Publications

2008
Harlan M Krumholz and Sharon-Lise T Normand. 2008. “Public reporting of 30-day mortality for patients hospitalized with acute myocardial infarction and heart failure.” Circulation, 118, 13, Pp. 1394-7.
Bruce E Landon, Meredith B Rosenthal, Sharon-Lise T Normand, Richard G Frank, and Arnold M Epstein. 2008. “Quality monitoring and management in commercial health plans.” Am J Manag Care, 14, 6, Pp. 377-86.Abstract
OBJECTIVE: To examine the current state of quality monitoring and management activities of US health plans. STUDY DESIGN: Cross-sectional survey. METHODS: We surveyed medical directors of 252 commercial HMOs (96% response rate) drawn from 41 nationally representative markets in the United States. We randomly sampled healthcare markets with at least 100,000 HMO enrollees. The markets in our sampling frame include an estimated 91% of US HMO enrollees and represent 78% of the metropolitan population. RESULTS: There was near-universal collection of data at the health plan level for each of the 7 outpatient measures we examined (ranging from 92.1% of health plans that collect data on hypertension control and cholesterol management (see p. 379) to 99.2% that collect data on patient satisfaction). There also was substantial data collection at the level of the individual provider or physician group (ranging from 50.4% for hypertension control to 81.4% for diabetes care); this was more common in health plans that primarily use capitation to reimburse primary care physicians. Health plans that collected data typically fed these data back to physician groups, but public reporting to enrollees was infrequent. CONCLUSIONS: Almost all health plans measured their performance on multiple indicators of quality. The majority of health plans also collected data at the level of the individual physician or group and used these data in quality improvement activities, but not in public reporting. Thus, adoption of physician-level performance measurement and reporting by the Centers for Medicare & Medicaid Services will likely entail a major change for individual physicians.
Glorisa Canino, Doryliz Vila, Sharon-Lise T Normand, Edna Acosta-Pérez, Rafael Ramírez, Pedro García, and Cynthia Rand. 2008. “Reducing asthma health disparities in poor Puerto Rican children: the effectiveness of a culturally tailored family intervention.” J Allergy Clin Immunol, 121, 3, Pp. 665-70.Abstract
BACKGROUND: Island and mainland Puerto Rican children have the highest rates of asthma and asthma morbidity of any ethnic group in the United States. OBJECTIVE: We evaluated the effectiveness of a culturally adapted family asthma management intervention called CALMA (an acronym of the Spanish for "Take Control, Empower Yourself and Achieve Management of Asthma") in reducing asthma morbidity in poor Puerto Rican children with asthma. METHODS: Low-income children with persistent asthma were selected from a national health plan insurance claims database by using a computerized algorithm. After baseline, families were randomly assigned to either the intervention or a control group. RESULTS: No significant differences between control and intervention group were found for the primary outcome of symptom-free days. However, children in the CALMA intervention group had 6.5% more symptom-free nights, were 3 times more likely to have their asthma under control, and were less likely to visit the emergency department and be hospitalized as compared to the control group. Caregivers receiving CALMA were significantly less likely to feel helpless, frustrated, or upset because of their child's asthma and more likely to feel confident to manage their child's asthma. CONCLUSION: A home-based asthma intervention program tailored to the cultural needs of low income Puerto Rican families is a promising intervention for reducing asthma morbidity.
Bruce E Landon, Sharon Lise T Normand, Ellen Meara, Ellen Meara, Steven R Simon, Richard Frank, and Barbara J McNeil. 2008. “The relationship between medical practice characteristics and quality of care for cardiovascular disease.” Med Care Res Rev, 65, 2, Pp. 167-86.Abstract
The settings in which health care services are delivered have the potential to influence the quality of health care services in numerous ways, but little is known about the relationship between characteristics of medical practices and quality of care. In this study, the authors studied patients with coronary heart disease (CHD). The authors surveyed 225 medical practices in 2000 and 2001 and obtained information on quality measures from the medical records for more than 1,600 of their patients with CHD. Results suggest that quality of care, at least for common conditions with agreed-on measures, is not strongly influenced by financial characteristics of medical practices, although there does seem to be some relationship with practice structure such as size and quality.
Dulal K Bhaumik, Anindya Roy, Subhash Aryal, Kwan Hur, Naihua Duan, Sharon-Lise T Normand, Hendricks C Brown, and Robert D Gibbons. 2008. “Sample Size Determination for Studies with Repeated Continuous Outcomes.” Psychiatr Ann, 38, 12, Pp. 765-771.
