Letters

To the Editor: As usual, Dr. Sharfstein raised important questions in his Taking Issue column "Some Interesting Lessons From Canada" in the March issue ( 1 ). Referring to a study published in the same issue, "Inequity in Mental Health Care Under Canadian Universal Health Coverage" ( 2 ), he pointed out that even in a country with universal health care access, disparities based on socioeconomic status still exist. Most strikingly, in the Canadian study the expected and desired inverse gradient "between socioeconomic status and utilization rates of mental health services" was in the opposite direction for psychiatrists in Toronto. The investigators could not determine whether less access for poor patients was patient driven or provider driven.

Dr. Sharfstein then asked several financially related questions about how this disparity problem could be addressed if a universal plan was implemented in the United States. I would like to venture a response to the questions about managed care, in part referring to our 15 years of experience directing managed mental health systems for culturally diverse populations of both higher and lower socioeconomic classes ( 3 ).

Dr. Sharfstein asked "Would managed care effectively address the equity issue in Canada? In a universal health care access plan in the United States, could managed care help avoid the distributive equity problem experienced in Canada?" My answer is a tentative yes. Despite the well-documented problems of managed care, if managed care is operationalized in a certain way, it could effectively improve the equity problem in Canada and in the United States ( 4 ). To begin to operationalize such a plan, it may be best to have only not-for-profit managed care so that the profit motivation does not divert too much of the funding and take priority over patient care.

To address the patient-driven part of the problem, another study in the same issue of Psychiatric Services suggests an answer ( 5 ). A simple $10 payment to low-income African-American patients with depression improved appointment adherence. When managed care systems control the funding, the contract created by the payer could stipulate that some of that funding be used in a similar way.

Financial incentives could also work for providers. Historically, psychiatrists who served poor patients in the United States generally make a lower income. A "pay for performance" component of a not-for-profit managed universal health care system could divert funds to pay a significant bonus to psychiatrists who serve poor populations and who demonstrate reasonable outcomes.

Whether one likes it or not, "money talks" to most everyone. The key may be to use the money in a socially responsible way.

Dr. Moffic is professor of psychiatry and behavioral medicine and family and community medicine at the Medical College of Wisconsin in Milwaukee.