Does capitation affect the health of the chronically mentally ill? Results from a randomized trial.

OBJECTIVE To determine the effect on health outcomes of enrollment of chronically mentally ill Medicaid recipients in prepaid plans vs traditional fee-for-service Medicaid. DESIGN A randomized controlled trial. Clients who were randomly assigned to prepaid care were then permitted to choose among four capitated health plans. Clients returned to fee-for-service care at the end of the demonstration. SETTING The Medicaid Demonstration Project in Hennepin County, Minnesota, the urban center of which is Minneapolis. PATIENTS Seven hundred thirty-nine Medicaid clients who were classified as having chronic mental illness on the basis of Medicaid claims. Clients were interviewed at baseline (time 1) and at two follow-up points. Data were available for 96% of participants at the end of the intervention (time 2). Average duration of follow-up was 11 months. A subset of 370 clients with schizophrenia was followed up 11 months after the return of the prepaid group to fee-for-service care (time 3). MAIN OUTCOME MEASURES General health status, physical functioning, social functioning, and psychiatric symptoms, assessed using the Schedule of Affective Disorders and Schizophrenia-Change version, the Global Assessment Scale, and indicators of community function. RESULTS No significant differences between prepaid and fee-for-service groups in general health or psychiatric symptoms from baseline to time 2. After regression adjustment, 12% fewer clients in the prepaid group reported being victimized (P less than .01). At the end of time 3, the regression-adjusted Global Assessment Scale scores had worsened by 7.6 points more in the prepaid group in comparison with the fee-for-service group (P less than .02). CONCLUSION There was no consistent evidence of harmful effects of enrolling chronically mentally ill Medicaid clients in prepaid care, at least in the short run. The generalizability of these findings may be limited to plans that control utilization by methods similar to those used in this study setting. Longer-term outcome studies should be undertaken to clarify the strength of the findings.

[1]  T. Carey,et al.  Prepaid versus traditional Medicaid plans: lack of effect on pregnancy outcomes and prenatal care. , 1991, Health services research.

[2]  W. Dubin,et al.  No free lunch: limitations on psychiatric care in HMOs. , 1991, Hospital & community psychiatry.

[3]  L. Scallet.  Paying for public mental health care: crucial questions. , 1990, Health affairs.

[4]  H. Goldman,et al.  Medicaid coverage for mental illness: balancing access and costs. , 1990, Health affairs.

[5]  Findings from the Medicaid Competition Demonstrations: A guide for States , 1990, Health care financing review.

[6]  M Finch,et al.  Minnesota: plan choice by the mentally ill in Medicaid prepaid health plans. , 1989, Advances in health economics and health services research.

[7]  E. Keeler,et al.  Effect of a health maintenance organization on physiologic health. Results from a randomized trial. , 1987, Annals of internal medicine.

[8]  D. Freund,et al.  Overview of Medicaid capitation and case-management initiatives , 1986, Health care financing review.

[9]  W. Manning,et al.  Use of outpatient mental health services in HMO and fee-for-service plans: results from a randomized controlled trial. , 1986, Health services research.

[10]  M. Schlesinger.  On the limits of expanding health care reform: chronic care in prepaid settings. , 1986, The Milbank quarterly.

[11]  C. Sherbourne,et al.  COMPARISON OF HEALTH OUTCOMES AT A HEALTH MAINTENANCE ORGANISATION WITH THOSE OF FEE-FOR-SERVICE CARE , 1986, The Lancet.

[12]  W. Manning,et al.  A controlled trial of the effect of a prepaid group practice on use of services. , 1984, The New England journal of medicine.

[13]  A. Lehman.  The effects of psychiatric symptoms on quality of life assessments among the chronic mentally ill. , 1983, Evaluation and program planning.

[14]  A. Stewart,et al.  Construction and Scoring of Aggregate Functional Status Measures , 1982 .

[15]  J. Fleiss,et al.  Brief vs standard hospitalization: for whom? , 1979, Archives of general psychiatry.

[16]  J. Endicott,et al.  A diagnostic interview: the schedule for affective disorders and schizophrenia. , 1978, Archives of general psychiatry.

[17]  J. Fleiss,et al.  The global assessment scale. A procedure for measuring overall severity of psychiatric disturbance. , 1976, Archives of general psychiatry.