Annotated Bibliography: Parity

Although recognition and treatment of mental health disorders have become integrated into routine medical care, inequities remain regarding limits on mental health outpatient visits and higher copayments and deductibles required for mental health services when accessed. Two federal laws were passed by Congress in 2008: The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act and the Medicare Improvements for Patients and Providers Act. Both laws became effective on January 1, 2010. The purpose of this articles to discuss provisions of each act and provide clinical examples describing how patients are affected by lack of parity and may potentially benefit from implementation of these new laws. Using available evidence, we examine the potential strengths and limitations of mental health parity legislation from the health policy perspectives of health care access, cost, and quality and identify the important role of nurses as patient and mental health parity advocates.

2. Milbank Q. 2010 Sep;88(3):404-33. doi: 10.1111/j.1468-0009.2010.00605.x.  A political history of federal mental health and addiction insurance parity.  Barry CL, Huskamp HA, Goldman HH.  Johns Hopkins University Bloomberg School of Public Health, Department of Health Policy and Management, Baltimore, MD 21205, USA. cbarry@jhsph.edu

CONTEXT: This article chronicles the political history of efforts by the U.S. Congress to enact a law requiring "parity" for mental health and addiction benefits and medical/surgical benefits in private health insurance. The goal of the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity(MHPAE) Act of 2008 is to eliminate differences in insurance coverage for behavioral health. Mental health and addiction treatment advocates have long viewed parity as a means of increasing fairness in the insurance market, whereas employers and insurers have opposed it because of concerns about its cost. The passage of this law is viewed as a legislative success by both consumer and provider advocates and the employer and insurance groups that fought against it for decades.

METHODS: Twenty-nine structured interviews were conducted with key informants in the federal parity debate, including members of Congress and their staff; lobbyists for consumer, provider, employer, and insurance groups; and other key contacts. Historical documentation, academic research on the effects of parity regulations, and public comment letters submitted to the U.S. Departments of Labor, Health and Human Services, and Treasury before the release of federal guidance also were examined.

FINDINGS: Three factors were instrumental to the passage of this law: the emergence of new evidence regarding the costs of parity, personal experience with mental illness and addiction, and the political strategies adopted by congressional champions in the Senate and House of Representatives.

CONCLUSIONS: Challenges to implementing the federal parity policy warrant further consideration. This law raises new questions about the future direction of federal policymaking on behavioral health.

3. J Behav Health Serv Res. 2010 Jul;37(3):283-4.  Medicare parity: we're not done yet! Rosenberg L. MSIU, National Council for Community Behavioral Healthcare, Washington, DC, USA.  MeenaD@thenationalcouncil.org

Comment on: J Behav Health Serv Res. 2010 Jul;37(3):285-90.

While Medicare's discriminatory copayments for mental and physical health care are being eliminated, much remains to be done to achieve true parity within Medicare. Medicare needs to recognize and pay for such critical mental health services as case management, psychiatric rehabilitation, and assertive community treatment. Medicare must cover payments for all behavioral health professionals. Also the 190-day lifetime limit on inpatient psychiatric hospital days under Medicare must be removed. We envision a time-in the not too distant future-when Medicare provides a mental health benefit that includes vital community services.

4. J Behav Health Serv Res. 2010 Jul;37(3):285-90. Epub 2009 Nov 4.  Medicare mental health parity: a high potential change that is long overdue. Ostrow L, Manderscheid R.  Human Services Research Institute, 2336 Massachusetts Avenue, Cambridge, MA 02140, USA. lostrow@hsri.org

Comment in: J Behav Health Serv Res. 2010 Jul;37(3):283-4.

Recent changes in legislation regarding mental health parity in Medicare will revolutionize payment for mental health care and delivery systems. This commentary discusses why this policy change was essential to promote adequate care for populations served by Medicare and to address expected changes in beneficiary, provider, and plan behavior as more equitable payments by Medicare are implemented.

