CHANGES IN THE PROCESS OF CARE FOR MEDICAID PATIENTS WITH SCHIZOPHRENIA IN UTAH PREPAID MENTAL-HEALTH PLAN

Objective: Changes in the process of psychiatric care received by Medi caid beneficiaries with schizophrenia were examined after the introduc tion of capitated payments for enrollees of some community mental heal th centers (CMHCs) under the Utah Prepaid Mental Health Plan. Methods: Data from the medical records of 200 patients receiving care in CMHCs participating in the prepaid plan were compared with data from the re cords of 200 patients in nonparticipating CMHCs, which remained in a f ee-for-service reimbursement arrangement. Using the Process of Care Re view Form, trained abstracters gathered data characterizing general pa tient management, social support, medication management, and medical m anagement before implementation of the plan in 1990 and for three foll ow-up years. Using regression techniques, differences in the adjusted changes between third-year follow-up and baseline were examined by tre atment site. Results: By year 3 at the CMHCs participating in the plan , psychotherapy visits decreased, the probability of a patient's termi nating treatment or being lost to follow-up increased, the probability of having a case manager increased, the probability of a crisis visit decreased (but still exceeded that at the nonplan sites), and the pro bability of treatment for a month or longer with a suboptimal dosage o f antipsychotic medication increased. Only modest changes in the proce ss of care were observed at the nonplan CMHCs. Conclusions: Change in the process of psychiatric care was more evident at the sires particip ating in the plan, where traditional therapeutic encounters were de-em phasized in response to capitation. The array of changes raises questi ons about the vigor of care provided to a highly vulnerable group of p atients.