A. Background

By using various cost-control methods, managed behavioral health care has made it possible to offer expanded parity-level benefits without dramatic cost increases. However, those same controls are also sufficiently powerful to prevent access to mental health services. During the last 2 years, more data sets became available for evaluating access and refining its measurement. While researchers were initially only able to measure the probability of any mental health use in a given year, they can now also identify the intensity (volume) of access. In addition, a very recent study was able to differentiate between the population with severe mental illness (SMI) and the non-SMI population while evaluating access to care.

B. Case Studies

Concerns that cost containment and price competition among managed care companies might have unduly restricted access to specialty treatment led the NAMHC Parity Workgroup to request a preliminary study to examine the relationship between insurance companies' expenditures on mental health (measured by cost per member per month, PMPM) and the probability of receiving any specialty mental health treatment. The analysis indicates that, in general, access to specialty treatment decreases as mental health expenditures fall (Weissman et al. 2000).

Case Study 2:

The pre- and post-parity study described in Subsection III C (Zuvekas et al. 2000) provides extensive data on the impact of parity and carve-out managed care on access to and use of inpatient and outpatient mental health services by adults and children. Overall treated prevalence (for employees, spouses, and dependents) rose from 4.9 percent pre-parity (Year 1 of the study) to 7.3 percent after 3 years of parity (Year 4).

As noted earlier, this case study also compared the experience of the large-employer group to other smaller groups who were not subject to the parity benefit. Treated prevalence also increased in these smaller groups over the same period, suggesting that factors other than parity and carve-out management may have contributed to better access to services. However, it is also clear that parity and carve-out management did not lead to reduced access at the same time that costs were dramatically reduced.

Inpatient Admissions: Between Year 1 and Year 4 of the Zuvekas et al. study, inpatient admissions for employees and their spouses rose by a little over one quarter. However, for dependents, inpatient admissions fell 40 percent overall, with admissions down 65 percent for 6- to 12- year-olds and down 45 percent for 13- to-17-year-olds, while admissions rose slightly for dependents 18 and older.

During the same period the average number of inpatient nights decreased substantially for employees from 83 nights per 1000 enrollees to 47 nights, and from 98 nights to 71 for spouses. Among children and adolescents, the number of inpatient nights decreased by 80 percent, with most decreases occurring among 6- to 17- year-olds. The average length of stay for these dependents fell from more than 30 nights per admission to about 10 nights per admission.

Although overall inpatient admissions for dependents, employees, and spouses fell slightly with parity (8 percent), the number of inpatient nights was reduced almost 70 percent. As noted above, dependents experienced the most dramatic changes. In the pre-parity period, 77 percent of dependents receiving inpatient treatment during the year spent more than 30 nights in the hospital, and 61 percent spent more than 60 nights. By the third year of parity, 52 percent of dependents receiving inpatient treatment spent more than 30 nights during the year as inpatients, and only 34 percent spent more than 60 nights. As noted in Section III, it is unclear if the decrease in inpatient use has a positive or negative impact, especially since outpatient use increased (see below). The long-term effect on mental health remains to be determined.

Outpatient Utilization: Overall, both the proportion of enrollees with any outpatient use and number of outpatient visits per 1000 increased by 50 percent under parity. Dependents were less likely than employees or spouses to use outpatient mental health and substance abuse services; they also tended to have slightly fewer visits when they did use them. In general, although a greater proportion of enrollees were using mental health services after parity, the mean number of visits for those with any use remained virtually unchanged.

C. Studies Based on National Data Sets

In theory, implementing parity for mental health can reduce financial barriers to access to mental health care (Rupp and Lapsley 2000). Research based on national data sets confirms that more people have access to mental health care under parity, but there is not necessarily more use per individual (Sturm and Sherbourne 2000). Another national study, which examined how parity affects the use of mental health services by people in poor mental health vs. those not in poor mental health, revealed a small increase in number of visits among the former group (Sturm and Wells 2000). Despite some limitations in the generalizability of this study, it suggests that even limited reductions in co-insurance rates and deductibles can increase access for those in greatest need for mental health services.

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This page was last updated: November 1, 2000.