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Book Forum: Mental Health Care and Diagnosis   |    
Managed Behavioral Health Services: Perspectives and Practice
STEVEN S. SHARFSTEIN, M.D.
Am J Psychiatry 2004;161:1726-1726. doi:10.1176/appi.ajp.161.9.1726
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Edited by Saul Feldman. Springfield, Ill., Charles C Thomas, 2003, 435 pp., $77.95; $57.95 (paper).

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Saul Feldman is chief executive officer of United Behavioral Health, one of the largest managed behavioral health care companies in the United States. He has put together in this volume an excellent compendium on the managed behavioral health services available today. Feldman has demonstrated through his intellectual leadership over the years that it is possible to have a broad vision of mental health care and also be a very successful businessperson in today’s medical marketplace.

The extraordinary influence of managed behavioral health care on the practice of psychiatry and access to care and treatment cannot be overstated. It is remarkable that, after a decade, we know so little about its effect. As Feldman states, "The effects of managed behavioral health and quality outcomes are still indeterminate and very much in the eye of the beholder" (p. xv). An incredible national managed care experiment has been performed over the past decade without informed consent and with little understanding of patients’ outcomes.

We do know some things about the process. Managed behavioral health care has led to more people being seen in mental health settings but less care being delivered. Its emphasis on short-term approaches, medications, and diversion from inpatient care has been very successful in managing clinical costs; the percentage of the health care dollar that goes toward mental health has actually decreased over the past decade. Its success in managing care, however, remains controversial, as this volume demonstrates, and the costs of administration have increased dramatically.

Clinicians have reported (albeit anecdotally) that managed behavioral health care is extremely wasteful and duplicative and that the reviewer typically does not know anything about the case in question. Managed care has failed to develop successful integrated delivery systems; psychiatric care has been carved out from the rest of medicine, and costs for the medical aspects of psychiatric care have been shifted to other payment systems in dysfunctional ways. The development of intensive services for truly sick patients in less costly settings has not occurred as these patients have been removed from inpatient treatment. The hostility of managed care toward day hospitals and the refusal to pay for residential or rehabilitation services underscore the problem.

Managed Behavioral Health Services provides multiple perspectives on these phenomena, including clinical, ethical, economic, and employers’ points of view. Chapter authors also discuss areas such as the potential of the Internet and information systems to transform care and the review process as well as the evolution of managed behavioral health care in the public sector. The community mental health care underpinning of managed behavioral health care is underscored in the excellent chapter on ethics by Sabin and Daniels, which provides an extensive discussion of the ethics of defining "medical necessity" and the potential ethical pitfalls of capitated and for-profit approaches. This chapter was, for me, a highlight of the volume.

It is to Feldman’s credit that although he has been very successful in the managed behavioral health care business, he remains a skeptic and asks some hard questions of the very movement that he helped begin.

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