Personality Disorders

Our field is at a moment of great excitement, opportunity and risk. Faced with the reality that resources for treatment have limits, a revolution in funding of mental health benefits has begun. In order to contain costs new strategies are emerging, like capitation, case rates, case management and utilization review, that closely limit or oversee treatment provided and/or ask providers to bear the financial risk of treatment. The attention of psychiatrists has been powerfully drawn to the financial arena, where the introduction of close management of benefits has introduced a sometimes dizzying array of hoops through which a clinician must leap, dragging the patient behind, in order to persuade a case manager or utilization reviewer that a particular treatment is indicated. Quality is in danger of falling by the wayside in favor of cost containment as the watchword by which clinicians practice their art.

The impact of managed care on psychiatry has the potential for positive effects through better resource management, but the turning of psychiatrists' attention away from quality to cost containment is worrisome if it means only minimal treatment will be authorized for patients. A recent Rand Corporation study of prepaid versus fee for service mental health benefits showed that depressed outpatients in prepaid plans were more likely to acquire new limitations in role or in their physical functioning than those treated in a fee for service model (1). The authors suggest that the presence of Axis II disorders may account for the finding. The shift to new reimbursement strategies is here to stay, but we ought to pay attention to the clinical consequences. One danger, which may explain some of the Rand Corporation study findings, is the way many of the new reimbursement strategies leave the patient out of the terribly important negotiations around the treatment plan and its funding. The crucial clinical and financial dialogues about treatment have increasingly been reassigned to the doctor or other clinician and case manager, without the patient's true participation. This has the potential to leave the patient in the position of being a passive recipient of treatment, rather than an active agent in it (2).