Effects of Mental Parity on High-Cost and Severely-Ill Individuals

描述（由申请人提供）：一个运作良好的保险市场的标志是对灾难性金融损失风险的保护。从历史上看，由于对精神健康/药物滥用服务的特殊福利限制，大多数私人健康保险计划都没有提供对精神健康/药物滥用服务造成的巨大损失的保护。平等政策旨在保护患有严重精神疾病的个人免受寻求治疗的灾难性费用，并在这样做的过程中提高保险市场的效率和公平性。2001年，要求所有参加联邦雇员健康福利方案的计划提供与一般医疗服务相同的健康保险/保健服务。FEHB平价指令是迄今为止颁布的最全面的平价政策。先前的均等研究发现，平均而言，实施MH/SA均等并没有导致反对者预测的MH/SA支出大幅增加，也没有导致心理健康倡导者预期的服务获得增加。均等使服务用户的平均自付支出减少相对较小。有可能是平均自付支出相对较小的变化所导致的平价采用是由具有最高成本的个人的子集驱动的;然而，这个问题还没有被审查。均等对患病最严重的个人和疾病带来最大经济负担的人的影响是现有关于均等的文献没有回答的核心问题。本申请的具体目的是：1）比较全面均等对医疗卫生/社会保障支出总额和自付医疗卫生/社会保障支出的影响，以确定均等是否不同程度地增加了对医疗卫生/社会保障支出高的个人的经济保护; 2）检查全面均等对他们接受的治疗的组成和强度的影响;和3）评估产次对因MH/SA状况再次住院的可能性以及诊断为双相情感障碍或重度抑郁症的患者接受适当的门诊治疗的可能性的影响。我们将使用一个准实验设计，比较FEHB计划参保者与不受FEHB平价指令约束的私人保险参保者的匹配对照组，以说明MH/SA使用和支出的长期趋势。我们将尝试通过比较使用分割的计划与不使用分割的计划，来理清平价和管理式医疗分割的影响。我们将估计纵向数据的两部分随机效应模型、潜在类随机效应模型、逻辑回归模型、泊松回归模型和风险模型的组合，以实现这些目标。

DESCRIPTION (provided by applicant): A hallmark of a well-functioning insurance market is protection against the risk of catastrophic financial losses. Historically, protection from large losses resulting from mental health/substance abuse (MH/SA) service use has been unavailable in most private health insurance plans because of special benefit limits on MH/SA services. Parity policies aim to protect individuals with severe mental illnesses against the catastrophic costs of seeking treatment, and, in doing so, increase efficiency and fairness in the insurance market. In 2001, all plans participating in the Federal Employees Health Benefits (FEHB) Program were required to offer coverage for MH/SA services on a par with general medical services. The FEHB parity directive represents the most comprehensive parity policy enacted to date. Previous studies of parity have found that, on average, implementation of MH/SA parity did not result in either the large increases in MH/SA spending predicted by opponents or increased access to services anticipated by mental health advocates. Parity has resulted in relatively small reductions in average out-of-pocket spending for service users. It is possible that the relatively small changes in average out-of-pocket spending resulting from parity adoption were driven by the subset of individuals with the highest costs; however, this issue has not been examined. The impact of parity on the sickest individuals and those carrying the greatest financial burden of illness constitutes the central question left unanswered by the existing literature on parity. The specific aims of this application are to: 1) Compare the effects of comprehensive parity on total and out-of-pocket MH/SA spending across the distribution of expenditures in order to determine whether parity differentially increased financial protection for individuals with high MH/SA expenditures; 2) Examine the effect of comprehensive parity on the composition and intensity of the treatment they receive; and 3) Assess the effect of parity on the likelihood of being rehospitalized for an MH/SA condition and the likelihood that patients diagnosed with bipolar disorder or major depression receive appropriate ambulatory treatment. We will use a quasi-experimental design to compare FEHB plan enrollees with a matched comparison group of privately-insured enrollees not subject to the FEHB parity directive to account for secular trends in MH/SA use and spending. We will attempt to disentangle the effects of parity and managed care carve-outs by comparing plans that used carve-outs with those that did not. We will estimate a combination of two-part random-effects models for longitudinal data, latent class random-effects models, logistic regression models, Poisson regression models, and hazard models to address these aims.