Better but Not Well: Mental Health Policy in the United States since 1950
http://www.100md.com
《新英格兰医药杂志》
Mental health policy has had a checkered history over the past half-century, particularly in regard to patients with the most serious and persistent mental disorders. In Better but Not Well, Richard Frank and Sherry Glied, two outstanding health economists, present an empirically based assessment of the evolution of mental health policies and services since 1950. They conclude that there have been many improvements in financing and treatments but that the field remains far from well. Mental health professionals too often focus on designated mental health funding, neglecting the important fact that mental health policy and the system of services are substantially driven by financial incentives and government programs that are external to mental health. This book is an excellent antidote to that mind-set.
Frank and Glied document the ways in which the changing character of mental health and substance abuse services are shaped by such programs as Medicaid, Medicare, Supplemental Security Income, Social Security Disability Insurance, and housing. An important framework for their review is the change over time from the traditional exceptionalism of mental health care administered, and often directly delivered, by state mental health authorities to greater mainstreaming, in which mental health and substance abuse care are more integrated with general medical services and supported by the same institutional and financial structures. Frank and Glied recognize that with these advantages come serious limitations, since policies on dominant reimbursement and care arrangements are largely made with other populations in mind and do not necessarily reflect the needs of people with mental illness, especially those with the most severe disorders.
This short book broadly summarizes major studies of the prevalence of mental illness and utilization of care, the increasing importance of national disability insurance and housing programs for community care, the enormous growth in the supply of mental health services, and the increasing involvement of general physicians as well as a wide range of nonmedical professionals. Frank and Glied devote much attention to pharmaceutical developments and their growing dominance in treatment, making a nice distinction between the advances made possible by the emergence of new, more effective medications and the abandonment, however slowly, of less effective treatments. They recognize that many of the purported recent advances associated with the introduction of selective serotonin reuptake inhibitors and the atypical antipsychotic medications have come less from improved efficacy and more from the perceived advantages of tolerance and safety.
The authors draw on a great deal of data to illustrate the importance of Medicaid in treating people with severe mental illness and the large role Medicaid policy and incentives have played in determining how states carry out their responsibilities to these people. The changes in response to incentives have been impressive. They include shifting populations from one treatment context to another; discouraging the use of states as direct providers of service; encouraging managed behavioral health approaches; redirecting state funds from other efforts in mental health care to their use as the required state Medicaid match; and accelerating the use of psychotropic medications, a large and growing component of Medicaid mental health expenditures.
The system has grown and changed in many ways, but services for the relatively small subgroup of the most seriously impaired patients remain poor in many ways. Such patients are now as likely to be found in prisons as in mental health clinics and hospitals. Their care, as the President's New Freedom Commission on Mental Health has noted, is fragmented and in disarray. Mental health advocates applaud the growing movement toward parity with insurance coverage for general medical care, but parity is hardly enough for patients with profound needs. As Frank and Glied recognize, these patients require a wide array of services that are fundamental for a decent quality of life: housing, adequate subsistence, and protection from victimization. Efforts to provide such services not only have failed to meet the challenge but are continually threatened. The quality of care remains poor, care is typically not evidence-based, and large socioeconomic and racial disparities remain. Unfortunately, most of the aggregate data documenting changing patterns of care indicate little about its quality. In concluding their analysis, however, Frank and Glied are on the mark, noting that mental health services are more abundant and used by more of the population than ever before and that the available technologies have improved, but that the system remains in need of significant repair. This book offers many insights beneficial to the informed reader.
David Mechanic, Ph.D.
Rutgers University
New Brunswick, NJ 08901
mechanic@rci.rutgers.edu(By Richard G. Frank and S)
Frank and Glied document the ways in which the changing character of mental health and substance abuse services are shaped by such programs as Medicaid, Medicare, Supplemental Security Income, Social Security Disability Insurance, and housing. An important framework for their review is the change over time from the traditional exceptionalism of mental health care administered, and often directly delivered, by state mental health authorities to greater mainstreaming, in which mental health and substance abuse care are more integrated with general medical services and supported by the same institutional and financial structures. Frank and Glied recognize that with these advantages come serious limitations, since policies on dominant reimbursement and care arrangements are largely made with other populations in mind and do not necessarily reflect the needs of people with mental illness, especially those with the most severe disorders.
This short book broadly summarizes major studies of the prevalence of mental illness and utilization of care, the increasing importance of national disability insurance and housing programs for community care, the enormous growth in the supply of mental health services, and the increasing involvement of general physicians as well as a wide range of nonmedical professionals. Frank and Glied devote much attention to pharmaceutical developments and their growing dominance in treatment, making a nice distinction between the advances made possible by the emergence of new, more effective medications and the abandonment, however slowly, of less effective treatments. They recognize that many of the purported recent advances associated with the introduction of selective serotonin reuptake inhibitors and the atypical antipsychotic medications have come less from improved efficacy and more from the perceived advantages of tolerance and safety.
The authors draw on a great deal of data to illustrate the importance of Medicaid in treating people with severe mental illness and the large role Medicaid policy and incentives have played in determining how states carry out their responsibilities to these people. The changes in response to incentives have been impressive. They include shifting populations from one treatment context to another; discouraging the use of states as direct providers of service; encouraging managed behavioral health approaches; redirecting state funds from other efforts in mental health care to their use as the required state Medicaid match; and accelerating the use of psychotropic medications, a large and growing component of Medicaid mental health expenditures.
The system has grown and changed in many ways, but services for the relatively small subgroup of the most seriously impaired patients remain poor in many ways. Such patients are now as likely to be found in prisons as in mental health clinics and hospitals. Their care, as the President's New Freedom Commission on Mental Health has noted, is fragmented and in disarray. Mental health advocates applaud the growing movement toward parity with insurance coverage for general medical care, but parity is hardly enough for patients with profound needs. As Frank and Glied recognize, these patients require a wide array of services that are fundamental for a decent quality of life: housing, adequate subsistence, and protection from victimization. Efforts to provide such services not only have failed to meet the challenge but are continually threatened. The quality of care remains poor, care is typically not evidence-based, and large socioeconomic and racial disparities remain. Unfortunately, most of the aggregate data documenting changing patterns of care indicate little about its quality. In concluding their analysis, however, Frank and Glied are on the mark, noting that mental health services are more abundant and used by more of the population than ever before and that the available technologies have improved, but that the system remains in need of significant repair. This book offers many insights beneficial to the informed reader.
David Mechanic, Ph.D.
Rutgers University
New Brunswick, NJ 08901
mechanic@rci.rutgers.edu(By Richard G. Frank and S)