5. J Leg Med. 2010 Jan;31(1):137-55.  Equity for all? Potential impact of the Mental Health Parity and Addiction Act of 2008. Garcia RA.  Southern Illinois University School of Law, Carbondale, Illinois 62901, USA.  ranthonygarcia@gmail.com

6. Health Aff (Millwood). 2009 May-Jun;28(3):922.  Perspective: After Parity-What's Next.  Shern DL, Beronio KK, Harbin HT

7. Health Aff (Millwood). 2009 May-Jun;28(3):922.  Medicare and mental health parity.  Ostrow L, Manderscheid R.

8. Health Aff (Millwood). 2009 May-Jun;28(3):713-22.  State variations in the out-of-pocket spending burden for outpatient mental health treatment.  Zuvekas SH, Meyerhoefer CD.  Center for Financing, Access, and Cost Trends, Agency for Healthcare Research and Quality, in Rockville, Maryland, USA. samuel.zuvekas@ahrq.hhs.gov

We examine the potential of mental health/substance abuse (MH/SA) parity laws to reduce the out-of-pocket spending burden for outpatient treatment at the state level by exploring cross-state variations and their causes, as well as the provisions of MH/SA parity laws. We find modest (yet important) variation in out-of-pocket burden across states overall, but-because prescription medications account for two-thirds of out-of-pocket spending and are generally beyond the scope of recently enacted federal parity laws-evidence suggests that those laws will do little to reduce the observed burden or its variation. Other policy measures, designed to expand and improve health insurance coverage or reduce racial/ethnic disparities, could have a more profound impact.

9. Health Aff (Millwood). 2009 May-Jun;28(3):663-5.  Implementing mental health parity: the challenge for health plans.  Dixon K.  CIGNA Corporation, in Eden Prairie, Minnesota, USA. Keith.Dixon@cigna.com

Comment in: Health Aff (Millwood). 2009 Sep-Oct;28(5):1552; author reply 1552-3.

By design, the new mental health parity law should work harmoniously with innovations that have helped slow down growth in mental health and substance abuse (MH/SA) treatment costs and improve their quality. The main purpose of the new law is to put coverage of MH/SA benefits on an equal footing with general medical benefits. But some unique features of care for MH/SA disorders will pose challenges in aligning benefits with general medical care. Successful navigation of these challenges will require, as in the passage of the parity law itself, cooperation from all stakeholder groups.

10. Health Aff (Millwood). 2009 May-Jun;28(3):w490-501. Epub 2009 Apr 14.  Beyond parity: primary care physicians' perspectives on access to mental health care. Cunningham PJ. Center for Studying Health System Change in Washington, DC, USA. pcunningham@hschange.org

Comment in: Health Aff (Millwood). 2009 Jul-Aug;28(4):1228.

About two-thirds of primary care physicians (PCPs) reported in 2004-05 that they could not get outpatient mental health services for patients-a rate that was at least twice as high as that for other services. Shortages of mental health care providers, health plan barriers, and lack of coverage or inadequate coverage were all cited by PCPs as important barriers to mental health care access. The probability of having mental health access problems for patients varied by physician practice, health system, and policy factors. The results suggest that implementing mental health parity nationally will reduce some but not all of the barriers to mental health care.

11. Matern Child Health J. 2009 Mar;13(2):176-86. Epub 2008 May 16.  The influence of health insurance on parent's reports of children's unmet mental health needs. Derigne L, Porterfield S, Metz S.   derigne@sbcglobal.net

OBJECTIVE: The purpose of this study was to examine the prevalence of unmet mental health needs in children identified by parents as having long-term emotional and behavioral problems, to identify the characteristics of these children, and to evaluate the influence of health insurance status and type on the odds of reporting unmet mental health needs.

METHODS: We used the National Survey of Children with Special Health Care Needs (NSCSHCN) to estimate the prevalence of unmet mental health needs among children with long-term emotional/behavioral conditions. Using logistic regression models, we also assessed the independent impact of insurance status and type on unmet needs.

