1. Difference-in-Difference Estimation for Policy and Practice Evaluation Neal Wallace, Ph.D. Portland State University February 2014

2. Overview • What is “difference-in-difference” estimation • When is it used • Why should you care • Underlying assumption • How it works • Getting started • Some Best Practices • MH services research example • Concluding Remarks • References

3. What is “Difference-in-Difference” (D-in-D) Estimation • D-in-D estimation is a research design and empirical process intended to assess the “true” effect of a policy or practice intervention where random assignment is not feasible. • The “true” effect of an intervention is the total effect of an intervention on an outcome, net any changes in outcome that would occur in the absence of the intervention.

4. What is “Difference-in-Difference” (D-in-D) Estimation • A D-in-D is the difference between two differences (or changes): • Difference #1: The change in outcome for an intervention group from pre- to post-intervention • Difference #2: The change in outcome for a control (non-intervention) group over the same pre- to post-intervention periods

5. When is D-in-D Used? • For policy or practice evaluations where experimental conditions reasonably exist except for randomization of subjects: • Natural Experiments – where the intervention is established independent of the researcher (e.g. public policy) • Quasi Experiments – where the researcher controls the intervention but randomization isn’t ethically or otherwise feasible.

6. Why Should You Care • D-in-D is becoming the gold standard for observational services research • Its effective and affordable • Programs and policy-makers love it • Incorporating it in your work can enhance your opportunities for funded research and publication.

7. A Main Underlying Assumption • Parallel Trends – in the absence of intervention, the unobserved differences between intervention and control groups are the same over time. • Relaxes assumption that intervention and control groups are the same in every respect apart from the intervention (randomization is supposed to achieve this) • Intervention group would follow the outcome “path” of control group if no intervention • Any pre-intervention outcome differences between intervention and control groups are constant effects that can be factored (differenced) out

8. How it works • Given an outcome Oit measured for pre-post intervention time periods (t=1,2) and control/ intervention groups (i=1,2)

9. How it Works • To estimate the D-in-D in a regression framework, we need dummy variables that will identify the four subject group and time period combinations: • P(ost) = 1 in post periods, =0 in pre periods • I(ntervention) = 1 if intervention, =0 if control • P(ost)xI(ntervention) = 1 if post & intervention, =0 otherwise • Note – Control group in pre-period is “excluded” group – will be measured by regression constant

10. How it works • A D-in-D regression model would look like: Oit = B0 + B1*I + B2*P + B3*PxI + e

11. Getting Started • You need: • An intervention (change) • Outcome measure(s) • Comparison group(s) • Information on subject characteristics

12. Some Best Practices • Know your intervention • Is there clear documentation of what they are doing(fidelity)? • Are there types of individuals that are more or less likely to respond to the intervention? • Are there likely anticipatory or shock (short-term) effects? (“wash out” periods) • Know its environment • Can you identify those receiving intervention from those not? • Is there anything else going on that might effect the outcomes you plan to measure? • Why is this being done now? In this particular place? (endogeneity)

13. Some Best Practices • Take the parallel trend assumption seriously • Thoughtfully choose control group(s) e.g. can subjects choose to be intervention or control? (selection) • Test for stable differences in outcomes between control/intervention groups across pre-intervention time periods. • Minimize all observable differences (covariates/ matching/weighting methods addressing subject characteristics) • Understand and be prepared to explain the “flow” of outcomes that result in the D-in-D – not just the D-in-D itself. • Be thorough and transparent • Seek additional ways to “test” your findings e.g. “internal” D-in-Ds on intervention subjects more and less likely to be affected to assure any outcome change is likely related to intervention • Report all aspects of the conduct and context of the study

14. Example: • Estimate effect of MH insurance parity in Oregon state on receipt of MH outpatient care within 30 days of MH inpatient stay. • Start with overall D-in-D to estimate policy effect for all Oregonians experiencing parity • Used pooled comparison group of subjects from states of Oregon, Washington, California • Followed with “internal” D-in-D estimating policy effects for individuals most likely to be affected by policy

17. Concluding Remarks • Thinking with a D-in-D mindset opens your eyes to “natural” experiments around you. • The “science” of D-in-D can be readily learned from example – the “art” of D-in-D requires experience and a willingness to immerse yourself in the details of MH service provision and receipt. • Regularized data collection protocols and D-in-D go hand in hand – each is a justification for the other….

18. Some D-in-D References • Some general ones.. • Angrist, J. D.; Pischke, J. S. (2008). Mostly harmless econometrics: An empiricist's companion. Princeton University Press. ISBN9780691120348. • Buckley, Jack & Yi Shang (2003). Estimating policy and program effects with observational data: the “differences-in-differences” estimator. Practical Assessment, Research & Evaluation, 8(24). Retrieved February 3, 2014 from http://PAREonline.net/getvn.asp?v=8&n=24 • Meyer, B.D. (1995). Natural and Quasi-Experiments in Economics. Journal of Business & Economic Statistics, Vol. 13, No. 2, JBES Symposium on Program and Policy Evaluation (Apr., 1995), pp. 151-161 • Just Google “difference in difference” – many useful class notes from professors out there… • Some MH services ones… • Wallace NT, McConnell KJ. 2013 “Impact of Comprehensive Insurance Parity on Follow-Up Care After Psychiatric Inpatient Treatment in Oregon”, Psychiatric Services, 64(10):961-966. • McConnell KJ, Gast SH, Ridgely MS, Wallace N, Jacuzzi N, Rieckmann T, McFarland BH, McCarty, D. 2012 “Behavioral Health Insurance Parity: Does Oregon’s Experience Presage the National Experience with the Mental Health Parity and Addiction Equity Act?”, American Journal of Psychiatry, 169:31-38. • Wallace NT, Bloom JR, Hu T and Libby AM 2005 “Psychiatric Medication Treatment Patterns for Adults with Schizophrenia under Medicaid Mental Health Managed Care in Colorado” Psychiatric Services, 56(11), November, pp.1402-1408. • Bloom JR, Hu TW, Wallace NT, Cuffel B, Hausman J, and Scheffler R 2002 “Mental Health Costs and Access Under Alternative Capitation Systems in Colorado,” Health Services Research, 37(2), April, pp. 315-340.

19. Questions? Thank You nwallace@pdx.edu Mark O. Hatfield School of Government Portland State University