U.S. Department of Health and Human Services Office of the Assistant Secretary for Planning and Evaluation

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In January 2001, the Federal Employees Health Benefits (FEHB) Program, the largest employer-sponsored health insurance program in the Nation, instituted a mental health and substance abuse (MH/SA) parity policy in compliance with an earlier Presidential directive. This policy mandated that MH/SA services would be covered to the same extent as general medical care with respect to benefit design features, such as deductibles, copayments, and limits on visits and inpatient days.

In the fall of 2000, the Department of Health and Human Services awarded a contract to evaluate the implementation and impact of MH/SA parity benefits in terms of access, utilization, cost, and quality of care. The findings of this evaluation are reported in the attached report.

As the report was being finalized for publication, ASPE commissioned an independent actuarial analysis of the impact of MH/SA parity on premiums. The results of this analysis are reported in a memorandum which is available at http://aspe.hhs.gov/health/reports/05/mhsamemo.htm.

U.S. Department of Health and Human Services

Evaluation of Parity in the Federal Employees Health Benefits (FEHB) Program: Final Report

Parity Evaluation Research Team

Northrop Grumman Information Technology
Harvard Medical School
RAND Corporation
University of Maryland, Baltimore
Westat

December 31, 2004

This report was prepared under contract #HHS-100-00-0025 between the U.S. Department of Health and Human Services (HHS), Office of Disability, Aging and Long-Term Care Policy (DALTCP) and Northrop Grumman Information Technology, Inc. Additional funds provided by the U.S. Office of Personnel Management. For additional information about the study, you may visit the DALTCP home page at http://aspe.hhs.gov/_/office_specific/daltcp.cfm or contact the ASPE Project Officer, Cille Kennedy, at HHS/ASPE/DALTCP, Room 424E, H.H. Humphrey Building, 200 Independence Avenue, SW, Washington, DC 20201. Her e-mail address is: Cille.Kennedy@hhs.gov.

Additional funding for this evaluation was provided by the National Institute of Mental Health, the National Institute on Drug Abuse, the National Institute of Alcohol Abuse and Alcoholism, the Substance Abuse and Mental Health Services Administration, the Agency for Healthcare Research and Quality, and the Centers for Medicare and Medicaid Services.

The views expressed are those of the authors and should not be attributed to the Federal Government or the Parity Evaluation Research Team agencies.

Comment on the Independent Actuarial Analysis of the Impact of Mental Health and Substance Abuse Parity in the FEHB Program

In interpreting the results of the actuarial analysis of parity alongside the statistical analysis of the policy change it is important to bear in mind key differences in methodology and definitions used in the two sets of analyses.

Definition of Mental Health and Substance Abuse Care

Mental health and substance abuse (MH/SA) spending in the Parity evaluation included all claims paid for treatment of mental health and substance abuse disorders. These included specialty inpatient and outpatient services (e.g. those delivered by specialized professionals such as psychologists and psychiatrists and inpatient services in psychiatric hospitals and general hospital psychiatric or substance abuse units), psychotropic drugs used to treat mental and addictive disorders, and services used to treat MH/SA problems provided by primary care physicians. In contrast, the actuarial analysis focused only on specialty inpatient and outpatient services. The implication of these definitional differences is that the actuarial analysis focuses on roughly 50% of total spending on MH/SA care. Thus, if the parity policy affected patterns of MH/SA treatment broadly, the actuarial analysis would reflect some but not all of the possible spending changes.

Evaluation Method

The actuarial analysis is based on comparing the before period trend to the after period trend and attributing the difference to parity. The Parity evaluation compared the before/after change in trend for the FEHB population to expenditure patterns for a matched control group of large insured populations to control for what the trend would have been absent parity. Since the period 1999-2003 was one in which there was considerable flux in the rates of change in health care spending, the two methods might well be expected to produce different estimates of the impact of the implementation of parity.

PARITY EVALUATION RESEARCH TEAM (PERT)

Northrop Grumman Information Technology, Inc., (Prime Contractor)
Federal Enterprise Solutions, Health Solutions

Carolyn Lichtenstein, Ph.D., Project Director
Margaret Blasinsky, M.A.¹
Jonathan Davis
Rebecca Gunning
Lisa Patton, Ph.D.²

University of Maryland, Baltimore
School of Medicine

Howard H. Goldman, M.D., Ph.D., Principal Investigator

Harvard Medical School
Department of Health Care Policy

Richard G. Frank, Ph.D., Research Director
Vanessa Azzone, Ph.D.
Colleen Barry, Ph.D.³
Alisa Busch, M.D.
Haiden Huskamp, Ph.D.
Sharon-Lise Normand, Ph.D.
Meredith Rosenthal, Ph.D.

The RAND Corporation

M. Audrey Burnam, Ph.D., Research Director
Melinda Beeuwkes Buntin, Ph.D.
David Dausey, Ph.D.
M. Susan Ridgely, J.D.
Stephanie Teleki, Ph.D.
Alex Young, M.D.

Westat

Susan T. Azrin, Ph.D., Research Director
Garrett Moran, Ph.D.
Joshua Noda, M.P.P.
Carolyn Boccella Bagin (Center for Clear Communication, Inc.)

ACKNOWLEDGEMENTS

First and foremost, the Parity Evaluation Research Team (PERT) thanks the FEHB Program plans that cooperated in various aspects of the evaluation. This is especially true of the eight plans that were site-visited and the nine plans for which we collected detailed claims and encounter data. As the individual plans remain anonymous in this report, the PERT can only thank them collectively.

Special thanks goes to Abby Block of the Office of Personnel Management, as well as to current and past Government Project Officers and the two work groups who advised the evaluation, the Federal Technical Work Group and the Technical Advisory Group.

Current Project Officers

Cille Kennedy, Ph.D.
Office of the Assistant Secretary for Planning and Evaluation
U.S. Department of Health and Human Services

Anne Easton Michael Kaszynski
Office of Personnel Management

Past Project Officers

Kevin D. Hennessy, Ph.D.⁴
Office of the Assistant Secretary for Planning and Evaluation
U.S. Department of Health and Human Services

Janet Pfleeger, M.A.
Office of Personnel Management

Federal Technical Work Group

Jeff Buck, Ph.D.
Center for Mental Health Services
Substance Abuse and Mental Health Services Administration
U.S. Department of Health and Human Services

William S. Cartwright, Ph.D.
National Institute on Drug Abuse
National Institutes of Health
U.S. Department of Health and Human Services

Mady Chalk, Ph.D.
Center for Substance Abuse Treatment
Substance Abuse and Mental Health Services Administration
U.S. Department of Health and Human Services

Harold Perl, Ph.D.
National Institute on Alcohol Abuse and Alcoholism
U.S. Department of Health and Human Services

Agnes Rupp, Ph.D.
National Institute of Mental Health
National Institutes of Health
U.S. Department of Health and Human Services

Fred Thomas, Ph.D.
Centers for Medicare and Medicaid
U.S. Department of Health and Human Services

Samuel H. Zuvekas, Ph.D.
Agency for Healthcare Research and Quality
U.S. Department of Health and Human Services

Technical Advisory Group

Teh-wei Hu, Ph.D.
University of California at Berkeley

Randall M. Lutz, J.D.
Hodes, Ulman, Pessin & Katz, P.A.

Dennis McCarty, Ph.D.
Oregon Health Sciences University

Tom McLellan, Ph.D.
Treatment Research Institute at University of Pennsylvania

Valerie Moore, M.S.P.H.
Blue Cross Blue Shield of Georgia

Stacia Murphy
National Council on Alcohol and Drug Dependence

Margo Rosenbach, Ph.D.
Mathematica Policy Research, Inc.

Steven S. Sharfstein, M.D., M.P.A.
Sheppard Pratt Health Systems

Donald Sloane Shepard, Ph.D.
The Heller Graduate School, Brandeis University

Carolyn Watts (Madden), Ph.D.
University of Washington

TABLE OF CONTENTS

EXECUTIVE SUMMARY

Background

Evaluation Design and Key Research Questions

Findings

Evaluation Findings in Brief

CHAPTER I. BACKGROUND TO THE POLICY OF PARITY

History of Mental Health Benefits and Parity Experiences in the Federal Government

State Experiences with Parity

CHAPTER II. DESIGN OF THE EVALUATION

Goals and Objectives of the Evalaution

Framework for Evaluating the Implementation of Parity in the FEHB Program

Research Questions

Overview of the Evaluation Methodology

Data Collection Issues

CHAPTER III. IMPLEMENTATION OF PARITY

Overview

Federal Employees Health Benefits Parity Reporting Requirement for All Plans

Structural Changes to Plan Benefits

Implementation Case Studies

FEHB Network Providers' Experience Implementing Parity

Summary of Findings on the Implementation of Parity in the FEHB Program

CHAPTER IV. IMPACT OF PARITY

Overview

Impact on Access to Care, Service Use, and Cost

Impact on Quality of Care

CHAPTER V. SUMMARY OF EVALUATION FINDINGS

Introduction

Research Questions and Findings in Brief

Summary of Findings on Implementing Parity in the FEHB Program

Summary of Findings on the Impact of Parity in the FEHB Program--Claims and Encounter Data

REFERENCES

NOTES

APPENDICES (available in separate PDF files)

APPENDIX A: Detailed Model Specification for Plan Exit and Carve-out Analyses

APPENDIX B: Site Visit Discussion Guide

APPENDIX C: Plan Sampling

APPENDIX D: List of Medications for Identifying MH/SA Use and Spending

LIST OF TABLES

TABLE II-1. Data sources, collection methods, and analysis methods for key research questions

