Social and legal implications of managed care in psychiatry

A health service perspective on anorexia nervosa

This article reviews anorexia nervosa from a health services perspective. From such a perspective, costs of care, changes in insurance types, lack of empirically supported treatments, and involvement of legislative and judicial processes are discussed. Based on this review, processes for designing optimal insurance strategies are outlined, needs for treatment, service, and prevention development suggested, and the need for systematic evaluation of effective treatments identified.

Suicide risk assessment: a review of risk factors for suicide in 100 patients who made severe suicide attempts. Evaluation of suicide risk in a time of managed care

A study of 100 patients who made a severe suicide attempt suggested that the managed care criteria often applied for approving admission to hospitals for potentially suicidal patients were not, in fact, predictive of features seen in patients who actually made such attempts. Severe anxiety, panic attacks, a depressed mood, a diagnosis of major affective disorder, recent loss of an interpersonal relationship, recent abuse of alcohol or illicit substances coupled with feelings of hopelessness, helplessness, worthlessness, global or partial insomnia, anhedonia, inability to maintain a job, and the recent onset of impulsive behavior were excellent predictors of suicidal behavior. The presence of a specific suicide plan or suicide note were not. Patients with managed care were overrepresented by 245% in the study.

Ethical and legal implications of managed care

This article addresses several ethical, regulatory, and legal issues in managed care with attention to recent court cases that focus on physicians' responsibility, fiduciary duty, and the impact that these legal decisions have on physicians practicing in a managed care environment. Discussion of the impact of changes in the control of decision-making processes for physicians, the use of managed care protocols, restriction of resources, and gatekeeping systems are addressed as are the specific duties and obligations of physicians to their patients.

Healthcare's greatest challenge: providing services for people with severe mental illness in managed care

The delivery of services for people with severe mental illness (SMI) is described as healthcare's most difficult challenge because SMI patients suffer from the combined effects of conditions that have 1) a chronic course, 2) disabling consequences, and 3) a high risk of poverty. The fundamental advantages of managed care for persons with chronic, disabling conditions are discussed along with an examination of how well these assumptions hold in actual practice for persons with SMI. The legal risks assumed by clinicians in managed care are reviewed, including the inherent risk of discriminating against high cost enrollees, such as patients with SMI. Finally, recommendations are made regarding the measures that might be taken to increase the "match" between the principles of managed care and the specialized needs of people with severe mental illness.