The Mental Health Parity and Addiction Equity Act Evaluation Study

Abstract

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. Method 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/month [p=0.03]). Conclusions MHPAEA was associated with modest increases in total and plan spending and outpatient utilization; e.g., 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 healthcare utilization and spending among enrollees with substance use disorders

“…An informative difference stands out from comparing the results of these complementary analyses: The level changes in total and plan expenditures are higher in this study (approximately $30 among adults with SUD in both carve-in and carve-out plans versus approximately $1 among all adults in carve-in plans and among all adults in carve-out plans). The expenditure changes observed among the SUD diagnosed sample are all the more notable given that among users of BH specialty services, the subset with SUD diagnoses has much higher pre-parity average per-member per-month total expenditures ($1035) compared to all carve-in users ($331) and all carve-out users ($302) (Ettner et al, 2016; Harwood et al, 2017). At first glance, the greater change in expenditures among the SUD population is not surprising, since 100% of the sample in this paper has a SUD diagnosis, and thus might be expected to increase utilization and expenditures to a greater degree than the other studies' samples which include those with and without SUD diagnoses.…”

“…Following MHPAEA's historically comprehensive reforms to BH benefits for commercially-sponsored insurance plans, earlier analyses have shown that the resulting increases in specialty BH utilization and expenditures among a population of adult enrollees were modest (Harwood et al, 2017). However, whether these reforms would be associated with utilization and expenditure increases among a population with SUD remained an open question.…”

“…the general population) (Harwood et al, 2017) and all adults in carve-out plans (Ettner et al, 2016). An informative difference stands out from comparing the results of these complementary analyses: The level changes in total and plan expenditures are higher in this study (approximately $30 among adults with SUD in both carve-in and carve-out plans versus approximately $1 among all adults in carve-in plans and among all adults in carve-out plans).…”

“…Examining the effects of MHPAEA among high-utilizers at one employer group, Grazier et al found an association between MHPAEA and increases in outpatient mental health service use (Grazier, Eisenberg, Jedele, & Smiley, 2015). Two additional studies documented modest increases in expenditures and utilization among all patients enrolled in carve-in plans, which administer both BH and medical benefits (Harwood et al, 2017) and carve-out plans, those that administer only BH benefits (Ettner et al, 2016). …”

The Mental Health Parity and Addiction Equity Act (MHPAEA) evaluation study: Did parity differentially affect substance use disorder and mental health benefits offered by behavioral healthcare carve-out and carve-in plans?

“…This can be costly for patients over time (French, Popovici, and Tapsell, 2008). Prior work documents that expenditures are substantially higher among privately-insured, non-elderly adults with SUD diagnoses compared to the same population as a whole (Harwood et al 2017; Friedman et al 2017). Since sufficiently generous financial requirements, commonly used insurance benefit design features, can reduce patients’ out-of-pocket expenditures for these services, they are a key determinant of access to SUD treatment.…”