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