Abstract This paper will discuss the different effects managed care has on the quality of mental health care for its clients. On the positive, managed care has increased availability to a client al that would otherwise not be able to afford mental health care. On the negative, there has been a reduction in quality in order for managed care corporations to keep costs low and still make money. Proper implementation of managed mental health care would likely result in high quality, low cost mental health care.

Introduction Two decades ago hospitals were for the physically ill and asylums were for the mentally ill. With the stigma fading from mental illness and a movement toward deinstitutionalization, this paradigm of segregation of mental and physical health care does not hold true today. A direct effect of the paradigm shift is a greater willingness on the part of the public to seek help for mental health problems. (Madonna, 2000, P 6) Managed care has stepped up to fill the increasing need for inexpensive mental health care coverage.

Each year, 52 million Americans have some form of mental health problem and out of those patients 60% are members of a managed care group. (Madonna, 2000, P 8) Managed mental health care's successes and failures now bear directly on the mental well being of 32 million particularly vulnerable Americans. Initially managed care was intended to be a "comprehensive approach to healthcare that included balancing cost, quality, utilization, and access." (Madonna, 2000, P 23) In theory, this is an optimal approach to the delivery of health care and it has proven somewhat successful in the area of physical health, but it has not provided the same success in the area of mental health. Mental health is still being treated as a separate and less important aspect of health care despite the fact that some mental health disorders, such as schizophrenia, have shown higher success rates than those of common medical procedure, such as angioplasty. (Etheredge, 2002, P 6) The Cons First and foremost managed mental health care is a business and good business often prevents good medicine.

Theoretically, a well implemented managed care could work well, but in order to make their stockholders happy, managed care companies do not always implement policies to help the patient. An example of this would be the common policy of company personnel making treatment decisions instead of mental health treatment providers. This organization of power raises concerns with patients and treatment providers alike. Historically managed care organizations have not switched mental health patients to less costly forms of treatment, they have just reduced care in general, restricting access to costly medical procedures. (Madonna, 2000, P 12) One reason a stigma is placed on forms of managed care, such as health maintenance organizations (HMO), is a highly publicized practice of providing material incentives to doctors to control the amount of costly tests and medications the doctor prescribes. Before providing these material incentives the HMOs would force the doctor to sign a gag rule, preventing the physician from disclosing any information pertaining to the unethical practice.

Since the doctors who participated in the bribery can not speak about the practice, there is no way to tell the impact of this practice, but one can assume that many patients received diminished treatment of illnesses, possibly resulting in harm. The Pros It may be hard for most people to believe that there are some pros to the existence of managed care, but this may be because only 8% of the thousands of articles write about managed mental health care in national publications have a positive influence on the reader. (Bernard & Shulkin, 1998, p. 2110) Despite the quantity of negative press (some of it is deserved), managed mental health care does have some positive aspects. Rising cost of health care has forced employers to cut back on health care services, mental health care often being the first to go, but managed care can be a viable way to both cut costs and improve the availability of mental health care." Contrary to trends in other areas of healthcare, enrollment in managed behavioral healthcare is expected to increase because of the attractive cost-saving premiums." (Coleman, 2003, p. 36) With an increase in enrollment comes an increase in demand for managed care's favorite tool in treating mental illness, the clinical social worker.

Clinical social workers are seen as low-risk, cost-effective professionals who produce quality patient outcomes with little case management. "Managed care companies have found that clinical social workers can provide psychotherapy services just as effectively as other, more expensive mental health professionals." (Coleman, 2003, p. 37) Through the use of short-term therapy, such as solution-focused therapy, they are able to stabilize clients and help them cope more quickly. Future of Managed Mental Health Care There are trends starting in the area of managed care that could have big impacts on managed mental health care as we know it. One such trend is the movement toward complete parity. Parity calls for the equality between mental health care and physical health care.

There have been some laws passed pertaining to parity, such as the Mental Health Parity Act of 1996. Although this act did not require employers to offer mental health care benefits, it did require parity if such benefits existed. Changes in the media's coverage of managed care could also impact the future development managed mental heath care companies. As mentioned earlier, the brunt of the media's coverage on managed care has been on patient horror stories. Recently, the media has decreased the number of stories about managed care, thus decreasing the coverage of negative (as well as the positive) aspects of managed care.

With most companies it is true that competition forces an increased focus on quality of service. This is not true with managed care companies because most companies refuse to disclose important information about their company, such as percentage of customers canceling service. This gives perspective customers little information to aid in the choice of health care. The choice of providers becomes a guess based on limited information. Currently there has been pressure on managed care companies by concerned customers for disclosure of information. If the customers succeed and companies do disclose important information, then the public will be able to make informed decisions based on quality.

This would cause a general increase in quality of managed care. Ecological Perspective A man recently visited his family doctor and stated that lately he has had strong feelings of sadness and has contemplated suicides. The doctor immediately sent the man to a nearby hospital's inpatient psychiatric ward. There he remained under observation until his HMO decided what and how much of his treatment they would pay for.

Once he started his anti-depressants and was deemed to not be a suicide risk any longer he was sent home with a referral to a clinical social worker. The man's HMO decided that to treat depression they would pay for 7 sessions. The clinical social worker knew that 7 sessions was not sufficient to treat severe depression, and decided to appeal to the HMO stating that it is reasonable to need 14 sessions to fully treat this patient. As a result of the social worker's appeal the HMO approves the extension, therefore increasing the likelihood that this patient will be able regain normal function in society. Conclusion It is the author's opinion that managed mental health care does work; it just does not work consistently. To increase consistency in services that managed mental health care provides three things must happen: increased competition, laws to protect the customer, and improved treatment provider ethics.

An increase in competition will in general help increase quality. To bring about competition all companies must disclose important information about their business. Also, the government needs to step up and pass legislation that puts more pressure on employers to include mental health coverage. Legislation pertaining to parity was a step forward, but an employer currently can simply drop mental health coverage to circumvent the laws. Finally, it is the duty of practitioners to serve the patients best interest, not that of the managed care company. Practitioners must put pressure on managed mental health care companies to place power back into the hands of the mental health professional who provide care for the patients daily.

Patients are people not numbers. References Coleman, M. (2003). Behind managed care's courtship of clinical social workers. Behavioral Heath Management, 23, 36-37. Madonna, T.

(2000). Providing mental health services under managed care arrangements. Hospital Topics, 78, 23-27. Bernard, D. & Shulkin, D.

(1998). The media vs. managed health care. Archives of Internal Medicine, 158, 2109-2111. Alexander, E. (1997).

Gags rules and trade secrets in managed care contracts. Archives of Internal Medicine, 157, 2037-2043. Etheredge, J. (2002). Misperceptions behind mental health policy. JAMA, 287, 1858-1859..