assess the impact of the 2008 Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act (MHPAEA) on mental and substance use disorder services in the private, large group employer-sponsored insurance market in the United States. Methods. We analyzed data from the IBM MarketScan Commercial Database from January 2005 through September 2015 by using population-level interrupted time series regressions to determine whether parity implementation was associated with utilization and spending outcomes. Results. MHPAEA had significant positive associations with utilization of mental and substance use disorder outpatient services. A spending decomposition analysis indicated that increases in utilization were the primary drivers of increases in spending associated with MHPAEA. Analyses of opioid use disorder and nonopioid substance use disorder services found that associations with utilization and spending were not attributable only to increases in treatment of opioid use disorder. Conclusions. MHPAEA is positively associated with utilization of outpatient mental and substance use disorder services for Americans covered by large group employer-sponsored insurance. Public Health Implications. These trends continued over the 5-year post-MHPAEA period, underscoring the long-term relationship between this policy change and utilization of behavioral health services.

Factors that Affect Choice of Mental Health Provider and Receipt of Outpatient Mental Health Treatment

According to the US Department of Health and Human Services, 91 million adults live in mental health professional shortage areas and 10 million individuals have serious mental illness (SMI). This study examines how the supply of psychiatrists, severity of mental illness, out-of-pocket costs, and health insurance type influence patients' decisions to receive treatment and the type of provider chosen. Analyses using 2012-2013 MarketScan Commercial Claims data showed that patients residing in an area with few psychiatrists per capita had a higher predicted probability of not receiving follow-up care (46.4%) compared with patients residing in an area with more psychiatrists per capita (42.5%), and those in low-psychiatrist-supply areas had a higher predicted probability of receiving prescription medication only (10.2 vs 7.6%). Patients with SMI were more likely than those without SMI to obtain treatment. A $25 increase in out-of-pocket costs had marginal impact on patients' treatment choices.

Association of Federal Mental Health Parity Legislation With Health Care Use and Spending Among High Utilizers of Services

BACKGROUND

Decades-long efforts to require parity between behavioral and physical health insurance coverage culminated in the comprehensive federal Mental Health Parity and Addiction Equity Act.

OBJECTIVES

To determine the association between federal parity and changes in mental health care utilization and spending, particularly among high utilizers.

RESEARCH DESIGN

Difference-in-differences analyses compared changes before and after exposure to federal parity versus a comparison group.

SUBJECTS

Commercially insured enrollees aged 18-64 with a mental health disorder drawn from 24 states where self-insured employers were newly subject to federal parity in 2010 (exposure group), but small employers were exempt before-and-after parity (comparison group). A total of 11,226 exposure group members were propensity score matched (1:1) to comparison group members, all of whom were continuously enrolled from 1 year prepolicy to 1-2 years postpolicy.

MEASURES

Mental health outpatient visits, out-of-pocket spending for these visits, emergency department visits, and hospitalizations.

RESULTS

Relative to comparison group members, mean out-of-pocket spending per outpatient mental health visit declined among exposure enrollees by $0.74 (1.40, 0.07) and $2.03 (3.17, 0.89) in years 1 and 2 after the policy, respectively. Corresponding annual mental health visits increased by 0.31 (0.12, 0.51) and 0.59 (0.37, 0.81) per enrollee. Difference-in-difference changes were larger for the highest baseline quartile mental health care utilizers [year 2: 0.76 visits per enrollee (0.14, 1.38); relative increase 10.07%] and spenders [year 2: $-2.28 (-3.76, -0.79); relative reduction 5.91%]. There were no significant difference-in-differences changes in emergency department visits or hospitalizations.

CONCLUSIONS

In 24 states, commercially insured high utilizers of mental health services experienced modest increases in outpatient mental health visits 2 years postparity.

Federal Parity and Spending for Mental Illness

BACKGROUND

Families of children with mental health conditions face heavy economic burdens. One of the objectives of the Mental Health Parity and Addiction Equity Act (MHPAEA) is to reduce the financial burden for those with intensive mental health service needs. Few researchers to date have examined MHPAEA's effects on children with mental health conditions and those with particularly high mental health expenditures.

