Managing Care, Not Dollars: The Continuum of Mental Health Services
by Robert K. Schreter, M.D., Steven S. Sharfstein, M.D., M.P.A., and
Carol A. Schreter, M.S.W., Ph.D. Washington, D.C., American Psychiatric
Press, 1997, 361 pp., $55.00.
Am J Psychiatry 155:985, July 1998
Book Forum: ECONOMIC ISSUES
Harold J. Bursztajn, M.D.
Cambridge, Mass.
According to the authors, "Overall, this book.is a guide to
setting up and using the emerging continuum of care" (p.
7). The book is well organized, in five sections prefaced by an overview
entitled "Managing Care, Not Dollars." This overview clearly
sets out the authors' goals, values, and approach to managing mental
health care. In the five sections that follow, the authors deliver
as promised. Although not a "why" book, Managing
Care, Not Dollars is a wonderful "how to" book.
Section 1, Components of the Continuum, covers a range of services from
office-based to acute inpatient treatment. Section 2 consists of five
chapters, each focused on an at-risk population, including children and
the elderly. Section 3 contains six chapters highlighting planning, administrative,
educational, and research issues. This most helpful section may well
become "must" reading for psychiatrists in administrative positions.
It is also a useful entrée into one of the most progressive elements
in the evolution of health care, which is conceptually separate from
the coincidental advent of managed health care: the emergence of evidence-based
medicine to support clinical decision making under conditions of uncertainty.
As others have emphasized, the emergence of evidence-based medicine may
be the most beneficial and lasting of the current changes, irrespective
of the eventual organizational structure of the health care economy.
Section 4, Public Policy Issues and the Continuum, consists of two chapters
focusing on the role of the public sector, the community, the family,
and consumer services. Section 5 is a well-written tour de force conclusion
recognizing that, today, "Clinical innovators must continue to learn
how to do more with less" (p. 361). Still, the more conflictual "why" issues
raised by the organizational practices of managed mental health care
need to be explored eventually.
At a time when many employers offer only one health care benefit package,
many patients are de facto captive. Among the issues this volume does
not address, 50 years after the promulgation of the Nuremberg Code, is
whether informed consent as a process is applicable to innovative, experimental
managed mental health care programs that are now doing "more with
less." At the same time, more remains to be said about such pernicious
managed care practices as physician profiles. Such profiles often penalize
physicians for hospitalizing patients, or even for requesting approval
to hospitalize patients when such approval is subsequently denied. There
thus exist de facto physician gag clauses, which not only substantially
control clinical judgment and practice but also compromise meaningful
informed consent as a process. Under these conditions, it is not surprising
that physicians whose practice survival is at stake will tend to err
more on the side of not recommending hospitalization, or of failing to
explore and address the expected initial patient resistance to hospitalization,
under the pretext of respecting the uninformed "choice" of
a gravely impaired patient. Anyone wanting to reflect seriously on these
issues will be grateful to the authors for courageously providing a factual
database of managed-mental-health-care-driven program innovations for
experimental alternatives to hospitalization.
I see this volume as a springboard for a much-needed analysis of the
clinical, ethical, and legal implications of economics-driven mental
health care program experiments. Given the data offered, the present
volume will no doubt become required reading for public policy programs
and mental health administration courses as well as for programs in mental
health, ethics, and the law that are ready to proceed to the requisite
next level of analysis. The present volume can also be enthusiastically
recommended to residents in training interested in each of these areas,
as well as to the relevant training faculty and program administrators.