MANAGE OR PERISH? THE CHALLENGES OF MANAGED MENTAL HEALTH CARE IN EUROPE MANAGE OR PERISH? THE CHALLENGES OF MANAGED MENTAL HEALTH CARE IN EUROPE Edited by Jose Guim6n, M.D. Professor and Chairman Department of Psychiatry University of Geneva Geneva, Switzerland and Norman Sartorius, M.D. Professor of Psychiatry University of Geneva Geneva, Switzerland Kluwer Academic / Plenum Publishers New York, Boston, Dordrecht, London, Moscow Library of Congress Cataloging-in-Publication Data Manage or perish?: the challenges of managed mental health care in Europe I edited by Jose Guim6n and Nonnan Sartorius. p.;cm. Includes bibliographical references and index. ISBN 0-306-46210-9 I. Managed mental health care--Europe--Congresses. I. Guim6n, J. II. Sartorius, N. [DNLM: I. Mental Health Services--Europe--Congresses. 2. Managed Care Prograrns--Europe--Congresses. WM 30 M265 I 1999] RA790.7.E9 .M36 1999 362.2'094--dc21 99-044528 Proceedings of an International conference on Manage or Perish? The Challenges of Managed Mental Health Care in Europe, held October 7-10, 1998, in Geneva, Switzerland ISBN 0-306-46210-9 ©1999 Kluwer Academic/Plenum Publishers, New York 233 Spring Street, New York, N.Y. 10013 10987654321 A C.I.P. record for this book is available from the Library of Congress All rights reserved No part of this book may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, microfilming, recording, or otherwise, without written permission from the Publisher PREFACE "Adapt or perish, now as ever, is Nature's inexorable imperative." -H.G. Wells, Mind at the End of Its Tether (1946) Doctors are trained to treat people suffering from various diseases. This is the main form of their activity and usually the reason for which they selected medicine as their profession. The notion that they should become managers and engage in activi ties such as programming, calculating cost, assessing cost-benefit ratios, and thinking about pricing in accordance with the social utility of their intervention, is both foreign and abhorrent to them. They are sometimes willing to say how much they need in order to have a well-functioning service: usually they prefer to state what specific apparatus and other things they require without specifying the price of their demand. They can be persuaded to add a price tag to what they think is necessary for their work: but that was about as far as they would go, until recently. The growing emphasis on human rights over the past few decades, the greater emphasis on quality of life and the public's heightened expectations about their health led, in many industrialized countries, to a greater demand for health services. This, com bined with improved possibilities of diagnosis and treatment (at higher cost!), led to a significant increase in financial demands which made governments and health-care systems uneasy and ready to accept any solution that would stop the spiral of seem ingly endless cost augmentation. An apparently sensible solution was to rationalize health care. The demand for rationality in the application of medical knowledge is not new and certainly makes good sense for societies, medical systems and for patients. What was new was that the word "rational" was used to indicate that cost must be kept steady or drop, without much consideration to a possible deterioration in the service given to patients or to the dissatisfaction of health-care staff, forced to work in conditions that their professional conscience did not allow them to accept. Since it did not seem that the health-care system in place would rapidly change its ways, an intermediary system-that of managed care organizations-emerged in the USA and soon after that elsewhere. The system had a number of apparent advantages. It sailed under the banner of rationality and of reduction of unnecessary cost (the definition of unnecessary was not unequivocal and precise criteria for that designation vary from one company to another). It absolved health authorities of the unpleasant duty of telling those in the health system that they will not receive as much as they would need, in order to meet their commitments. It enabled health authorities, those providing the funds for care, to invite competitive bids and even make savings when an offer from a particular managed care company was especially cleverly constructed. v vi Preface Notably, at its inception, managed care promised to abolish or keep in check the "cushy" incomes which were viewed by some as being characteristic of the entire medical profession. The immediate consequence of the appearance of managed care companies has been a change for physicians in managerial positions from program budgeting to budget programming. They were no longer expected (and often not even allowed) to state their requirements: rather, they began to have to make do with a sum of money provided by the Authority, plan and work with an amount of resources that they must not surpass. This change from the previous method of planning-in which personnel respon sible for health services stated what they needed and the chief physician summarized their requests passing them on to the higher financial authorities in the system-was both painful and confusing for most heads of service. It is thus becoming necessary to examine how best to