The Mental Health Parity and Addiction Equity Act evaluation study: Impact on specialty behavioral health utilization and expenditures among “carve-out” enrollees
Open accessAbstract
Interrupted time series with and without controls was used to evaluate whether the federal Mental Health Parity and Addiction Equity Act (MHPAEA) and its Interim Final Rule increased the probability of specialty behavioral health treatment and levels of utilization and expenditures among patients receiving treatment. Linked insurance claims, eligibility, plan and employer data from 2008 to 2013 were used to estimate segmented regression analyses, allowing for level and slope changes during the transition (2010) and post-MHPAEA (2011-2013) periods. The sample included 1,812,541 individuals ages 27-64 (49,968,367 person-months) in 10,010 Optum "carve-out" plans. Two-part regression models with Generalized Estimating Equations were used to estimate expenditures by payer and outpatient, intermediate and inpatient service use. We found little evidence that MHPAEA increased utilization significantly, but somewhat more robust evidence that costs shifted from patients to plans. Thus the primary impact of MHPAEA among carve-out enrollees may have been a reduction in patient financial burden.
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Among the general population, there is some evidence of modest utilization increases associated with MHPAEA.
“Among the general population, there is some evidence of modest utilization increases associated with MHPAEA.”
From The Mental Health Parity and Addiction Equity Act evaluation study: Impact on specialty behavioral healthcare utilization and spending among enrollees with substance use disorders (2017) · cites this paper as Ettner et al., 2016
The Results (page unavailable) report small increases in the probability of structured outpatient and inpatient care after MHPAEA. But the study covers carve-out enrollees, not the general population, and the Discussion describes the utilization findings as mixed, with no broad, consistent increase. (LLM, conf=0.86)
Experimental — accuracy not yet measuredTwo additional studies documented modest increases in expenditures and utilization among all patients enrolled in carve-in plans and carve-out plans.
“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).”
From The Mental Health Parity and Addiction Equity Act evaluation study: Impact on specialty behavioral healthcare utilization and spending among enrollees with substance use disorders (2017) · cites this paper as Ettner et al., 2016
The Results (Overall changes associated with MHPAEA; page unavailable) report a modest increase in plan expenditures and an increase in structured outpatient days among carve-out enrollees. But utilization changes were mixed, patient expenditures fell, and total expenditures had a declining trend. The paper does not support a general increase in both expenditures and utilization among all enrollees. (LLM, conf=0.87)
Experimental — accuracy not yet measuredThe 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) than in analyses of all adults in carve-in and carve-out plans (approximately $1).
“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).”
From The Mental Health Parity and Addiction Equity Act evaluation study: Impact on specialty behavioral healthcare utilization and spending among enrollees with substance use disorders (2017) · cites this paper as Ettner et al., 2016
The Results section (Overall changes associated with MHPAEA; page unavailable) reports an immediate $1.78 increase in monthly plan expenditures among all carve-out enrollees, broadly consistent with a change on the order of $1. It reports a negative change in the slope of total expenditures, but does not substantiate the claimed approximately $1 level change in total expenditures. This paper does not study the carve-in or SUD-only comparison groups. (LLM, conf=0.83)
Experimental — accuracy not yet measuredThe increases associated with MHPAEA are larger in magnitude than increases detected among a sample of all enrollees (i.e. not only those with SUD diagnoses).
“These increases, while modest in magnitude, are larger in magnitude than increases detected among a sample of all enrollees (i.e. not only those with SUD diagnoses).”
From The Mental Health Parity and Addiction Equity Act evaluation study: Impact on specialty behavioral healthcare utilization and spending among enrollees with substance use disorders (2017) · cites this paper as Ettner et al., 2016
The direction of this study's findings resembles results from similar analyses in all adults in carve-in plans and all adults in carve-out plans.
“The direction of this study's findings resembles results from similar analyses using the same source data, but conducted in a sample of all adults in carve-in plans (i.e. the general population) (Harwood et al., 2017) and all adults in carve-out plans (Ettner et al., 2016).”
From The Mental Health Parity and Addiction Equity Act evaluation study: Impact on specialty behavioral healthcare utilization and spending among enrollees with substance use disorders (2017) · cites this paper as Ettner et al., 2016
Among users of BH specialty services, the subset with SUD diagnoses has much higher pre-parity average PMPM total expenditures ($1035) compared to all carve-in users ($331) and all carve-out users ($302).
“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).”
From The Mental Health Parity and Addiction Equity Act evaluation study: Impact on specialty behavioral healthcare utilization and spending among enrollees with substance use disorders (2017) · cites this paper as Ettner et al., 2016
The Results section on descriptive statistics discusses pre-parity data for carve-out enrollees but does not give the claimed $302 average for users. Searches for $1035, $331, $302, and the SUD-versus-carve-in/carve-out comparison found no passage in our copy establishing those figures or the comparison. (LLM, conf=0.76)
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- Authors
- Ettner, S. L., M. Harwood, J., Thalmayer, A., Ong, M. K., Xu, H., Bresolin, M. J., Wells, K. B., Tseng, C.-H., & Azocar, F.
- Affiliations
- University of California, Los Angeles (US)
- UnitedHealth Group (United States) (US)
- Corresponding author
- Ettner, Susan L.
- ORCID
- Venue
- Journal of Health Economics
- Publisher
- Elsevier BV
- Published
- 2016-12
- Volume
- 50
- Pages
- 131-143
- ISSN
- 0167-6296 (ISSN-L)
- PMC
- PMC5127782
- OpenAlex
- W2523995877
- Cited by
- 53
- References
- 24
- Citations by year
- 2026: 2 · 2025: 2 · 2024: 3 · 2023: 3 · 2022: 4 · 2021: 5 · 2020: 6 · 2019: 9 · 2018: 10 · 2017: 8 · 2016: 1
- FWCI
- 18.13
- Type
- journal article
- Language
- en
- Open access
- green
- www.zora.uzh.ch
- Licence
- Locations
- Journal of Health Economics (publishedVersion)
- PubMed (publishedVersion)
- Zurich Open Repository and Archive (University of Zurich) (acceptedVersion, other-oa)
- PubMed Central (acceptedVersion)
- RePEc: Research Papers in Economics (submittedVersion)
- eScholarship (California Digital Library) (submittedVersion)
- Zurich Open Repository and Archive (University of Zurich) (submittedVersion, other-oa)
- Zurich Open Repository and Archive (University of Zurich)
- Funders
- National Institute on Drug Abuse (1R01DA032619-01)
- Topics
- Social Sciences › Economics, Econometrics and Finance › Economics and Econometrics › Healthcare Policy and Management
- Social Sciences › Psychology › Social Psychology › Mental Health Treatment and Access
- Health Sciences › Health Professions › General Health Professions › Health, Medicine and Society
- Keywords
- Mental Health Parity and Addiction Equity Act, mental health parity, addiction treatment, health care expenditure, employer-sponsored health insurance, patient financial burden, behavioral health services
- MeSH terms
- Adult, Health Expenditures, Female, Humans, Male, Mental Health, Mental Health Services, Middle Aged, Psychiatry, United States, Health Status Disparities
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