When a large insurer offers the same coverage for mental health and substance abuse services as it offers for general medical care, does use of these services lead to skyrocketing costs? The answer, according to a recently published evaluation of parity in the Federal Employees Health Benefits (FEHB) Program, is no—the impact of parity on service utilization and costs is very modest.
Moreover, out-of-pocket costs declined for service users in most plans, reflecting improved insurance protection. In addition, other changes that many feared would come with the introduction of FEHB parity—such as increased gate-keeping by primary care providers, reduced provider networks, concurrent or retrospective review, and increased financial risk sharing—occurred less frequently than anticipated. These and other results of the evaluation study are detailed in a final evaluation report http://aspe.hhs.gov/daltcp/reports/parity.htm). The findings on costs for adults are published in the March 30 issue of the New England Journal of Medicine.
In January 2001 the FEHB Program, the largest employer-sponsored health insurance program in the nation, mandated that mental health and substance abuse treatment services be covered to the same extent as general medical care with respect to benefit design features, such as deductibles, copayments, and limits on visits and inpatient days. The FEHB Program serves more than eight million federal employees, their dependents, and retirees. The program offers about 250 health plan choices and provides more than $29 billion in health care benefits annually.
Before the parity policy was implemented, the Department of Health and Human Services contracted with ROW Sciences (now Federal Enterprise Solutions/Health Solutions of Northrop Grumman Information Technology, Inc.) to lead an evaluation of the implementation and impact of the new parity policy. An evaluation team was formed with investigators from Harvard Medical School, the University of Maryland School of Medicine, Westat, and RAND. Howard H. Goldman, editor of Psychiatric Services, was principal investigator.
The design of the evaluation was quasi-experimental. Benefits information for all FEHB plans was analyzed, and claims data were examined for a subset of nine medium-to-large FEHB plans, both before the introduction of parity (1999 and 2000) and after (2001 and 2002). The nine plans represented point-of-service plans and health maintenance organizations from regions across the country. Because two of the nine plans were already close to parity before it was mandated, the NEJM report analyzed data from seven plans.
Changes in access, utilization, and costs for the seven plans were compared with changes for a control group—a matched set of non-FEHB plans selected from the Medstat MarketScan database. The comparison plans did not have parity and did not change benefits over the study period. Their inclusion made it possible to examine secular trends between 1999 and 2002 to determine the extent to which changes in the FEHB plans might have occurred if parity had not been introduced.
The evaluation found that all FEHB plans complied with the parity policy, which in most instances meant that plans enhanced their mental health and substance abuse benefits consistent with the policy. Compared with the Medstat MarketScan plans, FEHB plans were more likely to enter into managed care carve-out arrangements after the introduction of parity. Only one of the seven plans did not contract with a carve-out managed care vendor.
Overall, the impact of the policy on access to mental health and substance abuse services, spending, and quality was modest. Both adult and child beneficiaries in all seven FEHB plans were more likely to use mental health and substance abuse services after parity was implemented—but at a rate consistent with secular trends. Only one plan experienced a statistically significant increase in utilization attributable to parity, and it was the only plan that did not enter into a carve-out arrangement with a managed behavioral health care company. Access to substance abuse services increased slightly in all seven plans; however, the increase in use was significant in only four plans after secular trends were taken into account. Use of substance abuse services was extremely low both before and after parity implementation—less than 1 percent in nearly all plans.
Total costs for mental health and substance abuse treatment increased in line with secular trends for both adults and children. In three FEHB plans these increases were significantly smaller than the increases seen in the comparison plans. Per-user total spending on substance abuse treatment trended upward after the introduction of parity in all seven plans, but the increase attributable to parity was significant in only one plan.
In five of seven plans, parity was associated with a significant reduction in out-of-pocket spending by adult beneficiaries who used these services; the reductions attributable to parity ranged from $13.82 to $87.06 per user per year. In one plan, out-of-pocket spending declined less than in the comparison plan by $4.48. In all plans out-of-pocket costs decreased for children who used services.
Across all plans, the parity policy was associated with a substantial increase in total spending on medications for mental health and substance use disorders. Per-user medication spending ranged from $266 to $519 before the FEHB parity policy; in 2002 the range was $377 to $632.