TABLE II-2. Overview of data collection approaches

TABLE III-1. Changes in nominal benefits (2001, 2003)

TABLE III-2. Contracts with behavioral health vendors (2001, 2003)

TABLE III-3. Pharmacy benefits managed by behavioral health vendors

TABLE III-4. Type of behavioral health vendor contract

TABLE III-5. Changes in provider networks and financial incentives for providers

TABLE III-6. Use of behavioral health utilization controls by Association plans

TABLE III-7. Use of behavioral health utilization control by other FEHB health plans

TABLE III-8. FEHB plan behavioral health cost sharing

TABLE III-9. A national FFS plan

TABLE III-10. Probability of plan exit

TABLE III-11. Descriptive data on FEHB and Medstat comparison group plans

TABLE III-12a. Carving out behavioral health benefits with comparison group

TABLE III-12b. Interaction effect from prior model

TABLE III-13a. Predicted probabilities from pre-post carve-out model

TABLE III-13b. Predicted probabilities from pre-period

TABLE III-14. Pre-post carve-out model

TABLE III-15. The eight selected health plans and their FEHB enrollment pre-parity (2000)

TABLE III-16. Costs associated with the implementation of FEHB parity in 2001 (site visit data)

TABLE III-17. Changes in nominal benefit design in response to FEHB parity (from 2000 to 2001)

TABLE III-18. Use of MBHO vendors by health plans -- pre- and post-parity (2000 versus 2001)

TABLE III-19. Utilization management by health plans -- pre- and post-parity (2000 versus 2001)

TABLE III-20. Payment and risk-sharing with in-network providers -- pre- and post-parity (2000 versus 2001)

TABLE III-21. Access to specialty care – pre- and post-parity

TABLE IV.A.1. FFS-NAT--All Enrolled Beneficiaries by Age and Beneficiary Status

TABLE IV.A.2. FFS-MA1--All Enrolled Beneficiaries by Age and Beneficiary Status

TABLE IV.A.3. FFS-MA2--All Enrolled Beneficiaries by Age and Beneficiary Status

TABLE IV.A.4. FFS-NE1--All Enrolled Beneficiaries by Age and Beneficiary Status

TABLE IV.A.5. FFS-NE2--All Enrolled Beneficiaries by Age and Beneficiary Status

TABLE IV.A.6. FFS-W--All Enrolled Beneficiaries by Age and Beneficiary Status

TABLE IV.A.7. FFS-S--All Enrolled Beneficiaries by Age and Beneficiary Status

TABLE IV.A.8. HMO-W1--All Enrolled Beneficiaries by Age and Beneficiary Status

TABLE IV.A.9. HMO-NE--All Enrolled Beneficiaries by Age and Beneficiary Status

TABLE IV.A.10. Plan Probability of MH/SA Use

TABLE IV.A.11. Plan Probability of MH Use

TABLE IV.A.12. Plan Probability of SA Use

TABLE IV.A.13. Plan Probability of MH/SA Inpatient Use

TABLE IV.A.14. Plan Probability of MH Inpatient Use

TABLE IV.A.15. Plan Probability of SA Inpatient Use

TABLE IV.A.16. Total MH/SA Spending Per Enrollee

TABLE IV.A.17. Total SA Spending Per Enrollee

TABLE IV.A.18. Total MH/SA Spending Per User

TABLE IV.A.19. Total SA Spending Per User

TABLE IV.A.20. Total MH/SA Medication Spending Per Enrollee

TABLE IV.A.21. Total MH/SA Medication Spending per User

TABLE IV.A.22. MH/SA Out-of-pocket Spending Per Enrollee

TABLE IV.A.23. SA Out-of-pocket Spending Per Enrollee

TABLE IV.A.24. MH/SA Out-of-pocket Spending Per User

TABLE IV.A.25. SA Out-of-pocket Spending Per User

TABLE IV.B.0. Summary Across Plans for Adult MH/SA Use and Spending -- Before-after-parity Analysis

TABLE IV.B.1. FFS-NAT Adult MH/SA Use and Spending -- Before-after-parity Analysis

TABLE IV.B.2. FFS-MA1 Adult MH/SA Use and Spending -- Before-after-parity Analysis

TABLE IV.B.3. FFS-MA2 Adult MH/SA Use and Spending -- Before-after-parity Analysis

TABLE IV.B.4. FFS-NE1 Adult MH/SA Use and Spending -- Before-after-parity Analysis

TABLE IV.B.5. FFS-NE2 Adult MH/SA Use and Spending -- Before-after-parity Analysis

TABLE IV.B.6. FFS-W Adult MH/SA Use and Spending -- Before-after-parity Analysis

TABLE IV.B.7. FFS-S Adult MH/SA Use and Spending -- Before-after-parity Analysis

TABLE IV.B.8. HMO-W1 Adult MH/SA Use and Spending -- Before-after-parity Analysis

TABLE IV.B.9. HMO-NE Adult MH/SA Use and Spending -- Before-after-parity Analysis

TABLE IV.C.0. Summary Across Plans for Adult MH/SA Use and Spending -- Difference-in-differences Analysis

TABLE IV.C.1. FFS-NAT Adult MH/SA Use and Spending -- Difference-in-differences Analysis

TABLE IV.C.2. FFS-MA1 Adult MH/SA Use and Spending -- Difference-in-differences Analysis

TABLE IV.C.3. FFS-MA2 Adult MH/SA Use and Spending-Difference-in-differences Analysis

TABLE IV.C.4. FFS-NE1 Adult MH/SA Use and Spending -- Difference-in-differences Analysis

TABLE IV.C.5. FFS-NE2 Adult MH/SA Use and Spending -- Difference-in-differences Analysis

TABLE IV.C.6. FFS-W Adult MH/SA Use and Spending -- Difference-in-differences Analysis

TABLE IV.C.7. FFS-S Adult MH/SA Use and Spending -- Difference-in-differences Analysis

TABLE IV.C.8. HMO-W1 Adult MH/SA Use and Spending -- Difference-in-differences Analysis

TABLE IV.C.9. HMO-NE Adult MH/SA Use and Spending -- Difference-in-differences Analysis

TABLE IV.D.0. Summary Across Plans for Adult SA Service Use and Spending -- Before-after-parity Analysis

TABLE IV.D.1. FFS-NAT Adult SA Service Use and Spending -- Before-after-parity Analysis

TABLE IV.D.2. FFS-MA1 Adult SA Service Use and Spending -- Before-after-parity Analysis

TABLE IV.D.3. FFS-MA2 Adult SA Service Use and Spending -- Before-after-parity Analysis

TABLE IV.D.4. FFS-NE1 Adult SA Service Use and Spending -- Before-after-parity Analysis

TABLE IV.D.5. FFS-NE2 Adult SA Service Use and Spending -- Before-after-parity Analysis

TABLE IV.D.6. FFS-W Adult SA Service Use and Spending -- Before-after-parity Analysis

TABLE IV.D.7. FFS-S Adult SA Service Use and Spending -- Before-after-parity Analysis

TABLE IV.D.8. HMO-W1 Adult SA Service Use and Spending -- Before-after-parity Analysis

TABLE IV.D.9. HMO-NE Adult SA Service Use and Spending -- Before-after-parity Analysis

TABLE IV.E.0. Summary Across Plans for Adult SA Service Use and Spending--Difference-in-differences Analysis

TABLE IV.E.1. FFS-NAT Adult SA Service Use and Spending--Difference-in-differences Analysis

TABLE IV.E.2. FFS-MA1 Adult SA Service Use and Spending--Difference-in-differences Analysis

TABLE IV.E.3. FFS-MA2 Adult SA Service Use and Spending--Difference-in-differences Analysis

TABLE IV.E.4. FFS-NE1 Adult SA Service Use and Spending--Difference-in-differences Analysis

TABLE IV.E.5. FFS-NE2 Adult SA Service Use and Spending--Difference-in-differences Analysis

TABLE IV.E.6. FFS-W Adult SA Service Use and Spending--Difference-in-differences Analysis

TABLE IV.E.7. FFS-S Adult SA Service Use and Spending--Difference-in-differences Analysis

TABLE IV.E.8. HMO-W1 Adult SA Service Use and Spending--Difference-in-differences Analysis

TABLE IV.E.9. HMO-NE Adult SA Service Use and Spending--Difference-in-differences Analysis

TABLE IV.F.0. Summary Across Plans for Adult MH Service Use and Spending--Difference-in-differences Analysis

TABLE IV.F.1. FFS-NAT Adult MH Service Use and Spending--Difference-in-differences Analysis

TABLE IV.F.2. FFS-MA1 Adult MH Service Use and Spending--Difference-in-differences Analysis

TABLE IV.F.3. FFS-MA2 Adult MH Service Use and Spending--Difference-in-differences Analysis

TABLE IV.F.4. FFS-NE1 Adult MH Service Use and Spending--Difference-in-differences Analysis

TABLE IV.F.5. FFS-NE2 Adult MH Service Use and Spending--Difference-in-differences Analysis

TABLE IV.F.6. FFS-W Adult MH Service Use and Spending--Difference-in-differences Analysis

TABLE IV.F.7. FFS-S Adult MH Service Use and Spending--Difference-in-differences Analysis

TABLE IV.F.8. HMO-W1 Adult MH Service Use and Spending--Difference-in-differences Analysis

TABLE IV.F.9. HMO-NE Adult MH Service Use and Spending--Difference-in-differences Analysis

