The effect of a managed behavioral health carve-out on quality of care for medicaid patients diagnosed as having schizophrenia
The effect of a managed behavioral health carve-out on quality of care for medicaid patients diagnosed as having schizophrenia
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DOI：
10.1001/archpsyc.61.5.442
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发表时间：
2004-05-01
影响因子：
--
通讯作者：
Lehman, AF
中科院分区：
文献类型：
--
作者：
Busch, AB;Frank, RG;Lehman, AF
管理行为健康分离（mbhco）是公共和私人精神卫生保健系统的常规特征，并且在降低成本方面取得了成功。关于质量影响的证据是有限的，除了严重精神疾病患者可能是mbhco最不利的人群外，总体上表明质量相当。目的：探讨实施MBHCO对诊断为精神分裂症的参保人门诊服务质量的影响。设计和参与者：采用准实验设计的观察性回顾性队列研究，纳入1994年至2000年间在分割区和比较区被诊断患有精神分裂症的18至64岁的州医疗补助参保者（8082人-年）。环境：门诊护理。主要结果测量：质量指标来源于精神分裂症患者结果研究小组的建议。结果：在接受任何抗精神病药物治疗的可能性（优势比[OR]， 1.02； 95%可信区间[CI]， 0.81-1.29）、第二代抗精神病药物（包括氯氮平：OR， 1.05; 95% CI, 0.86-1.28；不包括氯氮平：OR， 1.05; 95% CI, 0.85-1.29）或抗锥体外系药物治疗的可能性（OR, 1.36; 95% CI, 0.84-2.19）方面，分离组和综合组之间无统计学差异。切出与接受任何个体治疗（OR, 0.27; 95% CI, 0.22-0.33）、团体治疗（OR, 0.19; 95% CI, 0.14-0.25）和心理社会康复（OR, 0.31; 95% CI, 0.26-0.38）呈负相关。在分离地区和一体化地区，家庭治疗的发生率均低于1%。结论：MBHCO与用药质量的变化无关（因此不存在财务风险）。它与接受心理治疗的可能性急剧下降（这在经济上有风险）显著相关，而与临床证据基础是否支持这些治疗无关。
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.