RESULTS: Analyses indicated that of the nearly 67% of children who needed mental health care or counseling in the previous 12 months, 20% did not receive it. Moreover, parents of uninsured children were more likely to report unmet mental health needs than insured children. Parents of children covered by public health insurance programs (Medicaid, Children Health Insurance Program-CHIP, Title V, Military, Native American) were less likely to report unmet mental health needs than those with children covered by private health insurance plans.

CONCLUSION: Results from this study suggest a need for expansion of health insurance coverage to children especially those with long-term mental health conditions. It also suggests a need for parity between mental and physical health benefits in private health insurance.

12. Health Aff (Millwood). 2009 Jul-Aug;28(4):1228.  Effects of mental health parity.  Manderscheid R.

Comment on: Health Aff (Millwood). 2009 May-Jun;28(3):w490-501.

13. Harv Ment Health Lett. 2009 Jan;25(7):4-5. Benefitting from mental health parity. Determining coverage, understanding the limits, appealing decisions.

14. Health Econ. 2009 Dec 22. [Epub ahead of print]  Mental health parity legislation, cost-sharing and substance-abuse treatment admissions.  Dave D, Mukerjee S.  Department of Economics, Bentley University and National Bureau of Economic Research, Waltham, MA, USA.

Treatment is highly cost-effective in reducing an individual's substance abuse (SA) and associated harms. However, data from Treatment Episodes (TEDS) indicate that per capita treatment admissions substantially lagged behind increases in heavy drug use from 1992 to 2007. Only 10% of individuals with clinical SA disorders receive treatment, and almost half who forgo treatment point to accessibility and cost constraints as barriers to care. This study investigates the impact of state mental health and SA parity legislation on treatment admission flows and cost-sharing. Fixed effects specifications indicate that mandating comprehensive parity for mental health and SA disorders raises the probability that a treatment admission is privately insured, lowering costs for the individual. Despite some crowd-out of charity care for private insurance, mandates reduce the uninsured probability by a net 2.4 percentage points. States mandating comprehensive parity also see an increase in treatment admissions. Thus, increasing cost-sharing and reducing financial barriers may aid the at-risk population in obtaining adequate SA treatment. Supply constraints mute effect sizes, suggesting that demand-focused interventions need to be complemented with policies supporting treatment providers. These results have implications for the effectiveness of the 2008 Federal Mental Health Parity and Addiction Equity Act in increasing SA treatment admissions and promoting cost-sharing. Copyright (c) 2009 John Wiley & Sons, Ltd.

15. Psychiatr Serv. 2009 Dec;60(12):1589-94.  Implementation of mental health parity: lessons from california. Rosenbach ML, Lake TK, Williams SR, Buck JA. Mathematica Policy Research, 955 Massachusetts Ave., Suite 801, Cambridge, MA 02139, USA. mrosenbach@mathematica-mpr.com

OBJECTIVE: This article reports the experiences of health plans, providers, and consumers with California's mental health parity law and discusses implications for implementation of the 2008 federal parity law.

METHODS: This study used a multimodal data collection approach to assess the first five years of California's parity implementation (from 2000 to 2005). Telephone interviews were conducted with 68 state-level stakeholders, and in-person interviews were conducted with 77 community-based stakeholders. Six focus groups included 52 providers, and six included 32 consumers. A semi structured interview protocol was used. Interview notes and transcripts were coded to facilitate analysis.

RESULTS: Health plans eliminated differential benefit limits and cost-sharing requirements for certain mental disorders to comply with the law, and they used managed care to control costs. In response to concerns about access to and quality of care, the state expanded oversight of health plans, issuing access-to-care regulations and conducting focused studies. California's parity law applied to a limited list of psychiatric diagnoses. Health plan executives said they spent considerable resources clarifying which diagnoses were covered at parity levels and concluded that the limited diagnosis list was unnecessary with managed care. Providers indicated that the diagnosis list had unintended consequences, including incentives to assign a more severe diagnosis that would be covered at parity levels, rather than a less severe diagnosis that would not be covered at such levels. The lack of consumer knowledge about parity was widely acknowledged, and consumers in the focus groups requested additional information about parity.

