From Buffalo, New York, Charles Sabatino is a Professor of Philosophy at Daemen College. For over twenty years, he has worked as a volunteer member of policy and planning boards to help improve the mental health system.

From Winter 1997

Market forces are coming to have a growing impact upon the mental health system, as many have been predicting for some time now. Quite soon, even those individuals experiencing a more severe disability with a mental illness, who thus far have been "carved out" and not touched by this process, will become affected by the mandates of managed care. The critical voices warning of the dangers accompanying this development are becoming louder. They point to the shortcomings of using the managed care approach to deliver mental health and substance abuse services, especially to those experiencing more serious problems. The critical voices warn that managed care has been misused to restrict individuals from receiving the services they need, that the gatekeepers, who are responsible for approving access to service, make decisions based on fiscal rather than clinical priorities. It is not hard to see there is a financial incentive for insurance companies within the managed care system to minimize the level of need individuals are experiencing, especially when it comes to those with a mental health or substance abuse disability. When this happens, individuals do not receive the care they need, or they receive far less than may be necessary.

I have no doubt that the fears raised by these critical voices are warranted, and that the dangers are real. However, there seems little question that managed care is here and will remain, at least for the immediate future. For this reason, I have come to believe that it is best not to fight, but to work through and with the managed care approach, to help shape it so that it might meet the needs of individuals as adequately as possible. I think our best chance to shape the direction managed care takes is by accepting its presence and trying to make it work rather than just pointing to its failings.

According to some individuals who feel more positively about what is taking place, there are some real benefits to be reaped, if we go about this task correctly. Some think we will be better able to individualize and tailor services to meet specific needs and that the system will be better able to respond to client/consumer needs rather than vice versa. There is the further possibility that demands for more efficiency and effectiveness in treatment, especially taking outcomes into account, will make the system more invested, even from a financial point of view, in helping individuals recover and maintain as healthy a life as possible. Also, there are potential gains to be realized by developing an integrated network of providers which includes the full array of services, so that an individual will have ready access to whatever services are needed upon entering the network. These are positive developments and it must be our hope that we will reap these benefits from the shifts occurring in our system. Thus, in spite of the fact that several individuals in the mental health community, for whom I have a great deal of respect, have tried to persuade me to speak against what is happening, I have chosen not to do so. Perhaps I am naive. However, I think we swim best not by fighting the current but by working with and through it.

Nevertheless, there are several real dangers which we must consider and address as our system of care comes increasingly under the demands placed upon it by market forces. In particular, I fear how easily we can begin to lose the human touch, the aspect of care and service that has always been fundamental to our community based system. The strength of our system, whatever its weaknesses, has been the personal care which individuals within the community offered in service to others who need their support, to whatever extent necessary. While the fee-for-service modality may indeed by wrought with inefficiency and ineffectiveness, nevertheless, it has always represented the commitment that treatment was a service which the community made available to individuals as needed.

That term, service, is a very powerful one. It suggests that the system is founded upon something personal and caring in nature and that treatment represents the responsibility and willingness of the community to respond to those with special needs. Unfortunately, market forces speak of treatment as a commodity to be purchased. The sense of service can all too easily become lost. As the system becomes caught up in the business of management, efficiency and effectiveness, its fundamental purpose to serve and care can become clouded over. There is no escaping this eventuality when fiscal interests and cost effectiveness become the overriding priority instead of being balanced against the quality of service as the more basic priority.

We can expect a real setback to our system if, in the process of instituting managed care, insurance companies are allowed to siphon off as profit an inordinate amount of public resources which would otherwise go to support the service system. The dangers will increase if, in the interest of cost containment, recipients will not be allowed access to the services they need to remain stable and enhance their recovery, or if the capitation rates allotted prove inadequate (ie, the amount an agency or network has to provide all necessary services), or if the essentially community based structure of services is undermined. Some of the reports coming from elsewhere in the country are not very encouraging in this regard. Apparently the number of individuals falling through the cracks of the system, even to the point of becoming homeless, is increasing.

When all things are considered, I do not think we can avoid these risks and dangers which are brought upon us by the recent developments of managed care. I even expect these risks will heighten as we move forward to put in place the Special Needs Plans (SNPs) which will serve those most seriously in need of mental health and substance abuse services in New York State. However, I think these developments are very much a part of the increased demands in our time for efficiency and accountability, and that it is best that we accept and work with these forces of managed care rather than oppose them.

Nevertheless, the dangers are real. It is essential that all of us, at whatever level our involvement, be wary lest the fundamental meaning of our system -- as care and service -- becomes lost. It does not matter whether one is a consumer, clinician or manager, or perhaps a governmental or community representative, the task to maintain the meaning of service will be a difficult one. Ultimately, it comes down to accountability. The mental health system must be assessed by standards other than the ruling market forces. While it may well be in our interest to adapt pertinent principles from the marketplace, our system of care must be held accountable to standards of service which demand of us something more personal and human than the marketplace knows of. So long as we keep that in mind, there is reason for hope that what we manage will indeed be worthy of the term care.