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Medicaid shifts to widely used mental health carve-out programs may interrupt therapy among the most needy patients

People who have schizophrenia and other serious mental illnesses who do not continue to take their antipsychotic medication run the risk of having acute psychotic episodes and being hospitalized. Once lost, medication adherence may be difficult to reestablish, and the ensuing clinical deterioration may not be reversible, explains Wayne A. Ray, Ph.D., of the Nashville Veterans Affairs Medical Center.

A July 1, 1996 shift in Tennessee's Medicaid program, TennCare, to provide mental health services through a specialized behavioral health "carve-out" program greatly bolstered the likelihood that seriously mentally ill patients would miss taking their antipsychotic medication for more than 2 months. These patients decreased their use of antipsychotic drugs immediately after the transition to the carve-out program, and the lower level of drug use persisted throughout the 12 months of followup, according to the study which was supported in part by the Agency for Healthcare Research and Quality (HS10384).

Dr. Ray and his colleagues observed adherence to antipsychotic therapy after this TennCare shift among patients 21 to 64 years of age who had adhered to antipsychotic therapy during a 6-month baseline period that preceded the 12 months of study followup. The researchers examined lack of adherence to antipsychotic therapy (missed treatment for more than 60 days) among 4,507 patients followed for 1 year after the shift (post-transition group) and 3,644 patients whose followup began 1 year earlier (pre-transition group).

Among high-risk patients (those requiring the administration of extended-release injections of antipsychotic medications and those who had been hospitalized for psychosis), for whom continued medication was most important, 29 percent in the post-transition cohort missed more than 60 days of antipsychotic therapy compared with 20 percent in the pre-transition group. They also had 14.4 fewer mean days of antipsychotic therapy than the pre-transition group. Continuity of outpatient care also decreased after the shift to the carve-out program.

More details are in "Effect of a mental health "carve-out" program on the continuity of antipsychotic therapy," by Dr. Ray, James R. Daugherty, M.S., and Keith G. Meador, M.D., M.P.H., in the May 8, 2003, New England Journal of Medicine 348(19), pp. 1885-1894.

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