David Mechanic, Ph.D., surveyed the gains and losses in mental health
services over the past two decades and identified challenges for the future in
the Benjamin Rush Lecture at APA's 2004 annual meeting in New York in
David Mechanic, Ph.D., speculated in an APA annual meeting award lecture
about whether the "glass was half full or half empty" in terms of
mental health services.
Mechanic, the Rene Dubos Professor of Behavioral Sciences at the Institute
of Health, Health Care Policy, and Aging Research at Rutgers University, said
that there has been "more progress than is generally
Mechanic, who has received numerous awards for his work in sociology and
health services research, also directs the National Institute for Mental
Health Center at Rutgers for Research on the Organization and Financing of
Care for the Severely Mentally Ill.
Among the improvements in care that he cited are better medications and
treatment, "enormous growth" in the number of mental health
personnel and the number of people seeking treatment, increased public support
for mental health services, a focus on comorbid disorders, and improved models
of community care and evidence-based practice.
Mechanic noted, however, that those improved models were "rarely
Mechanic cited data from the federal Center for Mental Health Services
(CMHS) showing an increase in the number of care episodes in mental health
organizations from slightly fewer than 2 million episodes in 1955 to
approximately 13 million episodes in 2000.
The percentage of children with a "treated disorder" has grown
from 5 percent in the mid 1980s to 8 percent in the late 1990s, he said.
The percentage of people receiving treatment for depression has also
increased. In 1987, 0.73 percent of the population received outpatient
treatment for depression. In 1997, the percentage had grown to 2.33.
The absolute number of mental health personnel has increased since the
1980s, and the characteristics of the workforce have changed as well.
When listing the major changes that have occurred within mental health
care, Mechanic observed that "most behavioral health care is now
managed." Among the well-known strategies employed by managed behavioral
health care organizations (MBHOs) to control costs are reducing the rate of
reimbursement to those providing care and shifting that care to less-expensive
Mechanic showed a chart that contrasted reimbursements and referrals under
indemnity insurance plans in 1994 with those administered by MBHOs in
In 1994, under the indemnity plan, 85 percent of the mental health
referrals went to psychiatrists, and 5 percent went to social workers. In
1995, under managed care, the respective rates were 11 percent to
psychiatrists and 56 percent to social workers.
Psychiatrists were reimbursed, on average, $150 per visit under the
indemnity plan and $90 from MBHOs. The respective rates for social workers
were $85 and $65.
That chart, created by E. Clarke Ross, appeared in the chapter "The
Promise and Reality of Managed Behavioral Health Care," in "Mental
Health, United States, 2000," published by CMHS in 2001.
In addition, the initiation of managed care has resulted in a decrease in
the number of days of inpatient care. Mechanic presented data that showed, for
example, a decline in the number of hospital days for mental health or
substance abuse treatment per 1,000 employees of the Xerox Corporation from
327 in 1987 to 61 in 1994.
Managed care practices are also being implemented in the public sector,
said Mechanic, adding that the trend poses special challenges. Those with
serious mental illness most frequently receive treatment in the public
He said that with the introduction of those practices, there are"
substantial cost reductions," but evidence from studies in
Minnesota, Utah, and Tennessee suggests that patients who have schizophrenia
do "less well" over time under a public-sector managed care
Managed care models "inadequately differentiate among levels of
severity [of illness] and need," said Mechanic
He also noted that states have been implementing cost-containment
strategies in their Medicaid programs over the last three years, as a response
to budgetary constraints.
During their Fiscal 2002 to Fiscal 2004 periods, every state used some
mechanism to control the costs of prescription drugs and either reduced or
froze payments to those providing mental health services, according to the
Kaiser Commission on Medicaid and the Uninsured.
Thirty-five states reduced benefits, 34 reduced or restricted eligibility
to them, and 32 increased copayments.
He cautioned advocates to be particularly wary of the use of caps on the
number of prescriptions that can be filled each month by Medicaid
beneficiaries. According to a study published in the September 8, 1994,
New England Journal of Medicine, costs exceeded savings by a factor
of 17 when New Hampshire Medicaid officials established a three-prescription
limit on antipsychotic medications.
Mechanic described the challenges to providing care for those with serious
mental illness and outlined actions that state Medicaid agencies should take
to ensure the adequacy of that care (see box).
"The Promise and Reality of Managed Behavioral Health
Care" is posted online at<http://mentalhealth.samhsa.gov/publications/allpubs/SMA01-3537/chapter9.asp>.▪