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Behav Healthc Tomorrow. 1998 Oct;7(5):32-8.

Dialogue. Prescription for problems? Capitating mental health drugs--the great debate.


With the issue of physician capitation far from being resolved, mental health drug capitation is understandably up for debate. Those who deem it essential point to the rising cost of mental health drugs and urge management techniques which they believe can hold the delicate balance between a plan's budgetary limitations and a patient's appropriate care. They suggest that with an objectively calculated capitation rate, based not on expenditure alone, but on a defined population and their care needs, providers will not have to choose between profitability and optimal care. But others, responding to increasing quality concerns under capitation, worry that the increasing use of formularies will preclude patients and their providers from ready access to newer, more effective medications. With advocates still striving for nationwide parity for mental health benefits, capitating medications is not likely to assuage their concerns. Driving the debate is the fact that new technology drugs are expensive and most health plans are unable to anticipate the funding of breakthrough pharmaceuticals. With the advent of marketing to consumers directly through television and print media, plans and providers are increasingly pressured to provide these medications. The recent clamor for Viagra is an excellent example of how quickly the word can spread. New mental health medications may be even more expensive and offer patients and their families greater effectiveness with far fewer side effects. Plans, providers, and patients are caught in the middle, each holding their distinct view of the problems and solutions. This issue's dialogue brings our readers a discussion of capitation of pharmaceuticals as a primary answer to the sharp rise in mental health drugs. Three points of view lay out the viability and cautions of developing formularies and systems that could keep costs under control while still providing patient access. Without question, the debate will continue as legislative and consumer pressure continues to focus on managed care's techniques for cost savings and patient management. More sophisticated systems, designed for increasingly integrated and complex treatment plans, are certain to be required in the future. However, decisions about how to develop practice guidelines and integrate formularies with expensive new pharmaceutical technology, must begin to take shape now.

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