Managed Care and Psychotherapy for Schizophrenia

To the Editor: The article by Gerard E. Hogarty, M.S.W., and colleagues (1) and the accompanying editorial (2) continue the valuable debate about the clinical and economic value of psychotherapy as an adjunct to medication and case management in the treatment of schizophrenia (3-5). It is reasonable to expect that availability of individual psychotherapy for persons with schizophrenia (many of whom receive Medicaid) will be further affected by the recent trend in many states toward mandatory assignment of the care of outpatients receiving Medicaid to behavioral managed care companies.

In April 1996, following approval from Medicaid, our outpatient system serving 1,814 persons with severe mental illness was converted into a partially capitated prepaid mental health plan. The plan received a fixed annual amount per enrolled patient instead of payment per patient visit. The basic benefit package included medication monitoring and case management, with additional services such as individual psychotherapy available as clinically needed. Individual psychotherapy was defined as weekly individual therapeutic sessions lasting 30 or more minutes with a clear therapeutic goal mutually agreed on by therapist and patient and provided by a Ph.D. psychologist, master's-level social worker, or nurse with a bachelor's degree. For the purposes of resource allocation, we asked physicians and clinicians to complete a form providing justification for individual psychotherapy for any patient with schizophrenia who requests individual therapy or agrees to receive individual psychotherapy at the recommendation of his or her physician.

In our prepaid plan, 1,036 outpatients carry the DSM-IV diagnosis of schizophrenia and, of this group, 180 (17.4%) patients were identified by physicians and clinical staff as being in need of individual psychotherapy and having adequate justification in the completed review forms. We noted that symptom management was the leading goal (N=94), followed by psychoeducation (N=55) and supportive therapy (N=31). We suspect that the higher rate for symptom management (52.2%) is related to an increase in the number of outpatients with active symptoms due to shortened hospital stays. There were no significant differences by gender, either in the need for or in the goals of individual psychotherapy. In our plan, it is difficult to determine the exact costs incurred in providing individual psychotherapy to this small subgroup of patients, but we estimate that when the cost is distributed to all patients with schizophrenia, it may add as much as $231 to the annual cost of treating each patient with the diagnosis of schizophrenia. It is logical to assume that continuation of additional services such as individual psychotherapy depends on research results demonstrating that such services will reduce overall costs of treating patients with schizophrenia.