TABLE IV.G.0. Summary Across Plans for Adult MH/SA Inpatient Use -- Before-after-parity Analysis

TABLE IV.G.1. FFS-NAT Adult MH/SA Inpatient Use -- Before-after-parity Analysis

TABLE IV.G.2. FFS-MA1 Adult MH/SA Inpatient Use -- Before-after-parity Analysis

TABLE IV.G.3. FFS-MA2 Adult MH/SA Inpatient Use -- Before-after-parity Analysis

TABLE IV.G.4. FFS-NE1 Adult MH/SA Inpatient Use -- Before-after-parity Analysis

TABLE IV.G.5. FFS-NE2 Adult MH/SA Inpatient Use -- Before-after-parity Analysis

TABLE IV.G.6. FFS-W Adult MH/SA Inpatient Use -- Before-after-parity Analysis

TABLE IV.G.7. FFS-S Adult MH/SA Inpatient Use -- Before-after-parity Analysis

TABLE IV.G.8. HMO-W1 Adult MH/SA Inpatient Use -- Before-after-parity Analysis

TABLE IV.G.9. HMO-NE Adult MH/SA Inpatient Use -- Before-after-parity Analysis

TABLE IV.H.0. Summary Across Plans for Adult Out-of-pocket Spending on MH/SA -- Before-after-parity Analysis

TABLE IV.H.1. FFS-NAT Adult Out-of-pocket Spending on MH/SA -- Before-after-parity Analysis

TABLE IV.H.2. FFS-MA1 Adult Out-of-pocket Spending on MH/SA -- Before-after-parity Analysis

TABLE IV.H.3. FFS-MA2 Adult Out-of-pocket Spending on MH/SA -- Before-after-parity Analysis

TABLE IV.H.4. FFS-NE1 Adult Out-of-pocket Spending on MH/SA -- Before-after-parity Analysis

TABLE IV.H.5. FFS-NE2 Adult Out-of-pocket Spending on MH/SA -- Before-after-parity Analysis

TABLE IV.H.6. FFS-W Adult Out-of-pocket Spending on MH/SA -- Before-after-parity Analysis

TABLE IV.H.7. FFS-S Adult Out-of-pocket Spending on MH/SA -- Before-after-parity Analysis

TABLE IV.H.8. HMO-W1 Adult Out-of-pocket Spending on MH/SA -- Before-after-parity Analysis

TABLE IV.H.9. HMO-NE Adult Out-of-pocket Spending on MH/SA -- Before-after-parity Analysis

TABLE IV.I.0. Summary Across Plans for Adult Out-of-pocket Spending on MH/SA -- Difference-in differences Analysis

TABLE IV.I.1. FFS-NAT Adult Out-of-pocket Spending on MH/SA -- Difference-in Differences Analysis

TABLE IV.I.2. FFS-MA1 Adult Out-of-pocket Spending on MH/SA -- Difference-in Differences Analysis

TABLE IV.I.3. FFS-MA2 Adult Out-of-pocket Spending on MH/SA -- Difference-in Differences Analysis

TABLE IV.I.4. FFS-NE1 Adult Out-of-pocket Spending on MH/SA -- Difference-in Differences Analysis

TABLE IV.I.5. FFS-NE2 Adult Out-of-pocket Spending on MH/SA -- Difference-in Differences Analysis

TABLE IV.I.6. FFS-W Adult Out-of-pocket Spending on MH/SA -- Difference-in Differences Analysis

TABLE IV.I.7. FFS-S Adult Out-of-pocket Spending on MH/SA -- Difference-in Differences Analysis

TABLE IV.I.8. HMO-W1 Adult Out-of-pocket Spending on MH/SA -- Difference-in Differences Analysis

TABLE IV.I.9. HMO-NE Adult Out-of-pocket Spending on MH/SA -- Difference-in Differences Analysis

TABLE IV.J.0. Summary Across Plans for Child MH/SA Use and Spending -- Before-after-parity Analysis

TABLE IV.J.1. FFS-NAT Child MH/SA Use and Spending -- Before-after-parity Analysis

TABLE IV.J.2. FFS-MA1 Child MH/SA Use and Spending -- Before-after-parity Analysis

TABLE IV.J.3. FFS-MA2 Child MH/SA Use and Spending -- Before-after-parity Analysis

TABLE IV.J.4. FFS-NE1 Child MH/SA Use and Spending -- Before-after-parity Analysis

TABLE IV.J.5. FFS-NE2 Child MH/SA Use and Spending -- Before-after-parity Analysis

TABLE IV.J.6. FFS-W Child MH/SA Use and Spending -- Before-after-parity Analysis

TABLE IV.J.7. FFS-S Child MH/SA Use and Spending -- Before-after-parity Analysis

TABLE IV.J.8. HMO-W1 Child MH/SA Use and Spending -- Before-after-parity Analysis

TABLE IV.J.9. HMO-NE Child MH/SA Use and Spending -- Before-after-parity Analysis

TABLE IV.K.0. Summary Across Plans for Child MH/SA Use and Spending -- Difference-in-differences Analysis

TABLE IV.K.1. FFS-NAT Child MH/SA Use and Spending -- Difference-in-differences Analysis

TABLE IV.K.2. FFS-MA1 Child MH/SA Use and Spending -- Difference-in-differences Analysis

TABLE IV.K.3. FFS-MA2 Child MH/SA Use and Spending -- Difference-in-differences Analysis

TABLE IV.K.4. FFS-NE1 Child MH/SA Use and Spending -- Difference-in-differences Analysis

TABLE IV.K.5. FFS-NE2 Child MH/SA Use and Spending -- Difference-in-differences Analysis

TABLE IV.K.6. FFS-W Child MH/SA Use and Spending -- Difference-in-differences Analysis

TABLE IV.K.7. FFS-S Child MH/SA Use and Spending -- Difference-in-differences Analysis

TABLE IV.K.8. HMO-W1 Child MH/SA Use and Spending -- Difference-in-differences Analysis

TABLE IV.K.9. HMO-NE Child MH/SA Use and Spending -- Difference-in-differences Analysis

TABLE IV.L.1. MDD diagnosis identification rates among all continuously enrolled enrollees (actual percentages)

TABLE IV.L.2. Person-year sample size by plan

TABLE IV.L.3. Proportion of MDD diagnosed enrollees who received any psychotherapy or antidepressant

TABLE IV.L.4. Proportion of MDD diagnosed enrollees who received any antidepressant

TABLE IV.L.5. Proportion of MDD diagnosed enrollees who received any psychotherapy

TABLE IV.L.6. Regression results for adjusted odds ratio of receiving any psychotherapy or any antidepressant in the post-parity period relative to the pre-parity period

TABLE IV.L.7. Regression results for adjusted odds ratios of receiving any antidepressant in the post-parity period relative to the pre-parity period

TABLE IV.L.8. Regression results for adjusted odds ratio of receiving any psychotherapy in the post-parity period relative to the pre-parity period

TABLE IV.L.9. Proportion of MDD acute phase episodes in pre- and post-parity periods (actual percentages)

TABLE IV.L.10. Proportion of MDD acute phase episodes that met quality measures for duration of follow-up (antidepressants and visits) for the 4 month period

TABLE IV.L.11. Proportion of MDD acute phase episodes that met quality measures for intensity of follow-up (any MH/SA visit) 1st 2months at least 2 per month

TABLE IV.L.12. Proportion of MDD acute phase episodes that met quality measures for intensity of follow-up (any MHSA visit) 2nd 2 months at least 1 visit per month

TABLE IV.L.13. Proportion of MDD acute phase episodes that met quality measures for duration of psychotherapy (individual, group, and family) for the first 3 months

TABLE IV.L.14. Proportion of MDD acute phase episodes that met quality measures for intensity of psychotherapy (individual, group or family) at least 2 per month

TABLE IV.L.15. Proportion of MDD acute phase episodes that met quality measures for cumulative antidepressant duration at least 3 months

TABLE IV.L.16. Regression analysis for odds of receiving acute phase quality measures

TABLE IV.M.1. Unadjusted rates and 95% confidence intervals for adults with any inpatient or residential SA treatment, per 1,000 continuously enrolled adults by plan and measurement year

TABLE IV.M.2. Unadjusted rate and 95% confidence intervals for adults with any outpatient SA treatment, per 1,000 continuously enrolled adults by plan and measurement year

TABLE IV.M.3. Mean number of inpatient stays and mean length of stay (LOS) among continuously enrolled adults with any inpatient SA care by plan and measurement year

TABLE IV.M.4. Mean number of outpatient visits among continuously enrolled adults with any outpatient SA care by plan and measurement year

TABLE IV.M.5. Unadjusted SA identification rates and 95% confidence intervals among adults with a new SA diagnosis, per 1,000 adult enrollees by plan and measurement year

TABLE IV.M.6. Unadjusted SA initiation rates and 95% confidence intervals among adults with a new SA diagnosis, per 100 adult enrollees identified with a new SA diagnosis by plan and measurement year

TABLE IV.M.7. Unadjusted SA engagement rates and 95% confidence intervals among continuously enrolled adults with a new SA diagnosis, per 100 adults with a new SA diagnosis by plan and measurement year

TABLE IV.M.8. Multivariate unconditional logistic regression analyses comparing three SA quality indicators, pre-parity and post-parity

LIST OF FIGURES

FIGURE I-1. Decomposing the differences in use in a health plan with a high and low option for Federal employees, 1983

FIGURE II-1. Logic Model: Evaluating parity in the FEHB program

FIGURE III-1a-c. Proportion of plans carving out before and after parity

FIGURE IV-1. Algorithm to identify use of MH/SA services

FIGURE IV-2. Difference-in-differences approach

EXECUTIVE SUMMARY

Background

President Bush has often pointed to the Federal Employees Health Benefits (FEHB) Program as a model for health insurance. The FEHB Program is the largest employer-sponsored health insurance program in the Nation, serving more than 8 million Federal employees, their dependents, and retirees. The U. S. Office of Personnel Management (OPM) administers the FEHB Program, which currently offers about 250 health plan choices, providing over $29 billion in health care benefits annually.

