The Rise of Managed Care

Beginning in the 1990s, insurance coverage for mental illness started to become more common, primarily through managed care organizations (MCOs). Managed care is described more fully in Chapter 8 but essentially refers to any system that controls health care spending by closely monitoring where patients re- ceive health care, what sorts of providers patients use, what treatments they receive, and with what consequences.

Research suggests that managed care can reduce the costs of mental health treatment, at least for less severe illnesses, by encouraging shorter rather than longer inpatient stays, outpatient rather than inpatient care, conservative rather than aggressive interventions, and use of lower-level clinicians (such as social workers) rather than psychologists or psychiatrists. According to David Mechanic, probably the most influential sociologist in the area of mental health care, it also may be able to improve the quality of care:

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By reducing inpatient admissions and length of stay, managed care programs potentially make available considerable resources for substitute services and other types of care. Managed care provides incentives to seek closer integration between inpatient and outpatient and primary and specialized services to achieve cost-effective substitutions.

Finally, laws that link mental illness with violence can increase the stigma experienced by those who live with it. Moreover, that stigma may be lifelong: It is hard to imagine how any national database could institute procedures for reliably identifying individuals who have recovered from mental illness and for removing those individuals’ names from the database. Certainly, no such procedures exist currently. Thus, legal requirements to report clients would in some cases require health care workers to break professional codes of ethics that require them to preserve confidentiality and to avoid harming their clients

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