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Book Review   |    
Leslie R. Pyenson
Psychiatric Services 2008; doi: 10.1176/appi.ps.59.4.451

by Roger Kathol, M.D., and Suzanne Gatteau; Westport, Connecticut, Praeger Publishers, 2007, 216 pages, $49.95

Dr. Pyenson recently retired as chief of medical and psychological analysis at the Central Intelligence Agency and is currently a clinical consultant with SpecTal, LLC, Reston, Virginia.

Almost any American can recite an example of how the U.S. health care system has caused personal stress and frustration. The urgent need for health care reform is debated regularly in the press, on television, in blogs, and in movie documentaries. Roger Kathol and Suzanne Gatteau offer a solution to an important aspect of the problem through an examination of "a fragmented health system, in which treatment of the mind (mental health) is severed from the body (physical health), resulting in mindless health care." Following the recommendations of an Institute of Medicine committee report (1), Kathol and Gatteau outline a program to integrate the treatment of physical and behavioral problems, which addresses concerns of patients, health care providers, and health plans.

The authors' evidence-based accounts of patients with familiar health complaints illuminate the problem: segregating treatment of behavioral issues from medical issues results in persistent health problems, increased costs, and a decline in employee productivity. The authors note that patients with frequent somatic complaints make excessive doctor and emergency room visits, resulting in two million unnecessary hospital admissions per year, and adding an estimated annual cost of $10 to $20 billion (2). Additionally, the cost to businesses in the United States because of alcohol- and drug-related disorders totals more than $100 billion a year. Despite high expenditures on services, in terms of quality of health care, treatment for alcohol dependence ranks last (3).

Rapidly rising health costs precipitated the development of a managed care system to replace traditional fee-for-service insurance. The managed care system was designed not only to deny coverage to patients who use services excessively but also to eliminate unnecessary procedures and tests. Unfortunately, this new system shifted decision-making power from clinicians to health plan administrators. Medicine became a business focused on quarterly profits and a favorable short-term expense-to-income ratio, rather than on the long-term strategic goal of improving overall health. The emphasis on treating physical illness took precedence over treating behavioral problems, which were historically perceived as unrelated to physical illness, overdiagnosed, and unprofitable.

The authors describe the flaws in those perceptions. They outline a new paradigm based on employer commitment, coordinated communication among health care providers, and consolidated administration of medical and behavioral health plan coverage, which would include equitable reimbursement for behavioral health personnel based on coding procedures used in physical medicine. They point out that adopting their paradigm would decrease utilization of services, lower health costs, increase employee productivity, and improve overall health.

Dr. Kathol is an adjunct professor of internal medicine and psychiatry at the University of Minnesota and president of Cartesian Solutions, an integrated health care consulting company. He is a past president of the American Academy of Clinical Psychiatry, the Academy of Psychosomatic Medicine, and the Association of Medicine and Psychiatry. His coauthor, Suzanne Gatteau, is a freelance writer.

Kathol's experience and Gatteau's writing skills have resulted in a book that offers a logical, rational solution to a complex health care problem. Health professionals, health plan administrators, consumers, and legislators seeking a solution to problems resulting from fragmented health care will find this book informative and practical. Its publication is especially timely in a presidential election year.

Institute of Medicine: Improving the Quality of Health Care for Mental and Substance-Use Conditions: Quality Chasm Series. Washington, National Academies Press, 2005
 
Feldman MD: Playing Sick? Untangling the Web of Munchausen Syndrome, Munchausen by Proxy, Malingering, and Factitious Disorder. New York, Brunner-Routledge, 2004
 
Lewis DC: Alcohol screening fulfills important duty to patients. American Medical News, March 6, 2006
 
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References

Institute of Medicine: Improving the Quality of Health Care for Mental and Substance-Use Conditions: Quality Chasm Series. Washington, National Academies Press, 2005
 
Feldman MD: Playing Sick? Untangling the Web of Munchausen Syndrome, Munchausen by Proxy, Malingering, and Factitious Disorder. New York, Brunner-Routledge, 2004
 
Lewis DC: Alcohol screening fulfills important duty to patients. American Medical News, March 6, 2006
 
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