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Public and Private Responsibility for Mental Health Services

Authors:
Leonard Bickman at Vanderbilt University
Leonard Bickman
Paul R. Dokecki at Vanderbilt University
Paul R. Dokecki
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Abstract

Relative to public services, private sector corporate mental health care has significantly increased since the late 1960s. The many tensions encountered in assigning public and private responsibility for mental health service give rise to significant value-laden questions for psychologists. These questions go to the heart of community mental health, deinstitutionalization, mental health policy development and evaluation, and many other areas in which psychologists are playing major roles. The public-private issue should be understood historically, from the twin vantage points of developments in general medicine and in mental health. Among the many public interest and public policy matters psychologists and others concerned with mental health should address are the emergence of corporate chains; the nature, cost, and quality of private sector services; the compatibility of profit motivation and the motivation to provide care; and patient selection issues (e.g., cream-skimming). Public and private cooperation and planning are certainly in order if the public interest is to be served in addressing the nation's mental health problems.
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... Kiesler and Simpkins (1991) documented increases in inpatient care in private psychiatric hospitals and in general hospital psychiatric units and psychiatric services between 1980 and 1985. The increased role of private-sector corporate mental health care is perhaps the most important theme of the 1980s (Bickman & Dokecki, 1989). Moreover, privatization of mental health services reflects a general societal trend toward privatization of traditionally governmental programs (Simons, 1989). ...
... As a cost control measure, we predict that the debate on rationing health care will intensify (Schneider & Guralnick, 1990). Functionally, a market economy already effects an implicit rationing for those who have no means of payment (Aaron & Schwartz, 1990;Bickman & Dokecki, 1989). More explicitly, health care rationing in the form of limiting Medicaid to a predetermined spending level per capita, with predefined priorities attached to different services, especially expensive life-extending technologies, is an emerging reality in Oregon (Brown, 1991;Fox & Leichter, 1991). ...
... Although Bickman and Dokecki (1989) speculated that the alternating cycle of public and private responsibility may presage "a burst of public purpose" (p. 1133) in the 1990s, we are more inclined to predict fiscal policies that continue to rely on the private sector. ...
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  • Jun 1992
Trends in mental health services for older adults during the past decade were used to predict salient issues for the current decade. These include overreliance on inpatient treatment, increased use of general hospitals as treatment sites, inadequate integration with the nursing-home industry, and insufficient mental health referrals from general medical providers. In the decade ahead, the mental health needs of older adults are unlikely to be an identified focus; rather the issues will overlap with other priorities (e.g., biomedical research on brain functioning, alternative treatment programs for the chronically mentally ill, and containing health care costs). Advocates for the elderly will be successful to the extent that they cast aging services within the context of these other concerns.
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... 33 As noted in previous research, registration patterns can also be the result of risk selection behaviour among providers, for instance, in the form of targeted advertising, language competence among the staff or the physical accessibility of care facilities. 14 In the present study, we investigate whether there is any empirical evidence that risk selection behaviour occurs in Swedish primary care. This is done by assessing if there are any socioeconomic differences between patients registered with private and public PHCCs. ...
Risk selection in primary care: A cross-sectional fixed effect analysis of Swedish individual data
Article
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  • Oct 2018
Objective To assess socioeconomic differences between patients registered with private and public primary healthcare centres. Design Population-based cross-sectional study controlling for municipality and household. Setting Swedish population-based socioeconomic data collected from Statistics Sweden linked with individual registration data from all 21 Swedish regions. Participants All individuals residing in Sweden on 31 December 2015 (n=9 851 017) were included in the study. Primary outcome measures Registration with private versus public primary healthcare centres. Results After controlling for municipality and household, individuals with higher socioeconomic status were more likely to be registered with a private primary healthcare provider. Individuals in the highest income quantile were 4.9 percentage points (13.7%) more likely to be registered with a private primary healthcare provider compared with individuals in the lowest income quantile. Individuals with 1–3 years of higher education were 4.7 percentage points more likely to be registered with a private primary healthcare provider compared with those with an incomplete primary education. Conclusions The results show that there are notable differences in registration patterns, indicating a skewed distribution of patients and health risks between private and public primary healthcare providers. This suggests that risk selection behaviour occurs in the reformed Swedish primary healthcare system, foremost through location patterns.
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... The number of private psychiatric hospitals in the United States increased from 180 to 250 between 1970 and 1985, and the number of psychiatric beds owned and operated by private hospital chains increased by about 15% in 1984 (Sullivan, Flynn, & Lewin, 1987). Bickman and Dokecki (1989), in an excellent summary of cyclical trends affecting the balance of private and public responsibilities for mental health services, described the increase in concentration of ownership of psychiatric hospitals by private chains. Currently, only four corporations own 59% of all private for-profit hospitals. ...
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Public and private responsibility for mental health services.
Article
  • Aug 1989
Relative to public services, private sector corporate mental health care has significantly increased since the late 1960s. The many tensions encountered in assigning public and private responsibility for mental health services give rise to significant value-laden questions for psychologists. These questions go to the heart of community mental health, deinstitutionalization, mental health policy development and evaluation, and many other areas in which psychologists are playing major roles. The public–private issue should be understood historically, from the twin vantage points of developments in general medicine and in mental health. Among the many public interest and public policy matters psychologists and others concerned with mental health should address are the emergence of corporate chains; the nature, cost, and quality of private sector services; the compatibility of profit motivation and the motivation to provide care; and patient selection issues (e.g., cream-skimming). Public and private cooperation and planning are certainly in order if the public interest is to be served in addressing the nation's mental health problems.
View
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Ownership and Mental Health Services: A Reappraisal of the Shift Toward Privately Owned Facilities
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The mental-health system in the United States is undergoing marked "privatization"--a growth in the importance of both private nonprofit and for-profit providers. Analyzing data collected in earlier surveys, we found that the type of ownership was linked to a number of important aspects of institutional performance: (1) private facilities, both for profit and not-for-profit, are more likely to screen out nonpaying patients than are government-owned providers; (2) services provided under public auspices are more expensive than those provided in private institutions; and (3) compared with private nonprofit facilities, for-profit providers devote fewer staff resources to patient care and offer fewer services with community-wide benefits. We conclude that ownership affects the organizational behavior of mental-health facilities. The contemporary shift from public to private provision of mental-health care raises important questions about ensuring adequate access to care, maintaining the supply of needed services, and adapting systems of reimbursement and regulation to the heterogeneous motivations of providers operating under different forms of ownership.
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