xx AACP Newsletter, Volume 13, Number 1, Winter 1999
Editor's Column: A Proactive Agenda for Public Community Psychiatry
By the time this gets to you, it will be 1999. We will be even further on into the waning moments of this tumultuous century and closer to our emergence into a new millenium. So these are fin d'siele musings. It seems a propitious time, albeit entirely socially constructed, to examine where public community psychiatry might go in the coming years. However, this is not an exercise in prognostication. There will be no predictions here. Rather, my intent is to draw out some trends and see where we might take then. With luck, others of you will see fit to offer other perspectives.
My point of departure is medicaid managed care. Without question, it constitutes the most profound change to the work of community psychiatrists since our modern origins with the creation of community mental health centers. I suppose it is only fitting that the millenium is occurring at this time, just to heighten the sense of potential cataclysm. As if the managed care revolution did not have enough gravity of its own!
Everyone is familiar with one of the manifestations of the managed care revolution, the intense attention to "the bottom line" and the growing limitations on financial resources. This has affected all of us, often not for the better, as processes are created to hold down expenditures. Much attention has already been paid to this issue and the ensuing controversies demonstrate no evidence of lessening in intensity. Concerns about quality of care and access to care will be issues of public community psychiatry for a good time to come. So will issues of payment to us for our services.
But these are "reactionary issues", meaning that they are reactions to managed care. They are not issues that capitalize on the change. I want to focus on a more proactive agenda, one that builds on the most significant change in health care policy engenderd by medicaid managed care. That is the much more explicit focus on population health, in this case the health of the medicaid population.
Some historians of community psychiatry may protest and claim that community psychiatry has a long tradition of focusing on population health, pointing to the gigantic state hospitals of yore and, more recently, the catchment areas of the community mental health centers. They would be right to some degree. But the prior populations and areas of concern were much more circumscribed. The psychiatrists in state hospitals have always been concerned with the population of mentally ill persons admitted to their institutions. Some community psychiatrists, in our more recent era of deinstitutionalization, have often focused on the same population living in the community. The limit of concern was and remains largely confined to this population's mental illness. The presense of addictions and this population's poor physical health, even recently, were largely ignored.
Other community psychiatrists, reflecting the ideology of the community mental health movement, have expressed a desire to address the mental health care needs of communities. But our system of health care finance conspired against this. Community mental health center catchment areas usually consisted of a mix of subpopulations with significant socioeconomic differences and differential access to the health care system. As a result, catchment area populations were often not socially coherent communities and catchment boundaries often fragmented coherent populations that crossed catchment area lines. The private mental health care market further fragmented the community, drawing off those who could pay. Community mental health centers therefore tended to focus on the public sector patients, who were unable to access the private mental health care market. But it did not focus on all of them, notably disregarding, until recently, those people with severe mental illness. In addition, within the community mental health movement, concern was frequently limited to mental health issues, frequently defined as not including drug and alcohol disorders. Links to the growing web of community social services, primary care medical services, and public health services were often minimal.
The advent of managed care medicaid has the potential to allow public community psychiatrists to develop a sharper yet more comprehensive focus on the medicaid population, (defined as impoverished persons, including uninsured persons, since there is a very rapidly revolving door between being uninsured and being on medicaid.) Confronted with the overlapping multiple health, behavioural health, and social service needs of the medicaid population, the fragmentation of services has been found to be highly inefficient in either improving the health status of the medicaid population or in reducing their associated costs. To compensate and overcome fragmentation, mental health care has been expanded to include drug and alcohol treatment services, and renamed behavioural health care. Catchment areas are being dismantled and a larger geographic scope is being substituted, one which incorporates the medicaid population in a region. Increasingly, medicaid behavioural health care services are being explicitly connected to the primary care system and the web of social services serving the medicaid population. In short, from a community psychiatry perspective, it is becoming apparent that for the overall success of medicaid managed health care, behavioural health care services must be fully integrated into the array of health and human services addressing the medicaid population.
It is important to realize there are clear subpopultions in the medicaid population, varying according to the type of eligibility (women and children receiving temporary aid for needy families, SSI recipients, the medically needy) and by sociodemographics (urban vs rural, minority status, gender, age). Each group faces particular issues in the current social environment (examples include welfare to work, schools and education, racism) Yet they are all defined by being impoverished and therefore tend to share many of the same social circumstances (distressed communities, inadequate public services, stigma, poverty). The task for public community psychiatry should be to help address the specific mental health needs of each subpopulation, while addressing their shared needs as well.
How can we be effective in this effort? There is clearly more to be said about this than the current space constraints allow, so I hope that this discussion can continue in a future edition. In the meantime, it is essential that we all think about this question. It may allow us to escape the reactive posture and to develop a truly proactive agenda for the coming millenium.
Kenneth S. Thompson, MD
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