Sharon-Lise T Normand. 2008. “Some old and some new statistical tools for outcomes research.” Circulation, 118, 8, Pp. 872-84.
Harlan M Krumholz, Patricia S Keenan, John E Brush, Vincent J Bufalino, Michael E Chernew, Andrew J Epstein, Paul A Heidenreich, Vivian Ho, Frederick A Masoudi, David B Matchar, Sharon-Lise T Normand, John S Rumsfeld, Jeremiah D Schuur, Sidney C Smith, John A Spertus, and Mary Norine Walsh. 2008. “Standards for measures used for public reporting of efficiency in health care: a scientific statement from the American Heart Association Interdisciplinary Council on Quality of Care and Outcomes Research and the American College of Cardiology Foundation.” Circulation, 118, 18, Pp. 1885-93.Abstract
The assessment of medical practice is evolving rapidly in the United States. An initial focus on structure and process performance measures assessing the quality of medical care is now being supplemented with efficiency measures to quantify the "value" of healthcare delivery. This statement, building on prior work that articulated standards for publicly reported outcomes measures, identifies preferred attributes for measures used to assess efficiency in the allocation of healthcare resources. The attributes identified in this document combined with the previously published standards are intended to serve as criteria for assessing the suitability of efficiency measures for public reporting. This statement identifies the following attributes to be considered for publicly reported efficiency measures: integration of the quality and cost; valid cost measurement and analysis; minimal incentive to provide poor quality care; and proper attribution of the measure. The attributes described in this statement are relevant to a wide range of efforts to profile the efficiency of various healthcare providers, including hospitals, healthcare systems, managed-care organizations, physicians, group practices, and others that deliver coordinated care.
Harlan M Krumholz, Patricia S Keenan, John E Brush, Vincent J Bufalino, Michael E Chernew, Andrew J Epstein, Paul A Heidenreich, Vivian Ho, Frederick A Masoudi, David B Matchar, Sharon-Lise T Normand, John S Rumsfeld, Jeremiah D Schuur, Sidney C Smith, John A Spertus, and Mary Norine Walsh. 2008. “Standards for measures used for public reporting of efficiency in health care: a scientific statement from the American Heart Association Interdisciplinary Council on Quality of Care and Outcomes research and the American College of Cardiology Foundation.” J Am Coll Cardiol, 52, 18, Pp. 1518-26.Abstract
The assessment of medical practice is evolving rapidly in the United States. An initial focus on structure and process performance measures assessing the quality of medical care is now being supplemented with efficiency measures to quantify the "value" of healthcare delivery. This statement, building on prior work that articulated standards for publicly reported outcomes measures, identifies preferred attributes for measures used to assess efficiency in the allocation of healthcare resources. The attributes identified in this document combined with the previously published standards are intended to serve as criteria for assessing the suitability of efficiency measures for public reporting. This statement identifies the following attributes to be considered for publicly reported efficiency measures: integration of the quality and cost; valid cost measurement and analysis; minimal incentive to provide poor quality care; and proper attribution of the measure. The attributes described in this statement are relevant to a wide range of efforts to profile the efficiency of various healthcare providers, including hospitals, healthcare systems, managed-care organizations, physicians, group practices, and others that deliver coordinated care.
Armando Teixeira-Pinto and Sharon-Lise T Normand. 2008. “Statistical methodology for classifying units on the basis of multiple-related measures.” Stat Med, 27, 9, Pp. 1329-50.Abstract
Both the private and public sectors have begun giving financial incentives to healthcare providers, such as hospitals, delivering superior 'quality of care'. Quality of care is assessed through a set of disease-specific measures that characterize the performance of healthcare providers. These measures are then combined into a unidimensional composite score. Most of the programs that reward superior performance use raw averages of the measures as the composite score. The scores based on raw averages fail to take into account typical characteristics of data used for performance evaluation, such as within-patient and within-hospital correlations, variable number of measures available in different hospitals, and missing data. In this paper, we contrast two different versions of composites based on raw average scores with a model-based score constructed using a latent variable model. We also present two methods to identify hospitals with superior performance. The methods are illustrated using national data collected to evaluate quality of care delivered by the U.S. acute care hospitals.
