From the Journals

MHPAEA lowers out-of-pocket spending for families of children with mental illnesses

Publish date: July 23, 2018

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Parity has limited impact on improving mental health services

While “we all hoped” mental health parity would achieve cost savings and improve payment of mental and physical health services, as well as workforce and access issues, there are limited savings seen when applying parity to these services for children. In addition, the study by Dr. Kennedy-Hendricks and associates revealed overall mental health spending and use more than doubled, which remains unexplained by parity, James M. Perrin, MD, said in an editorial.

He said, “the bottom line is that parity has some (but only limited) impact on the access to and costs of mental health services.” Other efforts, such as those to help prevent mental health conditions and integrate treatment of mental and behavioral health with the rest of pediatric health care, should be considered.

Can mental health parity still play a role? “The current study offers some hope, although it also suggests the need to monitor and enforce parity better than what seems to have occurred at least in its early years,” Dr. Perrin said. “Parity seems less likely to improve preventive efforts unless mental health benefits clearly support the many effective preventive interventions.”

“With a growing emphasis on the importance of mental and behavioral health and their influences on many other aspects of the health of children and adults, it may be time to think more imaginatively about health care financing that can better ensure attention to mental health concerns broadly,” he said. While new alternative payment models may help bridge the gap, this study emphasizes the need to improve the way in which mental and behavioral health care is paid.

Dr. Perrin is at the MassGeneral Hospital for Children and Harvard Medical School, both in Boston. He reported no relevant conflicts of interest. These comments summarize his editorial accompanying the article by Dr. Kennedy-Hendricks and associates. (Pediatrics. 2018 Jul 23. doi: 10.1542/peds.2018-1572 ).

FROM PEDIATRICS

Families of children with mental health conditions had lower spending when enrolled in insurance plans under the Mental Health Parity and Addiction Equity Act, but these cost savings did not represent a “substantial improvement” for families at the higher end of mental health spending, according to results of a study published in Pediatrics.

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Alene Kennedy-Hendricks, PhD, of the Johns Hopkins Bloomberg School of Public Health in Baltimore and her colleagues evaluated inpatient, outpatient, and pharmaceutical claims data from three national insurers available through the Health Care Cost Institute for children in 23 states born between 1990 and 2005 (who were between 3 and 18 years old in 2008); these patients had continuous medical, mental health, and pharmacy coverage before (2008-2009) and after (2011-2012) the Mental Health Parity and Addiction Equity Act (MHPAEA) went into effect. Using a difference-in-differences model, Dr. Kennedy-Hendricks and her colleagues compared these children to a similar group who had not been exposed to the parity law, and measured out-of-pocket (OOP), annual, and OOP share of total mental health spending as well as annual spending on psychotropic medications and the number of inpatient and outpatient mental health days.

They found children in plans subject to MHPAEA spent an average of $140 less on mental health care (95% confidence interval, −$196 to −$84), compared with expected “changes in the comparison group.” In families with a high level of spending for mental health, those who were insured with plans subject to parity had an average annual OOP mental health spending of $234 less (95% confidence interval, −$391 to −$76) than the comparison group.

In the first year after MHPAEA, all children subject to parity had $112 average lower spending (95% CI, −$167 to −$57), with $171 average lower spending (95% CI, −$241 to −$101) in the second year than the comparison group. Among high spenders, OOP spending was $210 lower (95% CI, −$414 to −$5) in the first year and $258 lower (95% CI, −$401 to −$114) in the second year than the comparison group.

Among patients with high mental health spending, there was a 0.5 increase in number of inpatient mental health days per year (95% CI, 0.1-0.9), according to the researchers. In addition, total mental health spending increased overall for high-spending families: Those who were self-insured paid an average of $5,302 preparity, compared with $8,708 postparity, whereas a comparison group of fully insured patients paid an average of $5,460 preparity, compared with $9,177 postparity.

“Our finding of a reduction in OOP mental health spending attributable to parity among all children with mental health conditions is consistent with the limited body of literature focused on children,” Dr. Kennedy-Hendricks and her colleagues wrote. “Although the estimated reduction in OOP spending was larger for children with high spending than among children with mental health conditions more broadly, given the much higher average annual OOP spending preparity among the high-spending group, this constitutes a relatively small reduction in OOP spending attributable to the law.”

The researchers noted as potential limitations that there may be differences in the children in the exposed and comparison group; selection of the high-spending group was based on both preparity and postparity; and there may be potential differences in other states not studied.

This study was funded by the National Institutes of Health and supported by a grant from the National Institute of Mental Health. The authors reported no relevant financial disclosures.

MHPAEA lowers out-of-pocket spending for families of children with mental illnesses

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