The Effect of a Managed Behavioral Health Carve-Out on Quality of Carefor Medicaid Patients Diagnosed as Having Schizophrenia

Abstract

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. ). 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.

Schizophrenia, Co-occurring Substance use Disorders and Quality of Care: The Differential Effect of a Managed Behavioral Health Care Carve-out

“…Such results have policy implications regarding the strong financial incentives in Medicaid contracts and quality assessment of CO performance. These implications have been addressed previously by the authors (Busch, Frank, & Lehman, 2004).…”

“…Prescription costs were borne by the state. Previous analysis of this CO for all persons diagnosed as having schizophrenia found it associated with a decreased likelihood of receiving some psychosocial treatments (both those with and without an evidence base to support them), but no change in the likelihood of receiving antiextrapyramidal symptoms medications or any anti-psychotic medications-even the newer, more expensive medications (Busch, Frank, & Lehman, 2004). …”

“…The schizophrenia cohort has been previously described (Busch, Frank, & Lehman, 2004). In brief, we balanced minimizing the false-positive and false-negative rates by using the following diagnostic algorithm to define the study cohort.…”

Managing Psychotropic Drug Costs: Will Formularies Work?

“…There is evidence that carve-out adoption has been associated with an increase in prescribing of mental health drugs in private health plans and with a decrease in psychosocial treatments for Medicaid patients diagnosed with schizophrenia. 28 In addition, plans and PBMs do not share with managed behavioral health care vendors the rebates they receive from manufacturers of psychotropic drugs, which would provide vendors with an incentive to encourage clinicians in their network to steer patients toward preferred drugs where appropriate.…”

Mental health and substance abuse insurance parity for federal employees: How did health plans respond?

“…Carve-outs do not appear to increase rates of re-hospitalization (Sturm, 1999;Merrick, 1998). However, studies have produced mixed results on their effects on continuity of care (Ray, 2003;Merrick, 1998), adherence to treatment guidelines (Busch, Frank, & Lehman, 2004;Busch, 2002), and clinical outcomes Manning & Liu, 1999).…”