Utah's Capitation Plan and the process of care

In Reply: Dr. Stevens ranges widely in his responses to our work but curiously does not acknowledge the data demonstrating that the prepaid providers (including his community mental health center [CMHC]) significantly restructured their care practices in response to a new funding mechanism. Although the consequences of these changes might be a point of discourse, the basic observations are quite clear. Given the financial rewards that his CMHC received under the capitated format and his concern with survival, perhaps Dr. Stevens is reluctant to examine the consequences for patients with chronic mental illness of modifying the delivery of and access to care.

Dr. Stevens' first argument deals with the impossibility of controlling for the variables that might account for the differences observed. Following this logic, no investigation would be undertaken at all. Study data demonstrate that there was significantly greater attrition from treatment for patients enrolled in the capitation plan versus those not in the plan. The relative importance of changes in the process of care versus speculations about housing costs remain to be established. Given the extent and number of other observed changes in care, we are not inclined to dismiss process as a key factor.

The Sullivan study cited by Dr. Stevens (reference 3 above) deals with rehospitalization, an outcome that was not an issue in our study. We did examine multiple proxies for medication compliance and social support, but not for alcohol abuse, given the low rates of alcohol abuse in Utah. It should be noted that in another, more recent study, Sullivan and associates (1) reported an association between fewer outpatient visits and noncompliance with medication.

As for the issue of survival and our myopia, we disagree sharply with Dr. Stevens. We need to understand as fully as possible the impact of financially mediated changes on the delivery of health care, not merely utter rhetoric that saving the system (or keeping it intact) independent of clinical consequences is satisfactory. In a study of the Utah Prepaid Mental Health plan published elsewhere, we report that those most severely afflicted with chronic mental illness in the Utah Prepaid Mental Health Plan are specifically disadvantaged by the introduction of capitated mental health care (2).

Though Dr. Stevens may wish it otherwise, the study data do raise reasonable concerns about the vigor of care rendered under the plan. We did not create the data set; the CMHC's practices are accountable. "Commitment to clinical excellence" is a laudable goal, but how is it objectified or gauged? It is regrettable that Dr. Stevens says little about the expectations or responses of his CMHC to the study findings, which indicate significant changes in the extent of psychotherapy and number of medication visits, increased attrition rates, and an increase in suboptimal antipsychotic dosages.