The Mental Health Parity and Addiction Equity Act Evaluation Study: Impact on Specialty Behavioral Health Care Utilization and Spending Among Carve-In Enrollees
Open accessAbstract
OBJECTIVE: The federal Mental Health Parity and Addiction Equity Act (MHPAEA) sought to eliminate historical disparities between insurance coverage for behavioral health (BH) treatment and coverage for medical treatment. Our objective was to evaluate MHPAEA's impact on BH expenditures and utilization among "carve-in" enrollees. METHODS: We received specialty BH insurance claims and eligibility data from Optum, sampling 5,987,776 adults enrolled in self-insured plans from large employers. An interrupted time series study design with segmented regression analysis estimated monthly time trends of per-member spending and use before (2008-2009), during (2010), and after (2011-2013) MHPAEA compliance (N=179,506,951 member-month observations). Outcomes included: total, plan, patient out-of-pocket spending; outpatient utilization (assessment/diagnostic evaluation visits, medication management, individual and family psychotherapy); intermediate care utilization (structured outpatient, day treatment, residential); and inpatient utilization. RESULTS: MHPAEA was associated with increases in monthly per-member total spending, plan spending, assessment/diagnostic evaluation visits [respective immediate increases of: $1.05 (P=0.02); $0.88 (P=0.04); 0.00045 visits (P=0.00)], and individual psychotherapy visits [immediate increase of 0.00578 visits (P=0.00) and additional increases of 0.00017 visits/mo (P=0.03)]. CONCLUSIONS: MHPAEA was associated with modest increases in total and plan spending and outpatient utilization; for example, in July 2012 predicted per-enrollee plan spending was $4.92 without MHPAEA and $6.14 with MHPAEA. Efforts should focus on understanding how other barriers to BH care unaddressed by MHPAEA may affect access/utilization. Future research should evaluate effects produced by the Affordable Care Act's inclusion of BH care as an essential health benefit and expansion of MHPAEA protections to the individual and small group markets.
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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 Harwood et al., 2017
The Discussion reports that MHPAEA was associated with modest increases in outpatient behavioral-health utilization. However, the study examined commercially insured adults in large-employer plans, not the general population; its finding does not establish an increase across that broader population. (LLM, conf=0.84)
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 Harwood et al., 2017
The Results (‘Changes among all enrollees’; page not provided) report MHPAEA-associated increases in spending and outpatient visits among all enrollees, supporting the comparison group described. The paper does not establish that increases among people with SUD diagnoses were larger than those increases. (LLM, conf=0.84)
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 Harwood et al., 2017
The Abstract’s Results report immediate increases of $1.05 in total spending and $0.88 in plan spending per member, supporting the approximately $1 comparison for adults in carve-in plans. The Methods’ Sample section says this paper studied carve-in plans and that carve-out plans were investigated separately; it does not support the approximately $1 figure for carve-out enrollees. The approximately $30 SUD result is presented as the citing study’s own finding, not a finding attributed to this source. (LLM, conf=0.88)
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 Harwood et al., 2017
Earlier analyses have shown that MHPAEA's reforms were associated with modest increases in specialty BH utilization and expenditures among a population of adult enrollees.
“Following MHPAEA's historically comprehensive reforms to BH benefits for commercially-sponsored insurance plans, earlier analyses have shown that the resulting increases in specialty BH utilization and expenditures among a population of adult enrollees were modest (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 Harwood et al., 2017
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 Harwood et al., 2017
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 Harwood et al., 2017
The Results (Sample characteristics; page unavailable) say the paper reports average behavioral-health spending among users, but the passages in our copy do not give the claimed $1,035, $331, or $302 figures or compare users with SUD diagnoses against the other groups. The Methods (Sample; page unavailable) state that this paper studies carve-in plans and that carve-out plans are investigated separately. Searches for the figures and the SUD comparison did not establish the claimed comparison from this source. (LLM, conf=0.75)
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“Discussion Following MHPAEA's historically comprehensive reforms to BH benefits for commerciallysponsored insurance plans, earlier analyses have shown that the resulting increases in specialty BH utilization and expenditures among a population of adult enrollees were modest (Harwood et al., 2017).”
BackgroundResultInfluentialSelf-citation
- Authors
- Harwood, J. M., Azocar, F., Thalmayer, A., Xu, H., Ong, M. K., Tseng, C.-H., Wells, K. B., Friedman, S., & Ettner, S. L.
- Affiliations
- University of California, Los Angeles (US)
- Optum, United Health Group, San Francisco, CA
- United States Department of Veterans Affairs (US)
- Corresponding author
- Harwood, Jessica M.
- Xu, Haiyong
- Ong, Michael K.
- Tseng, Chi-Hong
- Ettner, Susan L.
- ORCID
- Venue
- Medical Care
- Published
- 2017-02
- Volume
- 55
- Issue
- 2
- Pages
- 164-172
- ISSN
- 0025-7079 (ISSN-L)
- PMC
- PMC5233645
- OpenAlex
- W2922381200
- Cited by
- 28
- References
- 25
- Citations by year
- 2026: 2 · 2024: 3 · 2023: 2 · 2021: 1 · 2020: 1 · 2019: 10 · 2018: 5 · 2017: 3 · 2016: 1
- FWCI
- 12.33
- Type
- journal article
- Language
- en
- Open access
- green
- www.zora.uzh.ch
- Licence
- other-oa
- Locations
- Medical Care (publishedVersion)
- PubMed (publishedVersion)
- Zurich Open Repository and Archive (University of Zurich) (acceptedVersion, other-oa)
- PubMed Central (acceptedVersion)
- 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 Institutes of Health (TL1TR000121, TL1TR001883, UL1TR001881)
- National Institute on Drug Abuse (R01DA032619)
- National Center for Advancing Translational Sciences
- Topics
- Social Sciences › Economics, Econometrics and Finance › Economics and Econometrics › Healthcare Policy and Management
- Social Sciences › Psychology › Social Psychology › Mental Health Treatment and Access
- Social Sciences › Psychology › Clinical Psychology › Psychiatric care and mental health services
- Keywords
- Mental Health Parity and Addiction Equity Act, employer-sponsored health insurance, outpatient care utilization, intermediate care, inpatient utilization, out-of-pocket costs
- MeSH terms
- Adult, Health Expenditures, Female, Financing, Personal, Humans, Insurance Claim Review, Insurance, Psychiatric, Male, Mental Health Services, Middle Aged, Regression Analysis, United States, Interrupted Time Series Analysis
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