At the White House Conference on Mental Health in June 1999, former President Bill Clinton directed OPM to institute a policy of parity, expanding mental health and substance abuse (MH/SA) coverage within the FEHB Program.

The term parity refers to a policy in which specified MH/SA insurance benefits are equal to the benefits for general medical services. Typically this means expanding the coverage for MH/SA services by removing special limits on care (such as annual and lifetime ceilings on expenditures for MH/SA care or limits on the number of outpatient visits or inpatient days) or reducing copayments or deductibles for MH/SA care.

Parity in the FEHB Program

Historically, the FEHB Program has worked toward improved MH/SA benefits. For example, President Kennedy asked the Civil Service Commission (OPM’s predecessor agency) to modify the FEHB Program to treat mental illnesses in the same manner as general medical illnesses (Hustead et al., 1985). In response, from 1967 to 1975, the FEHB Program’s two nationwide health insurance plans offered parity benefits. Beginning in 1975, however, when more flexibility in benefit design was permitted, MH/SA coverage began to erode, with diminution of benefits continuing into the early 1980s. From 1980 to 1997, the share of total claims accounted for by MH/SA claims declined from 7.8% to 1.9% (Foote and Jones, 1999). This trend reflects MH/SA coverage in the larger health care market. It should be noted, however, that other health care costs (e.g., prescription medications) escalated during this time period.

In its annual “call letter” to carriers each spring, OPM issues benefits policy guidance on negotiations for the next contract year. The “call letter” issued by the OPM in 2000 stated that beginning in January 2001, an MH/SA parity policy would go into effect. The aim of the parity policy would be to provide insurance coverage for MH/SA services the same as that for general medical care with respect to benefit design features, such as deductibles, copayments, and limits on visits and inpatient days.

Services to be covered under the parity arrangements are identified as “clinically proven treatment for mental illness and substance abuse… conditions listed in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition” (American Psychiatric Association, 1994). The descriptions of covered services and benefits imply and encourage “management” of the care process. Specifically, this takes the form of developing treatment plans, applying medical necessity criteria, employing utilization management methods, and creating networks of providers, among other techniques. Parity benefits may be limited to in-network providers only.

It should be noted that prescription medications were already covered with parity between prescription medications used to treat MH/SA disorders and prescription medications used to treat general medical conditions.

Before the FEHB parity policy went into effect, FEHB plans offered mental health benefits with coverage limits that resembled other plans in the private health insurance market.¹ The plans included in the analysis and described in chapter II, Design of the Evaluation, cover about 95% of the beneficiaries from the baseline year. Ninety-eight percent of plans continuously participating in the FEHB Program over the four-year study period contained at least one benefit feature in 1999 that was more restrictive for MH/SA care than for general medical care. For example, in 1999, some health plans limited annual outpatient mental health care to 28 visits and inpatient mental health care to 38 days on average. Substance abuse benefits were similarly limited.

Parity for MH/SA Benefits

MH/SA care and its financing have been influenced by a number of secular trends over the last decade including the passage of State parity laws, a shift to managed care and MH/SA carve-outs, and increased use of pharmaceuticals in health care generally and MH/SA care in particular (U.S. Department of Health and Human Services, 1999; Olfson, Marcus, Druss, et al, 2002).

A series of efforts at parity legislation has occurred at the State level. Some States target their parity legislation narrowly to include only people with severe mental disorders, while others cover a broader range of mental illnesses that may also include substance abuse disorders (Hennessy and Goldman, 2001). To date, 37 States have enacted statutes that might broadly be characterized as parity laws. However, these statutes vary substantially in terms of the type of benefits covered, diagnoses included, populations eligible, and level of explicit regulatory direction with regard to the use of managed care. While some of these statutes are quite limited in scope, 26 States have passed more comprehensive parity statutes that prohibit imposing special inpatient day limits, outpatient dollar limits, and differential cost sharing for mental health conditions (Hennessy and Barry, 2004).

Evaluation Design and Key Research Questions

The design of the evaluation was quasi-experimental. It analyzed plan benefits data for all FEHB plans and claims data on access, utilization, and cost for a subset of nine FEHB plans, both before (1999 and 2000) and after (2001 and 2002) the introduction of FEHB parity. Changes in access, utilization and cost were compared to changes in a matched set of non-FEHB comparison plans. For the subset of plans selected for in-depth study, case studies on the implementation of the parity policy were prepared based on a site visit to each selected plan.

The key research questions on how the FEHB parity policy was implemented and the impact of the policy are shown below.

Implementation Key Research Questions

• Did all FEHB plans comply with the parity policy?
• How did the FEHB parity policy affect MH/SA benefit design and management?
• How did the FEHB parity policy affect the benefit design and management for general medical care?
• Did FEHB plans incur additional expenses in implementing the parity policy?
• How did providers experience the FEHB parity policy?

Impact Key Research Questions

• How did the parity policy affect access to and utilization of MH/SA care?
• How did the parity policy affect cost of MH/SA care to the beneficiary and OPM?
• How did any changes in these areas compare to secular trends?
• How did the parity policy affect utilization and spending on medications for MH/SA disorders?
• Was quality of care affected by the parity policy?

Plan Selection

FEHB plans were selected for in-depth study on the basis of various characteristics on which they were likely to differ, i.e., geographic location; the breadth of parity in State law; differences in plan type and structure (e.g., health maintenance organization [HMO], point of service [POS], or fee-for-service (FFS) with a preferred provider option [PPO]); size of the enrollee population; and the plan’s interest in collaborating on the evaluation. The nine selected plans represent over 3.2 million FEHB beneficiaries.

Limitations of the Study

The evaluation is limited in several ways. First, the study design was not experimental, so it is more difficult to attribute all of the effects to parity rather than the secular trend in MH/SA care generally. However, the matched non-FEHB comparison group diminished this threat considerably. Second, while the effect of State parity laws may have mitigated the impact of the FEHB parity policy, the FEHB parity policy is actually substantially broader than nearly all State parity regulations. Finally, generalizations from these selected plans to all FEHB plans must be made cautiously.

Findings

How was the FEHB Parity Policy Implemented?

All of the FEHB plans complied with the parity policy, most incurred no added administrative costs, and none reported major problems with implementation. The policy change enhanced MH/SA benefits for FEHB Program enrollees. Table 1 shows the key research questions regarding how the parity policy was implemented and the corresponding findings.

FEHB Plans Complied with the Parity Policy

All FEHB plans complied with the parity policy. No plan left the FEHB Program to avoid implementing the policy, and plans enhanced their MH/SA nominal benefits as required by the policy change.

Most Plans Enhanced their MH/SA Benefits and were More Likely to Carve-out

The majority of plans enhanced their MH/SA benefits in the post-parity period consistent with the FEHB parity policy. Eighty-four percent of the plans made changes in the amount, scope, or duration of mental health benefits and 73% made such changes for substance abuse benefits. Deductible, copayment or coinsurance limits on mental health benefits were changed by 75% of the plans, and by 64% of the plans for substance abuse benefits.

With the introduction of the parity policy, FEHB plans were more likely to enter into managed care carve-out arrangements with specialty behavioral health care organizations than were comparable non-FEHB plans. However, most other hypothesized changes (e.g., increased gate-keeping at the primary care provider level, reduced provider networks, concurrent or retrospective review, use of disease management programs for MH/SA care, and increased financial risk sharing) occurred less frequently than had been anticipated. While many plans required the submission of treatment plans prior to the parity policy, many more plans required it after the parity policy was implemented.

Finally, while all plans complied with the parity policy for services offered by in-network providers, no plan extended parity to care delivered by out-of-network providers.

General Medical Care was Unaffected by the Parity Policy

While half of the plans changed deductible, copayment and coinsurance limits on general medical benefits, there is no indication that these changes resulted from the FEHB parity policy.

Most Plans Incurred No Added Administrative Costs in Implementing Parity While Benefit Costs Increased for Some Plans

Two-thirds of the FEHB plans reported incurring no added administrative costs in implementing the FEHB parity policy and no plan expressed concerns about any cost increases they did incur. Forty-two percent of the plans reported increased benefit costs only in the immediate post-parity period (2001), and an additional 20% of plans reported these costs increased in both 2001 and 2003.

Providers Had Little Awareness of FEHB Parity

Based on focus groups in three regions of the country, the evaluation found that FEHB plan providers had little awareness of the FEHB parity policy. They also had very limited understanding of the parity benefit itself, often confusing the FEHB parity policy with their State parity laws.

What was the Impact of the Parity Policy on Access, Utilization and Cost?

Overall, the impact of the parity policy on MH/SA service access and utilization, spending, and quality was modest. Utilization and spending results for mental health services alone were not substantially different from those results for MH/SA services combined, nor were utilization and spending results for adults and children significantly different from one another. Table 2 shows the key research questions on the impact of the parity policy on MH/SA access, utilization, spending, and quality and the corresponding findings.