Laura Mauri and Sharon-Lise T Normand. 2008. “Studies of drug-eluting stents: to each his own?” Circulation, 117, 16, Pp. 2047-50.
2007
Brahmajee K Nallamothu, Yongfei Wang, Peter Cram, John D Birkmeyer, Joseph S Ross, Sharon-Lise T Normand, and Harlan M Krumholz. 2007. “Acute myocardial infarction and congestive heart failure outcomes at specialty cardiac hospitals.” Circulation, 116, 20, Pp. 2280-7.Abstract
BACKGROUND: Outcomes of patients with acute myocardial infarction (AMI) and congestive heart failure (CHF) at specialty cardiac hospitals are uncertain. METHODS AND RESULTS: From 2003 Medicare data, we used hierarchical regression to calculate 30-day standardized mortality ratios and risk-standardized mortality rates for AMI and CHF at 16 cardiac and 121 peer general hospitals in 15 healthcare markets. We then compared cardiac and general hospitals by determining (1) the proportion of facilities with statistically higher, no different, or lower than expected mortality based on 95% interval estimates of standardized mortality ratios and (2) differences in risk-standardized mortality rates between the types of facilities after stratification within healthcare markets. We identified 1912 patients with AMI and 1275 patients with CHF at cardiac hospitals and 13,158 patients with AMI and 18,295 patients with CHF at general hospitals. Patients at cardiac hospitals were younger, were more likely to be male, and had a much lower prevalence of noncardiovascular diseases. After adjustment for patient differences, standardized mortality ratios were significantly better than expected for 4 (25%) and 5 (31%) cardiac hospitals for AMI and CHF, respectively, compared with 5 (4%) and 6 (5%) general hospitals. Risk-standardized mortality rates were modestly lower at cardiac hospitals (15.0% versus 16.2% for AMI, P<0.001, and 10.7% versus 11.3% for CHF, P<0.01). CONCLUSIONS: Patients with AMI and CHF at cardiac hospitals differ considerably from those at peer general hospitals. Although outcomes were modestly better at cardiac hospitals, substantial variation was noted across individual facilities.
Oliver J Wang, Yun Wang, Judith H Lichtman, Elizabeth H Bradley, Sharon-Lise T Normand, and Harlan M Krumholz. 2007. “"America's Best Hospitals" in the treatment of acute myocardial infarction.” Arch Intern Med, 167, 13, Pp. 1345-51.Abstract
BACKGROUND: The ranking of "America's Best Hospitals" by U.S. News & World Report for "Heart and Heart Surgery" is a popular hospital profiling system, but it is not known if hospitals ranked by the magazine vs nonranked hospitals have lower risk-standardized, 30-day mortality rates (RSMRs) for patients with acute myocardial infarction (AMI). METHODS: Using a hierarchical regression model based on 2003 Medicare administrative data, we calculated RSMRs for ranked and nonranked hospitals in the treatment of AMI. We identified ranked and nonranked hospitals with standardized mortality ratios (SMRs) significantly less than the mean expected for all hospitals in the study. RESULTS: We compared 13 662 patients in 50 ranked hospitals with 254 907 patients in 3813 nonranked hospitals. The RSMRs were lower in ranked vs nonranked hospitals (16.0% vs 17.9%, P<.001). The RSMR range for ranked vs nonranked hospitals overlapped (11.4%-20.0% vs 13.1%-23.3%, respectively). In an RSMR quartile distribution of all hospitals, 35 ranked hospitals (70%) were in the lowest RSMR or best performing quartile, 11 (22%) were in the middle 2 quartiles, and 4 (8%) were in the highest RSMR or worst performing quartile. There were 11 ranked hospitals (22%) and 28 nonranked hospitals (0.73%) that each had an SMR significantly less than 1 (defined by a 95% confidence interval with an upper limit of <1.0). CONCLUSIONS: On average, admission to a ranked hospital for AMI was associated with a lower risk of 30-day mortality, although about one-third of the ranked hospitals fell outside the best performing quartile based on RSMR. Although ranked hospitals were much more likely to have an SMR significantly less than 1, many more nonranked hospitals had this distinction.
