Managed Mental Health Care in the Public Sector: A Survival Manual

Less is more" is a recurrent theme in the care and treatment of persons with severe and persistent mental illness (1). In the 19th century we invented the economies of scale of large institutions as a way of caring for individuals considered incurable by the medical technology and ideology of the time. In the mid-20th-century we invented deinstitutionalization as a way of cost shifting and cost savings, and it brought about in part a revised medical technology for treatment of severe mental illness—potent antipsychotic and mood stabilizing agents.

Both of these eras of "less is more" turned out to be "less is less." As the 20th century comes to a close, we are in the midst of a third era of "less is more" through managed care and its use of modern information technologies to manage service utilization and costs for many thousands of patients in community settings.

Managed Mental Health Care in the Public Sector: A Survival Manual is an ambitious and comprehensive effort to educate policy makers, clinicians, patients, and families about the nuts and bolts of public-sector managed care. Twenty-five chapters by 45 authors are skillfully organized to introduce new concepts and technologies to a potentially wide audience of mental health providers and consumers in the public sector.

There are chapters here on community mental health ideologies and ethics in public-sector managed care and on systems-level issues, including case studies of the experiences of Massachusetts, Los Angeles County, and the Veterans Affairs system in relation to managed care. A section on program management, such as development of community-based provider networks and contracting issues, is especially important for administrators of public-sector managed care. A variety of chapters on specific clinical issues such as alternatives to acute hospitalization, work with primary care providers, the integration of addiction and mental health services, and brief or "time-sensitive" treatments are designed for clinicians who practice in the public sector. The final section, on topics related to advocacy, evaluation, and training, gives this book the comprehensiveness that is the editors' intention.

Public-sector managed care is, as the editors suggest, a "radical departure" from the traditional budgetary and planning processes of state government and public community mental health care. When the power of information systems technology is introduced into public psychiatry, clinical and administrative decision making is profoundly changed. Will patients and families—the most critical "customers" in the new managed marketplace—benefit as a result? Will the two-class system of mental health care get better or get worse? In the less-is-more eras, great hopes and high-minded rhetoric initially were attached to asylums and then to community mental health. Unfortunately, in each of those eras, reality was far below the expectations of the visionaries and planners. Managed care may be another era of "less is less" if history is to be relied on in predicting the future.