METHODS

A difference-in-differences approach was used to compare commercially insured children ages 3 to 18 years (in 2008) who were continuously enrolled in plans newly subject to parity under MHPAEA to children continuously enrolled in plans never subject to parity. Data included inpatient, outpatient, and pharmaceutical claims for 2008-2012 from 3 national commercial insurers. We examined annual mental health service use and spending outcomes.

RESULTS

Among children with mental health conditions who were enrolled in plans subject to parity, parity was associated with $140 (95% confidence interval: -$196 to -$84) lower average annual out-of-pocket (OOP) mental health spending than expected given changes in the comparison group. Among children who were ≥85th percentile in total mental health spending, parity was associated with $234 (-$391 to -$76) lower average annual OOP mental health spending.

CONCLUSIONS

MHPAEA was associated with increased financial protection on average for children with mental health conditions and among those at the higher end of the spending distribution. However, estimated reductions in OOP spending were likely too modest to have substantially reduced financial burden on families of children with particularly high mental health expenditures.

The Role of HIPAA Omnibus Rules in Reducing the Frequency of Medical Data Breaches: Insights From an Empirical Study

Policy Points: Frequent data breaches in the US health care system undermine the privacy of millions of patients every year-a large number of which happen among business associates of the health care providers that continue to gain unprecedented access to patients' data as the US health care system becomes digitally integrated. Implementation of the HIPAA Omnibus Rules in 2013 has led to a significant decrease in the number of privacy breach incidents among business associates.

CONTEXT

Frequent data breaches in the US health care system undermine the privacy of millions of patients every year. A large number of such breaches happens among business associates of the health care providers that continue to gain unprecedented access to patients' data as the US health care system becomes digitally integrated. The Omnibus Rules of the Health Insurance Portability and Accountability Act (HIPAA), which were enacted in 2013, significantly increased the regulatory oversight and privacy protection requirements of business associates. The objective of this study is to empirically examine the effects of this shift in policy on the frequency of medical privacy breaches among business associates in the US health care system. The findings of this research shed light on how regulatory efforts can protect patients' privacy.

METHODS

Using publicly available data on breach incidents between October 2009 and August 2017 as reported by the Office for Civil Rights (OCR), we conducted an interrupted time-series analysis and a difference-in-differences analysis to examine the immediate and long-term effects of implementation of HIPAA omnibus rules on the frequency of medical privacy breaches.

FINDINGS

We show that implementation of the omnibus rules led to a significant reduction in the number of breaches among business associates and prevented 180 privacy breaches from happening, which could have affected nearly 18 million Americans.

CONCLUSIONS

Implementation of HIPAA omnibus rules may have been a successful federal policy in enhancing privacy protection efforts and reducing the number of breach incidents in the US health care system.

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.

Justice-Involved Adults With Substance Use Disorders: Coverage Increased But Rates Of Treatment Did Not In 2014

More than one-third of US adults in the criminal justice system have substance use disorders, which contribute to health problems and recidivism. Health insurance and criminal justice reforms initiated in the last decade offer opportunities for increasing treatment access among justice-involved individuals. Using national survey data, we examined trends in treatment of substance use disorders from 2004 to 2014 among adults who reported past-year criminal justice contact and met screening criteria for substance use disorders. We found that the uninsurance rate was relatively unchanged in that population from 2004 to 2013. In 2014, the first year of the Affordable Care Act Medicaid expansion, the uninsurance rate among justice-involved individuals with substance use disorders declined from 38 percent to 28 percent. Although overall treatment rates did not increase in 2014, individuals receiving treatment were more likely to have their care paid for by Medicaid than in the prior decade. Medicaid reimbursement can be a critical lever for improving the quality and continuity of substance use disorder treatment for justice-involved populations.

Federal Parity In The Evolving Mental Health And Addiction Care Landscape

The intent of the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 is to eliminate differences between health insurance coverage of mental health and substance use disorder benefits and coverage of medical or surgical benefits. The Affordable Care Act significantly extended the reach of the Wellstone-Domenici law by applying it to new insurance markets. We summarize the evolution of legislative and regulatory actions to bring about federal insurance parity. We also summarize available evidence on how the Wellstone-Domenici law has contributed to addressing insurance discrimination; rectifying market inefficiencies due to adverse selection; and altering utilization, spending, and health outcomes for people with mental health and substance use disorders. In addition, we highlight important gaps in knowledge about how parity has been implemented, describe the groups still lacking parity-level coverage, and make recommendations on steps to improve the likelihood that the Wellstone-Domenici law will fulfill the aims of its architects.

