CLINICAL HANDBOOK OF SCHIZOPHRENIA

514 VII. POLICY, LEGAL, AND SOCIAL ISSUESManaged CareEnrollment of people with schizophrenia in managed care plans, which have incentives toreduce costs, has lagged behind that of other diagnostic groups, largely because of theperceived risk of catastrophic costs. However, special “carveout” managed care planshave been created in a growing number of states (15 states as of 2005, according to theNational Alliance on Mental Illness [NAMI]). These plans usually include higher paymentsfor persons with severe mental illness and often offer special protections from financialrisk, such as reinsurance, which insures managed care organizations against substantialfinancial losses or outlier payments that cover some or all additional payments for beneficiarieswith unusually high costs.Managed care for persons with severe mental illness has been hotly contested in theUnited States over the past two decades. Many questions remain about its impact on thehealth of individuals and cost to payers. However, dire predictions of greatly restrictedaccess to needed service and adverse health effects have not been borne out by research todate. It is likely that managed care will play an increasing role in coverage for people withschizophrenia in coming years.KEY POINTS• Schizophrenia imposes a disproportionately high cost on society compared to other mentaldisorders.• Treatment of schizophrenia consumes almost one-third of all mental health expenses in theUnited States.• The indirect costs associated with the illness are also considerable and at least as high asthe direct cost of treatment.• With continuing reliance on drug treatment, there is concern about the sharply escalatingcost of atypical antipsychotic drugs.• With the exception of clozapine, which emerges as the most efficacious and cost-effectivedrug for patients with treatment-resistant schizophrenia, evidence has failed to clearly establishclinical or cost-effectiveness advantage of new atypical antipsychotics.• Several evidence-based psychosocial interventions, including ACT, SE, and integratedtreatment of people with co-occurring severe mental and substance use disorders can becost-effective compared to standard care, mainly among high health service users.• Treatment of mental disorders in the United States is predominantly and increasingly paidfor by government, because private insurers and market forces fail to meet the need of peoplewith persistent psychiatric disorders.• Evidence of the impact of managed care on quality of care for individuals with severe mentaldisorders is ambiguous; however, managed care for people with schizophrenia has notexpanded as much as for the remainder of the U.S. health sector.REFERENCES AND RECOMMENDED READINGSArno, P., Levine, C., & Memmott, M. (1999). The economic value of informal caregiving. Health Affairs,18(2), 182–188.Center for Mental Health Services. (2000). Mental health, United States, 2000 (Sections 3 and 4)(DHHS Publication No. (SMA) 01-3537). Washington, DC: Author.Clark, R. (1994). Family costs associated with severe mental illness and substance use. Hospital andCommunity Psychiatry, 45(8), 808–813.Clark, R., & Samnaliev, M. (2005). Psychosocial treatment in the 21st century. International Journalof Law and Psychiatry, 28, 532–544.