Not long ago, I attended a psychiatric educational meeting where the focus was on biomedical/psychopharmacologic aspects of treatment. A former Medical Director of an HMO reviewed insurance company thinking as it applies to psychiatric/pharmacologic treatment. He made the point that the "correct" forms of treatment for psychiatric disorders are described "in the literature," and that insurance company planners use these data to budget for the cost of care. He further implied that "there are plenty of substandard practitioners out there" who don't consistently follow these recommended treatment actions, thus introducing unwanted variability into the budgetary process. He then resumed his seat between two internationally known psychopharmacologists who, responding to an audience question, argued passionately about a basic psychopharmacologic question: whether or not to use a neuroleptic in the treatment of a dangerously psychotic manic patient. One of these scientists stated flatly that neuroleptics should never be used under these circumstances, and the other responded that they should be used “ always”. It did not appear (to me) that the former Medical Director fully perceived that an obvious discrepancy in the literature of treatment had just been stated most clearly.

Businesses must carefully identify the needs of their customer base (patients), to establish the services necessary to meet these needs in a standardized fashion, and to uniformly "cost out" these services. Variability in practice patterns, as suggested by the two psychopharmacologic experts, is likely to result in unpredictability in treatment costs-- an undesirable situation for budgetary planners. The identification of "outliers" (practitioners who, sometimes deviate from the formats produced by these analyses) are then a focus of "management efforts". That renowned clinician/researchers disagreed on a basic pharmacologic treatment strategy in a rather common clinical situation serves to illustrate how an aspect of our profession remains an art, even in one of its most scientific applications. The resulting treatment practices are, therefore, difficult to quantify. The art of psychopharmacology necessitates very careful decision-making by the physician on the case, and may sometimes deviate from strictly standardized practice patterns. Good treatment may require considerable creativity.

HMO and insurance company business practices have been intrusively inserted into the consulting room, sometimes with catastrophic results for the patient. Medical practice and business practice do not always mix well, and less than adequate patient outcomes are often the result. Consumers (patients) are becoming aware of this discrepancy and are demanding reform through legislation. Hopefully this will soon occur, and be complete enough to be meaningful.

Medical care, unlike other necessities of life, cannot be obtained in any way other than by depending on a highly trained practitioner. Access to medical care (beyond the simple prevention level) always renders the individual patient dependent on others (physicians) to recommend and carry out treatment. Those without adequate medical training do not have the required knowledge to safely and effectively direct appropriate treatment.

Major technologic changes have also taken place in recent years. These changes include a resurgence of interest in ECT (done in much more technologically sophisticated ways then in the past), and the emergence of new fields such as phototherapy, vagal nerve stimulation, sleep deprivation protocols, repetitive transcranial magnetic stimulation (rTMS), and possibilities in the area of functional MRI.

For someone who has practiced through these years of change, I find the newer understanding of the disorders and the evolving technologies with which we treat them to be not only very exciting, but also highly liberating. Many of the timed-tested methods, such as the psychotherapies, are still available to us and should be used where appropriate to the clinical situation. These are exciting times for psychiatry. Our new understandings have brought us to levels of sophistication that allow us to be more effective in shorter periods of time than has been possible in the past.

Our task, as I see it, is to bring these two areas of practice (business and medicine) into consonance with each other in such a way that we can use our art, skill, technology, and special knowledge to their maximum effect in the treatment of these most vulnerable of patients.

It seems to me that we are reaching a second stage in the evolution of managed care, arising out of the sometimes bitter experiences of the last few years. This new era will hopefully be one in which we can offer the full range of treatment possibilities to our patients, while carefully managing our resources in order to ensure that efficiencies are carefully balanced with the efficacy, resulting in the best possible outcomes for our patients.