CONCLUSIONS: Experiences in California suggest that implementation of the 2008 federal parity law should include monitoring health plan performance related to access and quality, in addition to monitoring coverage and costs; examining the breadth of diagnoses covered by health plans; and mounting a campaign to educate consumers about their insurance benefits.

16. Implement Sci. 2008 May 16;3:26.  Toward a policy ecology of implementation of evidence-based practices in public mental health settings. Raghavan R, Bright CL, Shadoin AL. George Warren Brown School of Social Work, and Department of Psychiatry, School of Medicine, Washington University in St. Louis, St. Louis, MO, USA. raghavan@wustl.edu

BACKGROUND: Mental health policymaking to support the implementation of evidence-based practices (EBPs) largely has been directed toward clinicians. However, implementation is known to be dependent upon a broader ecology of service delivery. Hence, focusing exclusively on individual clinicians as targets of implementation is unlikely to result in sustainable and widespread implementation of EBPs.

DISCUSSION: Policymaking that is informed by the implementation literature requires that policymakers deploy strategies across multiple levels of the ecology of implementation. At the organizational level, policies are needed to resource the added marginal costs of EBPs, and to assist organizational learning by re-engineering continuing education units. At the payor and regulatory levels, policies are needed to creatively utilize contractual mechanisms, develop disease management programs and similar comprehensive care management approaches, carefully utilize provider and organizational profiling, and develop outcomes assessment. At the political level, legislation is required to promote mental health parity, reduce discrimination, and support loan forgiveness programs. Regulations are also needed to enhance consumer and family engagement in an EBP agenda. And at the social level, approaches to combat stigma are needed to ensure that individuals with mental health need access services.

SUMMARY: The implementation literature suggests that a single policy decision, such as mandating a specific EBP, is unlikely to result in sustainable implementation. Policymaking that addresses in an integrated way the ecology of implementation at the levels of provider organizations, governmental regulatory agencies, and their surrounding political and societal milieu is required to successfully and sustainably implement EBPs over the long term.

17. J Ment Health Policy Econ. 2008 Jun;11(2):55-6.  The impact of mental health parity law on the access to mental health services of children with mental disorders. Editorial.

18. J Ment Health Policy Econ. 2008 Jun;11(2):57-66.  Caring for children with mental disorders: do state parity laws increase access to treatment?  Barry CL, Busch SH.  Yale University School of Medicine, New Haven, CT 06520, USA.  colleen.barry@yale.edu

BACKGROUND: High prevalence rates of mental health disorders in childhood have garnered increased public attention in recent years. Yet, among children diagnosed with serious mental health problems, a majority receive no treatment. Improving access to mental health services for children with behavioral and emotional disorders constitutes an important policy concern.

AIMS OF THE STUDY: To study whether living in a state that has implemented a mental health parity law affects a child's use of outpatient mental health services. Methods: We use the National Survey of America's Families (NSAF) 1997 to 2002 to study whether enacting a state parity law increases the probability that a privately insured child receives mental health treatment (N=26,916). Using a differences-in-differences model, we control for detailed information on a child's health and functioning, and compare mental health care use before and after state parity implementation with non-parity states serving as a comparison group.

RESULTS: Regression results indicate that state parity laws do not affect the likelihood of a child receiving outpatient mental health services. Among the subset of children identified with a greater need for mental health care, the effect of parity appears to be somewhat larger in magnitude but remains insignificant.

DISCUSSION: State mental health parity policies aim to improve equity in private insurance coverage for mental health care and could provide a mechanism for reducing unmet need among children with mental health care disorders. Yet, our results suggest these policies do little to affect rates of use.

IMPLICATIONS FOR HEALTH CARE PROVISION AND UTILIZATION: Parity policies do not appear to represent a sufficient strategy for addressing access to mental health care among children and adolescents.