Utilization of MH/SA Care Increased on Par with Secular Trends  

Both adult and child FEHB beneficiaries in all nine plans were more likely to use MH/SA services after parity was implemented, but at a rate consistent with secular trends. (The same was true for mental health services alone.) Thus, the increased utilization of MH/SA care was unlikely a direct result of the parity policy. The parity policy was not associated with changes in inpatient utilization, however, in eight of nine plans.

Access to substance abuse services increased slightly but significantly in all nine plans, but the increase was significant in only four of these plans after accounting for secular trends. Substance abuse services utilization was extremely low, however, both prior to and after the implementation of the parity policy, less than 1% in nearly all plans.

Total Spending on MH/SA Care Increased on Par with Secular Trends and Out-of-Pocket Spending Generally Declined

Overall, FEHB plan total spending increases experienced by the majority of plans generally reflected secular trends in spending on MH/SA care for both adults and children. The FEHB parity policy afforded beneficiaries some improvement in insurance protection in that beneficiaries in five of the nine plans experienced significant decreases in out-of-pocket spending, while no plan’s child beneficiaries experienced an increase in out-of-pocket spending greater than the secular trend.

When secular trends were taken into account, total spending on MH/SA care actually declined in seven of the nine plans, though this decline was significant in only four of the plans. For the two other plans, the spending increases were not significant.

For six of the nine plans, out-of-pocket costs to beneficiaries using MH/SA services declined--even though most plans experienced little or no significant change in use of these services. While three plans experienced significant out-of-pocket spending increases, these increases were in line with secular trends. Patterns of total spending on mental health services alone were nearly identical to those for MH/SA services combined.

Per user total spending on substance abuse care trended upward after the introduction of parity in seven of nine plans, but was significant in only one plan. (Of the two plans experiencing spending decreases, only one was significant). When secular trends were taken into account, total spending on substance abuse care was a mixed picture of spending increases and decreases, but only one plan experienced a significant spending change, i.e., reduced spending of $288 per user of substance abuse care.

Across all plans, the parity policy was associated with a substantial increase in total spending on medications for MH/SA disorders. While per user medication spending ranged from $266 to $519 prior to the FEHB parity policy, in 2002 it increased to a range of $377 to $632.  

Quality of Care Improved Slightly or was Unaffected by the Parity Policy

Quality of MH/SA care for two tracer conditions--major depressive disorder and substance use disorders--was slightly improved or unaffected by the parity policy.

Measures of quality for substance abuse treatment in adults included rates of utilization, identification of individuals with substance use disorders, and engagement in treatment. Except for a small increase in rates of identification, there was no evidence of significant quality change associated with the FEHB parity policy.

Measures of quality for treating major depressive disorder in adults either did not change or improved only slightly with introduction of FEHB parity in all but one of the FEHB plans studied. Quality improvement was more notable in the use of medication than for psychotherapy in the treatment of MDD.

Evaluation Findings in Brief

As of January 1, 2001, all of the FEHB plans had complied with the parity policy, two-thirds incurred no added administrative costs, and none reported major problems with implementation. Furthermore, no plans left the FEHB Program to avoid the parity policy. The policy change enhanced MH/SA benefits for FEHB Program enrollees. At the time of policy implementation, two-thirds of the plans had entered into managed care arrangements with a specialty MH/SA vendor (called a “carve out”).

The impact of the parity policy was assessed in detail in nine FEHB plans that reflect both fee-for-service and health maintenance organizations from regions across the country where Federal employees, their dependents, and retirees reside. Overall, the evaluation showed that parity could be implemented with some increase in access to MH/SA care but little or no increase in total MH/SA spending. Users of services in most but not all plans experienced a decrease in out-of-pocket spending, indicating that parity provided the intended additional financial protection for MH/SA expenditures for many enrollees. There was also little or no impact on quality of treatment of major depressive disorder or substance abuse disorder.

For adults, access to MH/SA services (as measured by the probability of MH/SA service use) in these plans increased from before to after parity. Only one plan showed a significant increase in utilization, however, when secular trends were taken into account; two plans showed a significant decrease in utilization. For substance abuse services alone, all of the plans showed a small absolute increase in access that was significant in all cases when compared to secular trends. Total spending on MH/SA services, however, declined in seven of nine plans; four of these decreases were significant. In all but one instance, substance abuse spending either declined or was unchanged. Out-of-pocket expenditures for MH/SA services decreased in six plans and increased in three plans. The impact of the parity policy on children’s utilization and spending for MH/SA services was similar to that observed for adults.

Overall, the parity policy was implemented as intended with little or no significant adverse impact on access, spending, or quality, while providing users of MH/SA care improved financial protection in most instances.

I. BACKGROUND TO THE POLICY OF PARITY

In a speech in Albuquerque, New Mexico, on April 29, 2002, announcing the creation of the President’s New Freedom Commission on Mental Health, President George W. Bush reiterated the importance of mental health parity. President Bush said, “Americans with mental illness…deserve a health care system that treats their illness with the same urgency as a physical illness.” While noting the importance of “full mental health parity,” he emphasized that it must be accomplished without significantly raising health care costs. In July 2003, the Commission issued its final report, Achieving the Promise: Transforming Mental Health Care in America (2003), in which it observed that mental health benefits have traditionally been more restricted than general medical benefits. The Commission stated its support for parity and cautioned,

“Insurance plans that place greater restrictions on treating mental illnesses than on other illnesses prevent some individuals from getting the care that would dramatically improve their lives.”

President Bush has often pointed to the Federal Employees Health Benefits (FEHB) Program as a model for health insurance. The FEHB Program is the largest employer-sponsored health insurance program in the Nation, serving more than 8 million Federal employees, annuitants, and their dependents. The U. S. Office of Personnel Management (OPM) administers the FEHB Program, which currently offers about 250 health plan choices, providing over $29 billion in health care benefits annually.

At the White House Conference on Mental Health in June 1999, former President Bill Clinton directed OPM to institute a policy of parity, expanding mental health and substance abuse (MH/SA) coverage within the FEHB Program. OPM and the Office of the Assistant Secretary for Planning and Evaluation (ASPE) of the Department of Health and Human Services (HHS) contracted with ROW Sciences (now Northrop Grumman Information Technology, Inc., Federal Enterprise Solutions/Health Solutions [HS]) to lead an evaluation of the implementation and impact of the new parity policy in the FEHB Program. With investigators from the Harvard Medical School, University of Maryland Medical School, Westat, and the RAND Corporation, HS established the Parity Evaluation Research Team (PERT) as the vehicle for conducting this evaluation.

The term parity refers to a policy in which specified MH/SA insurance benefits are equal to the benefits for general medical services. Typically, this means expanding the coverage for MH/SA services by removing special limits on care (such as annual and lifetime ceilings on expenditures for MH/SA care or limits on the number of outpatient visits or inpatient days) or reducing copayments or deductibles for MH/SA care.

Historically these types of limits and higher cost-sharing provisions have led to MH/SA insurance benefits that differed from those for general medical care and have been considered a barrier to accessing adequate MH/SA care and treatment. Several national and State efforts have initiated MH/SA parity policies. The following sections of the report describe these efforts.

History of Mental Health Benefits and Parity Experiences in the Federal Government

Federal Legislative Trends Affecting Parity in Mental Health Insurance Coverage

Although Federal legislative initiatives on parity in mental health insurance coverage dates from the 1960s, the 1996 Mental Health Parity Act represents the first Federal parity legislation. Implemented in 1998, this legislation focused on only one aspect of the difference in mental health insurance coverage -- catastrophic benefits. It prohibited using lifetime and annual limits on coverage for mental health care that were different from general medical care.⁵

The Parity Act was limited in a number of important ways. For example, companies with fewer than 50 employees were exempt. Parity provisions did not apply to other forms of benefit limits, such as per-episode limits on length of stay or visits, copayments, or deductibles, which could remain different for mental health treatment. Substance abuse was not covered by the provisions of the legislation. And if an insurer experienced more than a 1% rise in premium as a result of implementing parity, it could apply for an exemption.

The Federal Employees Health Benefits Program

The FEHB Program is the largest employer-sponsored health insurance program in the Nation. As of 2002, the Program was serving more than 8 million Federal employees, annuitants, and their dependents. To understand the process of implementing parity in the FEHB Program, it is critical to understand how the program operates.

The OPM as Purchaser

OPM administers the FEHB Program, which offers a substantial degree of choice to its enrollees and provides them with relatively detailed information on the characteristics, cost, and performance of participating health plans. Health plans compete for enrollees based on benefits, cost, and quality. OPM manages the enrollment process for FEHB Program enrollees and negotiates specific benefit packages and associated premiums with individual carriers.

To qualify as an FEHB participating plan, a carrier must be licensed to sell group insurance within every area it proposes to operate as an FEHB plan. OPM requires participating health plans to establish an internal quality assurance program that meets the OPM’s contract standards, administer a uniform patient satisfaction survey, and implement patient safety improvement programs. OPM also requires health maintenance organizations (HMOs) to provide data from the Health Plan Employer Data and Information Set (HEDIS) and credential/re-credential providers (DHHS, 2000).

OPM pays health plans in one of two ways: Fee-for-service and some HMO plans are paid an experience-rated premium. The basic premium or subscription fee consists of three components: claims costs, administrative costs, and profit. Most HMO plans are paid on a community-rated capitation basis. Community rates are set on the basis of the two largest non-FEHB Program groups within the “community.” Adjustments are made through annual benefit and rate negotiations for differences between specific FEHB plan requirements and prevailing community benefit packages. Large HMOs must provide documentation of premiums from large non-Federal employers in the community. HMOs can also adjust rates based on factors such as the age and sex of enrolled populations.

