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

Policy Levers to Promote Access to and Utilization of Children's Mental Health Services: A Systematic Review

Policies have potential to help families obtain behavioral healthcare for their children, but little is known about evidence for specific policy approaches. We reviewed evaluations of select policy levers to promote accessibility, affordability, acceptability, availability, or utilization of children's mental and behavioral health services. Twenty articles met inclusion criteria. Location-based policy levers (school-based services and integrated care models) were associated with higher utilization and acceptability, with mixed evidence on accessibility. Studies of insurance-based levers (mental health parity and public insurance) provided some evidence for affordability outcomes. We found no eligible studies of workforce development or telehealth policy levers, or of availability outcomes.

Impact of Mental Health Parity and Addiction Equity Act on Costs and Utilization in Alabama's Children's Health Insurance Program

OBJECTIVE

The Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008 mandates equivalent insurance coverage for mental health (MH) and substance use disorders (SUD) to other medical and surgical services covered by group insurance plans, Medicaid, and Children's Health Insurance Programs (CHIP). We explored the impact of MHPAEA on enrollees in ALL Kids, the Alabama CHIP.

METHODS

We use ALL Kids claims data for October 2008 to December 2014. October 2008 through September 2009 marks the period before MHPAEA implementation. We evaluated changes in MH/SUD-related utilization and program costs and changes in racial/ethnic disparities in the use of MH/SUD services for ALL Kids enrollees using 2-part models. This allowed analyses of changes from no use to any use, as well as in intensity of use.

RESULTS

No significant effect was found on overall MH service-use. There were statistically significant increases in inpatient visits and length of stay and some increase in overall MH costs. These increases may not be clinically important and were concentrated in 2009 to 2011. Disparities in utilization between African-American and non-Hispanic white enrollees were somewhat exacerbated, whereas disparities between other minorities and non-Hispanic whites were reduced.

CONCLUSIONS

Findings indicate that MHPAEA led to a 14.3% increase in inpatient visits, a 12.5% increase in length of inpatient stay, and a 7.8% increase in MH costs. The increases appear limited to 2009 to 2011, suggesting existing pent-up "needs" among enrollees for added MH/SUD services that resulted in a temporary spike in service use and cost immediately after MHPAEA, which subsequently subsided.

Heterogeneity and the effect of mental health parity mandates on the labor market

Health insurance benefit mandates are believed to have adverse effects on the labor market, but efforts to document such effects for mental health parity mandates have had limited success. I show that one reason for this failure is that the association between parity mandates and labor market outcomes vary with mental distress. Accounting for this heterogeneity, I find adverse labor market effects for non-distressed individuals, but favorable effects for moderately distressed individuals and individuals with a moderately distressed family member. On net, I conclude that the mandates are welfare increasing for moderately distressed workers and their families, but may be welfare decreasing for non-distressed individuals.

Effects of mental health benefits legislation: a community guide systematic review

CONTEXT

Health insurance benefits for mental health services typically have paid less than benefits for physical health services, resulting in potential underutilization or financial burden for people with mental health conditions. Mental health benefits legislation was introduced to improve financial protection (i.e., decrease financial burden) and to increase access to, and use of, mental health services. This systematic review was conducted to determine the effectiveness of mental health benefits legislation, including executive orders, in improving mental health.

EVIDENCE ACQUISITION

Methods developed for the Guide to Community Preventive Services were used to identify, evaluate, and analyze available evidence. The evidence included studies published or reported from 1965 to March 2011 with at least one of the following outcomes: access to care, financial protection, appropriate utilization, quality of care, diagnosis of mental illness, morbidity and mortality, and quality of life. Analyses were conducted in 2012.

EVIDENCE SYNTHESIS

Thirty eligible studies were identified in 37 papers. Implementation of mental health benefits legislation was associated with financial protection (decreased out-of-pocket costs) and appropriate utilization of services. Among studies examining the impact of legislation strength, most found larger positive effects for comprehensive parity legislation or policies than for less-comprehensive ones. Few studies assessed other mental health outcomes.

CONCLUSIONS

Evidence indicates that mental health benefits legislation, particularly comprehensive parity legislation, is effective in improving financial protection and increasing appropriate utilization of mental health services for people with mental health conditions. Evidence was limited for other mental health outcomes.

New estimates of the demand for physical and mental health treatment

Consumers' price responsiveness is central to US health-care reform proposals, but the best available estimates are now more than 25 years old. We estimate health-care demands by calculating expected end-of-year prices and incorporating them into a zero-inflated ordered probit model applied to several overlapping panels of data from 1996 to 2003. Results from our correlated random effects specification indicate that the price responsiveness of ambulatory mental health treatment has decreased substantially and is now slightly lower than physical health treatment. This suggests that concerns over moral hazard alone do not warrant less generous coverage for mental health. However, prescription drug demand is more price elastic.

Impact of full mental health and substance abuse parity for children in the Federal Employees Health Benefits Program

OBJECTIVE

The Federal Employees Health Benefits Program implemented full mental health and substance abuse parity in January 2001. Evaluation of this policy revealed that parity increased adult beneficiaries' financial protection by lowering mental health and substance abuse out-of-pocket costs for service users in most plans studied but did not increase rates of service use or spending among adult service users. This study examined the effects of full mental health and substance abuse parity for children.

METHODS

Employing a quasiexperimental design, we compared children in 7 Federal Employees Health Benefits plans from 1999 to 2002 with children in a matched set of plans that did not have a comparable change in mental health and substance abuse coverage. Using a difference-in-differences analysis, we examined the likelihood of child mental health and substance abuse service use, total spending among child service users, and out-of-pocket spending.

