Managed care and the discharge dilemma

Efforts at cost containment in medicine and psychiatry are ubiquitous. The escalating costs of health care have led to a variety of initiatives to manage the use of expensive settings and treatments. Cost containment aims to be cost efficient. When it is applied to the treatment of the severely mentally ill, clinical and ethical dilemmas intensify. Access to health insurance is more restricted for the mentally ill (Sharfstein et al. 1984). The benefits that are available are rationed by "fourth party" case managers, independent operators who make money by selling "third party" insurance companies the services of reviewing ongoing care in such a way as to contain costs and conserve resources. Most often this involves pressure to develop discharge plans and to move patients from the expensive inpatient to the less expensive outpatient setting as soon as it is safe and feasible (Melnick and Lyter 1987). For some patients, however, as illustrated below, this proves to be a most formidable task.