Parity in the FEHB Program

Historically, the FEHB Program has worked toward improved MH/SA benefits. For example, President Kennedy asked the Civil Service Commission (OPM’s predecessor agency) to modify the FEHB Program to treat mental illnesses in the same manner as general medical illnesses (Hustead et al., 1985). In response, from 1967 to 1975, the FEHB Program’s two nationwide health insurance plans offered parity benefits. Beginning in 1975, however, when more flexibility in benefit design was permitted, MH/SA coverage began to erode, with diminution of benefits continuing into the early 1980s. From 1980 to 1997, the share of total claims accounted for by MH/SA claims declined from 7.8% to 1.9% (Foote and Jones, 1999). This trend reflects MH/SA coverage in the larger health care market. It should be noted, however, that other health care costs (e.g., prescription medications) escalated during this time period.

In its annual “call letter” to carriers each spring, OPM issues benefits policy guidance on negotiations for the next contract year. The “call letter” issued by the OPM in 2000 stated that beginning in January 2001, the aim of parity would be to provide insurance coverage for MH/SA services the same as that for general medical care with respect to benefit design features, such as deductibles, copayments, and limits on visits and inpatient days.

Services to be covered under the parity arrangements are identified as “clinically proven treatment for mental illness and substance abuse… conditions listed in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition” (American Psychiatric Association, 1994). The descriptions of covered services and benefits imply and encourage “management” of the care process. Specifically, this takes the form of developing treatment plans, applying medical necessity criteria, employing utilization management methods, and creating networks of providers, among other techniques.

Other key features of the FEHB Program’s parity benefit include the following:

• Parity benefits may be limited to in-network providers only,
• Plans may limit the parity benefit if the beneficiary does not comply with the treatment plan, and
• MH/SA benefit levels are based on the benefit category for comparable medical treatment.

It should be noted that the prescription medication benefit was not subject to the FEHB parity policy in that in most FEHB plans, there was already parity between prescription medications used to treat MH/SA disorders and prescription medications used to treat general medical conditions.

Before the parity policy, FEHB plans offered mental health benefits with coverage limits that resembled other plans in the private health insurance market.⁶ As reported in Mental Health, United States, 2002, the following 1999 data obtained from the FEHB plan brochures provide average benefit information for the subset of health plans (152) continuously participating in the FEHB Program over the four-year study period (1999 to 2002) and having benefit design information available (Hennessy and Barry, 2004).⁷

The 152 plans included in the analysis and described in chapter II, Design of the Evaluation, cover about 95% of the beneficiaries from the baseline year. Ninety-eight percent of plans continuously participating in the FEHB Program over the four-year study period contained at least one benefit feature in 1999 that was more restrictive for MH/SA care than for general medical care. For example, in 1999, some health plans limited annual outpatient mental health care to 28 visits and inpatient mental health care to 38 days on average.

Substance abuse benefits were similarly limited. For example, 9% of FEHB plans placed annual dollar limits ranging from $3,000 to $50,000 on substance abuse coverage, and 15% of plans used lifetime limits most often in the form of two 28-day inpatient stays. Dollar limits on substance abuse were more common among fee-for-service plans compared with health maintenance organizations (HMOs). Sixty-eight percent of plans also required higher cost-sharing for outpatient MH/SA services and 23% of plans required higher cost-sharing for inpatient services in 1999.⁸

Adverse Selection in the FEHB Program

A number of analysts have pointed to adverse selection problems in the FEHB Program over the years (Price and Mays, 1985). Adverse selection refers to the tendency for individuals who expect to use particular health care services to select insurance coverage that meets their anticipated service needs. Mental health care is an area in which adverse selection appears to exert a strong impact. Mental disorders tend to be persistent, and individuals with these disorders expect to spend more on mental health care than other individuals. As a result, they are attracted to health plans with generous mental health care coverage. Health insurers have a financial incentive to avoid enrolling these individuals. For example, in the early 1980s, the use of mental health services was two to three times higher in the FEHB Program’s Blue Cross High Option plan than in the standard option, even though only minor differences existed in the actuarial value of benefits in the two options.

Figure I-1 illustrates the selection incentives in the FEHB Program. The left panel compares inpatient utilization in the two plans, while the right panel compares ambulatory utilization. The grey segments of the bars represent base-level use in the standard or low option plan. The black segments reflect the demand response to the reduced cost-sharing provisions (i.e., reduced deductibles or co-payments) of the high option plan. These were calculated by applying the demand response parameters estimated in the RAND Health Insurance Experiment (Newhouse, 1993).

Figure I-1. Decomposing the differences in use in a health plan with a high and low option for Federal employees, 1983

The white segments of the high option bars represent the estimated utilization differences that are due to selection. The implication is that offering slightly more generous cost-sharing provisions attracted a significantly higher utilizing group of enrollees. Therefore, plans could gain financially by avoiding such enrollees via limited benefits.

Selection incentives may cause health plans to alter plan features other than the nominal benefits described in plan brochures. These so-called effective benefits involve a host of utilization management techniques (Frank, Glazer, and McGuire, 2002). For example, the Plan brochure may state that 30 outpatient visits are offered as nominal benefits. Plans may also use other mechanisms, such as managed care, to bring about the intended change in the effective benefits. These changes may then lead consumers to change plans or use their benefits differently, such as by going to a primary care doctor for services.

State Experiences with Parity

A series of efforts at parity legislation has also occurred at the State level (Hennessy and Stephens, 1997). Some States target their parity legislation narrowly to include only people with severe mental disorders, while others cover a broader range of mental illnesses that may also include substance abuse disorders. Experiences with parity policy at the State level are derived primarily from two sources:

• parity laws enacted by State governments , and
• State employee plans that design a parity MH/SA benefit for their health plans.

Valuable lessons can be gleaned from each set of experiences.

State Parity Laws

To date, 37 States have enacted statutes that might broadly be characterized as parity laws. However, these statutes vary substantially in terms of the:

• type of benefits covered,
• diagnoses included,
• populations eligible, and
• level of explicit regulatory direction with regard to the use of managed care.

Some of these statutes are quite limited in scope. For example, South Carolina currently has a parity policy that applies only to the health insurance of State and local public-sector employees. North Carolina and Arizona have mandates that mirror the Federal parity law by requiring that insurers eliminate special annual or lifetime dollar limits for mental health coverage. Finally, some State parity laws essentially copy the 1996 Mental Health Parity Act and thus do not expand a State’s parity policy beyond the Federal parity law.

Twenty-six States have passed more comprehensive parity statutes that prohibit imposing special inpatient day limits, outpatient visit, and/or dollar limits, and differential cost sharing for mental health conditions. These policies differ in terms of the mental health conditions they cover. For example, 17 of these States have limited parity for diagnoses designated as severe mental illnesses or biologically based disorders. Illnesses frequently characterized as severe tend to include schizophrenia, schizoaffective disorder, bipolar disorder, and major depression.

Nine of these more comprehensive policies require parity in coverage for all medically necessary services to treat MH/SA conditions listed in the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV; American Psychiatric Association, 1994). Nine States include coverage for substance abuse treatment under the terms of their parity statutes.⁹

State statutes also differ regarding:

• whether the law applies to both individual and group plans,
• if the law mandates coverage or simply requires parity if mental health benefits are offered,
• whether the law includes a small business exemption, or
• if the law exempts employers experiencing cost growth attributable to parity.

Below we describe three of the more comprehensive state parity laws, as well as parity regulations for State employees in two States, each of which has been evaluated in terms of outcomes.

Vermont State Parity Law

In 1998, Vermont implemented the nation’s most comprehensive parity law. Vermont parity legislation includes both mental health and substance abuse treatment, defines mental illnesses broadly, and requires that mental illnesses and general medical conditions be accorded the same service limits and cost-sharing.

California State Parity Law

In 2001, California implemented a parity statute covering a limited set of diagnoses that focus on serious mental illnesses for adults and serious emotional disturbances for children and youth. The California State parity law prohibited more restrictive benefit limits and higher deductibles and copayments than those for general medical care. Substance abuse disorders were excluded in this legislation.

Maryland State Parity Law

Maryland enacted a parity law in 1994 that prohibits using separate annual and lifetime dollar limits, special deductibles, and special inpatient day and outpatient visit limits for MH/SA disorders. However, it retains a tiered outpatient coinsurance structure of coverage, with higher copayment rates after five visits, which increase again after 30 visits.

State Employee Parity Regulations

Experiences with parity for MH/SA have been studied systematically among two privately insured populations--Massachusetts and Ohio State employees. Experiences reported in those evaluations might predict the likely impacts of the FEHB Program parity initiative.

Massachusetts

State of Massachusetts employees enrolled in PPO and indemnity plans had a parity benefit implemented at the same time as a behavioral health carve-out, i.e., MH/SA care was managed separately from general medical care.

Ohio

Again, parity was introduced after or at the same time as the implementation of a behavioral health carve-out. All health plans serving State of Ohio employees implemented parity (in 1990 for employees in the Ohio indemnity medical plan and in 1995 for all other employees) by expanding the scope of a carve-out program to cover all MH/SA services in all health plans (Sturm, Goldman, and McCulloch, 1998).

