The new economics of medicine: special challenges for psychiatry

The ongoing economic overhaul of medicine creates two basic imperatives--boosting profits and containing costs--that pose special ethical and philosophical challenges for psychiatry. Because insurance coverage still favors inpatient care, pressures to raise revenues translate into a corresponding pressure on psychiatry as a whole to expand its diagnostic categories, and on individual psychiatrists to ascribe these diagnoses liberally and to hospitalize as many patients as possible. Reciprocally, cost containment requires all physicians to justify their care as clearly as possible and to eliminate those interventions that are not of demonstrable value. Scientific outcome studies are markedly more difficult in psychiatry than elsewhere in medicine, particularly for psychotherapeutic as opposed to pharmacologic modes of care. An emphasis on biological over psychological conceptions of mental illness and treatment might result, not because it is more likely to be correct, but because it is easier to document in conventional ways and less expensive to deliver. An economics-driven reorganization of psychiatry therefore poses serious philosophical challenges, not only for the profession and its future, but for the clinical care of patients.