rectify the situation: this will probably have to include an exchange of information and a series of consultations between service providers, clients, managed care companies, and those who will even tually have to foot the bill. Such consultations will have to be marked by respect (for and by all those involved) and by a spirit of compromise that will allow the provision of care, in an equitable fashion, to those who need it. The objective of the Geneva encounters was to contribute to the process of seeking equitable solutions, bringing together outstanding scientists, managers of ser vices, expert economists, representatives of patients and families, government officials, and service providers. This volume assembles 73 of the papers that were presented and discussed at the meeting. They have been grouped in a somewhat artificial manner. Under "General Aspects", two papers are given-one on the terminology of managed care and the other on the pitfalls and possible advantages that psychiatrists may find in these cost containment procedures. The next three sections present a number of texts dealing with the experience undergone in the United States with managed care, the "European Ver sions" of these cost-containment strategies, and repercussions in other regions of the world. A section on "Managed Care and Specific Mental Disorders" puts together ten papers dealing with the evaluation of results and the cost of several specific psychiatric problems. Under "Methodology", six papers describe the specific ways of evaluating needs, outcome and general mental health data. A section on "Ethical Issues in Managed Care" assembles several papers written by representatives of both the pro fession and outside advocates. Section Eight gives psychiatry's users a forum for their arguments on cost-containment policies. A section on "Teaching and Research" tries to evaluate the impact of the introduction of managed care on these pursuits. A final section, on the role of "Interference of Managed Care with Social Support Networks" as a mechanism for fulfilling psychiatric needs through non-formal assistance, brings this book to a close. The authors and editors wish to thank Mary Ritchie for her invaluable help in coordinating the organization of our meeting with MCI Travel, and most especially for her enthusiastic and skilled work in translating and copy editing the manuscripts of this book. Jose Guim6n Norman Sartorius CONTENTS I. General Aspects 1. Understanding Managed Care: A Primer for the World Psychiatric Association "Congress Manage or Perish", Geneva, Switzerland 1 Peter D. Yates 2. The Future of Psychiatrists under Managed Care 11 Jose Guim6n II. The U.S. Experience 3. For-Profit Managed Care in the USA: Growth and Decline? 23 Zebulon Taintor and Robert Cancro 4. The American Experience with Managed Care: How Europe Can Avoid It ........................................................ 43 John A. Talbott 5. Managed Care and American Psychotherapy 57 John C. Markowitz 6. Private Practice and Managed Care: The American Experience 65 Michael C. Hughes 7. Health Economics and Services for Children with Mental Health Problems in the USA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71 David F. Raney 8. Is Psychiatric Rehabilitation Something Special to Managed Care in the USA? ...................................................... 75 Zebulon Taintor and Gregory C. Bunt III. The European Versions 9. Introduction to Plenary Session II "Managed Care in European Countries" .................................................... . 79 Fran~ois Borgeat vii viii Contents 10. Managed Care in Europe 81 Elena Sternai-Saraceno II. Transcultural Perspectives of the Management of Mental Health Care: Challenges in Europe and in Low-Income Countries . . . . . . . . . . . . . . . . 95 Edvard Hauff 12. Managed Mental Health Care in the UK 101 Martin Knapp 13. Managed Care in Germany 115 Wolfgang Gaebel 14. Managed Mental Health Care in France 123 Pierre F. Chanoit 15. The Minimal Psychiatric Summary (M.PS.) and the Current Organization in Mental Health Care . . . . .. . . . . . . . . . . . . . . . . . . . . . .. . 131 I. Pelc, 1. Joosten, L. From, I. Bergeret, Y. Ledoux, and 1. Tecco 16. Minimal Psychiatric Summary: The French Way 143 Raymond Tempier 17. Managed Care in Scandinavian Countries 153 Kari Pylkki'men 18. Manage or Perish: The Situation in Switzerland 161 Ursula Steiner-Konig 19. New Models of Financing: What Is the Future of Psychotherapy in Switzerland? . .. . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . .. ... . .. . . . 167 Jacqueline Lalive-Aubert and Roland Eisele 20. The Provision of Mental Health Care in the Russian Federation 173 VN. Krasnov 21. Functional and Dysfunctional Aspects of the 1990 Reform of the Health-Care System: Hungary in 1998: Before Managed Care ......... 181 Istvan Bitter and Katalin Hideg 22. The French Public Psychiatric Team Confronted with the Demand for New Collaboration: A Space for Rehabilitation ..................... 189 Jacques Dubuis 23. The German Social Insurance Program's Role in the Rehabilitation of Mentally III Patients ............................................. 195 F. Michael Stark, Esther Maylaht, and Zebulon Taintor 24. Models of Health Care Systems in Europe: Their Consequences for Psychiatric Care ................................................. 