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APA President's Statement and Responses   |    
Behavioral Health Care Then and Now: Significant Progress, But More Work to Do
Jonathan Book, M.D.
Psychiatric Services 2002; doi: 10.1176/appi.ps.53.10.1249
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The behavioral health care system has come a long way in the past ten to 20 years. Managed behavioral health care has brought significant change for consumers, for psychiatrists and other practitioners, and for payers. Although no one would argue that the current U.S. behavioral health system is perfect, it is in many ways an improvement over what came before.

If we look back to the pre-managed care era, we see a system that was failing society. For patients and payers, this era was not the good old days. There were few standards, little accountability, and a shortage of practitioners. Treatment options and benefits were limited. When consumers were not deterred by powerful stigma, they bore a higher portion of the cost of behavioral health care than they did for other medical care.

A growing share of the costs of care was borne by employers, who had little influence on the quality of, demand for, or supply of services. Expensive inpatient services were overutilized, and alternative outpatient interventions were underdeveloped. There was a gross excess of hospital beds, and rates of hospital occupancy were low. Direct-to-consumer advertising of hospital and residential treatment services encouraged people to seek inpatient services whether they were appropriate or not. This system spawned scandals of excess and clinical impropriety that have been well documented by the media.

By and large, outside the public sector, individuals had two choices—inpatient or office-based treatment. Outpatient practice was oriented toward prescheduled appointments, which left hospital emergency rooms as the primary site for crisis evaluation and intervention. If an individual required services outside routine scheduled hours or services organized and coordinated among several clinicians, the only choice was a potentially disruptive and stigmatizing inpatient stay.

Equally disturbing was the lack of accountability. There was little, if any, oversight of the services being delivered and few standards for quality of care. Stories about individuals remaining hospitalized for months or years with only slight improvement were not uncommon. Treatment was likely to be tailored to a patient's insurance benefit rather than to the individual clinical situation, and insurance companies simply paid up to the benefit limit without asking questions about medical necessity and appropriateness and quality of care, clinical outcome, or patient satisfaction. When benefits and other personal resources were exhausted, patients with serious mental illness had only the public health system as an alternative and faced waiting lists for state hospitals and community clinics.

Employers, faced with staggering increases in the costs associated with providing behavioral health care, attempted to mitigate the increases by restricting benefits. But even this approach was unsuccessful. Costs continued to escalate to the point that employers considered eliminating such benefits altogether. These circumstances led to the introduction of managed care in the behavioral health arena.

What has happened in our field since managed care came on the scene? Managed behavioral health care coincided to a large extent with significant scientific advances in the understanding and treatment of mental illness and substance-related disorders, which led to an increase in the number and diversity of clinical tools available to practitioners. With advances in knowledge, clinical practice has become more evidence based, which has contributed to greater respect for the clinical fields related to behavioral health and a broader recognition that behavioral health disorders are real illnesses—as real as heart disease and diabetes. The advances in knowledge have also contributed to a gradual lessening of the stigma associated with mental illness and substance-related disorders. During the managed care era the consumer advocacy movement blossomed, raising national awareness of the plight of people with behavioral health disorders and attacking the injustice of a prejudicial health care system and the inadequacies of behavioral health service delivery.

Managed behavioral health care brought a focus on medical necessity and cost that resulted in an expansion of available treatment settings. We have progressed from a system that essentially offered two options to one that offers a continuum of services. Thus we have greater flexibility in meeting the needs of patients and greater success in managing costs.

The introduction of managed behavioral health care has improved access to behavioral health services for millions of consumers. Experience in the public and the private sector has shown that the number of people seeking and receiving services has increased since the introduction of managed care. Managed care not only yields an expansion of services but also results in their redistribution. Hospitalization rates and average lengths of stay typically declined with managed care, whereas the use of other treatment settings increased.

Managed behavioral health care introduced accountability to a system that lacked it. Although many people continue to adjust to this change, it was a needed measure that has benefited patients, payers, society, and—I believe—practitioners. We have an obligation to our patients to alleviate suffering in the most expeditious and effective way possible, and we have an obligation to the behavioral health care system and to society to accomplish these goals in a manner that makes the most responsible use of limited resources. The influence of managed care has helped shift practice patterns in the behavioral health care arena in a way that has led to more effective and more efficient treatment.

The managed behavioral health industry has not only imposed accountability on others, it has embraced it for itself. The American Managed Behavioral Healthcare Association has worked closely with other mental health and substance abuse treatment organizations to find common ground on appropriate performance measures and to develop national standards and accreditation programs.

Another benefit that we can attribute collectively to managed behavioral health care, to the consumer advocacy movement, and to advances in the science of behavioral health is a better understanding among payers of the services that practitioners and managed care organizations deliver and the results that can be expected from them. The accountability for quality and cost introduced by managed care has made possible the expansion of insurance benefits through parity legislation. Lawmakers in 34 states have been able to pass some form of parity bill largely because they could demonstrate that parity would not break the bank for employers—and they could show it only because of the introduction of managed behavioral health care. Parity legislation that prohibits higher copayments and deductibles for behavioral health care—such as the legislation that is before the U.S. Congress—also eliminates financial disincentives that represent yet another barrier to seeking help for behavioral health problems.

Despite the benefits to the system that managed care has made possible, no one would argue that it is a perfect solution. In many ways, we have made great strides because of it, but we have additional work ahead of us if we want to continue to improve the system. Managed care must become less burdensome for consumers and practitioners. In addition, managed behavioral health care companies must do a better job of streamlining processes, reducing paperwork and micromanagement, and meeting obligations to practitioners to operate efficiently.

There continue to be significant geographic variations in behavioral health practice that are not explained by the needs of the population. Practitioners too often make key treatment decisions on the basis of custom or personal preference rather than patients' needs and scientific evidence. Certainly, we have more work to do to develop a comprehensive service system and to address the geographic maldistribution of resources.

Furthermore, discrimination against individuals with behavioral health disorders must be eliminated. Full parity in insurance coverage for behavioral health disorders should be passed, and the remaining barriers to access to the full continuum of behavioral health services should be removed.

Despite the challenges, there is reason for real optimism. The science continues to advance. More effective diagnostic and treatment alternatives emerge. Traditional but unsubstantiated therapies and practice patterns are giving way to evidence-based practice. To further build on these opportunities, clinicians and managed care companies must work together to bring the best that our field has to offer to people in need in the most effective and efficient manner.

Dr. Book is chair of the American Managed Behavioral Healthcare Association and chief medical officer of Magellan Behavioral Health, 6950 Columbia Gateway, Columbia, Maryland 21046.

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