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Parity analysis reminds us that a new law doesn't end the discussion

February 17, 2011
by Gary A. Enos, Editor
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It will take time for equal coverage to translate to better care

While a new analysis of substance abuse parity requirements bolsters earlier findings that parity mandates don’t cause insurance costs to soar, the latest data might disappoint those who assume that parity also leads to greater utilization of services.

A study published in the February issue of the American Psychiatric Association (APA) journal Psychiatric Services examined longstanding parity requirements in federal employee benefit plans, finding that the mandates had little impact on substance use treatment initiation or engagement.

The study doesn’t clarify the factors that might have contributed to this, though its authors consider the findings not surprising since quality improvement is believed to occur only after multiple, concerted efforts to change practice, not by simply altering the terms of insurance coverage.


The APA’s director of healthcare systems and financing, Sam Muszynski, says care providers need to be reminded that the fight for parity did not end with the long struggle to see comprehensive federal legislation passed. “It took 10 to 12 years to get this; it’s going to take at least half that long to sort it all out,” Muszynski says. The Psychiatric Services paper looks at parity protections for beneficiaries covered by Federal Employees Health Benefit (FEHB) plans; these were written into law nearly a decade before the 2008 adoption of the broader federal parity law. Researchers at Harvard Medical School’s Department of Health Care Policy and at RAND examined six preferred provider organization (PPO) plans under FEHB and compared substance abuse treatment spending, utilization and quality in the two-year periods before and after parity took effect.


They then conducted the same analysis for a matched set of health plans that were not subject to parity requirements during the same period. In their analysis of quality, the researchers looked at three measures: identification of substance abuse services (proportion of enrollees who received any treatment), initiation of treatment (proportion of enrollees with a new substance use diagnosis who had either an inpatient admission or an initial outpatient service), and engagement in treatment (the proportion of enrollees receiving at least two additional treatment services within 30 days of initiation).


The researchers found that while total substance abuse spending increased in the period studied, the increase did not differ based on the presence of parity coverage. Out-of-pocket spending for substance abuse services was significantly lower for individuals in the parity plans, which is the intent of parity laws.


But while parity resulted in identification of more individuals with substance abuse treatment needs, the individuals in parity plans were no more likely to initiate or engage in treatment services. Muszynski believes future research needs to examine more closely why this is the case. “What we don’t know is what happens between the identification and the engagement stages,” he says.


Clearly there can be a number of potential barriers to engagement, from client hesitation to systemic hurdles such as managed care requirements for authorization. Muszynski believes providers need to be able to identify what types of issues in the marketplace might run afoul of parity mandates. “We’re seeing some new prior authorization requirements” in some plans, he points out.

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