Measures of the quality of substance abuse treatment were based on claims data and included utilization rates, identification of substance use disorders, and engagement in treatment. Except for a small increase in the identification rate, no evidence was found of significant changes in quality. Measures of the quality of treatment for major depressive disorder either did not change or improved only slightly in all but one of the FEHB plans studied.
The report thus concludes that overall the parity policy was implemented as intended in the context of managed care with little or no significant adverse impact on access, spending, or quality and with improved financial protection for beneficiaries in most instances.
Carolyn Robinowitz, M.D., of Bethesda, Maryland, was chosen president-elect of the American Psychiatric Association (APA) in 2006 balloting by APA members. Dr. Robinowitz will assume the presidency in May 2007. The current president-elect, Pedro Ruiz, of Houston, Texas, will become APA president next month. He will succeed Steven Sharfstein, M.D., of Baltimore.
Dr. Robinowitz, who is in private practice, is currently serving a two-year term as APA secretary-treasurer. From 1976 to 1995 she was an APA staff member, serving as founding director of APA's office of education as well as senior deputy medical director and chief operating officer. After leaving APA she was professor of psychiatry and academic dean at Georgetown University.
Donna Norris, M.D., of Wellesley, Massachusetts, won the race to succeed Dr. Robinowitz as secretary-treasurer. Dr. Norris is currently APA's area 1 trustee.
Amy M. Ursano, M.D., from Chapel Hill, North Carolina, was elected early career psychiatrist trustee-at-large.
APA's members in training elected Abigail Donovan, M.D., a resident at Massachusetts General Hospital and McLean Hospital, as the next member-in-training trustee-elect.
Three APA areas had elections for their trustee positions. Jeffrey Geller, M.D., M.P.H., of Worcester, Massachusetts, was elected area 1 trustee. Incumbent Sydney Weissman, M.D., was reelected area 4 trustee, and William Womack, M.D., of Seattle, won the race for area 7 trustee.
As in recent years, about a third of APA members who were eligible to vote submitted ballots (9,819 of 30,306, or 32.4 percent). About 28 percent of voters cast online ballots, up from 9 percent in 2004. The new officers and trustees will take office at the conclusion of the 2006 APA annual meeting in Toronto.
A report from the National Alliance on Mental Illness confirms in state-by-state detail what the President's New Freedom Commission called a fragmented "system in shambles." Nationally, the system is in trouble—its grade is no better than a D. Only five states received a B: Connecticut, Maine, Ohio, South Carolina, and Wisconsin. Seventeen received Cs, 19 earned Ds, and eight are failing: Iowa, Idaho, Illinois, Kansas, Kentucky, Montana, North Dakota, and South Dakota.
The 231-page report is the first comprehensive survey and grading of state adult public mental health systems in more than 15 years—since a similar report issued by NAMI in 1990 gained nationwide attention. The latest report measures each state's progress toward a proven, cost-effective system of care founded on evidence-based practices. The practices include assertive community treatment, integrated treatment for co-occurring disorders, illness management and recovery, supported employment, and family psychoeducation. A table for each state presents its overall grade and its grade in four categories—infrastructure, information access, services, and recovery—calculated on the basis of 39 criteria.
Each table also includes per capita and total spending on mental health services and the state's rank among other states. The per capita income in each state and its rank are also given. Boxes summarize "recent innovations" and "urgent needs" for each state. The table and boxes are accompanied by narratives that put this information in context. An appendix contains large tables in which data for all 50 states are presented to facilitate comparison.
The evaluation relied on four main sources of information. First, state mental health agencies provided written responses to detailed questionnaires, which they submitted in the last quarter of 2005. (Colorado and New York were the only states that declined to participate in the survey, for which they were graded U for "unresponsive," although narratives and other information are provided.) Second, public information was reviewed, such as state applications for block grant funds, agency reports, Web site content, and newspaper articles. Third, the accessibility of information was measured by a "consumer and family test drive" of every state agency's Web site and telephone routing system. Finally, interviews were conducted with consumer and family advocates, which provided additional information for the state narratives.
Grading the States: A Report on America's Health Care System for Serious Mental Illness can be downloaded from the NAMI Web site (www.nami.org) or ordered from the bookstore (800-950-6264).