The Mental Health Parity and Addiction Equity Act Evaluation Study: Impact on Mental Health Financial Requirements among Commercial "Carve-In" Plans

OBJECTIVE

Did mental health cost-sharing decrease following implementation of the Mental Health Parity and Addiction Equity Act (MHPAEA)?

DATA SOURCE

Specialty mental health copayments, coinsurance, and deductibles, 2008-2013, were obtained from benefits databases for "carve-in" plans from a national commercial managed behavioral health organization.

STUDY DESIGN

Bivariate and regression-adjusted analyses compare the probability of use and (conditional) level of cost-sharing pre- and postparity. An interaction term is added to compare differential levels of pre- and postparity cost-sharing changes for plans that were and were not already at parity pre-MHPAEA.

FINDINGS

Controlling for employer/plan characteristics, MHPAEA is associated with higher intermediate care copayments ($15.9) but lower outpatient ($2.6) copayments among in-network-only plans. Among plans with in- and out-of-network benefits, MHPAEA is associated with lower inpatient ($23.2) and outpatient ($2.5) copayments, but increases in inpatient and intermediate in-network and out-of-network coinsurance (about 1 percentage point). Among the few plans not at parity pre-MHPAEA, changes in use and level of cost-sharing associated with MHPAEA were more dramatic.

CONCLUSION

Mixed evidence that MHPAEA led to more generous mental health benefits may stem from the finding that many plans were already at parity pre-MHPAEA. Future policy focus in mental health may shift to slowing growth in cost-sharing for all health services.

The economic burden of bipolar I disorder in the United States in 2015

BACKGROUND

The current societal costs of bipolar I disorder (BDI) have not been comprehensively characterized in the United States, as previous studies are based on data from two decades ago.

METHODS

The costs of BDI were estimated for 2015 and comprised direct healthcare costs, non-healthcare costs, and indirect costs, calculated based on a BDI prevalence of 1%. The excess costs of BDI were estimated as the difference between the costs incurred by individuals with BDI and those incurred by individuals without BD or individuals from the general population. Direct healthcare costs were assessed using three large US claims databases for insured individuals and the literature for uninsured individuals. Direct non-healthcare and indirect costs were based on the literature and governmental publications.

RESULTS

The total costs of BDI were estimated at $202.1 billion in 2015, corresponding to an average of $81,559 per individual, while the excess costs of BDI were estimated at $119.8 billion, corresponding to an average of $48,333 per individual. The largest contributors to excess costs were caregiving (36%), direct healthcare costs (21%), and unemployment (20%). In sensitivity analyses, excess costs ranged from $101.2 to $124.3 billion.

LIMITATIONS

Direct healthcare costs were calculated based on a BDI diagnosis, thus excluding undiagnosed patients. Direct non-healthcare and indirect costs were based on combined estimates from the literature.

CONCLUSIONS

Besides direct healthcare costs, BDI was associated with substantial direct non-healthcare and indirect costs. More effective treatments and practices are needed to optimize therapeutic strategies and contain direct and indirect costs.

Achieving Mental Health and Substance Use Disorder Treatment Parity: A Quarter Century of Policy Making and Research

The Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008 changed the landscape of mental health and substance use disorder coverage in the United States. The MHPAEA's comprehensiveness compared with past parity laws, including its extension of parity to plan management strategies, the so-called nonquantitative treatment limitations (NQTL), led to significant improvements in mental health care coverage. In this article, we review the history of this landmark legislation and its recent expansions to new populations, describe past research on the effects of this and other mental health/substance use disorder parity laws, and describe some directions for future research, including NQTL compliance issues, effects of parity on individuals with severe mental illness, and measurement of benefits other than mental health care use.

An audience research study to disseminate evidence about comprehensive state mental health parity legislation to US State policymakers: protocol

BACKGROUND

A large proportion of the US population has limited access to mental health treatments because insurance providers limit the utilization of mental health services in ways that are more restrictive than for physical health services. Comprehensive state mental health parity legislation (C-SMHPL) is an evidence-based policy intervention that enhances mental health insurance coverage and improves access to care. Implementation of C-SMHPL, however, is limited. State policymakers have the exclusive authority to implement C-SMHPL, but sparse guidance exists to inform the design of strategies to disseminate evidence about C-SMHPL, and more broadly, evidence-based treatments and mental illness, to this audience. The aims of this exploratory audience research study are to (1) characterize US State policymakers' knowledge and attitudes about C-SMHPL and identify individual- and state-level attributes associated with support for C-SMHPL; and (2) integrate quantitative and qualitative data to develop a conceptual framework to disseminate evidence about C-SMHPL, evidence-based treatments, and mental illness to US State policymakers.

