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Thursday, May 12, 2016

The Impact of Mandates

The Politics of Autism includes an extensive discussion of insurance legislation in the states.

At IMFAR, David Mandell and Colleagues have a paper titled "The Effects of Autism Insurance Mandates on Treated Prevalence and Service Use."  The abstract:
Background: In the US, 42 states have passed autism insurance mandates that require commercial insurance plans to pay for autism-related services. These mandates have not been rigorously evaluated. The few studies of the mandates have not assessed their effects directly on the number of children diagnosed with autism or the services they received as a result of the mandates.
Objectives: To assess the effects of the autism insurance mandates on the treated prevalence of autism and use of and spending on behavioral therapies among children with autism.
Methods: We used data from the Health Care Cost Institute from 2008–2012. HCCI data includes health care claims from three large insurance companies in 50 states and the District of Columbia. A difference-in-differences design with state and year fixed effects was used to identify the independent effects of the mandates, separate from other state characteristics. Outcomes among four groups of children were compared: 1) children in states with an active mandate who had insurance subject to the mandate; 2) children in states with an active mandate whose insurance was not subject to the mandate; 3) children in states without a mandate whose insurance would have been subject to the mandate if one were active; and 4) children in states without a mandate whose insurance would not have been subject to the mandate if one were active. Additional analyses estimated the impact of mandates on treated prevalence in the first, second, and third or later years after implementation. Regression models also adjusted for patient age, sex, insurance plan type, and calendar month and standard errors were adjusted to account for clustering at the state level. A second set of analyses using a similar analytic approach will examine the effects of the mandates on service use among children diagnosed with autism.
Results: Analyses of the effects of the mandate on service use and spending are ongoing. Mandates were implemented in 29 states by the end of the study period. Mandate enactment increased the treated prevalence of autism overall by 12.2% (95% confidence interval [CI]: 6.1%, 18.63%) from a base of 2.4 per 1,000. Treated prevalence increased by an average of 9.9% (95% CI: 4.7%, 15.2%) in the first year after enactment, by 16.6% (95% CI: 7.1%, 26.0%) in the second year, and by 17.2% (95% CI: 8.6%, 25.8%) in the third or later year.
Conclusions: This study represents the most rigorous analysis to date of a widespread state-level insurance mandate policy in the US. We found that autism mandates have had a statistically significant but small effect on treated prevalence, which remains far below what would be expected based on community prevalence studies. Mandates may be a necessary but not sufficient policy for helping children obtain services reimbursed through private insurance. Analyses that will be completed prior to the conference will examine whether the mandates had an effect on use of behavioral health care, functional therapies, and other types of relevant care and total and out-of-pocket spending on these services paid for through private insurance.
At Kaiser Health News, Shefali Luthra reports on the study and quotes Alycia Halladay, chief science officer at the Autism Science Foundation:
"You can't rely on these mandates alone. You can't say, 'OK now, everything's hunky-dory, and everyone's being served the right way,' " she said.
There are a few possible reasons the coverage requirements aren't always translating to people getting treatment.
Even if insurers have to cover care, there is wide variation in how generous the coverage is. Plans can argue that certain services like speech and occupational therapy as well as applied behavioral therapy aren't necessary. Or insurers can require higher cost-sharing, or reimburse at a low enough rate that providers don't participate. Also, not all mandates are equal — some states cap coverage, allow ceilings to the number of visits or limit the age range of beneficiaries.
Even when a mandate is in place, it's often unclear what insurance plans are actually required to pay for, said Halladay. Plus parents of autistic children may not realize what services are covered, she added.
Then there's also the fact that, compared to the need, not enough doctors are familiar with autism treatments, noted Mandell, who co-authored a qualitative study published last November in the journal Autism. The research presented Wednesday will appear this summer in JAMA Pediatrics.
"There are long waiting lists for people to get medical referrals for their autism-related problems. There are wait lists all over the place. And that's because there aren't enough people trained," Halladay said. "It's not an easy problem to solve."