by George U. Balis, M.D.
[April 1995; Vol. 22 No. 2]
The forces that seem to be shaping the future of psychiatry are: (1) market forces, driven by corporate profit-making incentives; (2) managerial forces, driven by cost reduction-minded government technocrats; and (3) powerful special interests lobbying on spineless or greedy politicians.
The protagonist in this process is managed care, a profit-driven gating system that allows expensive and loosely regulated intermediaries to ration health care. Managed care does not represent a “movement” in health care reform; it is, in reality, an economic system that offers business opportunities for profit-making in what has become the “health industry.”
Of course, there is nothing wrong with the concept of “managed care” if it means cost-containment and better utilization of limited resources. Unfortunately, the basic dynamics that drive managed care is a capitalist profiteering system which creates a marginal health care proletariat of a rationed public and a gulag archipelagos of salaried physicians. In this gloomy scene, psychiatry is being disparaged as redundant, costly, and out of sync with managed care.
Cloaked under the euphemisms of “efficiency” and “cost-containment,” managed care is defining our professional roles and practices; in its worst form, it dictates substandard care. Agreeing to provide patients with substandard care is ethically questionable and may eventually invite malpractice suits.
We seem to accept passively what is being handed down to us. While outsiders are questioning our professional values, we seem to be acting as if we are still the advocates of seemingly vestigial ideologies (e.g., biopsycho-social model, psychotherapy).
Clearly, we need to learn to deal with managed care in a pragmatic manner. However, realism should not compromise the integrity of our relationship with patients nor obscure what we consider our professional standards. After all, it may not be long before the citizens of this country realize that what they feared about socialized medicine is already here with us in its most malignant form. When that time comes, the public will demand from their politicians a system that assures quality care for all, that is, a national health plan, divested of profit-making, with caps on services, and under a single payor system that has no need for managed care.
In the mean time, the highest risk in our effort for survival is to identify with the aggressor.