Findings from State Parity Laws and Regulations

Vermont State Parity Law

The implementation and effects of the Vermont State parity law are also the most systematically studied (Rosenbach, Lake, Young, et al., 2003). Very few Vermont employers (0.3%) dropped health coverage due to the parity law, and out-of-pocket expenses for MH/SA services declined after the parity implementation. For example, among people with serious mental disorders, the proportion of individuals spending more than $1,000 out of pocket annually was reduced by more than 50%. The implementation of parity was characterized by an increase in managed care for MH/SA services, which was a major factor in controlling costs and may have reduced access and utilization for some services and beneficiaries.

California State Parity Law

One year after California’s State parity implementation, researchers found no evidence of adverse consequences in the State’s health insurance market, such as large premium increases (Lake, Sasser, Young, and Quinn, 2002). Examining the effects of California’s parity law on two large employers in the first year of implementation, Branstrom and Sturm (2002) reported that the parity law was generally producing the intended effects in that “…plans with high costs and high service use show stable or declining spending, and lower-cost plans show increases at tolerable levels (less than 1%).”

Maryland State Parity Law

The National Advisory Mental Health Council (1998) reported on the implementation of parity in the State of Maryland using data from carve-out programs. The Council’s main finding was that parity could be implemented without excessive cost increases.

Ohio State Employees

First, the results for seven years after implementing parity for State of Ohio employees (1990 through 1997 for those in the indemnity plan and 1995 through 1997 for those in other plans) showed no increase in spending within the preferred provider organization (PPO) and indemnity health plans that were part of a carve-out program. The implication is that managed care responds to benefit design to control “moral hazard” effects, i.e., the increase in use and cost of benefits resulting from the price-lowering effect of insurance coverage.

Second, MH/SA spending increased slightly in the health maintenance organization (HMO) plans in response to the benefit expansion, but those plans had very constrained MH/SA benefits before implementing parity.

The Ohio evaluation indicates that the impact of parity is likely to differ across health plans depending on the pre-parity benefits and the organization of the health plan. Moreover, even with a large increase in coverage, the cost increases were modest compared to what one might have expected on the basis of demand response under indemnity insurance (Newhouse and the Insurance Experiment Group, 1993). The Ohio study, however, did not examine changes in enrollment patterns across health plans that may have resulted from the parity benefit.

Massachusetts State Employees

Ma and McGuire (1998) showed that for Massachusetts State employees, the overall impact of managed care exceeded the impact of parity with respect to per person spending on MH/SA. Huskamp (1999) focused her analysis on the outpatient benefits for which the benefit expansion was greatest. She showed that the managed care effect exceeded the moral hazard effect of a benefit expansion. Spending per person fell significantly for MH/SA care, and the statistical analysis also showed a sizable reduction in the probability of use. Her work used a continuously enrolled population and thereby minimized any effects of biased selection due to coverage changes.

Implications of State Parity Experiences for the Evaluation of Parity in the FEHB Program

Because of the variation in the scope of State parity laws and regulations, caution is necessary in drawing inferences from State experiences to the FEHB Program parity initiative. Evidence on the effects of State parity laws comes from both multi-State analyses and single-State case studies. The Health Care for Communities (HCC) and Community Tracking Study (CTS) national household surveys have been used to study effects of parity across States (Sturm, 2000; Capula and Sturm, 2000; Gitterman, 2001; and Bao and Sturm, unpublished manuscript). These studies generally found little overall impact on either access or use due to State parity laws, although some improved access was found for more seriously ill subpopulations. But again, these results must be interpreted with great care.

In addition, Maxfield, Achman, and Cook (2004) found that less than half of Americans in 1999 were affected by either State of Federal parity laws. The Employee Retirement Income Security Act (ERISA) provides the biggest exemption of health plans from State parity laws. ERISA exempts self-insured employer-sponsored health plans, meaning that these health plans are subject only to Federal parity regulations, but exempt from any State parity policy that goes further than the 1996 Mental Health Policy Act. The impact of this exemption is substantial in that Maxfield and colleagues found that 39% of those in employer-sponsored health insurance plans are in self-insured plans. In addition, many states and the Federal parity law also exempt small employers (most States define a “small employer” as one with 50 or fewer employees) for compliance with State parity laws.

This set of studies suggests that the State context may be quite important for assessing the impact of parity in the health plans included in the FEHB Program evaluation. If a State parity law is broad and affects many insured populations, including FEHB enrollees, the subsequent FEHB parity policy may have little effect. If a State parity law is narrow and does not affect many plans, however, the impact of the FEHB parity policy may be larger. Case-studies on the implementation of more comprehensive State parity laws have been conducted in a number of States, including Vermont, California, and Maryland, and are discussed further below.

II. DESIGN OF THE EVALUATION

Goals and Objectives of the Evaluation

The Federal Employees Health Benefits (FEHB) Program evaluation addressed changes in cost, access, utilization, and quality as a result of the parity policy. Additionally, the evaluation focused on adverse selection arising from the managed competition that exists in the FEHB Program. Adverse selection refers to the tendency for individuals to choose insurance plans whose benefits will cover services that they expect to use. For example, people with mental health and substance abuse (MH/SA) conditions tend to select health plans with more generous MH/SA coverage.

The overall goals of the evaluation were to examine both the implementation of the parity requirement for FEHB plans and the intermediate and long-term impacts of the FEHB parity policy on the FEHB plans.

The objectives of this evaluation were to:

• Assess the degree to which the parity requirement affects
  • benefit design and management;
  • access to MH/SA services;
  • utilization of MH/SA services;
  • costs to beneficiaries, plans, and Office of Personnel Management (OPM);
  • quality of MH/SA services; and
  • providers’ awareness and perceptions of the policy change.
• Examine the patterns in these effects across subgroups of plans and providers.
• Assess the interrelationships among changes in
  • benefit design and management,
  • costs,
  • access,
  • utilization, and
  • quality.

Framework for Evaluating the Implementation of Parity in the FEHB Program

The logic model for understanding the relationship between implementing benefit changes and new methods for managing care and their impact on access, utilization, cost, and quality appears in Figure II-1. The logic model provides a framework for the evaluation. It depicts a sequence of moves from implementing the policy of the President to have all FEHB Program plans offer MH/SA parity, through the required plan changes, to expected changes in access, utilization, and cost and their impact on quality. The logic model also provides a template that maps the research questions and data collection approaches. The result is a matrix of research domains, questions, and methods that is presented in Table II-1.

Figure II-1. Logic Model: Evaluating parity in the FEHB program

The logic model describes a rational approach to policy and programmatic changes with the following sequence of steps. It was anticipated that carriers and plans would alter their nominal benefits according to the instructions in the call letter from the OPM. In other words, they would eliminate special deductibles and copayments and other “demand side” limits on, for example, inpatient days or outpatient visits that previously applied to MH/SA benefits. Plans could be expected to respond to this change in nominal benefits by altering their management and payment practices in an effort to control costs on the “supply side,” such as through changes in utilization management practices and risk-sharing arrangements with providers. Such changes in effective benefits could be expected to have the following consequences:

• changes in access and patterns of use,
• selection of specific plans by individuals, and
• changes in plan and beneficiary spending.

Changing patterns of access and utilization might also affect the quality of care provided.

Research Questions

The study’s key research questions are described in Table II-1 and reflect the logic model in Figure II-1. Table II-1 identifies the data sources and collection methods most relevant to each research question. chapter III, Implementation of Parity, and chapter IV, Impact of Parity, provide further details on more specific research questions, data sources, data collection methods, and analytic strategies.

Overview of the Evaluation Methodology

The design of the evaluation was quasi-experimental. Plan data on nominal benefits (for all FEHB plans) and archival (claims) data on access, utilization, and cost (for nine selected plans) were studied before and after the implementation of parity.Changes in these measures were compared to changes in matched non-FEHB comparison group plans from the Medstat Group MarketScan® Benefit Plan Design database (Medstat).

For selected plans, the Parity Evaluation Research Team (PERT) prepared case studies based on a site visit to each selected plan. These studies were also quasi-experimental in design. They inquired retrospectively about conditions and experiences before and after the parity policy went into effect.

Including the non-FEHB comparison group plans (i.e., Medstat) allowed for assessing secular trends occurring over the same pre- and post-parity implementation period. In this way, it was possible to determine to what extent pre- to post-parity implementation changes could be attributed to the policy change versus changes in the health care system that might have occurred regardless of the parity policy.

The analysis of changes from pre-parity to post-parity relied primarily on the archival claims data and information on nominal MH/SA benefits, as these were the only data that were not reported retrospectively. The pre-parity to post-parity changes from the archival claims data were compared to changes in the matched comparison group set of claims data covering the same period. In addition, the study investigated FEHB plan benefits, policies, and procedures, including changes implemented within the first two years of parity.

Detailed data were obtained through site visits to eight health plans and more limited data were obtained for all FEHB plans (with over 500 enrollees) through a Parity Reporting Requirement (PRR) instituted by the OPM. Information on changes in FEHB health plan structures, policies, and procedures were obtained by site visits with the key plan personnel, resulting in selected plan case studies. The case studies yielded a rich context for understanding results from the archival claims data analysis.

Each of the five domains described in the logic model was examined by the indicated analytic methods. The PERT began its examination of each domain with descriptive analyses covering all data elements relevant to that domain. These analyses entailed both quantitative and qualitative methods, depending on the data element. The more complex research questions were addressed by sophisticated methods, such as statistical modeling, using the claims data and case study methodologies to examine differences in plans’ benefits.

