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

Harold J. Bursztajn, M.D.
Cambridge, Mass.

According to the authors, "Overall, this 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.