IMPLICATIONS FOR HEALTH POLICIES: Developing new approaches to encourage the receipt of high value mental health care in youth constitutes a persisting challenge under both public and private insurance arrangements.

IMPLICATIONS FOR FURTHER RESEARCH: Since other research has shown that state parity laws are helpful in reducing the family financial burden of caring for a mentally ill child and do not drive up total health care costs, these policies serve a vital function. However, given persistent access problems in the child population, research aimed at increasing rates of mental health services use is needed. In addition, future research on parity laws should consider whether, conditional on having a visit, children in parity states are likely to have more visits compared with other children.

19. Inquiry. 2008 Fall;45(3):308-22.  New evidence on the effects of state mental health mandates. Busch SH, Barry CL.  Department of Health Policy and Administration, School of Public Health, Yale University, New Haven, CT 06520, USA. susan.busch@yale.edu

State mental health parity laws improve equity in private insurance coverage for mental and physical health services, but prior research shows no effect on service use. We study whether state parity differentially affects individuals by employer size since large firms are often exempt from state health mandates due to the Employee Retirement Income Security Act. We also examine whether state parity laws differentially affect use among individuals with low incomes or in poor mental health. We find that individuals in smaller firms are more likely to use services post-parity implementation and that this effect is concentrated among low-income individuals.

20. JAMA. 2008 Dec 24;300(24):2879-85.  Insurance parity and the use of outpatient mental health care following a psychiatric hospitalization. Trivedi AN, Swaminathan S, Mor V. Department of Community Health, Warren Alpert Medical School at Brown University, Box G-S121, Providence, RI 02912, USA. amal_trivedi@brown.edu

Comment in: JAMA. 2009 May 13;301(18):1880-1; author reply 1881.

CONTEXT: Mental health services are typically subject to higher cost sharing than other health services. In 2008, the US Congress enacted legislation requiring parity in insurance coverage for mental health services in group health plans and Medicare Part B.

OBJECTIVE: To determine the relationship between mental health insurance parity and the use of timely follow-up care after a psychiatric hospitalization.

DESIGN, SETTING, AND POPULATION: We reviewed cost-sharing requirements for outpatient mental health and general medical services for 302 Medicare health plans from 2001 to 2006. Among 43 892 enrollees in 173 health plans who were hospitalized for a mental illness, we determined the relation between parity in cost sharing and receipt of timely outpatient mental health care after discharge using cross-sectional analyses of all Medicare plans and longitudinal analyses of 10 plans that discontinued parity compared with 10 matched control plans that maintained parity.

MAIN OUTCOME MEASURES: Outpatient mental health visits within 7 and 30 days following a discharge for a psychiatric hospitalization.

RESULTS: More than three-quarters of Medicare plans, representing 79% of Medicare enrollees, required greater cost sharing for mental health care compared with primary or specialty care. The adjusted rate of follow-up within 30 days after a psychiatric hospitalization was 10.9 percentage points greater (95% confidence interval [CI], 4.6-17.3; P < .001) in plans with equivalent cost sharing for mental health and primary care compared with plans with mental health cost sharing greater than primary and specialty care cost sharing. The association of parity with follow-up care was increased for enrollees from areas of low income and less education. Rates of follow-up visits within 30 days decreased by 7.7 percentage points (95% CI, -12.9 to -2.4; P = .004) in plans that discontinued parity and increased by 7.5 percentage points (95% CI, 2.0-12.9; P = .008) among control plans that maintained parity (adjusted difference in difference, 14.2 percentage points; 95% CI, 4.5-23.9; P = .007).

CONCLUSION: Medicare enrollees in health plans with insurance parity for mental health and primary care have markedly higher use of clinically appropriate mental health services following a psychiatric hospitalization.

