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The effects of federal parity on substance use disorder treatment
Susan H. Busch, PhD;1 Andrew J. Epstein, PhD;2,3 Michael O. Harhay, MPH;2 David A. Fiellin, MD;1
Hyong Un, MD;4 Deane Leader Jr;4 Colleen L. Barry, PhD MPP5
1 Yale University; 2 University of Pennsylvania; 3 Veterans Affairs; 4 Aetna Inc; 5 Johns Hopkins University
 Analyses focused on enrollees in 10 states with
pre-existing SUD parity laws
 Under ERISA, fully insured plans are subject to
state parity laws, but self-insured plans are
exempt
 Compared pre-post changes in outcomes among
individuals newly subject to federal parity with
changes among individuals already subject to
pre-existing state SUD laws
 Used difference-in-differences models
 Controlled for enrollee gender, age and state
 Logistic regression for binary outcomes
 Two-part models for spending outcomes
 Method of recycled predictions and
nonparametric block bootstraps to calculate
effect size and confidence intervals
Methods Results
 Concern that federal parity would
greatly increase health care spending,
at least related to SUD treatment, was
unfounded
Policy Implications
 Historically, more stringent limits on coverage
for mental health and substance use disorder
(SUD) services
 In 2008, the U.S. Congress enacted the Paul
Wellstone and Pete Domenici Mental Health
Parity and Addiction Equity Act (MHPAEA)
 Required insurers to equalize private
insurance coverage for mental health and SUD
services with coverage for general medical
services
 Includes all financial requirements and
treatment limits
 Effective January 1, 2010
 Expected effects of parity on SUD treatment
are ambiguous, and no published information
is yet available
Background
 To examine the effects of the MHPAEA on
substance use disorder treatment
Objectives
Funded by NIH grants
NIDA DA026414 and
NIMH MH093414-01A1
 Aetna claims data for members continuously
enrolled during 2009 (pre) and 2010 (post)
 Annual total SUD spending per enrollee
includes all SUD-related inpatient, partial
hospitalization, intensive outpatient, and
outpatient services, and Rx drugs
Data and Measures
Baseline characteristics of study sample, 2009
Probability of use & spending per enrollee on
SUD services
Out-of-pocket (OOP) SUD spending per user
HEDIS measures: Identification
HEDIS measures: Treatment initiation
HEDIS measures: Treatment engagement
 No change in use of any SUD services
 Small increase in total annual SUD cost per
enrollee (i.e., $10 per enrollee per year)
 No change in OOP spending per SUD user
 No change in HEDIS measures
Summary of findings
Self insured
(N=162,761)
Fully insured
(N=135,578)
(p-value)
N (%) N (%)
Female 84,530 (54.1) 71,755 (52.9) p<0.001
Age p<0.001
18-31 years 40,520 (24.9) 35,205 (26.0)
32-46 years 63,903 (39.3) 50,870 (37.5)
47-62 years 58,338 (35.8) 49,503 (36.5)
Selected diagnoses
• Any substance use disorder
treatment
1,752 (1.1%) 912 (0.7%) p<0.001
• Any alcohol use
disorder treatment
653 (0.4) 342 (0.3) p<0.001
• Any illicit drug use disorder
treatment
1,099 (0.7) 570 (0.4) p<0.001
• Any opioid use
disorder treatment
323 (0.2) 166 (0.1) p<0.001
Change in value before
and after parity
Probability of
using SUD
treatment (%)
Total SUD
spending per
enrollee ($)
Probability
of using SUD
services (%)
Total SUD
spending
per enrollee ($)
Pre
parity
Post
parity
Pre
parity
Post
parity
95% CI 95% CI
Self insured
treatment
group
(N=162,761)
1.04 1.18 36.51 52.62
0.05
[-0.03, 0.12]
9.99
[2.54, 18.21]Fully insured
comparison
group
(N=135,578)
0.70 0.79 26.58 32.70
OOP spending for SUD
services
per user ($)
Change in value
before and after
parity ($)
Pre
parity
Post
parity
95% CI
Self insured
treatment group
449.48 538.70
39.00
[-71.05, 145.13]Fully insured
comparison group
572.23 622.45
Identification of SUD
service receipt (%)
Change in value
before and after
parity (%)
Pre
parity
Post
parity
95% CI
Self insured
treatment group
0.81 0.91
0.01
[-0.074, 0.94]Fully insured
comparison group
0.53 0.62
Treatment initiation (%)
Change in value before
and after parity
Pre
parity
Post
parity
% 95% CI
Self insured
treatment group
34.71 33.33
0.44 [-5.07, 6.40]
Fully insured
comparison group
32.63 30.81
Treatment engagement
(%)
Change in value before
and after parity
Pre
parity
Post
parity
% 95% CI
Self insured
treatment group
19.29 19.57
1.84 [-2.79, 6.65]
Fully insured
comparison group
19.40 17.84

