Schizophrenia, Co-occurring Substance use Disorders and Quality of Care: The Differential Effect of a Managed Behavioral Health Care Carve-out

  • Alisa B. Busch
  • Richard G. Frank
  • Anthony F. Lehman
  • Shelly F. Greenfield


This study explores the differential effect of a managed behavioral health Carve-Out (CO) on outpatient treatment quality for persons with schizophrenia (SCHZ) alone and co-occurring substance use disorders (SUD) (SCHZ+SUD). We used claims data from a state Medicaid program and employed a retrospective, quasi-experimental design with logit and difference in difference formula regression models. The results show the CO was associated with greater changes in treatment quality for the SCHZ population, compared to the SCHZ+SUD population. Most pronounced across both populations were decrements in receiving the psychosocial treatments for enrollees in the CO arrangement.

Key words

Co-occurring disorders Schizophrenia Substance use disorders Quality of care Managed care 



We gratefully acknowledge funding from the NIMH (R01MH62028, R01MH62028: Drs. Busch and Frank; and R01MH59254: Dr. Frank), NIDA (K08 DA00407: Dr. Greenfield; 2 P50 DA10233-06A2: Drs. Frank and Greenfield), the McLean Hospital Maria Lorenz-Pope Award (Dr. Busch) and the National Center on Minority Health and Health Disparities (Dr. Busch). The funding organizations had no role in the collection, analysis or interpretation of the data. They also had no role in the preparation, review or approval of this manuscript. We also thank Christina Fu, Ph.D. for her programming expertise on this project.