Sudeep S Gill, Susan E Bronskill, Sharon-Lise T Normand, Geoffrey M Anderson, Kathy Sykora, Kelvin Lam, Chaim M Bell, Philip E Lee, Hadas D Fischer, Nathan Herrmann, Jerry H Gurwitz, and Paula A Rochon. 2007. “Antipsychotic drug use and mortality in older adults with dementia.” Ann Intern Med, 146, 11, Pp. 775-86.Abstract
BACKGROUND: Antipsychotic drugs are widely used to manage behavioral and psychological symptoms in dementia despite concerns about their safety. OBJECTIVE: To examine the association between treatment with antipsychotics (both conventional and atypical) and all-cause mortality. DESIGN: Population-based, retrospective cohort study. SETTING: Ontario, Canada. PATIENTS: Older adults with dementia who were followed between 1 April 1997 and 31 March 2003. MEASUREMENTS: The risk for death was determined at 30, 60, 120, and 180 days after the initial dispensing of antipsychotic medication. Two pairwise comparisons were made: atypical versus no antipsychotic use and conventional versus atypical antipsychotic use. Groups were stratified by place of residence (community or long-term care). Propensity score matching was used to adjust for differences in baseline health status. RESULTS: A total of 27,259 matched pairs were identified. New use of atypical antipsychotics was associated with a statistically significant increase in the risk for death at 30 days compared with nonuse in both the community-dwelling cohort (adjusted hazard ratio, 1.31 [95% CI, 1.02 to 1.70]; absolute risk difference, 0.2 percentage point) and the long-term care cohort (adjusted hazard ratio, 1.55 [CI, 1.15 to 2.07]; absolute risk difference, 1.2 percentage points). Excess risk seemed to persist to 180 days, but unequal rates of censoring over time may have affected these results. Relative to atypical antipsychotic use, conventional antipsychotic use was associated with a higher risk for death at all time points. Sensitivity analysis revealed that unmeasured confounders that increase the risk for death could diminish or eliminate the observed associations. LIMITATIONS: Information on causes of death was not available. Many patients did not continue their initial treatments after 1 month of therapy. Unmeasured confounders could affect associations. CONCLUSIONS: Atypical antipsychotic use is associated with an increased risk for death compared with nonuse among older adults with dementia. The risk for death may be greater with conventional antipsychotics than with atypical antipsychotics.
Sharon-Lise T Normand, Robert E Wolf, John Z Ayanian, and Barbara J McNeil. 2007. “Assessing the accuracy of hospital clinical performance measures.” Med Decis Making, 27, 1, Pp. 9-20.Abstract
OBJECTIVE: To control costs and improve quality, payers are designing new hospital reimbursement policies that link payment to quality. The authors determine the extent to which quality measures discriminate hospitals into tiers in 2 geographic areas. DATA SOURCES: Administrative and medical record data for patients discharged with acute myocardial infarction (AMI) in 368 California and 81 Massachusetts hospitals. METHODS: Through simulation, the minimum numbers of patients per hospital needed to identify high-quality hospitals with sensitivity ranging from 75% to 95% under a variety of clinical scenarios are determined. RESULTS: Massachusetts hospitals had twice the number of eligible patients per hospital than California hospitals. Regardless of state, few hospitals had sufficient sample size needed to achieve >85% sensitivity for high-variation quality measures. CLINICAL IMPLICATIONS: Reliability of quality-based reimbursement systems relies on the distribution of the hospital sample sizes within geographic areas and the size of practice differences. Selection of conformance thresholds and sensitivity levels depends on the user of the information. To assess the usefulness of performance measures to tier hospitals, information regarding between-hospital variation in quality for specific clinical measures needs to be collected and reported.
David M Shahian, Treacy Silverstein, Ann F Lovett, Robert E Wolf, and Sharon-Lise T Normand. 2007. “Comparison of clinical and administrative data sources for hospital coronary artery bypass graft surgery report cards.” Circulation, 115, 12, Pp. 1518-27.Abstract
BACKGROUND: Regardless of statistical methodology, public performance report cards must use the highest-quality validated data, preferably from a prospectively maintained clinical database. Using logistic regression and hierarchical models, we compared hospital cardiac surgery profiling results based on clinical data with those derived from contemporaneous administrative data. METHODS AND RESULTS: Fiscal year 2003 isolated coronary artery bypass grafting surgery results based on an audited and validated Massachusetts clinical registry were compared with those derived from a contemporaneous state administrative database, the latter using the inclusion/exclusion criteria and risk model of the Agency for Healthcare Research and Quality. There was a 27.4% disparity in isolated coronary artery bypass grafting surgery volume (4440 clinical, 5657 administrative), a 0.83% difference in observed in-hospital mortality (2.05% versus 2.88%), corresponding differences in risk-adjusted mortality calculated by various statistical methodologies, and 1 hospital classified as an outlier only with the administrative data-based approach. The discrepancies in volumes and risk-adjusted mortality were most notable for higher-volume programs that presumably perform a higher proportion of combined procedures that were misclassified as isolated coronary artery bypass grafting surgery in the administrative cohort. Subsequent analyses of a patient cohort common to both databases revealed the smoothing effect of hierarchical models, a 9% relative difference in mortality (2.21% versus 2.03%) resulting from nonstandardized mortality end points, and 1 hospital classified as an outlier using logistic regression but not using hierarchical regression. CONCLUSIONS: Cardiac surgery report cards using administrative data are problematic compared with those derived from audited and validated clinical data, primarily because of case misclassification and nonstandardized end points.