METHODS

The study uses a multi-level (policymaker, state), mixed method (QUAN→qual) approach and is guided by Kingdon's Multiple Streams Framework, adapted to incorporate constructs from Aarons' Model of Evidence-Based Implementation in Public Sectors. A multi-modal survey (telephone, post-mail, e-mail) of 600 US State policymakers (500 legislative, 100 administrative) will be conducted and responses will be linked to state-level variables. The survey will span domains such as support for C-SMHPL, knowledge and attitudes about C-SMHPL and evidence-based treatments, mental illness stigma, and research dissemination preferences. State-level variables will measure factors associated with C-SMHPL implementation, such as economic climate and political environment. Multi-level regression will determine the relative strength of individual- and state-level variables on policymaker support for C-SMHPL. Informed by survey results, semi-structured interviews will be conducted with approximately 50 US State policymakers to elaborate upon quantitative findings. Then, using a systematic process, quantitative and qualitative data will be integrated and a US State policymaker-focused C-SMHPL dissemination framework will be developed.

DISCUSSION

Study results will provide the foundation for hypothesis-driven, experimental studies testing the effects of different dissemination strategies on state policymakers' support for, and implementation of, evidence-based mental health policy interventions.

The Mental Health Parity and Addiction Equity Act evaluation study: Impact on specialty behavioral healthcare utilization and spending among enrollees with substance use disorders

BACKGROUND

The federal Mental Health Parity and Addiction Equity Act (MHPAEA) sought to eliminate historical disparities between behavioral health and medical health insurance benefits among the commercially insured. This study determines whether MHPAEA was associated with increased BH expenditures and utilization among a population with substance use disorder (SUD) diagnoses.

METHODS

Claims and eligibility data from 5,987,776 enrollees, 2008-2013, were obtained from a national, commercial, managed behavioral health organization. An interrupted time series study design with segmented regression analysis estimated time trends of per-member-per-month (PMPM) spending and use before (2008-2009), during (2010), and after (2011-2013) MHPAEA compliance. The study sample contained individuals with drug or alcohol use disorder diagnosis during study period (N=2,716,473 member-month observations). Outcomes included: total, plan, patient out-of-pocket spending; outpatient utilization (assessment/diagnostic evaluation visits; medication management; individual, group and family psychotherapy, and structured outpatient care); intermediate care utilization (day treatment; recovery home and residential); and inpatient utilization.

RESULTS

Starting at the beginning of the post-parity period, MHPAEA was associated with increased levels of PMPM total and plan spending ($25.80 [p=0.01]; $28.33 [p=0.00], respectively), as well as the number of PMPM assessment/evaluation, individual psychotherapy, and group psychotherapy visits, and inpatient days (0.01 visits [p=0.01]; 0.02 visits [p=0.01]; 0.01 visits [p=0.03]; 0.01days [p=0.01], respectively). Following these initial level changes, MHPAEA was also associated with monthly increases in PMPM total, plan, and patent out-of-pocket spending ($2.56/month [p=0.00]; $2.25/month [p=0.00]; $0.27 [p=0.03], respectively), as well as structured outpatient visits and inpatient days (0.0012 visits/month [p=0.01]; 0.0012days/month [p=0.00]).

CONCLUSION

MHPAEA was associated with modest increases in total, plan, and patient out-of-pocket spending and outpatient and inpatient utilization. These increases, while modest in magnitude, are larger in magnitude than increases detected among a sample of all enrollees (i.e. not only those with SUD diagnoses).

Was federal parity associated with changes in Out-of-network mental health care use and spending?

Background

The goal of the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act is to eliminate differences in insurance coverage between behavioral health and general medical care. The law requires out-of-network mental health benefits be equivalent to out-of-network medical/surgical benefits. Insurers were concerned this provision would lead to unsustainable increases in out-of-network related expenditures. We examined whether federal parity implementation was associated with significant increases in out-of-network mental health care use and spending.

