Transition to mental health carveouts disrupts care for most fragile

May 07, 2003

A study in the May 8 edition of the New England Journal of Medicine describes the disruptive effects that a transition to a mental health "carveout" system in Tennessee had on antipsychotic therapy for people with schizophrenia, and how lessons about the chaotic transition could help other states' programs.

"When the system of preventive mental health for fragile patients is changed, care has to be taken to prevent disruption of services such as community services essential to help patients comply with their medication regimens," says Wayne Ray, Ph.D., professor of preventive medicine at Vanderbilt University Medical Center. "In these patients, loss of compliance can have severe consequences.

"Also, it was clear that carve-out programs need to include incentives for increasing the quality of care as well as containing costs. This was missing in the original Tennessee carveout," he says. Sixteen other states currently have similar carveout systems.

In a cost-saving move in 1996, thousands of Tennesseans receiving Medicaid for mental health services were transferred into two behavioral health maintenance organizations under a program called TennCare Partners, creating a mental health carveout.

Ray, James Daugherty, an data analyst at Vanderbilt, and Dr. Keith Meador at Duke poured over the records of 8,000 of these mental health patients, most of whom had schizophrenia. They studied antipsychotic therapy during a six-month period of care prior to the transition to establish a baseline and compared those findings to the first year of care following the move.

The post-transitional group missed a statistically significant higher percentage of patients who missed more than 60 days of antipsychotic therapy, including drug therapy, and they received fewer days of antipsychotic therapy overall. They were less likely to see the same physician as the patients before the transition.

It is well know that compliance with medication is an essential part of treatment of schizophrenia, Ray says. On medication, "they can maintain fairly normal lives. But if they stop, control over the disease may disappear and they may have very unfavorable consequences.

Jerry Avorn, M.D., associate professor of medicine at Harvard Medical School, reviewed the study before publication. He says, "This study reminds us that cost-containment measures can have negative impacts on the care of patients, especially the most vulnerable ones. It provides important evidence that we need to follow the consequences of such cutbacks on the people they affect. Dr. Ray's study shows that this can be done rigorously. Unfortunately, those responsible for making these changes often fail to evaluate them this carefully."

While new medications receive years of scrutiny prior to entering the marketplace, policy often evades tough examination. "Some argue that the same kind of standard ought to be applied to policies, at least you ought to evaluate them to see if they're achieving the benefits they are supposed to achieve and if they have any unanticipated effects."

The Tennessee Department of Health and its TennCare program have made changes in its delivery system since Ray's study began. But, he says, in other states these problems linger.
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Addition Media contact: Clinton Colmenares, pager 615-835-1591

Vanderbilt University Medical Center

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