New Roles for Psychiatrists in Organized Systems of Care

In this book, the editors set themselves two tasks—to help psychiatrists to understand the changes managed care has brought to the profession and to proactively anticipate the role they need to play in the new patient care delivery system. On the whole, the editors accomplish these tasks well—but they probably do better on the first.

Both Dr. Lazarus and Dr. Sharfstein are seasoned and respected experts in the area of psychiatry and managed care. Their expertise shows throughout the book in the even flow and logical coherence of the multiauthored chapters. The book itself is an outgrowth of a 1994 conference organized through the managed care and the ethics committees of the American Psychiatric Association, which turns out to be both the book's strength and its weakness. It is a strength because of the illustrious panel of contributors; it is a weakness because, with an occasional exception, most of the authors omit material published after 1994.

The book is divided into four sections: the transformation of American psychiatry by managed care; psychiatrists' roles in the new marketplace; training, guidelines and ethics; and the future of psychiatry in a managed care world. The chapter by Lloyd Sederer, M.D., is a particularly good overview of psychiatry and managed care. He reminds us of the epochal nature of the psychiatric profession and points out that with the passage of each epoch, we ended up a stronger profession.

Likewise, the chapter by Norman Clemens, M.D., on private office practice and managed care is excellent. It contains a fine section on how to try to work with a managed care company by providing "progressive" psychiatric care. Another outstanding chapter is by Alan Stone, M.D., on the "paradigms, preemptions, and stages" of managed care. As always, Dr. Stone's insights and perspectives are penetrating. His discussion of ERISA (the Employment Retirement Income Security Act of 1976) as the statute that unleashed managed care is lucid and informative, and his forewarning about the power of potential oligopsonies in the psychiatric marketplace is chilling.

Much has happened to psychiatry and managed care since 1994. One wishes the book included more about behavioral health carve-outs; about our daily professional and ethical dilemmas of providing care in generally underfunded capitation pools; and about the market power of a Magellan oligopsony. However, the chapters provide a good introduction to these different topics.

I would recommend the book to any colleague interested in understanding more about the effects of managed care on our professional lives. The book can easily be read for those chapters that are of most interest to the reader.

Dr. Herzog is vice-president for medical affairs at Hartford (Conn.) Hospital and professor of clinical psychiatry at the University of Connecticut School of Medicine.