Managed care in mental health: The ethical issues

Prologue: Managed care in mental health, as in general health, is neither as good nor as evil as its advocates or detractors want us to believe. Critics, on the one hand, contend that managed care , as it reduces the intensity of services, jeopardizes the physician/patient relationship. Supporters counter this with evidence that managed care can broaden access to needed services, with no obvious erosion of this relationship. In this paper Philip Boyle and Daniel Callahan tackle the debate in the context of mental health care. The ethical issues are similar whether one is looking at mental or physical health; however, for mental health the population in question has unique characteristics that make the debate all the more compelling. They do not point accusatory fingers at the reimbursement system itself.

"After reviewing [the problems that are unique to managed mental health care]," Boyle and Callahan write, "we believe that [it]...need not be judged any more inequitable than the present mental health fee-for-service system and, if anything, can be judged potentially more equitable and accountable." This paper emanates from a three-year project at The Hastings Center, funded by The John D. and Catherine T. MacArthur Foundation, to examine ethical issues inherent in the distribution of resources in the health care system. Mental health is but one aspect of this project. Boyle is associate for medical ethics at The Hastings Center, a research and educational organization devoted to examination of ethical issues in medicine , biology, and the environment. He received a doctorate in theology from St. Louis University. Callahan is president of The Hastings Center, which he cofounded in 1969. He holds a doctorate in philosophy from Harvard and has written or edited thirty-one books, the most recent of which (coedited with Boyle), What Price Mental Health?, is reviewed in this issue of Health Affairs.

The trend in health care seems unstoppable: Managed care, including attempts to manage mental health care, is on the upswing.(1) Public reaction to this trend has been mixed, and the sentiments about managed care in the mental health sector are all the more conflicted. Those who welcome managed care in mental health--including health maintenance organizations (HMOs), vendors of managed mental health services, and employers--believe that it will benefit patients, providers, payers,...