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Alisa B. Busch, MD, MS; Richard G. Frank, PhD; Anthony F. Lehman, MD, MSPH

Arch Gen Psychiatry. 2004;61:442-448.

Context  Managed behavioral health carve-outs (MBHCOs) are a regular feature of public and private mental health care systems and have been successful in reducing costs. The evidence on quality impacts is limited and suggests comparable quality overall, except that people with severe psychiatric disorders may be those most disadvantaged by MBHCOs.

Objective  To explore the effect of implementing an MBHCO on the quality of outpatient care received by enrollees diagnosed as having schizophrenia.

Design and Participants  Observational retrospective cohort study using a quasi-experimental design of state Medicaid enrollees diagnosed as having schizophrenia, aged 18 to 64 years between 1994 and 2000 in the carve-out and comparison regions (8082 person-years).

Setting  Ambulatory care.

Main Outcome Measures  Quality indicators derived from the Schizophrenia Patient Outcomes Research Team recommendations.

Results  There was no statistical difference between the carve-out and integrated arrangements in the likelihood of receiving any antipsychotic medication (odds ratio [OR], 1.02; 95% confidence interval [CI], 0.81-1.29), second-generation antipsychotics (including clozapine: OR, 1.05; 95% CI, 0.86-1.28; not including clozapine: OR, 1.05; 95% CI, 0.85-1.29), or antiextrapyramidal medication (OR, 1.36; 95% CI, 0.84-2.19). The carve-out was negatively associated with receiving any individual therapy (OR, 0.27; 95% CI, 0.22-0.33), group therapy (OR, 0.19; 95% CI, 0.14-0.25), and psychosocial rehabilitation (OR, 0.31; 95% CI, 0.26-0.38). Family therapy occurred for less than 1% of this population in both carve-out and integrated regions.

Conclusions  The MBHCO was not associated with changes in medication quality (for which it was not at financial risk). It was significantly associated with sharp decreases in the likelihood of receiving psychosocial treatments (for which it was financially at risk)—independent of whether a clinical evidence base supported them.

From the Departments of Psychiatry (Dr Busch) and Health Care Policy (Dr Frank), Harvard Medical School, Boston, Mass; Department of Psychiatry, University of Maryland School of Medicine, Baltimore, Md (Dr Lehman); Alcohol and Drug Abuse Treatment Program, McLean Hospital, Belmont, Mass (Dr Busch); and National Bureau of Economic Research, Cambridge, Mass (Dr Frank).

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