The evaluation design incorporated multiple data collection approaches, including:

• nominal plan benefits data from the OPM website,
• parity implementation reports from all FEHB plans with 500 or more enrollees,
• site visits to acquire detailed plan data from selected plans and OPM,
• archival enrollment and claims/encounter data from selected FEHB plans and a matched set of comparison group plans, and
• focus groups of providers.

Table II-2 summarizes the project’s data collection approaches and the evaluation domains addressed by each approach. It should be noted that several of the evaluation domains were addressed by the combination of multiple data collection approaches, which is indicated when a domain appears in more than one row of the table. In this chapter, each of these approaches is discussed in depth.

Data Collection Issues

Plan Selection

The study design included selecting a small number of plans for in-depth study, i.e., obtaining archival claims data, conducting plan site visits, and conducting focus groups with providers (from a subset of the selected plans). Plans were selected on the basis of various characteristics on which they were likely to differ:

• geographic location;
• the breadth of parity in State law;
• differences in plan type and structure (e.g., health maintenance organization [HMO], point of service [POS], or fee-for-service [FFS] with a preferred provider option [PPO]);
• size of the enrollee population; and
• the plan’s interest in collaborating on the evaluation.

Based on these considerations, the following eight plans were selected for site visits:

• Fee-for-service national plan (FFS-NAT),
• HMO West #1 plan (HMO-W1),
• Fee-for-service West plan (FFS-W),
• Fee-for-service Mid-Atlantic #1 plan (FFS-MA1),
• Fee-for-service Mid-Atlantic #2 plan (FFS-MA2),
• Fee-for-service South plan (FFS-S),
• HMO Northeast plan (HMO-NE), and
• HMO West #2 plan (HMO-W2).¹⁰

The first nine plans (excluding HMO-W2) that contributed to the impact analysis that comprises chapter IV represent a total of 3,209,617 FEHB beneficiaries. The FFS-NAT is a very large national fee-for-service (FFS) plan covering over a million lives. HMO-W1 is an HMO, and HMO-NE is an HMO with a POS option within the FEHB Program. The remaining six plans are licensees of a large national association (the “Association”). All six are FFS plans with a PPO, managed in somewhat different ways in each location by a variety of managed behavioral health care organization (MBHO) vendors¹¹. Individual Association plans were selected to represent a range of geographic locations with large numbers of beneficiaries.

For two additional plans, FFS-NE1 and the FFS-NE2, the PERT collected utilization and cost data but was unable to obtain detailed implementation data due to resource constraints.

Because of the small number of selected plans, this represents a purposive sampling process, rather than random sampling. It was intended to produce a sample roughly representative of all the FEHB plans with 500 or more enrollees, along the qualitative dimensions just described.

Procedures to Ensure Confidentiality

The PERT maintained confidentiality for all data collected in the study. Site visit interviews were summarized anonymously in all study materials. For the archival data analysis, each participating health plan created scrambled participant identification numbers; deleted names, addresses, and other unique identifiers; and sent the claims data file to the PERT. When requested, the PERT signed a data user agreement.

Limitations of the Evaluation Design and Analyses

The evaluation design and subsequent analyses are not without limitations. Key limitations in the evaluation design and within each data collection approach and analysis strategy are addressed in their respective sections of this report.

Broader limitations that may make it difficult to draw inferences about the impact of the parity implementation are summarized below:

• The study design was quasi-experimental and did not include a randomized control group observed at the same points in time, making it difficult to interpret changes over time.
• A significant portion of the FEHB plans had State parity laws in varying stages of implementation. These regulations differed greatly in their requirements and location of beneficiary residence. The effect of variations in State parity laws represents a potential confound to the study. Even though State parity laws do not directly affect FEHB plan benefits (the FEHB parity policy supersedes State parity laws), insurers’ prior experiences with State parity laws may have influenced their approach to implementing the FEHB parity policy. The matched national non-FEHB comparison group diminished this threat considerably for the archival data, however. The effect of State parity laws may have also mitigated the impact of the FEHB parity implementation. Compared to nearly all State parity regulations, though, the FEHB parity policy is substantially broader.
• The selected plans were chosen purposively on the basis of various characteristics on which the plans were likely to differ. Thus, generalizations from these selected plans to all FEHB plans must be made cautiously.
• Only the archival claims and enrollment truly represent pre-parity data. Other data collection did not occur until after parity implementation (January 1, 2001).
• There is the possibility of adverse selection resulting from parity-related changes in benefits coverage across plans, complicating the estimation of the effect of parity on spending and use. This was partially addressed by comparing continually enrolled cohorts to all enrollees and by examining enrollment changes across the years.
• The evaluation included no data on beneficiaries’ experiences or unmet need for MH/SA treatment.
• The evaluation time frame captures only two years post-parity, and therefore does not address any longer term effects of MH/SA parity in the FEHB program.

III. IMPLEMENTATION OF PARITY

Overview

This chapter examines the implementation of the parity policy in the FEHB Program in terms of its effect on nominal and effective plan benefits, as illustrated in the evaluation logic model shown in FigureII-1. The research questions, data sources and collection methods, and analysis methods--summarized in the “Benefits” panel of Table II-1--are detailed in this chapter, as are the relevant findings.

The PERT employed the following approaches to examine the implementation of the FEHB parity policy:

• the Parity Reporting Requirement (PRR), completed by all FEHB plans, to collect descriptive data on all FEHB plans’ parity implementation;
• FEHB plan benefit design data abstracted from plan brochures on the OPM website for two time periods, pre- and post-parity;
• comparison group data, to account for time trends during the pre- to post-parity time period; and
• implementation case studies of the eight plans that are the focus of the analysis in order to provide more extensive data on a subset of FEHB plans.

Federal Employees Health Benefits Parity Reporting Requirement for All Plans

As part of the Office of Personnel Management’s (OPM’s) contract with the FEHB plans, each health plan was required to submit to the OPM a report on implementing mental health and substance abuse (MH/SA) parity in the first quarter of 2002 and in the first quarter of 2003.¹² The report, The Parity Reporting Requirement (PRR), designed by PERT investigators, focused on delivering MH/SA benefits in the year before parity implementation (2000), in the year of parity implementation (2001), and two years afterwards (2003).

Key Research Questions

In response to the OPM’s parity policy, the PERT developed the following research questions about FEHB health plans’ behavior:

Nominal Benefit Design

• Will health plans expand the amount, scope, and duration of MH/SA benefits to be equivalent to those for general medical care?
• Will health plans change deductible, copay, and coinsurance on MH/SA benefits to be equivalent to those for general medical care?
• Will health plans add new MH/SA benefits?

Effective Benefit Design

• Will health plans that contracted with managed behavioral health care organizations (MBHOs) pre-parity continue to carve out post-parity?
• Will health plans that did not carve out pre-parity carve out post-parity?
• Will health plans carve out substance abuse as well as mental health benefits post-parity?
• Will health plans move to risk-based contracting with vendors post-parity?
• Will health plans change financial incentives for their providers post-parity?
• Will health plans expand the number and disciplinary mix of MH/SA providers post-parity?
• Will health plans increase the number or mix of utilization controls they employ post-parity?

Implementation Experience

• Will health plans incur modest administrative costs in implementing parity?
• Will health plans report increased MH/SA benefits costs for their FEHB product?

Data Collection

The PERT collaborated with OPM to choose a limited number of implementation domains to make up a PRR that OPM would include in its annual reporting requirements for FEHB health plans. OPM has legislative authority to require FEHB health plans to “furnish such reasonable reports as the Office determines to be necessary to enable it to carry out its functions…” Contracts between OPM and the FEHB health plans stipulate that health plans will furnish reports requested by OPM.

PRR Instrument

PERT researchers developed closed-ended, fixed-choice survey items for the PRR that were FEHB-specific. Because the PERT was unable to use previously field-tested items, it conducted cognitive testing of the instrument with the nine FEHB plans.

A mix of plans were selected that varied on the basis of:

• size of plan,
• type of plan (health maintenance organization [HMO] and fee-for-service [FFS] plans), and
• geographic area.

OPM distributed the draft PRR to representatives of the nine plans and obtained feedback. PERT researchers also sought and received feedback from U.S. Department of Health and Human Services (HHS) project officers and other HHS-funded investigators working in the field of managed behavioral health care (i.e., Brandeis investigators Drs. Constance Horgan and Deborah Garnick). Suggested revisions were incorporated into the final version of the PRR. The relevant PERT organizations’ institutional review board reviewed and approved the PRR data collection plan.

Administering the PRR to the Association Plans

The “Association” is a national, fee-for-service plan administered jointly by the Association and 64 participating Association licensees across the country. All Federal employees and annuitants who are eligible for the FEHB Program may enroll in the Association. Enrollment in the Association represents over 50% of the total FEHB Program enrollment.

A national contract is negotiated between the Association and OPM but local Association plans underwrite the risk. Therefore, decisions about health care delivery, such as whether to contract with an MBHO, are local Association plan decisions. While the Association is subject to OPM’s regular reporting requirements, individual local Association plans do not individually report to OPM, but are accounted for in the Association reports.

For the PRR data collection, in collaboration with the Association, the PERT constructed a short form of the PRR to be administered at a single point in time (2003) to the Association plans. The short-form PRR included only questions on the use of MBHOs and utilization management. Respondents provided retrospective (pre- and post-parity) and current (2003) information in 2003.

The short-form PRR was sent by e-mail attachment to Association plans with instructions to return the completed PRR to OPM. All copies were forwarded to the PERT for data entry, cleaning, and analysis. The response rate for the Association plans was 100%, largely due to the active follow-up efforts of Association staff. (Note that the responses from two of the Association plans