Am

TOPICAL

PAPERS:

Mental BY

Health

BENJAMIN

Future

Care

LIVFZIN,

Mental

Delivery

Health

Systems:

PAPERS in this section were presented at a special session of the 130th annual meeting of the American Psychiatric Association in 1977. The major purpose of the session was to bring to the attention of practitionens and policy makers the distinction between a health cane financing system and a health cane delivery systern. The former refers to how services will be paid for, an issue that has received a great deal of publicity because of the interest in national health insurance (13). The latter refers to how services are organized and delivered, issues relevant to discussions ofthe relative merits of community mental health centers, health maintenance organizations, private practice, etc. It is important to understand the nature of the delivery system because changes in the financing system will have intended on unintended consequences for what services are delivered to which patients in what settings. An understanding of the different cornponents of the delivery system will put policymakers in a better position to encourage on discourage the delivery of particular services to particular populations. For example, one proposal for national health insurance would limit the number of office visits to a private practitioner but would pay for an unlimited number of visits to a community mental health center (CMHC). Although such a proposal would capitalize on the cost containment features of an organized care setting operating on a limited budget, it ignores the question of

Revised version of a paper presented the American Psychiatric Association, 2-6, 1977. Liptzin

Belmont, chiatry,

is Assistant

Mass. Harvard

02178, Medical

Psychiatrist,

and Assistant

at the 130th annual meeting of Toronto, Ont., Canada, May

McLean

Professor,

115 Mill St., Department of Psy-

Hospital,

School.

The papers in this section are Editor considers this material 1350

Delivery

/35:/i,

November

1978

Systems

Introduction

M.D.

THE

Dr.

Care

J Psychiatry

whether a community mental health center could provide high-quality intensive psychotherapy or whether the patient population treated at the CMHC would use such services. The papers presented here were written by leading spokesmen for four major components of the system for providing services to individuals with mental disorders. These are primary health care programs (Morrill) and, within the specialty mental health sector, private psychiatric practice (Lebensohn), state mental health programs (0km), and community mental health centers (Sharfstein). They provide a policy penspective of where we are today and where we may be in the next several years. Policy issues that are not addressed in depth in any of the individual papers include the need to coordinate the cane received in different mental health settings as well as the need to integrate mental health services with other health and human services. The patchwork of funding and organizational arrangements has made coordination and integration difficult. From a policy analytic perspective, there is also a need for more detailed information on which patients use what services in what settings and to what effect. A first step has been taken by Regier and associates (4), who have estimated the number of individuals in treatment in different settings. Weissman and Klenman (5) have recently urged the expansion of research efforts in psychiatric epidemiology. This should include studies designed to learn what agencies or persons “untreated” individuals rely on when they experience emotional distress. The knowledge gained from health services research and psychiatric epidemiology will be essential to future planning of mental health delivery systems.

grouped around a specific topic. to constitute a comprehensive

0002-953X/78/001

1-1350$0.35

©

1978

Publication analysis

American

here does of the topic’.

Psychiatric

Association

not,

however,

imply

that

the

Am

J Psychiatry

/35:1/,

November

/978

RICHARD

REFERENCES 1.

Myers and

ES: future

2. Nelson 3.

SH:

health. Mechanic

The

Insurance prospects.

Am

A new

BY

coverage Am

look

for

RICHARD

illness:

Health

at national

health

4. Regier health

status 1970

insurance

for mental health

Health

ben-

orders.

in Primary

.

,

,

PRIMARY HEALTH CARE is currently undergoing a significant revitalization in this country as a result of past overspecialization, patient dissatisfaction rising health cane costs, and new government funding priorities. At the same time there has been a continuing trend toward increasing organization in health care delivery, e.g., group practice and health maintenance organizations. The intersection of these trends is primary health care on comprehensive health care through organized ambulatory health care delivery settings. This presents important new opportunities to reverse ,

Revised version of a paper presented the American Psychiatric Association, 2-6, 1977. Morrill

is Clinical

Government

Director,

Center,

insurance.

35:685-693, 1978 MM, Klerman GL:

Arch Gen

Health

Am

I

Public

CA: The de facto health perspective. Epidemiology

of

Health

US mental Arch Gen mental

dis-

Psychiatry 35:705-712, 1978

Care

Programs

some of the isolation and fragmentation that separate mental health programs have undergone in relation to the rest of health cane. This paper will present issues and findings gathered from the literature and from my work in integrated health-mental health settings: the Roxbuny Comprehensive Community Health Center and Upham’s Corner Neighborhood Health Center in Boston. A number of potent forces leading toward the integration of health and mental health services have developed in recent years. Psychiatry has undergone considerable role diffusion since the social movements of the 60s and is generally rediscovering its linkage with medicine. Some primary care training programs are trying to give higher priority to the psychological side of health cane. Mental health services are more likely to be reimbursed by third-party payers than formerly, and health care programs are less defensive about including them. The much heralded community mental health centers have not fulfilled their promise because of lack of financing and perhaps because they attempted too much too soon. Deinstitutionalization is usually not followed by the promised comprehensive community care. Mental health services are making progress, albeit with difficulty, in quality control, cost containment, and utilization review-thus following trends present in health care generally. The federal government is withdrawing support from the training of mental health care providers in favor of the training of primary health care providers with mental health skills. The traditional areas of health-mental health interaction have been several. Consultation and liaison units from departments of psychiatry have worked within general and teaching hospitals. Such units were often quite peripheral to their health cane setting, on which they had little influence. In the ambulatory area, hospitals have run separate medical, pediatric, gynecological, and psychiatric clinics, with little communi-

.

Dr.

health

MORRILL

M.D.

Our large/v separate nental health s’stem has developed in relationship to a health care systeFn oriented tott’ard specialization and solo practice. Noti’ the health care system is moving in the direction of primary care and group and organizational practice. Nett’ftrms of,nental health delivery’ are needed to ‘naximize the potential ofthese nest’ health care programs for nental health services The author describes these tie ti integrated programs which bring mental health providers into the primar’ health care progra,nsfor direct services as ;i’ell as consultation. Issues discussed include mutual roles, changes in services, the referralprocess, and provider relationships The advantages ofsuch integrated programs include decreased stigma increased prevention through earlier detection and referral, increasedfam i/v orientation greater coordination of care, and less duplic’ation.

Center,

national 1978

DA, Goldberg ID, Taube services system: a public

Psychiatry

5. Weissman

1973 of mental

Mental

MORRILL,

present

60:1921-1930,

43:622-631, in the design

for C.

mental

I Public

I Orthopsychiatry D: Considerations

Future

efits under 68:482-488,

0.

at the 130th annual meeting of Toronto, Ont., Canada, May

Erich

Boston,

Lindemann

Mass.

0002-953X/78/00l

Mental

Health

02114. 1-135 l$0.50

©

1978

American

Psychiatric

Association

1351

Mental health care delivery systems: introduction.

Am TOPICAL PAPERS: Mental BY Health BENJAMIN Future Care LIVFZIN, Mental Delivery Health Systems: PAPERS in this section were presented a...
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