COMMENTARY AND PERSPECTIVEPsychiatrists’ views of managed care and the future of psychiatry
Introduction
Insurers have attempted recently to lower their health care costs. This has radically shaken psychiatric practice. Insurers for inpatients and the indigent and the Veterans Administration have long controlled psychiatric care costs. Recently, care management spread more to private systems. Under managed care, psychiatric care is cost accountable. The insurer rather than the patient engages the psychiatrist, and the patient agrees that his medical care will be controlled by the insurer’s manager. As managed care penetrates the U.S., Health Maintenance Organization (HMO) staffing patterns forecast that in the next 5 years, psychiatrists will fall from about 30,000 full-time equivalent physicians at present to between 11,000 and 18,000 [1]. Already, psychiatry has lost autonomy and trainees.
Along with managed care, compelling advances in neuroscience appeared that relatively lessened interest in the psychological aspects of behavior. Consequently, psychiatry may lose some of its traditional identity as a specialty that engages the patient’s feelings.
The falling financial axes have provoked psychiatrists. Although they may be as self-interested as insurers are, their distress affects their practices and therefore seems worth cataloguing. This article seeks to briefly list and to gather in one place the many problems facing psychiatry what at present seem like their more obvious implications. The dizzying chaos of published opinion suggests specific issues that will shape psychiatry in the future.
Personally, I hope some basic psychiatric care will become available to all, with elective frills available for self-payers, such as one finds in most developed countries. This would relieve the uninsured while limiting government outlays and placating voters skeptical of a comprehensive government health insurance [2]. Like most psychiatrists, I fathom little how much this would cost in other social goods such as public health, family support, education or technical progress. My opinion makes me part of the conflicting constituencies that encumber government managers and leave corporate managers to reform health care according to price competition 3, 4.
Other opinions from psychiatrists include untempered protestations even in mainstream medical journals. Managed care begot the “plight” and “curse” of “American medicine and the U.S. health care system” [5], which is evolving “from an era of luxurious wastefulness to one of shortsighted stinginess and enhanced profits for a lucky few” [6]. A recent president of the American Psychiatric Association (APA) raged, “We are under attack by a rapacious, dishonest, destructive, greed-driven insurance/managed-care/big business combine that is in the process of decimating all health care in America, particularly and most egregiously, the care of the mentally ill” [7]. Other doctors protest that patients have a right to “quality care” [8] or “innovative treatment” [9]. Thirty percent of 249 non-psychiatrist health plan physicians said their patients often cannot obtain needed psychiatric care [10]. The approximately 40,000 member APA received more than 10,000 complaints that managed care companies compromised their patients’ interests [11]. Distress pervades psychiatry.
Section snippets
Changes in psychiatric practice
Managed care is not the only force to change health care. The “bio” part of the biopsychosocial model of mental disorder has expanded rapidly. New information has changed treatments, for instance, information about the mood effects of winter darkness, estrogen, prolactin, sleep apnea, or internal circadian desynchrony. New drugs have been designed by their physiologic mechanism, changing psychopharmacology. These developments enriched care choices just when support for such choices decreased.
Changes in psychiatric theory and nosology
The massive and unprecedented changes now underway will surely rattle the theoretical foundations of psychiatry. A major shift in theoretical emphases began with the Diagnostic and Statistical Manual, 3rd edition (DSM-III). Before DSM-III, mainstream biopsychosocial theory proposed that the mind was shaped by biography. Each person stood on a continuum between high functioning and devastating mental disorder. Life’s adversities could push one into the dysfunctional range. If trauma were intense
Changes in public attitudes
Psychiatry paradoxically relies on political support, but challenges popular ideas. It challenges the notion of individual responsibility when it recognizes the “victims” of alcoholism and “eating disorders,” or when it confirms that anti-social aggression can result from irresistible mental disorders [51] or responses to poverty [52]. Since the US suffers such high rates of drug abuse, obesity, and violence, psychiatric determinism potentially questions the bedrock assumption of democracy,
Psychiatrist neutrality
Psychiatrists traditionally were supposed to prioritize the interest of the patient. Psychiatrists’ “neutrality” meant they gave impartial feedback to patients. But now, managed care psychiatrists contract with the insurer not the patient. They cannot be the neutral observers or patient advocates they once sought to be. They will oppose capitation patients who seek traditional care at capitation premiums. They can still help patients accept the reality of insurance benefits and relieve
Losses in psychiatric training and trainees
Since the 1980s, medical students have found psychiatry less appealing. The number of psychiatry residents fell 19% between 1978 [60] and 1997 [61], while year 1 psychiatry residents fell 22% between 1994 and 1996 [62]. Psychiatry seems to lack clear focus, identity, or accountability 63, 64. Many medical schools tipped admission criteria more toward hard sciences [65] and trimmed the number of psychiatry instructors [66]. Psychiatry was the only one of nine major specialties that lost academic
Changes in research
Self-injurious behavior underlies many problems managed by general medicine, for instance obesity, fatigue, smoking, or violence. Research increasingly relates psychiatry to physical factors, which complicates the definition of psychiatric research. Factors such as genetic, neurophysiological, circadian, hormonal, metabolic, fitness, nutritional, toxic, and pharmacological factors will tend to diffuse the borders and hence the identity of psychiatry. Even though behavioral problems probably
Defending psychiatric care
Many observers wish that minimum standards of medical care, such as a minimum number of postpartum hospital days, were more widely mandated 90, 91. Despite their popularity, care mandates sacrifice more efficient types of care and slice the health care pie thinner, e.g., for prevention programs to teenage pregnancy or to support prenatal care.
Many psychiatrists hope that selective constraints on mental health coverage will be abolished [92] and that psychiatrists who have a “clear vision” of
Priorities
The crisis in psychiatry is part of a national crisis. Medical costs outstripped our willingness to pay for equal care access. Many insured Americans avow care access for all, even if it means care inefficiency [97], but many do not [98], and oppose the transfer of the circa $80 billion needed that would be taken away from their own health care to cover presently uninsured Americans [99].
Most voters are healthy and satisfied with their health insurance. They would probably espouse comprehensive
Acknowledgements
Jonathan Borus, Harriet Rosenstein, George Vaillant, Leon Eisenberg, and James Sabin critically reviewed earlier versions of the manuscript.
References (109)
- et al.
The effect of managed care on the treatment outcome of substance use disorders
Gen Hosp Psychiatry
(1995) - et al.
Long-term functioning and well-being outcomes associated with physical activity and exercise in patients with chronic conditions in the medical outcomes study
J Clin Epidemiol
(1994) - et al.
Long-term anti-arrhythmic therapy
Am J Med
(1984) A proposed vision for psychiatry at the turn of the century
Comp Psychiatry
(1995)- et al.
Wagons hoforward on the managed care trail
Gen Hosp Psychiatry
(1995) Forecasting the effects of health reform on U.S. physician workforce requirement. Evidence from HMO Staffing Patterns
JAMA
(1994)The uncertain future of managed care
N Engl J Med
(1999)- et al.
Psychiatrist and non-physician mental health provider staffing levels in health maintenance organizations
Am J Psychiatry
(1998) - et al.
How large employers are shaping the health care marketplace
N Engl J Med
(1998) - Lieberman JA, Rush AJ: Redefining the role of psychiatry in medicine. Am J Psychiatry 153:1388–1386,...