Community mental health and managed care (original) (raw)

1993, New Directions for Mental Health Services

The current and anticipated debate about health care reform in the United States is the most vigorous and sustained since the creation of Medicare and Medicaid. It is focused on the delivery and financing of health care and on the integration of such care into managed systems. Ironically, this movement toward managed health and mental health in both the public and private sectors is taking place during the thirtieth anniversary of the Community Mental Health Centers (CMHC) Construction Act of 1963. The original concepts embodied in the legislation emphasized a comprehensive, integrated, and coordinated system of mental health care, provided in the least restrictive environment. It is clear that today's proposed managed behavioral health systems incorporate many of the original features and elements of the CMHC movement. The social philosophy and values underlying the movement emphasized comprehensive community care through services for prevention, diagnosis, care, treatment, and rehabilitation. The 1960s context of social engineering was reflected in the core values of comprehensiveness, centralized services to meet all needs within a particular area, and the creation of a self-sustaining mental health system integrated over time with mainstream health care (Levy, 1986). Key elements of the original legislation included the delivery of five essential mental health services-inpatient care, outpatient care, partial hospitalization, twenty-four-hour emergency services, and consultation and education-to all without regard to age, race, religion, place of national origin, or diagnostic classification. It was the intent of Congress that CMHCs would become self-sufficient, and the federal grants were intended as seed money. Early planners believed NEW DIRECTIONS FOR MENTAL HEALTH SERVICES, no. 59, Fall 1993 0 Jossey-Bass Publishers 89 90 MANAGED MENTAL HEALTH CARE that while federally funded CMHCs would be required to provide a "reasonable volume" of free or reduced-cost care, fee-for-service insurance reimbursement and other third-party payments would provide a diversified funding base (Brown and Kane, 1963). It should be noted that this original design predated Medicare and Medicaid as well as the major increase in third-party indemnity coverage for behavioral health during the 1980s. While the problems of financing CMHCs dominated the decade of the 1970s, Congress in 1976 expanded the required number of core services from five to twelve, added requirements dealing with quality assurance and cultural sensitivity, expanded CMHC governance to more closely approximate the population in the area served, and instituted multiple reporting requirements. As a result, CMHCs by the mid 1980s were dramatically different from the original concept. These changes led to great variability among CMHCs, and they have essentially become community mental health organizations (CMHOs). Ironically, the CMHOs that pioneered many of the innovative, resourcesensitive, and clinically effective programs (such as partial hospitalization, psychosocial rehabilitation, home health care, and case management) now find that these have been adopted by private sector providers who compete with CMHOs for behavioral health benefit dollars.