21. Health Aff (Millwood). 2007 Nov-Dec;26(6):w706-16. Epub 2007 Oct 23.  Equity in private insurance coverage for substance abuse: a perspective on parity.  Barry CL, Sindelar JL.  Yale University in New Haven, Connecticut, USA. colleen.barry@yale.edu

Congress is considering enactment of comprehensive parity legislation. The intent of parity is to equalize private coverage of behavioral and general medical care, thereby improving efficiency and fairness in insurance markets. One issue is whether to extend parity to substance abuse (SA) benefits. In the past, inclusion of substance abuse has been a hurdle to passage of parity. We examine the politics of SA parity, compare coverage trends for substance abuse and mental health, and assess the rationale for equalizing benefits. We conclude that the justification for SA parity is as compelling as it is for mental health parity.

22. Health Serv Res. 2007 Jun;42(3 Pt 1):1061-84.  Do state parity laws reduce the financial burden on families of children with mental health care needs?  Barry CL, Busch SH.  Department of Epidemiology and Public Health, Yale University School of Medicine, Division of Health Policy and Administration, 60 College Street, New Haven, CT 06520, USA.

OBJECTIVE: To study the financial impact of state parity laws on families of children in need of mental health services.

DATA SOURCE: Privately insured families in the 2000 State and Local Area ntegrated Telephone Survey National Survey of Children with Special Health Care Needs (CSHCN) (N=38,856).

STUDY DESIGN: We examine whether state parity laws reduce the financial burden on families of children with mental health conditions. We use instrumental variable estimation controlling for detailed information on a child's health and functional impairment. We compare those in parity and nonparity states and those needing mental health care with other CSHCN.

PRINCIPLE FINDINGS: Multivariate regression results indicate that living in a parity state significantly reduced the financial burden on families of children with mental health care needs. Specifically, the likelihood of a child's annual out-of-pocket (OOP) health care spending exceeding $1,000 was significantly lower among families of children needing mental health care living in parity states compared with those in nonparity states. Families with children needing mental health care in parity states were also more likely to view OOP spending as reasonable compared with those in nonparity states. Likewise, living in a parity state significantly lowered the likelihood of a family reporting that a child's health needs caused financial problems. The likelihood of reports that additional income was needed to finance a child's care was also lower among families with mentally ill children living in parity states. However, we detect no significant difference among residents of parity and nonparity states in receipt of needed mental health care.

CONCLUSION: These results indicate that state parity laws are providing important economic benefits to families of mentally ill children undetected in prior research

23. Health Aff (Millwood). 2007 Jul-Aug;26(4):w483-7. Epub 2007 Jun 7.  Parity for whom? Exemptions and the extent of state mental health parity legislation.  Buchmueller TC, Cooper PF, Jacobson M, Zuvekas SH. Ross School of Business, University of Michigan, Ann Arbor, MI, USA.  tbuch@umich.edu

Between 1997 and 2003, the share of workers subject to mental health parity laws greatly increased. But because of exemptions for self-insured firms and small firms, coverage is much lower than a simple tally of state mandates would suggest. Limits on the types of conditions covered further weaken these laws. This paper summarizes the extent and scope of state parity legislation in terms of the number of insured private-sector employees covered. It explicitly accounts for the Employee Retirement Income Security Act (ERISA) exemption for self-insured plans, exemptions for small employers, and the range of conditions covered by the law.

24. Find Brief. 2007 Aug;10(6):1-3.  Financial relief: the effect of state mental health parity laws on families of children with mental health care needs.  Demchak C.

Families of children with mental health care needs who live in states with mental health parity laws have lower out-of-pocket spending and are more likely to view their spending as reasonable compared with those living in non parity states. This suggests that mental health parity laws provide important financial benefits to families of children with mental healthcare needs.

25. J Adolesc Health. 2006 Sep;39(3):318-27.  Financing mental health services for adolescents: a background paper.  Kapphahn C, Morreale M, Rickert VI, Walker L.  Division of Adolescent Medicine, Stanford University School of Medicine, Mountain View, California 94040, USA. kapp@stanford.edu

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.