199 1. Agustin Ozamiz Contents ix IV. Experience in Other Countries 25. Managed Care and Quality Assurance Methods in Mental Health in Latin America .................................................. 207 Rodolfo Fahrer 26. Almost a Rcvolution: Towards Managed Mental Health Care in Israel .. . .. .. . .. . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. .. . 213 Mordechai Mark, Moshe Zvi Abramowitz, and Arieh Eldad 27. Challenges of Managed Mental Health Care in the South-East Mediterranean Region. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223 Ahmed Ok ash a 28. Cost Management of Mental Patients' Care: Is Traditional Healing an Alternative in Developing Countries? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 233 D. Moussaoui, I. Tazi, and F. Boussaid V. Managed Care and Specific Mental Disorders 29. Quality of Life Assessment in Schizophrenia ........................ 239 J. Bobes, M.P. Gonzalez, M.T. Bascaran, P.A. Saiz, and M. Bousono 30. Traditional Methodology and Outcome Assessment in Studies on the Course of Schizophrenia ......................................... 249 Anita Riecher-Rossler 31. Comparison of Antipsychotics in Randomized Clinical Trials: Economic and Quality of Life Outcomes .................................... 259 Dennis A. Revicki 32. Methodological Problems of Schizophrenia Trials in Community Settings ........................................................ 267 Tom Burns 33. Antidepressant Use and Clinical and Economic Outcomes in a Primary Care Psychiatry Center in Spain: A Review of a Naturalistic Study 277 William H. Crown, Timothy R. Hylan, Angel Luis Montejo, Jose A. Sacristan, Inmaculada Gilaberte, and Laurie Meneades 34. Assessment of the Impact of Long-Term Lithium Prophylaxis on the Course of Bipolar Disorder: Methodological Problems and Empirical Data ................................................. 289 Mario Maj 35. Cost Effectiveness in the Prevention of Suicide 295 Lars von Knorring, Kerstin Bingefors, Lisa Ekselius, Anne-Liis von Knorring, and Gunilla Olsson x Contents 36. Economic Aspects of Anxiety Disorders 311 Franc;oise Radat 37. Cost and Management of Bipolar Disorders 317 Marc-Louis Bourgeois 38. Major Depression: Brief versus Long-Term Treatment 325 Roland Eiseh~ VI. Methodology 39. From Supply and Demand to Need and Demand: Service Planning and the New Epidemiology .... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 335 Harry B. Pomerantz and Martin W. de Vries 40. Outcome Measures and Cultural Factors in Managed Care: A Literature Review ............................................... 347 Ariel Eytan and Juan E. Mezzich 41. Use of the EPCAT Model of Care for Standard Description of Psychiatric Services: The Experience in Spain ....................... 359 L. Salvador-Carulla, C. Atienza, C. Romero, and the PS[COST/EPCAT Group 42. Total Quality Management in Mental Health: A Pilot Program 369 Eduardo de la Sota 43. Research and Communication of Mental Health Data: Three Years on the Net ........................................................ 375 Francesco Bollorino and Alexia Piaggio 44. Assessing Psychotherapy Outcome: The State of the Art 381 Alice Dazord VII. Ethical Issues in Managed Care 45. Ethical Problems in the Practice of Psychiatrists under Managed Care 391 Jose Guimon 46. Managed Care: Will it Destroy the Doctor-Patient Relationship? 397 Marianne Kastrup 47. Does Managed Care Threaten the Therapeutic Relationship? or When a Third Party Comes between a Doctor and Patient . . . . . . . . . . . . . . . . . . 401 Claude Aubert Contents xi 48. When the Therapeutic Team becomes Dysfunctional because of Managed Care .................................................. 411 Miguel Angel Gonzalez-Torres, Aranzazu Fernandez-Rivas, Jose Mariano Galletero, lfiaki Eguiluz, and Michol Gonzalez-Torres 49. Cherish or Perish: The Values of Private Psychiatry 417 Theodore Hovaguimian 50. Ethical and Legal Dimensions of Medical Confidentiality in European Law of Human Rights ............................................ 421 Thomais Douraki 51. Care of People with Psychiatric Subthreshold Disorders: Ethical Challenges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 429 Hanfried Helmchen 52. Ethical Committees as a Guarantee of Observation of Human Rights in Managed Care Systems .................................. 441 Yuri S. Savenko and Liubov N. Vinogradova VIII. Managed Care and Psychiatry's Users 53. Unmet Needs and Cost Containment: A Non-Linear Relationship 445 Elena Sternai-Saraceno, Philippe Huguelet, and Jose Guim6n 54. The Patient's View of Managed Psychiatry 453 John P. Kummer 55. The Young Psychiatric Patients' Rights: An Overview of the Current International Legislation ......................................... 457 Marie-Fran<;oise Lucker-Babel 56. Manage or Perish, or Choosing to Live without Neuroleptic Drugs: Difficulties and Chances ......................................... 469 Peter Lehmann 57. What the Patients Tell Us: A Preliminary Report on the GAMIAN International Survey, with Specific Reference to the Italian Data 475 Paolo Lucio Morselli 58. The Role of Advocacy in an Era of Managed Care 485 Rodney Elgie 59. Alternatives to Psychiatry and Managed Care 491 Maths Jesperson