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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 MPP 5 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 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., $10 per enrollee per year) No change in OOP spending per SUD user No change in HEDIS measures Summary of findings Self insured (N=162,761 ) Fully insured (N=135,578 ) (p- value) N (%) N (%) Female 84,530 (54.1) 71,755 (52.9) p<0.001 Age p<0.001 18-31 years 40,520 (24.9) 35,205 (26.0) 32-46 years 63,903 (39.3) 50,870 (37.5) 47-62 years 58,338 (35.8) 49,503 (36.5) Selected diagnoses • Any substance use disorder treatment 1,752 (1.1%) 912 (0.7%) p<0.001 • Any alcohol use disorder treatment 653 (0.4) 342 (0.3) p<0.001 • Any illicit drug use disorder treatment 1,099 (0.7) 570 (0.4) p<0.001 • Any opioid use disorder treatment 323 (0.2) 166 (0.1) p<0.001 Change in value before and after parity Probabilit y of using SUD treatment (%) Total SUD spending per enrollee ($) Probabili ty of using SUD services (%) Total SUD spending per enrollee ($) Pre pari ty Post pari ty Pre parit y Post parit y 95% CI 95% CI Self insured treatment group (N=162,76 1) 1.04 1.1 8 36.5 1 52.6 2 0.05 [-0.03, 0.12] 9.99 [2.54, 18.21] Fully insured compariso n group 0.70 0.7 9 26.5 8 32.7 0 OOP spending for SUD services per user ($) 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