26. J Ment Health Policy Econ. 2006 Sep;9(3):155-63.  Coverage for mental health treatment: do the gaps still persist?  Zuvekas SH, Meyerhoefer CD.  Center for Financing, Access and Cost Trends, Agency for Healthcare Research and Quality, Rockville, MD 20850, USA. szuvekas@ahrq.gov

BACKGROUND: Consumers have long faced high out-of-pocket costs for mental health and substance abuse treatment in private health insurance plans, the predominant form of insurance coverage in the United States. Nominal mental health benefits may have improved from the mid-1990s onwards, as many states passed mental health parity mandates and other employers voluntarily improved coverage. However, the rapid rise of managed behavioral health care organizations (MBHOs) may have effectively offset these gains in nominal coverage.

AIMS OF THE STUDY: We examine how effective mental health benefits, as measured by actual out-of-pocket expenses, compares to coverage for non-mental health treatment and how this has changed in recent years.

METHODS: We used detailed data on health care use and expenses from the nationally representative, Medical Expenditure Panel Survey (MEPS) to describe the distribution of out-of-pocket expenses for mental health and non-mental health ambulatory visits and prescription drug fills and demonstrate how this changed between 1996 and 2003. In addition, we use two-limit tobit regression models to descriptively examine the factors associated with higher out-of-pocket costs for ambulatory mental health treatment.

RESULTS: While out-of-pockets shares generally decreased over the 1996-2003 period, from 39 to 35 percent of total expenses for ambulatory mental health visits and from 31 to 26 percent for non-mental health ambulatory visits, the ratio of out-of-pockets costs is still significantly higher for mental health care. Out-of-pocket expenses per visit fell as the number of non-mental health visits increased but out-of-pocket expenses for mental health visits rose with more visits. Out-of-pocket expenses for visits to specialty mental health providers were substantially higher than for non-psychiatrist physicians. Though prescription drug spending increased substantially, the percent paid out-of-pocket did not change for mental health and non-mental health related fills.

DISCUSSION: Our results suggest that expenses for ambulatory mental health visits, especially for specialty providers, effectively remain less well covered than other medical visits.

IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: Continued high out-of-pocket expenses for mental health treatment may impede access to mental health treatment, especially for those who need greater treatment intensity.

IMPLICATIONS FOR HEALTH POLICIES: Mental health parity may not ensure that coverage for mental health services is, in actuality, equal.

IMPLICATIONS FOR FURTHER RESEARCH: Additional research is needed in understanding relative changes in nominal vs. actual or effective coverage.

27. Med Care. 2006 Jun;44(6):506-12.  The impact of parity on major depression treatment quality in the Federal Employees' Health Benefits Program after parity implementation. Busch AB, Huskamp HA, Normand SL, Young AS, Goldman H, Frank RG. Department of Psychiatry, Harvard Medical School, McLean Hospital, Alcohol and Drug Abuse Treatment Program, Belmont, Massachusetts 02478, USA.  abusch@hcp.med.harvard.edu

BACKGROUND: Since the 1990s, parity laws have been implemented to reduce inequities in mental health coverage compared with that for general medical conditions. It is unclear if parity under managed care is associated with improvements in mental health treatment quality. Major depressive disorder (MDD) is a prevalent but often undetected and undertreated and thus could potentially benefit from parity implementation.

OBJECTIVE: The objective of this study was to examine the association between parity implementation and changes in MDD treatment quality in the Federal Employees' Health Benefits (FEHB) Program.

METHODS: We conducted retrospective analyses of insurance claims data. Logistic regression models estimated quality changes for MDD-diagnosed enrollees from pre-to postparity.

SUBJECTS: Subjects included MDD-diagnosed FEHB insured enrollees, aged 18-64, across multiple states and 6 FEHB plans before (1999-2000) and after (2001-2002) parity implementation.

MEASURES: Measures included receipt of any antidepressant or psychotherapy within a given calendar year of diagnosis; receipt of appropriate psychotherapyfrequency/intensity and duration; and pharmacotherapy duration during acute-phase treatment episodes.