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Epstein,andy ispor poster_2013

  • 1. The effects of federal parity on substance use disorder treatment Susan H. Busch, PhD;1 Andrew J. Epstein, PhD;2,3 Michael O. Harhay, MPH;2 David A. Fiellin, MD;1 Hyong Un, MD;4 Deane Leader Jr;4 Colleen L. Barry, PhD MPP5 1 Yale University; 2 University of Pennsylvania; 3 Veterans Affairs; 4 Aetna Inc; 5 Johns Hopkins University  Analyses focused on enrollees in 10 states with pre-existing SUD parity laws  Under ERISA, fully insured plans are subject to state parity laws, but self-insured plans are exempt  Compared pre-post changes in outcomes among individuals newly subject to federal parity with changes among individuals already subject to pre-existing state SUD laws  Used difference-in-differences models  Controlled for enrollee gender, age and state  Logistic regression for binary outcomes  Two-part models for spending outcomes  Method of recycled predictions and nonparametric block bootstraps to calculate effect size and confidence intervals Methods Results  Concern that federal parity would greatly increase health care spending, at least related to SUD treatment, was unfounded Policy Implications  Historically, more stringent limits on coverage for mental health and substance use disorder (SUD) services  In 2008, the U.S. Congress enacted the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act (MHPAEA)  Required insurers to equalize private insurance coverage for mental health and SUD services with coverage for general medical services  Includes all financial requirements and treatment limits  Effective January 1, 2010  Expected effects of parity on SUD treatment are ambiguous, and no published information is yet available Background  To examine the effects of the MHPAEA on substance use disorder treatment Objectives Funded by NIH grants NIDA DA026414 and NIMH MH093414-01A1  Aetna claims data for members continuously enrolled during 2009 (pre) and 2010 (post)  Annual total SUD spending per enrollee includes all SUD-related inpatient, partial hospitalization, intensive outpatient, and outpatient services, and Rx drugs Data and Measures Baseline characteristics of study sample, 2009 Probability of use & spending per enrollee on SUD services Out-of-pocket (OOP) SUD spending per user HEDIS measures: Identification HEDIS measures: Treatment initiation HEDIS measures: Treatment engagement  No change in use of any SUD services  Small increase in total annual SUD cost per enrollee (i.e., $10 per enrollee per year)  No change in OOP spending per SUD user  No change in HEDIS measures Summary of findings Self insured (N=162,761) Fully insured (N=135,578) (p-value) N (%) N (%) Female 84,530 (54.1) 71,755 (52.9) p<0.001 Age p<0.001 18-31 years 40,520 (24.9) 35,205 (26.0) 32-46 years 63,903 (39.3) 50,870 (37.5) 47-62 years 58,338 (35.8) 49,503 (36.5) Selected diagnoses • Any substance use disorder treatment 1,752 (1.1%) 912 (0.7%) p<0.001 • Any alcohol use disorder treatment 653 (0.4) 342 (0.3) p<0.001 • Any illicit drug use disorder treatment 1,099 (0.7) 570 (0.4) p<0.001 • Any opioid use disorder treatment 323 (0.2) 166 (0.1) p<0.001 Change in value before and after parity Probability of using SUD treatment (%) Total SUD spending per enrollee ($) Probability of using SUD services (%) Total SUD spending per enrollee ($) Pre parity Post parity Pre parity Post parity 95% CI 95% CI Self insured treatment group (N=162,761) 1.04 1.18 36.51 52.62 0.05 [-0.03, 0.12] 9.99 [2.54, 18.21]Fully insured comparison group (N=135,578) 0.70 0.79 26.58 32.70 OOP spending for SUD services per user ($) Change in value before and after parity ($) Pre parity Post parity 95% CI Self insured treatment group 449.48 538.70 39.00 [-71.05, 145.13]Fully insured comparison group 572.23 622.45 Identification of SUD service receipt (%) Change in value before and after parity (%) Pre parity Post parity 95% CI Self insured treatment group 0.81 0.91 0.01 [-0.074, 0.94]Fully insured comparison group 0.53 0.62 Treatment initiation (%) Change in value before and after parity Pre parity Post parity % 95% CI Self insured treatment group 34.71 33.33 0.44 [-5.07, 6.40] Fully insured comparison group 32.63 30.81 Treatment engagement (%) Change in value before and after parity Pre parity Post parity % 95% CI Self insured treatment group 19.29 19.57 1.84 [-2.79, 6.65] Fully insured comparison group 19.40 17.84