Peter C Austin, Paul Grootendorst, Sharon-Lise T Normand, and Geoffrey M Anderson. 2007. “Conditioning on the propensity score can result in biased estimation of common measures of treatment effect: a Monte Carlo study.” Stat Med, 26, 4, Pp. 754-68.Abstract
Propensity score methods are increasingly being used to estimate causal treatment effects in the medical literature. Conditioning on the propensity score results in unbiased estimation of the expected difference in observed responses to two treatments. The degree to which conditioning on the propensity score introduces bias into the estimation of the conditional odds ratio or conditional hazard ratio, which are frequently used as measures of treatment effect in observational studies, has not been extensively studied. We conducted Monte Carlo simulations to determine the degree to which propensity score matching, stratification on the quintiles of the propensity score, and covariate adjustment using the propensity score result in biased estimation of conditional odds ratios, hazard ratios, and rate ratios. We found that conditioning on the propensity score resulted in biased estimation of the true conditional odds ratio and the true conditional hazard ratio. In all scenarios examined, treatment effects were biased towards the null treatment effect. However, conditioning on the propensity score did not result in biased estimation of the true conditional rate ratio. In contrast, conventional regression methods allowed unbiased estimation of the true conditional treatment effect when all variables associated with the outcome were included in the regression model. The observed bias in propensity score methods is due to the fact that regression models allow one to estimate conditional treatment effects, whereas propensity score methods allow one to estimate marginal treatment effects. In several settings with non-linear treatment effects, marginal and conditional treatment effects do not coincide.
James D Neaton, Sharon-Lise Normand, Annetine Gelijns, Randall C Starling, Douglas L Mann, and Marvin A Konstam. 2007. “Designs for mechanical circulatory support device studies.” J Card Fail, 13, 1, Pp. 63-74.Abstract
BACKGROUND: There is increased interest in mechanical circulatory support devices (MCSDs), such as implantable left ventricular assist devices (LVADs), as "destination" therapy for patients with advanced heart failure. Because patient availability to evaluate these devices is limited and randomized trials have been slow in enrolling patients, a workshop was convened to consider designs for MCSD development including alternatives to randomized trials. METHODS AND RESULTS: A workshop was jointly planned by the Heart Failure Society of America and the US Food and Drug Administration and was convened in March 2006. One of the panels was asked to review different designs for evaluating new MCSDs. Randomized trials have many advantages over studies with no controls or with nonrandomized concurrent or historical controls. These advantages include the elimination of bias in the assignment of treatments and the balancing, on average, of known and unknown baseline covariates that influence response. These advantages of randomization are particularly important for studies in which the treatments may not differ from one another by a large amount (eg, a head-to-head study of an approved LVAD with a new LVAD). However, researchers have found it difficult to recruit patients to randomized studies because the number of clinical sites that can carry out the studies is not large. Also, there is a reluctance to randomize patients when the control device is considered technologically inferior. Thus ways of improving the design of randomized trials were discussed, and the advantages and disadvantages of alternative designs were considered. CONCLUSIONS: The panel concluded that designs should include a randomized component. Randomized designs might be improved by allowing the control device to be chosen before randomization, by first conducting smaller vanguard studies, and by allowing crossovers in trials with optimal medical management controls. With use of data from completed trials, other databases, and registries, alternative designs that include both a randomized component (eg, 2:1 allocation for new device versus control) and a nonrandomized component (eg, concurrent nonrandomized control, historical control, or a comprehensive cohort design) should be evaluated. This will require partnerships among academic, government, and industry scientists.