RESULTS: Postparity, several plans improved significantly in the likelihood of receiving antidepressant medication. In the acute-phase episodes, the greatest improvement was seen in the likelihood of follow up >or=4 months. Few or no other changes were observed in the acute-phase treatment intensity or duration quality measures.

CONCLUSIONS: Parity under managed care was associated with modest improvements. The observed improvements were consistent with secular trends in MDD treatment. Whereas mental health parity is an important policy goal, these results highlight its limitations: improving the financing of care may not be sufficient to improve quality.

28. Med Care. 2006 Jun;44(6):499-505.  The effects of state parity laws on the use of mental health care.  Harris KM, Carpenter C, Bao Y.  Substance Abuse and Mental Health Services Administration, Rockville, Maryland, USA. kharris@rand.org

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 bycomparing 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.

29. Harv Rev Psychiatry. 2006 Jul-Aug;14(4):185-94.  The political evolution of mental health parity.  Barry CL.  Department of Epidemiology and Public Health, Yale University School of Medicine,  60 College St., New Haven, 06520 CT, USA. colleen.barry@yale.edu

This article traces the evolution of the mental health parity debate in American politics, with a focus on how interest groups and politicians have attempted to influence perceptions about treatment effectiveness and the cost of benefit expansion. When parity laws are in place, they require health plans operating in the private health insurance market to provide an equivalent level of coverage for mental health and general medical care. Business and insurance industry groups oppose parity due to cost concerns. The mental health community has framed parity as an antidiscrimination measure that would achieve greater insurance equity across disease groups. The role of personal experience with mental illness among lawmakers and others in framing the parity debate is also considered.

30. Inquiry. 2005 Spring;42(1):86-97.  Spillover effects of benefit expansions and carve-outs on psychotropic medication use and costs.  Zuvekas SH, Rupp AE, Norquist GS.  Center for Financing, Access and Cost Trends, Agency for Healthcare Research and  Quality, Rockville, MD 20850, USA. szuvekas@ahrq.gov

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 ininpatient specialty MH/SA costs. However, we find evidence that the MBHO may have restrained growth in prescription medication spending.

31. Health Aff (Millwood). 2005 Nov-Dec;24(6):1668-71.  The impacts of mental health parity and managed care in one large employer group: a reexamination. Zuvekas SH, Rupp AE, Norquist GS. Center for Financing, Access, and Cost Trends, Agency for Healthcare Research and Quality, Rockville, MD, USA. szuvekas@ahrq.gov

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.

32. Quinnipiac Health Law J. 2004-2005;8:325-61.  Can legislation alone solve America's mental health dilemma? Current state legislative schemes cannot achieve mental health parity. Kaplan DL. Quinnipiac University School of Law, USA.

33. Harvard J Legis. 2004 Summer;41(2):363-75.  Why we must end insurance discrimination against mental health care.  Kennedy PJ.  United States House of Representatives, USA.

In this Policy Essay, Representative Patrick Kennedy argues that insurance discrimination against those suffering from mental illness constitutes a serious and often overlooked deficiency of the modern American health care system. While the Mental Health Parity Act of 1996 was an important step toward resolutions of this issue, many loopholes remain that allow insurance companies to deny much-needed coverage to those suffering from such illnesses. This Essay details how improving access to health insurance for the mentally ill is not only socially beneficial, but also economically sound; the cost of instituting mental health parity is far outweighed by the costs that employers bear because of the reduced productivity of untreated mental illness sufferers. Representative Kennedy recommends that these problems may be addressed by additional mental health policy legislation--specifically, the proposed Paul Wellstone Act.

Other resources

For comprehensive information on federal parity see the Mental Health Parity homepage on the Mental Health America website http://takeaction.mentalhealthamerica.net/site/PageServer?pagename=Equity_Campaign_parity_legislation

Website for an ongoing initiative to provide privately insured children with coverage for serious emotional disturbances (SED) that interfere with their ability to function successfully at home, school and in the community. http://www.texansforsedcoverage.org/