care is potentially advantageous for certain populations, such as older people and minorities, which are less inclined toward use of specialty mental health care (US DHHS, 1999). Managed care’s potential pitfalls are poorer quality of care, denial of needed care, under-treatment, and disruption in the continuity of clinician–patient relationships (IOM, 1997; Mechanic, 1997).

The impact of managed care on mental health services has been profound in terms of costs: there is strong evidence that managed care has lowered the cost of mental health services (US DHHS, 1999). The study cited above by the Hay Group (1998) indicated that during the growth of managed care, there was a 50 percent reduction in the mental health portion of total health care costs paid by employer-based insurance. Whether these cost reductions have lowered access to, and quality of, mental health services for people who need them is a critical topic for research, but one for which answers have been elusive. Research has been stymied by the dramatic pace of change in the health care marketplace, the difficulty of obtaining proprietary claims data, and the lack of information systems tracking mental health quality or outcome measures (Fraser, 1997; US DHHS, 1999). Most concerns center on potentially poorer quality and outcomes of care from limited access to mental health specialists, reduced length of inpatient care, and reductions in intensity of outpatient mental health services (Mechanic, 1997; Mechanic, 1998). There are also concerns that more impaired populations and children will be adversely affected (US DHHS, 1999). The 1999 Surgeon General’s Report on Mental Health concluded that, while research is sparse, existing incentives in managed care did not encourage an emphasis on quality of mental health care (US DHHS, 1999).

The impact of managed care expressly on detection or treatment of suicide has been largely unstudied. The limited body of relevant research has focused on depression treatment, spotlighting problems in quality of care and outcomes. The first major studies of prepaid managed care versus traditional fee-for-service care found generally no overall differences in outcome, but poorer outcomes for patients with the most severe mental illness (Lurie et al., 1992; Rogers et al., 1993). Later studies, focusing exclusively on primary care, found that less than 50 percent of depressed patients in staff-model health maintenance organizations received antidepressant medication that met practice guidelines (Katon et al., 1995; Simon et al., 1996b). One of few managed care studies to have addressed suicide, at least tangentially, was of 1204 outpatients with depression receiving care from seven managed care organizations of varying organizational structures (Wells et al., 1999). Using patient questionnaires, the study found that about 48–60 percent of patients with depressive disorder received some sort of mental health care. Only 35–42 percent of depressed



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