RESULTS

The apparent increase in the rate of children's mental health and substance abuse service use after implementation of parity was almost entirely due to secular trends of increased service utilization. Estimates for children's mental health and substance abuse spending conditional on this service use showed significant decreases in spending per user attributable to parity for 2 plans; spending estimates for the other plans were not statistically significant. Children using these services in 3 of 7 plans experienced statistically significant reductions in out-of-pocket spending attributable to the parity policy, and the average dollar savings was sizeable for users in those 3 plans. In the remaining 4 plans, out-of-pocket spending also decreased, but these decreases were not statistically significant.

CONCLUSIONS

Full mental health and substance abuse parity for children, within the context of managed care, can achieve equivalence of benefits in health insurance coverage and improve financial protection without adversely affecting health care costs but may not expand access for children who need these services.

Financing mental health services for adolescents: a background paper

Good mental health provides an essential foundation for normal growth and development through adolescence and into adulthood. Many adolescents, however, experience mental health problems that significantly impede the attainment of their full potential. The majority of these adolescents do not receive needed mental health services, in part because of financial obstacles to care. This article reviews the magnitude and impact of mental health problems during adolescence and highlights the importance of insurance coverage in assuring access to mental health services for adolescents. Significant limitations in private health insurance coverage of mental health services are outlined. Recent federal and state efforts to move toward parity in private insurance coverage between mental and physical health services are discussed, including an explanation of the role of Medicaid and the State Children's Health Insurance Program (SCHIP) in providing access to mental health services for adolescents. Finally, other elements that would facilitate financial access to essential mental health services for adolescents are presented.

The Effects of State Parity Laws on the Use of Mental Health Care

OBJECTIVE

We used a quasiexperimental research design to measure the effect of state parity laws on the use of mental health care in the past year.

METHODS

We pooled cross-sectional data from the 2001, 2002, and 2003 National Surveys on Drug Use and Health. Our sample included 83,531 adults 18 years of age or over with private health insurance stratified by the level of mental and emotional distress experienced in the worst month of the past year. We used a state and year-fixed effects approach to measure the effect of parity. Similar to a difference-in-difference analysis, the effect of parity was measured by comparing pre-/postchanges in mental health service use within states that switched active parity status to changes in service use within states that did not change parity status in the same calendar year. For each subgroup, we report predictions of the percentage point change in any mental health care use, prescription drug use, and outpatient care use resulting from parity laws.

RESULTS

Depending on the time window used to define active parity status, we found that parity increased the probability of using any mental health care in the past year by as much as 1.2 percentage points (P<0.01) for the lower distress group and by as much as 1.8 percentage points (P<0.05) in the middle distress group. We found no statistically significant changes in service use for the upper distress group. Whether measured differences were attributable to changes in the use of prescription drug or outpatient care also depended on the definition of active parity status.

CONCLUSIONS

Overall, the results of this study suggest that state parity laws succeeded in expanding access to mental health care for those with relatively mild mental health problems.

Health plans respond to parity: managing behavioral health care in the Federal Employees Health Benefits Program

The government often uses the Federal Employees Health Benefits (FEHB) Program as a model for both public and private health policy choices. In 2001, the U.S. Office of Personnel Management (OPM) implemented full parity, requiring that FEHB carriers offer mental health and substance abuse benefits equal to general medical benefits. OPM instructed carriers to alter their benefit design but permitted them to determine whether they would manage care and what structures or processes they would use. This article reports on the experience of 156 carriers and the government-wide BlueCross and BlueShield Service Benefit Plan. Carriers dropped cost-restraining benefit limits. A smaller percentage also changed the management of the benefit, but these changes affected the care of many enrollees, making the overall parity effect noteworthy.

Are mental health insurance mandates effective? Evidence from suicides

Many states in the US have passed laws mandating insurance companies to provide or offer some form of mental health benefits. These laws presumably lower the price of obtaining mental health services for many adults, and as a result, might improve health outcomes. This paper analyzes the effectiveness of mental health insurance mandates by examining the influence of mandates on adult suicides, which are strongly correlated with mental illness. Data on completed suicides in each state for the period 1981-2000 are analyzed. Ordinary least squares and two-stage least squares results show that mental health mandates are not effective in reducing suicide rates.

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

Although the impacts of carve-outs to managed behavioral health care organizations (MBHOs) and parity mandates on costs are largely settled in the literature, their impacts on access are less clear. Here we reexamine a study published by Samuel Zuvekas and colleagues in this journal, which found that the number of people receiving mental health/substance abuse treatment increased by almost 50 percent after the introduction of mental health parity and an MBHO. Using multivariate panel data methods, we now suggest that secular trends were largely responsible for this increase.

Spillover effects of benefit expansions and carve-outs on psychotropic medication use and costs

This paper extends the previous literature examining the impacts of managed behavioral health care carve-outs and mental health parity mandates on mental health and substance abuse (MH/SA) specialty treatment use and costs by considering the effects on psychotropic prescription medication costs. We use multivariate panel data methods to remove underlying secular growth trends, driven by increased demand for improved MH/SA treatment related to pharmaceutical innovations. We find that psychotropic medication costs continued to increase after the introduction of a substantial benefit expansion and carve-out to a managed behavioral health organization (MBHO), offsetting large declines in inpatient specialty MH/SA costs. However, we find evidence that the MBHO may have restrained growth in prescription medication spending.

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.