  1. Alterman, A. I., Erdlen, D. L., & Murphy, E. (1982) Effects of illicit drug use in an inpatient psychiatric population. Addictive Disorders, 7, 231–242CrossRefGoogle Scholar
  2. Barbee, J. G., Clark, P. D., Crapanzano, M. S., Heintz, G. C., & Kehoe, C. E. (1989) Alcohol and substance abuse among schizophrenic patients presenting to an emergency psychiatric service. Journal of Nervous and Mental Disease, 177, 400–407PubMedCrossRefGoogle Scholar
  3. Bartels, S. J., Drake, R. E., & Wallach, M. A. (1995) Long term course of substance use disorders among patients with severe mental illness. Psychiatric Services, 46(3), 248–251PubMedGoogle Scholar
  4. Bloom, J. R., Hu, T.-W., Wallace, N., Cuffel, B., Hausman, J. W., Sheu, M.-L., & Scheffler, R. (2002) Mental health costs and access under alternative capitation systems in Colorado. Health Services Research, 37(2), 315–340CrossRefPubMedGoogle Scholar
  5. Busch, A. B., Frank, R. G., & Lehman, A. F. (2004) The effect of a managed behavioral health carve-out on quality of care for Medicaid patients diagnosed as having schizophrenia. Archives of General Psychiatry, 61(5), 442–448CrossRefPubMedGoogle Scholar
  6. Carpenter, W. T. J., Heinrichs, D. W., & Alphs L. D. (1985) Treatment of negative symptoms. Schizophrenia Bulletin, 11, 440–452PubMedGoogle Scholar
  7. Cohen, L. J., Test, M. A., & Brown, R. L. (1990) Suicide and schizophrenia: Data from a prospective community treatment study. American Journal of Psychiatry, 147(5), 602–607PubMedGoogle Scholar
  8. Cuffel, B. J., Bloom, J. R., Wallace, N., Hausman, J. W., & Hu, T.-W. (2002) Two-year outcomes of fee-for-service and capitated Medicaid programs for people with severe mental illness. Health Services Research, 37(2), 341–359CrossRefPubMedGoogle Scholar
  9. Dickey, B., Normand, S.-L. T., Hermann, R. C., Eisen, S. V., Cortes, D. E., Cleary, P. D., & Ware, N. (2003) Guideline recommendations for treatment of schizophrenia. Archives of General Psychiatry, 60(4), 340–348CrossRefPubMedGoogle Scholar
  10. Drake, R. E., & Wallach, M. A. (1989) Substance abuse among the chronic mentally ill. Hospital and Community Psychiatry, 40, 1041–1046PubMedGoogle Scholar
  11. Farris, C., Brems, C., Johnson, M. E., Wells, R., Burns, R., & Kletti, N. (2003) A comparison of schizophrenic patients with or without coexisting substance use disorder. Psychiatric Quarterly, 74(3), 205–222CrossRefPubMedGoogle Scholar
  12. Frank, R. G., & McGuire, T. G. (1998). The economic functions of carve-outs in managed care. American Journal of Managed Care, 4(SP):SP31–SP39PubMedGoogle Scholar
  13. Frank, R. G., & McGuire, T. G. (2000) Economics and mental health. In: Culyer, A., Newhouse, J. (Eds.), Handbook of health economics (pp. 893–954). Amsterdam, ElsevierGoogle Scholar
  14. Hays, P., & Aidroos, N. (1986) Alcoholism followed by schizophrenia. Acta Psychiatrica Scandinavica, 74(2), 187–189PubMedCrossRefGoogle Scholar
  15. Hunt, G. E., Bergen, J., & Bashir, M. (2002) Medication compliance and comorbid substance abuse in schizophrenia: Impact on community survival 4 years after a relapse. Schizophrenia Research, 54, 253–264CrossRefPubMedGoogle Scholar
  16. Kirchner, J. E., Owen, R. R., Nordquist, C., & Fischer, E. P. (1998) Diagnosis and management of substance use disorders among inpatients with schizophrenia. Psychiatric Services, 49(1):82–85PubMedGoogle Scholar
  17. Landmark, J., Cernovsky, Z. Z., & Merskey, H. (1987) Correlates of suicide attempts and ideation in schizophrenia. British Journal of Psychiatry, 151, 18–20PubMedCrossRefGoogle Scholar
  18. Lehman, A. F., Steinwachs, D. M., & the Co-Investigators of the PORT Project (1998). Translating research into practice: The schizophrenia Patient Outcomes Research Team (PORT) treatment recommendations. Schizophrenia Bulletin 24(1), 1–10PubMedGoogle Scholar
  19. Linszen, D. H. M. D., Dingemans, P. M., & Lenior, M. E. (1994) Cannabis abuse and the course of recent-onset schizophrenic disorders. Archives of General Psychiatry, 51(4), 273–279PubMedGoogle Scholar
  20. Lurie, N., Popkin, M., Dysken, M., Moscovice, I., & Finch, M. (1992). Accuracy of diagnoses of schizophrenia in Medicaid claims. Hospital and Community Psychiatry, 43(1), 69–71PubMedGoogle Scholar
  21. Mark, T., Coffey, R. M. M. D., Harwood, H., King, E., Bouchery, E., Genuardi, J., Vandivort, R., Buck, J.A., & Dilonardo, J. (2005). National expenditures for mental health services and substance abuse treatment: 1991–2001 (pp. 1–69), U.S. Department of Health and Human Services: Substance Abuse and Mental Health Services AdministrationGoogle Scholar
  22. Mechanic, D., & McAlpine, D. D. (2000) Utilization of specialty mental health care among persons with severe mental illness: The roles of demographics, need, insurance and risk. Health Services Research, 35(1), 277–292PubMedGoogle Scholar
  23. Negrete, J. C., Knapp, W. P., Douglas, D. E., & Smith, W. B. (1986) Cannabis affects the severity of schizophrenia symptoms: Results of a clinical survey. Psychological Medicine, 16, 515–520PubMedCrossRefGoogle Scholar
  24. Ray, W. A., Daugherty, J. R., & Meador, K. C. (2003) Effect of a mental health “carve-out” program on the continuity of antipsychotic therapy. The New England Journal of Medicine, 348(19), 1885–1894CrossRefPubMedGoogle Scholar
  25. Regier, D. A., Farmer, M. E., Rae, D. S., Locke, B. Z., Keith, S. J., Judd, L. L., & Goodwin, F. K. (1990) Comorbidity of mental disorders with alcohol and other drug abuse. Results from the Epidemiologic Catchment Area (ECA) Study. JAMA, 264(19), 2511–2518CrossRefPubMedGoogle Scholar
  26. Shern, D. L., Robinson, P., Stiles P., et al (2000) Evaluation of Florida’s prepaid mental health plan Year 3 report. University of South Florida, TampaGoogle Scholar
  27. Shern, D. L., Giard, J., Robinson, P., Stiles, P., Boothroyd, R., Murrin, M. R., Chen, H., Boaz, T., Dow, M., & Ward, J. (2001). Evaluation of Florida’s prepaid mental health plan: Year 4 report. Tampa: Louis de la Parte Florida Mental Health Institute, University of South FloridaGoogle Scholar
  28. Sokolski, K. N., Cummings, J. L., Abrams, B. O., MeMet, E. M., Katz, L. S., & Costa, J. F. (1994) Effects of substance abuse on hallucination rates and treatment responses in chronic psychiatric patients. Journal of Clinical Psychiatry, 55, 380–387PubMedGoogle Scholar
  29. Substance Abuse and Mental Health Services Administration (1999). SAMHSA managed care initiative state profiles: Substance Abuse and Mental Health Services Administration (SAMHSA), U.S. Department of Health and Human ServicesGoogle Scholar
  30. Substance Abuse and Mental Health Services Administration (2002). Report to Congress on the prevention and treatment of co-occurring substance abuse disorders and mental disorders. U.S. Department of Health and Human Services, Washington, D.C.Google Scholar
  31. Suominen, K. H., Isometsae, E. T., & Loennqvist, J. K. (2002) Comorbid substance use reduces the health care contacts of suicide attempters with schizophrenia spectrum or mood disorders. Schizophrenia Bulletin, 28(4), 637–647PubMedGoogle Scholar
  32. Young, A. S., Klap, R., Sherbourne, C. D., & Wells, K. B. (2001) The quality of care for depressive and anxiety disorders in the United States. Archives of General Psychiatry, 58(1), 55–61CrossRefPubMedGoogle Scholar
  33. Zeger, S. L., & Liang, K. Y. (1986). Longitudinal data analysis for discrete and continuous outcomes. Biometrics 42, 121–130PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, Inc. 2006

Authors and Affiliations

  • Alisa B. Busch
    • 1
  • Richard G. Frank
    • 2
  • Anthony F. Lehman
    • 3
  • Shelly F. Greenfield
    • 4
  1. 1.Alcohol and Drug Abuse Treatment Program and the Department of Health Care PolicyMcLean Hospital and Harvard Medical SchoolBelmontUSA
  2. 2.Department of Health Care PolicyHarvard Medical School and National Bureau of Economic ResearchBostonUSA
  3. 3.Department of PsychiatryUniversity of Maryland School of MedicineBaltimoreUSA
  4. 4.Alcohol and Drug Abuse Treatment ProgramMcLean Hospital and Harvard Medical SchoolBelmontUSA

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