Managing Mental Health: Whose Responsibility?

Abstract

A famous landmark and center near the University of Milwaukee campus, the Oriental Drugstore, recently shut its doors. Having served cross section of Milwaukeeans since 1926, its lunch counter was place where frail old cloudy-eyed black man mumbling to himself, purple-haired chain-smoking young woman with twitch in her cheek and tremulous hand on her coffee cup, and gaunt young man with AIDS all could chat comfortably with other customers as they waited for their prescriptions in the familiar sociable surroundings. The waitresses and the pharmacists knew their customers' names; the food was plain and affordable. Immortalized on the neighboring movie marquee as a place where people really cared, this public space represented what Putnam (1995) called institutions of civic engagement; the exchanges that occurred there spilled over, generating community social capital. The Oriental Drugstore sold out to national discount drugstore chain. The pressure to sell came from competition and from the preference of local managed care companies for contracting with large chain drugstores offering administrative convenience and discount pricing. The big shiny new drug emporium half mile away has no food service, no place to linger with other people. Large corporations are too big to deal with independent pharmacies or small private independent vendors catering to poor clients. The loss of the neighborhood drugstore portends an erosion of care for poor and mentally ill residents. The enormous growth in managed care, recently documented in this column (Keigher, 1995), has staggering implications for people with mental illnesses in the United States and for workers employed in the mental health care field who recognize the value of familiarity, affordability, and personal compassion. Managed care, working its way into physical health care for the past 20 years, has emerged as vendor of mental health care in the form of health care plans in the past 15 years. Managed behavioral health care organizations' interest in patients with severe and persistent mental illnesses has been sparked largely by recent government efforts to reduce their costs of caring for chronically mentally ill people, spurring the Medicaid experiments now developing in many states (Essock & Goldman, 1995). Social workers in mental health care settings are reacting dramatically to the cost containment changes being imposed on them. In 1992 NASW found that 37 percent of its surveyed membership had already changed their treatment approach because of managed care. A recent survey of 173 mental health practitioners in San Francisco found that 44 percent were considering leaving the field of mental health treatment because of managed care (Hymowitz & Pollock, 1995). Although work practice with all populations stands to be fundamentally altered by the incursion of managed care's cost containment strategies into previously foreign territory, practice with seriously and persistently mentally ill clients is especially vulnerable. The large numbers of workers in mental health transform the issue into one of imminent concern to the profession. Mental health is the leading field of work practice; the National Institute of Mental Health reported that 47 percent of the patient care staff in outpatient psychiatric clinics are workers (Hopps & Pinderhughes, 1987). Although the cost of health care has grown to 12 percent of the gross national product (Dorwart, 1990), only 12 percent to 14 percent of total health care dollars are for mental health services. The total estimated spending on mental health services, both public and private, was approximately $42.5 billion in 1990 (Medicaid and Mental Health, 1995). The pattern of use by mental health care consumers is not unlike that of users of physical health care - about 10 percent of mental health care users account for about 50 percent of all outpatient expenditures (Durenberger, 1989), and another 10 percent account for 60 percent of the inpatient days (Scharfstein & Beigel, 1985). …