Research paper
The United States’ Federal Parity Act and treatment of substance use disorders: Administrators’ familiarity and perceptions of impact

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Abstract

Background

The 2008 Wellstone and Domenici Mental Health Parity and Addiction Equity Act (MHPAEA) aims to secure parity in private insurance coverage between behavioral and other medical disorders in the United States (U.S.). This legislation represents an important change in the operating field of substance use disorder treatment, but to date, its impact on treatment centers has not been widely examined. The current study measured the extent of center leaders’ familiarity with the MHPAEA and their perceptions of its overall impact on their centers.

Methods

Using a nationally representative sample of treatment centers in the U.S., we examined the extent of MHPAEA familiarity and its perceived impact as reported by treatment center leaders. We further employed logistic and ordered logistic regressions to determine personal and organizational characteristics associated with their reported familiarity and experienced impacts, including changes in the number of privately-insured clients seeking treatment and in the treatment coverage of those clients.

Results

We found that dissemination of parity information was low. Only 36% of administrators reported high levels of familiarity and 16% used professional sources of information. The majority of administrators (71%) reported no impact of the legislation on their organization, but those that reported any impact were more likely to state positive impact. Greater parity knowledge and perceived positive impacts were associated with administrator and organizational characteristics indicative of greater access to industry-specific knowledge, a medical model orientation, and reliance on private insurance revenue.

Conclusion

This study demonstrates that dissemination of parity information is lacking and that the majority of leaders have yet to experience an impact of the MHPAEA. Leaders of centers with more sophisticated structures are most likely to be familiar with the legislation and perceive a positive impact. Research concerning the effective management of treatment centers, including environmental scanning techniques, continues to be needed.

Introduction

In the United States (U.S.), public policy has held an historic influence in the provision of substance use disorder (SUD) treatment services. Over the past several decades, multiple federal acts have shifted the societal management of SUD from the criminal justice system to medicalized care and control (Beauchamp, 1980, Finn, 1985). Further, agencies within the National Institutes of Health have been mandated to conduct research on SUD and provide policy leadership for treatment providers (Metlay, 2013, Roman, 2014). Most recently, the 2010 Patient Protection and Affordable Care Act (ACA), which is arguably the most extensive U.S. public policy concerning healthcare ever to be established, expressly seeks to enhance Americans’ access to SUD treatment.

Much of U.S. policy regarding SUD treatment has been heavily influenced by activists committed to treating SUD “as a disease like any other” (Beauchamp, 1980). These activists have stressed disparities between U.S. healthcare systems’ response to mental health disorders, including SUD, and other physical illnesses in terms of treatment accessibility, quality, and insurance coverage. These concerns are at the heart of the 2008 Wellstone and Domenici Mental Health Parity and Addiction Equity Act (MHPAEA). This Act is intended to create national parity between third-party health insurance reimbursement for the treatment of SUD and comparable reimbursements for treatment of other medical disorders, and has served as the foundation for the ACA's approach to SUD as well. The current study's aim is to examine the extent to which SUD treatment center leaders are informed about this legislation and their initial perceptions about its impact, using a nationally representative sample of U.S. SUD treatment centers.

Section snippets

U.S. healthcare financing and SUD treatment

The U.S. healthcare system is costly and complex. For example, healthcare spending in the U.S. is far greater than in other industrialized nations (Lorenzoni, Belloni, & Sassi, 2014), and its healthcare financing is composed of an intricate and globally unique amalgam of private and public insurance providers (World Health Organization, 2015). While variation in healthcare financing is evident, the U.S. relies more heavily on private insurance providers than any other comparable country (

The MHPAEA

The MHPAEA is a national response to these common coverage limitations. It also serves as a way to achieve greater uniformity in SUD and mental health coverage as it supersedes pre-existing state legislation, which rarely achieved comprehensive parity (NAMI, 2009). While it does not require insurance plans to offer SUD benefits, if such benefits are present, they must be on par with a plan's physical health benefits. Further, if a plan does not impose a financial requirement or treatment

The MHPAEA and SUD treatment

While state-level parity legislation has often excluded or limited SUD protections (NAMI, 2009), the MHPAEA includes SUD in its definition of mental health conditions. Thus, the MHPAEA has the potential to positively influence treatment on a national scale for a disorder that is remarkably under-treated. In 2013, the U.S. National Survey of Drug Use and Health reported that 89% of individuals with SUD did not receive treatment (Substance Abuse and Mental Health Services Administration [SAMHSA],

The MHPAEA and SUD treatment center administration

SUD treatment center administrators hold a central role in the organizational make-up and treatment orientations of their institutions. In particular, how administrators understand and utilize industry changes, like the MHPAEA, can have a profound influence on centers’ access to resources and treatment delivery (Pfeffer & Salancik, 1978). Policies governing reimbursement for treatment services have been at the core of the highly uncertain resource environment for SUD treatment providers since

Sample

Data for this study were taken from a nationally representative sample of SUD treatment programs. Using SAMHSA's Substance Abuse Treatment Services Locator, treatment programs within the 48 contiguous states (i.e. all states excluding Alaska and Hawaii) were randomly selected for eligibility screening via telephone. This sampling methodology ensured that each treatment program in the continental U.S. had an equal probability of selection. Several criteria were used to establish eligibility.

Results

Descriptive results can be found in Table 1. First, contrary to our expectations, perceived parity familiarity was rather low. The mean of the familiarity scale was 2.9 on scale of zero to five. Only 36% of center administrators reported a high level of familiarity (i.e. answered a four or five on the familiarity scale). Further, the majority of administrators (71%) perceived that the MHPAEA had no impact on their centers. This contrasted to the 22% who perceived a positive impact, and the 7%

Discussion

In addition to being legislation that could impact revenue for SUD treatment centers, the MHPAEA could empower providers to demand better insurance coverage when equity is not present. With such potential importance, one would expect those charged with administering SUD treatment programs in the U.S. to approach this legislation with a great deal of curiosity. The low levels of sensitivity about and information-seeking behavior relative to parity legislation among this critical group is

Limitations

While the current study provides an important opportunity for better understanding SUD treatment center administrators’ opinion and familiarity with the MHPAEA, it is not without its limitations. Because correctional and other facilities that are not open to the general public were excluded from the sampling frame, the results of this study cannot be generalized to those facilities. Also, the cross-sectional nature of our data does not allow for causal relationships to be identified. Future

Conclusion

Our findings indicate that, while parity familiarity was low and the majority of center leaders did not perceive an impact on their centers, those that had perceived an impact were most likely to see that impact as positive. Center leaders with greater parity knowledge were more likely to be highly educated, utilize professional information sources, and manage centers that incorporate the medical model into treatment. In terms of perceived impact, MHPAEA familiarity was associated with

Acknowledgement

Data collection for these analyses was funded by the National Institute on Alcohol Abuse and Alcoholism (Grant R01AA015974).
Conflict of interest statement

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper. The paper has not been published previously and is not under consideration for publication elsewhere.

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