May 9, 2003

TennCare lowers care quality for schizophrenic patients: VUMC study

Featured Image

Wayne Ray, Ph.D. led the research at VUMC.

TennCare lowers care quality for schizophrenic patients: VUMC study

A Vanderbilt University Medical Center researcher points to a tactic by TennCare to save money that resulted in a dramatic decrease in the quality of care of mental health patients in the state.

Wayne Ray, Ph.D., professor of Preventive Medicine and director of the Division of Pharmacoepidemi-ology, along with James Daugherty of Vanderbilt University and Dr. Keith Meador of Duke University, studied the medical records of more than 8,000 patients who received mental health care under TennCare, TennCare Partners or both.

TennCare Partners was implemented in July 1996. Under the “carve-out” program, TennCare transferred management of its mental health services to two behavioral health organizations. This program was implemented as a cost-saving measure.

Ray and his co-workers conducted a retrospective study of thousands of individuals enrolled in the carve-out program to determine TennCare Partners’ effect on patient care. Their findings are detailed in an article titled, “Effect of a Mental Health ‘Carve-Out’ Program on the Continuity of Antipsychotic Therapy,” published in the May 8 edition of the New England Journal of Medicine.

Ray and his fellow researchers discovered that patients’ therapy was more likely to be interrupted and was shorter in duration under TennCare Partners. These differences were most pronounced among high-risk patients.

These data suggest that the TennCare Partners program resulted in a lower quality of health care for the affected patients and that the most high-risk patients experienced the greatest loss in service.

Ray has a longstanding interest in studying the effects of changes in government health policy. These policy changes can “have major effects on lots of people but oftentimes once they’re implemented there is little effort put forth to evaluate them,” said Ray.

He makes an analogy to the scrutiny new medications receive prior to entering the marketplace, in which safety and effectiveness must be demonstrated. “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 researchers poured through TennCare records and identified patients — nearly all suffering from schizophrenia — who were suitable for study. Individuals included in the study were those who had complied with antipsychotic therapy of 100 mg thioridazine daily (or an equivalent medication) for a six-month period, called the baseline period. Eligible individuals were then divided into two groups, or cohorts — the pretransitional and posttransitional cohorts.

For both cohorts, this initial six-month baseline period occurred prior to July 1996. Conclusions of the study were drawn based on a one-year “follow-up” period and this differed between the two cohorts. The pretransitional cohort follow-up period ended on June 30, 1996, the day before the TennCare Partners program began. The posttransitional follow-up period began July 1, 1996 and coincided with the first year of the TennCare Partners program. The two cohorts were similar in terms of average age, racial make-up and antipsychotic therapy received during the baseline period.

After identifying the two cohorts, the researchers then compared and contrasted the antipsychotic therapy the two groups received during the follow-up period. They found several differences between the two groups.

The posttransitional cohort showed a statistically significant higher percentage of patients who missed more than 60 days of antipsychotic therapy. This same group also showed a lower average number of days of antipsychotic therapy. Among those patients in each cohort whose well being was especially dependent on continuity of therapy, these differences were even greater.

Continuity of therapy is crucial for persons suffering from schizophrenia. “Compliance with medication is an essential part of treatment” of schizophrenia, said Ray. Schizophrenics “can maintain fairly normal lives when they’re taking their medication,” he continued, “but if they stop, control over the disease may disappear and they may have very unfavorable consequences.”

Ray’s analysis also showed several other negative effects of the carve-out program. The trend of more missed treatment and fewer days of treatment for the posttransitional cohort persisted throughout the entire follow-up period, not simply in the first few months after the transition to TennCare Partners.

Patients in the posttransitional cohort who required outpatient visits in the follow-up period were less likely to see the same physician than those in the pretransitional cohort. The researchers also looked at patients not included in the two cohorts because they had received only sporadic treatment during the baseline period. The study found TennCare Partners did not improve the health care situation for these patients. They were equally as likely to miss antipsychotic therapy before July 1, 1996 as after.

“This study reminds us that cost-containment measures can have negative impacts on the care of patients, especially the most vulnerable ones,” said Dr. Jerry Avorn, an associate professor at Harvard Medical School and a reviewer of this study prior to its publication. “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.”

Ray said he is in communication with the Tennessee Department of Health and TennCare and has informed them of their findings. He also said while this study obviously appears too late to effect implementation of the TennCare Partners program, TennCare has made a number of changes to correct the problems identified in this study.

This research was supported in part by a grant from the National Institute of Mental Health and a cooperative agreement with the Centers for Education and Research on Therapeutics of the Agency for Healthcare Research and Quality.