Methods

We conducted an interrupted time series analysis using health insurance claims from self-insured employers (2007–2012). We examined changes in the probability of using out-of-network mental health services and, conditional on out-of-network mental health service use, changes in the number of outpatient out-of-network mental health visits and total out-of-network mental health spending associated with the implementation of federal parity in 2010.

Results

From 2007 to 2012, the proportion of individuals receiving any out-of-network mental health services each month declined dramatically from 18 to 12%, with a one-time drop of 3 percentage points at parity implementation (p < .01). Among out-of-network mental health service users, there was an increase in the number of visits per month (.12 visits; p < .01) and total spending per month ($49; p < .01) at parity implementation. Although there was a one-time increase in spending at parity implementation, this increase was accompanied by an attenuation of a trend toward increased spending growth, such that spending was back to original predictions by the end of our study period.

Conclusions

Despite concerns expressed by the health insurance industry when federal parity was enacted, out-of-network mental health spending did not substantially increase after parity implementation. In addition, use of out-of-network mental health services appears to have contracted rather than expanded, suggesting insurers may have implemented other policies to curb out-of-network use, such as increasing access to in-network providers.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-017-2261-9) contains supplementary material, which is available to authorized users.

The Mental Health Parity and Addiction Equity Act Evaluation Study: Impact on Specialty Behavioral Health Care Utilization and Spending Among Carve-In Enrollees

OBJECTIVE

The federal Mental Health Parity and Addiction Equity Act (MHPAEA) sought to eliminate historical disparities between insurance coverage for behavioral health (BH) treatment and coverage for medical treatment. Our objective was to evaluate MHPAEA's impact on BH expenditures and utilization among "carve-in" enrollees.

METHODS

We received specialty BH insurance claims and eligibility data from Optum, sampling 5,987,776 adults enrolled in self-insured plans from large employers. An interrupted time series study design with segmented regression analysis estimated monthly time trends of per-member spending and use before (2008-2009), during (2010), and after (2011-2013) MHPAEA compliance (N=179,506,951 member-month observations). Outcomes included: total, plan, patient out-of-pocket spending; outpatient utilization (assessment/diagnostic evaluation visits, medication management, individual and family psychotherapy); intermediate care utilization (structured outpatient, day treatment, residential); and inpatient utilization.

RESULTS

MHPAEA was associated with increases in monthly per-member total spending, plan spending, assessment/diagnostic evaluation visits [respective immediate increases of: $1.05 (P=0.02); $0.88 (P=0.04); 0.00045 visits (P=0.00)], and individual psychotherapy visits [immediate increase of 0.00578 visits (P=0.00) and additional increases of 0.00017 visits/mo (P=0.03)].

CONCLUSIONS

MHPAEA was associated with modest increases in total and plan spending and outpatient utilization; for example, in July 2012 predicted per-enrollee plan spending was $4.92 without MHPAEA and $6.14 with MHPAEA. Efforts should focus on understanding how other barriers to BH care unaddressed by MHPAEA may affect access/utilization. Future research should evaluate effects produced by the Affordable Care Act's inclusion of BH care as an essential health benefit and expansion of MHPAEA protections to the individual and small group markets.

The Mental Health Parity and Addiction Equity Act evaluation study: Impact on specialty behavioral health utilization and expenditures among "carve-out" enrollees

Interrupted time series with and without controls was used to evaluate whether the federal Mental Health Parity and Addiction Equity Act (MHPAEA) and its Interim Final Rule increased the probability of specialty behavioral health treatment and levels of utilization and expenditures among patients receiving treatment. Linked insurance claims, eligibility, plan and employer data from 2008 to 2013 were used to estimate segmented regression analyses, allowing for level and slope changes during the transition (2010) and post-MHPAEA (2011-2013) periods. The sample included 1,812,541 individuals ages 27-64 (49,968,367 person-months) in 10,010 Optum "carve-out" plans. Two-part regression models with Generalized Estimating Equations were used to estimate expenditures by payer and outpatient, intermediate and inpatient service use. We found little evidence that MHPAEA increased utilization significantly, but somewhat more robust evidence that costs shifted from patients to plans. Thus the primary impact of MHPAEA among carve-out enrollees may have been a reduction in patient financial burden.