Emerging Trends In Mental Health Policy

The continuing deinstitutionalization of patients in public mental hospitals and the growth of managed care are fundamentally altering mental health practice. Managed care provides opportunities for achieving parity of insurance coverage between mental and physical illness, but serious problems persist in integrating mental health, substance abuse, and general medical care and assuring an appropriate range of services and programs for persons with serious mental illness residing in community settings. Hospital and community care are poorly coordinated, and hospital care needs to be integrated into a more balanced system of services. Important new roles are emerging for purchasers, patient advocates, and mental health authorities. M anaged behavioral health care has already had an impact on almost every aspect of mental health practice and has the potential to profoundly shape the organization and provision of mental health and substance abuse services. It has aroused opposition from mental health providers, who see their income and autonomy threatened, and patients’ advocates, who fear that patients’ options will be restricted. Managed care, however, describes a variety of structures, approaches, and strategies that can be used to improve care as well as to ratchet down costs or increase profits. Change has occurred rapidly and unevenly, and much finetuning is needed. How behavioral health care evolves will depend not only on decisions and practices of the managed care industry but even more on the proactive and informed responses of purchasers, advocacy organizations, and regulatory authorities. The Context Of Managed Mental Health Care Managed care approaches—including capitation and sharing of risk, case management, and utilization review—can be combined in innumerable ways with varying objectives. A great deal depends on the philosophies and motives of management, the quality of the professionals involved, and the coherence of incentive structures. Because the idea of managed care offers a centralized and clearly visible target, any anecdote of denial of treatment or mistreatment can be attributed to managed care as a generic form. But anecdotes are not evidence. Some of the criticisms typically made pertain to poor professional service, others to for-profit operators trying to make a fast buck, and still others to denial of some service or restrictions on provider choice. These problems are not new or unique to managed care. Payment for anything professionals want to do, the long-standing traditional pattern, is no longer realistic and never was ideal. Mental health services delivery and policy have a long history of periodic cycles of “reform.” These changes often have been more a response to changes in financial structures, social ideologies, and MENTAL 83