Abstract
The ideological context of managed care health system that dominates US health policy favours the generalist at the expense of the specialist. The result is the simplistic morality that the right ethical choice for health is to save costs. Nowhere is the consequence of such questionable ethics more in evidence than psychiatry, where the managed care paradigm has resulted in a trivialising of psychological problems, with the new centrality of primary care at the heart of the healthcare system (p.98).
Thus informed, this book's social context is articulated in US President Bill Clinton's State of the Union Address in January 1998, advocating for a new ‘Consumer Bill of Rights’ where he says: ‘Every American deserves quality care…You have a right to know all your medical options, not just the cheapest…Medical decisions ought to be made by medical doctors, not insurance company accountants’.
Professor Roger Meyer, a distinguished professor of psychiatry, researcher, clinician and academic, paints a disturbing picture of US academic psychiatry. His two-fold vision for US psychiatry in the 21st century is first, to reclaim the biopsychosocial model in the context of managed care; second, to rediscover and update the multidisciplinary team of 30 years ago. The main themes relate to the ‘viability’ and ‘survival’ of academic psychiatry; strategies for the future with the likely decline of the current level of medical schools and teaching hospitals; the decrease in medical school's applicants as they begin to appreciate the full impact of cost-cutting and downsizing promoted by managed care policies on the profession (p. 172).
Combined, these factors highlight academic psychiatry threatened by the entrepreneurial culture of contemporary US health care. The response by academic health centres is detailed in seven chapters with tables and analyses that focus on the present and future profiles of psychiatry departments; the response of academic psychiatry to managed care; the place of education and research in the academic ‘mission’; the new frontiers of psychiatry and integration with primary care; and a 50-year perspective on the impact of academic psychiatry on the mental health care of veterans. The ‘data’ is derived from case studies of Departments of Psychiatry at the University of Colorado, Louisville, Dartmouth Hitchcock Medical Centre, University of Maryland-Baltimore, Sheppard and Enoch Pratt Hospital, Maryland and the Stanford University. These departments responded to the crisis in funding created by the managed care environment by reconfiguring their clinical, educational and primary care collaboration programs. Conclusion: ‘The bottom-line message is that the times call for significant changes in the practice and teaching of psychiatry’ (p.23). For example, in those systems that charge business expenses for departments on the basis of the number of transactions rather than on the basis of percentage of charges, psychiatry pays a disproportionate share of the operating costs. Overall, psychiatry departments seem to collect about 50% of billed charges for professional services. In practice, this means that for a 50-minute psychiatric treatment that attracts $150 as an office consultation receives only $65 from managed behavioural care companies. Thus, at 50% rate, the academic department will receive $32.50 per hour of faculty time. This highlights the financial problem of academic departments.
Australian psychiatrists will read this book at a time when our own health culture is changing with contracts and privatisation, trials of integrated delivery systems, and the proposed changes in the Medicare system with the Relative Value Study. We may ask whether the Americanisation of our health system, as the title of the book suggests, interposing managed care between brain and mind, will result, as proponents of managed care suggest, in greater social justice and parity in health care, or the opposite, increased polarity and inequity. The evidence based on the US experience appears to point to the latter.
This book certainly highlights the fact that academic psychiatry, as the generator of a great body of knowledge, the intellectual property of psychiatry, has a duty to provide future generations with that rich estate of knowledge. Yet, in the US managed care environment everything becomes a ‘commodity’, including knowledge. The profound ethical questions that relate to the ownership, distribution and access to new discoveries are not discussed.
Also demanding answers are basic questions on safeguards to ensure that the advancement of discoveries are available to improve the care of psychiatric patients, even if more costly then existing treatments. We already know that the clinical practice guidelines of some managed care companies restrict the use of the more effective, and expensive, SSRI drugs as first line treatment for depression. Is this contempt for patient suffering, in the name of cost saving, an ethically acceptable standard of practice in psychiatry? I would have thought that a book that looks at the future of US academic psychiatry, the guardian of psychiatric knowledge base for generations to come would address such questions. Sadly, there is deafening silence.
Nevertheless, Australian psychiatrists will find much in this book that will illuminate possible paths our own profession will follow in the years ahead. To be forewarned is to be forearmed.