In Reply: Although Professor Stone starts by asking the familiar question of whether "ethical managed care is an oxymoron," he does not simply repeat the litany of anti-managed-care platitudes that have rendered organized psychiatry a strident but ineffective critic of health care policy. Stone recognizes that resources are limited and that rationing is ultimately an ethical necessity. As a result, he is able to formulate the central ethical issue for the next decade—when is stewardship ethically justified, and when is it a "pious hypocrisy?"
To answer these questions about Massachusetts Medicaid, Harvard Pilgrim Health Care, and the mental health carve-out, we have to ask if Massachusetts is spending a reasonable amount on mental health services and if the carve-out is delivering a reasonable amount of benefit per dollar of expenditure. An adequate response requires a combination of empirical inquiry and deliberation about values. We have argued that this process, which we call "accountability for reasonableness," is a prerequisite for legitimate resource allocation and limit setting in health care (1,2).
Stone fears that the market consolidation he describes as oligopsony is creating a "race to the bottom." He could be right—the danger is real. The main antidote is informed public deliberation about how much value (defined as quality divided by cost) it wishes to purchase. This kind of deliberation is all too rare for commercial (employer-based) health insurance. Because public purchasers are working in a fishbowl and are accountable to the electorate, they are much more likely to deliberate about value and to hold managed care programs accountable for the reasonableness of their policies.
Since Professor Stone wrote his letter, Harvard Pilgrim Health Care has gone into receivership. Its anxiety about incurring further financial losses was clearly warranted. The crisis created by the receivership may be stimulating the kind of reflective dialogue about the health care system that needs to happen more widely. As Hamlet said, "The time is out of joint." It will probably require many more crises of the sort Massachusetts is experiencing to set it right.