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Book Forum: MANAGED CARE   |    
Managing Managed Care: Quality Improvement in Behavioral Health, by the Institute of Medicine Committee on Quality Assurance and Accreditation Guidelines for Managed Behavioral Health Care
Am J Psychiatry 1999;156:792-793.
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Portland, Maine

edited by Margaret Edmunds, Richard Frank, Michael Hogan, Dennis McCarty, Rhonda Robinson-Beale, and Constance Weisner. Washington, D.C., National Academy Press, 1997, 356 pp., $49.95.

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This is a consensus document produced by an Institute of Medicine committee. Listed on page iii, the committee members are an impressive group of managed care executives, state-level public department heads, academics, and patient advocates. Clearly, a lot of energy and sincere effort was put into producing this book. Much of it is remarkably honest and accurate in its survey description of the contemporary mental health scene in the United States. I did not necessarily expect a consensus statement to confront problems as directly as this book does.

Alas, however, it does little more than that. The text seems often to stop at description of problems. This lack of critical commentary contrasts with the liveliness of highlighted quotes set apart from the main body of the text, which derive from public workshops the Institute of Medicine gave around the United States. For example, Margaret O’Kane of the National Committee for Quality Assurance, a group unknown to me, is quoted as saying, "We know that there is competition in the health care marketplace today. I don’t think anybody doubts that. But it is very much a price-driven competition. And that, we think, is very dangerous to the quality of care that patients are receiving" (p. 31). Like most of the quotes, this one would be a nice departure for debate—I for one agree with it—but the text neither takes a real position nor elaborates a debate.

So it goes throughout the volume, culminating in a set of bland findings and recommendations: "The problems of reduced access and increased cost shifting may be aggravated by the use of managed care approaches.…High-quality managed care, however,…can improve access to appropriate treatment while controlling costs.…Payment arrangements that reduce incentives to underserve individuals with behavioral health conditions should be encouraged.…The reform of state and local systems through the use of managed care should incorporate a…responsiveness to the unique needs of consumers served by public systems" (pp. 242–243). In other words, fish will need to swim, and we’re working on it.

This may sound harsh, particularly toward the public servants who put their time and thought into these recommendations, but I have been lucky to learn a little about deconstructionism from my "Generation X" patients. Just as psychoanalysis looks for the function of a symptom, deconstructionism would here ask, What is the cultural function or purpose of this document, apart from the conscious intentions of its authors? To reassure us that something is being done? To demonstrate that managed care executives can say the right things when sitting on a committee? My deconstructionist tutors would say that this Institute of Medicine committee represents an alliance of elite groups whose interests overlap. Corporations seek to augment their power, and public bureaucracies seek more quietly to perpetuate theirs. This consensus statement invokes the current reigning ideology, outcomes-based research, to suggest that difficult moral decisions can be turned into solvable technical problems.

Free enterprise is not appropriate to health care. Until we have a universal single-payer system in the United States, those in power will continue to insulate health care policy decisions from any truly democratic process while enriching or perpetuating themselves. We need a single-payer system. Books like this serve to obscure this fact.




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