The current third-party fee-for-service mode of reimbursement for mental health services emphasizes individual, pathology-oriented intervention and thus has disadvantages for clients and carriers. This article focuses on the mode's effects on outpatient services for children, youth, and families. It examines the ways in which common payment modes seriously limit services and create an incentive for psychologists to take a narrow, often nonempirical, perspective. Suggestions that allow for multisystem, ecological skill building hinge on building relationships between psychologists and the carriers. Desired results take two forms: modification of contingencies between providers and carriers and modification of contingency between insured and carrier. Examples of each are presented.
That community programs have been sharply reduced in recent years needs no emphasis. In roughly the same time period, psychologists have obtained and consolidated independent access to third-party insurers. These two factors have resulted in a substantial shift toward treatment approaches based on pathology in the individual and away from multisystem and ecological approaches.
So prevalent is the third-party fee-for-service (3FS) mechanism that a study of the current mental health delivery system must include an examination of the role, effects, and needs of the fiscal intermediaries, the 3FS carriers. Incentives currently offered to providers suggest dangerous trends in the service network. However, new possibilities open up when the carriers are added to the picture of the service network or service ecosystem as legitimate and responsive members. Dialogue with carriers can promote multisystem, ecological, skill-based, and other nonpathological approaches and can thus result in more effective service at lower cost.
This article focuses in particular on outpatient services for children, youth, and families because of their major, unmet needs and low national priority (Edelman, 1981;Miller, 1983). After analysis of service-payment interaction, it concludes with suggestions for action.
Forming Guidelines for Good Children's Services
Special Characteristics of the Group
As a potential patient or client group, children have several special characteristics that must be taken into account in forming guidelines for good children's services. For example, children's problems always involve the concept of development. Their repertoires of skills, conflicts, emotions, etc. are moving targets, influenced by their physical background and constitution, their history, and their current environment. Some pathologies are particularly difficult to distinguish from developmental phases (Jones,