egies are altering the organization and delivery of private- and public-sector services.

Currently, the vast majority of individuals who have health insurance also have some coverage for behavioral health treatment (see Chapter 1). As has already been discussed, a substantial number of people with behavioral health disorders—especially those with less acute or disabling conditions—receive some care from their primary care practitioners.

Although most private health plans provide some coverage for care of behavioral health problems, most of these plans and Medicare have coverage limits that tend to be more restrictive than the coverage limits for treatment of physical illnesses. Annual limits on the number of outpatient visits and inpatient hospital days are common (IOM, 1993). Other limits in insurance coverage (low lifetime coverage caps, restricted benefits, higher coinsurance) mean that most private health care coverage does not offer protection against catastrophic mental or addictive disorders.

In thinking about health care in general, the special problems faced by uninsured individuals are usually recognized. Behavioral health care faces a distinct problem: in addition to the substantial population of uninsured individuals, who by definition have no coverage for specialty care, the limits described above create gaps in coverage for the privately insured. This is where the public sector comes in. Since the establishment of asylums for the treatment of mental illness in the 19th century, the public system has specialized in the care and support of indigent individuals with the most serious and protracted conditions. In fact, it can be argued that the existence of this public safety net has mitigated against improvements in private coverage.

Individuals who have severe mental illness thus are a group with special needs under managed care, and advocates have identified specific concerns about how well those needs will be met. Less frequently identified as having special needs are those individuals who do not have severe mental illness but who have severe personality disorders or post-traumatic stress disorder. These patients often use extensive treatment resources with little clear improvement. If private coverage for these patients is limited, they may leave the prepaid system or pay out of pocket for their treatment. They do not usually qualify for public-sector services, but they may need more than private coverage may provide.

The result of this counterproductive division of labor is that private coverage tends to be available for the time-limited and traditional treatments for behavioral health problems (e.g., benefits for limited inpatient treatment and limited

FRONT MATTER (R1-R24)

SUMMARY (1-14)

INTRODUCTION (15-39)

TRENDS IN MANAGED CARE (40-75)

CHALLENGES IN DELIVERY OF BEHAVIORAL HEALTH CARE (76-121)

STRUCTURE (122-167)

ACCESS (168-183)

PROCESS (184-225)

OUTCOMES (226-240)

FINDINGS AND RECOMMENDATIONS (241-254)

GLOSSARY (255-260)

APPENDIX A (261-270)

APPENDIX B (271-311)

APPENDIX C (312-335)

APPENDIX D (336-348)

APPENDIX E (349-354)

APPENDIX F (355-356)

INDEX (357-370)