With the availability of new treatments and better insurance coverage, most of psychiatry-including social psychiatry-seemed to forget about the social ramifications of costs. The unexpected rise of general health care costs at the turn of this decade was a major concern of business and governmental payers, and the costs were rising even more dramatically in mental health care. Cost concerns were coupled with a lack of accountability as evidenced by overutilization, perfunctory peer review and wide variations in quality of care, and the groundwork was
laid for managed behavioral health care systems-often carved out from general health care-that could reduce costs and monitor outcomes. To do so, the business practices of managed care companies introduced new industrial administrative processes and a concern with profit margins.
Whatever the successes of managed care, the remaining social problems are well apparent. The number of uninsured individuals, already in the millions, is still rising, and millions more need psychiatric care but are not receiving it. Prevention is still a promise, quality of care is questionable, behavioral health care continues to be separated from the rest of health care, and the morale of clinicians is plummeting. A new report issued by the National Center on Health Statistics found that poorer and less educated people suffered more from virtually every health problem, and died earlier.
If we honestly examine the strengths and weaknesses of our prior fee-for-service and public sector systems, different managed behavioral systems and other systems of care around the world, perhaps we can come to a better consensus of what is needed to combine the best of business and health care ethics (Moffic, 1997). A 10-point millennium plan might include:
1) Universal coverage for humane, adequate and competent care of all people.
2) A single payer that would develop uniform administrative principles.
3) Management of care that would reduce overutilization, underutilization and variations in quality of care.
4) A biopsychosocial approach using evidence-based guidelines.
5) Integration of psychiatry with the rest of medicine.
6) Prevention whenever possible.
7) Outreach to those needing psychiatric treatment but not receiving it.
8) Clearer roles for all mental health disciplines.
9) Reimbursement based at least in part on cost-effectiveness and outcomes.
10) Reduction of sociocultural discrimination of patients and clinicians.
Not long ago, a psychiatrist at an AASP meeting commented that social psychiatry "does not hit my pocketbook." To the contrary, ignoring costs and accountability has affected all of our pocketbooks in one way or another. Paying attention to cost-effectiveness in our individual patient encounters and in our systems of care is crucial for the new millennium. The social psychiatric perspective should help us to do so in a fair way.