Meredith B Rosenthal, Bruce E Landon, Sharon-Lise T Normand, Richard G Frank, Thaniyyah S Ahmad, and Arnold M Epstein. 2007. “Employers' use of value-based purchasing strategies.” JAMA, 298, 19, Pp. 2281-8.Abstract
CONTEXT: Value-based purchasing by employers has often been portrayed as the lynchpin to quality improvement in a market-based health care system. Although a small group of the largest national employers has been actively engaged in promoting quality measurement, reporting, and pay for performance, it is unknown whether these ideas have significantly permeated employer-sponsored health benefit purchasing. OBJECTIVE: To provide systematic descriptions and analyses of value-based purchasing and related efforts to improve quality of care by health care purchasers. DESIGN, SETTING, AND PARTICIPANTS: We conducted telephone interviews with executives at 609 of the largest employers across 41 US markets between July 2005 and March 2006. The 41 randomly selected markets have at least 100,000 persons enrolled in health maintenance organizations, include approximately 91% of individuals enrolled in health maintenance organizations nationally, and represent roughly 78% of the US metropolitan population. Using the Dun & Bradstreet database of US employers, we identified the 26 largest firms in each market. Firms ranged in size from 60 to 250,000 employees. MAIN OUTCOME MEASURE: The degree to which value-based purchasing and related strategies are reported being used by employers. Percentages were weighted by number of employees. RESULTS: Of 1041 companies contacted, 609 employer representatives completed the survey (response rate, 64%). A large percentage of surveyed executives reported that they examine health plan quality data (269 respondents; 65% [95% confidence interval {CI}, 57%-74%]; P<.001), but few reported using it for performance rewards (49 respondents; 17% [95% CI, 7%-27%]; P=.008) or to influence employees (71 respondents; 23% [95% CI, 13%-33%]). Physician quality information is even less commonly examined (71 respondents; 16% [95% CI, 9%-23%]) or used by employers to reward performance (8 respondents; 2% [95% CI, 0%-3%]) or influence employee choice of providers (34 respondents; 8% [95% CI, 3%-12%]). CONCLUSION: Surveyed employers as a whole do not appear to be individually implementing incentives and programs in line with value-based purchasing ideals.
Sharon-Lise T Normand. 2007. “Evaluating the optimal timing of angiography: landmark or off the mark?” Circulation, 116, 23, Pp. 2656-7.
Susan T Azrin, Haiden A Huskamp, Vanessa Azzone, Howard H Goldman, Richard G Frank, Audrey M Burnam, Sharon-Lise T Normand, Susan M Ridgely, Alexander S Young, Colleen L Barry, Alisa B Busch, and Garrett Moran. 2007. “Impact of full mental health and substance abuse parity for children in the Federal Employees Health Benefits Program.” Pediatrics, 119, 2, Pp. e452-9.Abstract
OBJECTIVE: The Federal Employees Health Benefits Program implemented full mental health and substance abuse parity in January 2001. Evaluation of this policy revealed that parity increased adult beneficiaries' financial protection by lowering mental health and substance abuse out-of-pocket costs for service users in most plans studied but did not increase rates of service use or spending among adult service users. This study examined the effects of full mental health and substance abuse parity for children. METHODS: Employing a quasiexperimental design, we compared children in 7 Federal Employees Health Benefits plans from 1999 to 2002 with children in a matched set of plans that did not have a comparable change in mental health and substance abuse coverage. Using a difference-in-differences analysis, we examined the likelihood of child mental health and substance abuse service use, total spending among child service users, and out-of-pocket spending. RESULTS: The apparent increase in the rate of children's mental health and substance abuse service use after implementation of parity was almost entirely due to secular trends of increased service utilization. Estimates for children's mental health and substance abuse spending conditional on this service use showed significant decreases in spending per user attributable to parity for 2 plans; spending estimates for the other plans were not statistically significant. Children using these services in 3 of 7 plans experienced statistically significant reductions in out-of-pocket spending attributable to the parity policy, and the average dollar savings was sizeable for users in those 3 plans. In the remaining 4 plans, out-of-pocket spending also decreased, but these decreases were not statistically significant. CONCLUSIONS: Full mental health and substance abuse parity for children, within the context of managed care, can achieve equivalence of benefits in health insurance coverage and improve financial protection without adversely affecting health care costs but may not expand access for children who need these services.

Pages