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Guideline Recommendations for Treatment of Schizophrenia
The Impact of Managed Care
Barbara Dickey, PhD;
Sharon-Lise T. Normand, PhD;
Richard C. Hermann, MD, MS;
Susan V. Eisen, PhD;
Dharma E. Cortés, PhD;
Paul D. Cleary, PhD;
Norma Ware, PhD
Arch Gen Psychiatry. 2003;60:340-348.
Background Medicaid-managed care has been shown to reduce the number and length of psychiatric hospitalizations, but little is known about the clinical and social consequences of such managed care programs. The purpose of this study was to compare the treatment of schizophrenia for disabled Medicaid beneficiaries who were and were not enrolled in managed care.
Methods This was a prospective observational study of patients who sought care for a psychiatric crisis from June 7, 1997, to May 13, 1999. Patients were followed up for 6 months. Inpatient and outpatient mental health facilities in Massachusetts were studied. The participants included 420 adult Medicaid beneficiaries, aged 24 to 64 years, who were treated for schizophrenia; 784 eligible beneficiaries were originally contacted and invited to participate (53.6% response). A private managed behavioral health care organization administered the Medicaid mental health benefit for about half the patients in the study. The other half were enrolled in the dually insured fee-for-service Medicare/Medicaid plan. The main outcome measures were adherence to the Schizophrenia Patient Outcomes Research Team treatment recommendations from inpatient and outpatient medical records, self-reported quality of interpersonal interactions between patient and clinician, self-reported care experiences and outcomes, and clinician-reported outcomes.
Results There were no differences between the managed care plan and the unmanaged fee-for-service plan in adherence to the schizophrenia treatment guidelines. However, much outpatient care in both programs was inconsistent with treatment guidelines. Inpatient treatment was far more likely to conform to guidelines than outpatient treatment. Patient ratings of their care were positive and not different between plans. Clinical outcome and health-related quality of life were not different between plans.
Conclusions A major change in Massachusetts in the way mental health care is organized and financed had neither a negative nor a positive effect on care quality. However, adherence to nationally accepted guidelines for care was only modest, suggesting a need to improve the delivery of treatment to the most disabled highest-risk adults with schizophrenia.
From the Departments of Psychiatry (Drs Dickey, Hermann, Cortés, and Ware), Health Care Policy (Drs Normand and Cleary), and Social Medicine (Drs Cleary and Ware), Harvard Medical School, Departments of Biostatistics (Dr Normand) and Health and Social Behavior (Dr Cleary), Harvard School of Public Health, Boston, Mass; McLean Hospital, Belmont, Mass (Dr Hermann); The Cambridge Hospital, Cambridge, Mass (Drs Dickey, Cortés, and Ware); and Department of Health Services, Boston University School of Public Health, and Veterans Affairs Medical Center, Bedford, Mass (Dr Eisen).
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