CLINICAL HANDBOOK OF SCHIZOPHRENIA

48. The Economics of Schizophrenia 513with severe mental disorders, leading to a rate of almost 40% employment amongthose who enroll in SE programs. Earlier vocational rehabilitation approaches (e.g.,sheltered employment and prevocational training) have not been as effective. A form ofSE, the individual placement model, is specifically adapted for people with severe mentalillness. Some of the distinguishing characteristics of this approach are ongoing,onsite, individualized support in a competitive employment environment and integrationwith mental health services. Because, earnings among people with schizophrenia are typicallynot high, the cost-effectiveness of SE is largely dependent on how the program isimplemented. For example replacing SE to existing vocational programs or day treatmentcan be cost-effective. SE has not been found to translate into reduced utilizationrates and costs of treatment.Cognitive-Behavioral TherapyCognitive-behavioral therapy (CBT) among people with schizophrenia is a relatively recentpractice that shows promising results. Randomized clinical trials consistently indicatethat compared to conventional pharmacological treatment or other psychosocialinterventions, CBT reduces or stabilizes psychotic symptoms, although it is unclearwhether CBT improves relapse or hospitalization rates in the long run. The cost-effectivenessof CBT among schizophrenia patients has barely been addressed. Among people withco-occurring schizophrenia and substance misuse, CBT ( in combination with motivationaland family therapy), along with routine pharmacological treatment, has beenfound to be more effective and of comparable cost to pharmacological treatment alone(Haddock et al., 2003).Public PayersFINANCING OF MENTAL HEALTH CARECompared with treatment in other chronic illnesses, a greater proportion of schizophreniatreatment costs tend to be paid by government. Almost two-thirds of mental healthtreatment in the United States is paid by local, state, or Federal government. Between1991 and 2001, the percentage of mental health care coverage by public payers increasedfrom 58 to 65%. Less than one-half of all other health care is paid by public sources.The largest government payers for mental health treatment in the United States areMedicaid, a joint state–Federal insurance program for people with low income, and directappropriations by state or local government. Each of these sources pays slightly morethan 25% of the costs. An additional 13% is paid by Federal programs such as Medicare,which covered about 7% of all mental health care in 2001.Private PayersLow rates of employment among people with schizophrenia prevent many individualsfrom accessing private health insurance. Most private insurance policies also have lifetimecoverage caps that effectively end reimbursement after a beneficiary reaches a presetutilization or spending limit. Insurers often limit mental health coverage more stringentlythan care for other conditions in an effort to discourage adverse selection, enrollment ofpersons with schizophrenia or other severe and persistent psychiatric disorders whomthey see as poor financial risks. Legislative attempts to achieve parity between coveragefor physical and mental disorders have had limited success.