Who will pay for involuntary civil commitment under capitated managed care? An emerging dilemma

Involuntary civil commitment in managed care settings may create conflicts between providers and payers. Providers may determine that a patient, particularly one who presents a risk to self or others, must be confined beyond the period reimbursed by the payer. Court decisions have upheld clinicians' ethical obligations to provide care in these situations. In addition, civil commitment may be used to shift costs of long-term care to another provider. The author explores these issues and suggests six strategies that providers can use to address them. They include avoiding negotiations with payers over individual patients' care by ensuring that contracts with payers address civil commitment and patients at risk of harming themselves or others, identifying and creating services and social supports to reduce the necessity for commitment and allowing creative use of benefits, adopting formal risk assessment protocols to standardize the process for all patients and and clinicians, conducting research on the use of civil commitment and coercion in managed care settings, ensuring that incentives do not exist in states' Medicaid managed care programs to use civil commitment to shift costs, and holding discussions with treatment staff about the growing encroachment of financial considerations into treatment decisions.