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84 monopolies Don’t Work “Tom” Tom was a young psychologist who also had business savvy, having completed an MBA and having worked for a large mental health care service provider. He saw the need for a new approach to treating serious mental illness, based on providing in-home and community services rather than always expecting the patient to come in for weekly visits. Research had demonstrated the effectiveness of “home- and community-based care” (e.g., Drake 1998) for those who do not respond well to traditional treatment—especially homeless people with serious mental illness. Living in a large metropolitan area with a huge homeless population, Tom was sure that a new approach to treatment would help many successfully get off the streets and back into their home communities and that it could be done in a profitable manner for reasonable cost. So he contacted the Department of Mental Health, was referred to the contracting division, and began a long and tortuous process that eventually sapped his desire to do business with the state. The forms sent to him (by e-mail attachment or to be downloaded from various state Web sites) seemed endless and contradictory. He would spend a lot of time drafting a business plan, budget, and services presentation to meet state criteria, only to find that those criteria had shifted because of new agency regulations. Finally he completed an application packet for a specific “Request for Proposal” (RFP) that seemed to fit his vision, only to find that the window for applications had closed earlier than expected.7 He called or met with dozens of department employees searching for someone who would support his desire to offer innovative, state-of-the-art services for people who were homeless and mentally ill. Instead, he found many tired voices whose primary interest seemed to be to explain the state’s procedures and to avoid the headache of anything that challenged the status quo. Eventually, Tom gave up. He continued to work as a mental health provider but regretted not being allowed the opportunity to offer a new approach to care that could have made such a difference in the lives of those with serious mental illness. monopolies Don’t Work 85 What would help? Streamlined contracting processes designed not to discourage innovation but to support creative new ideas for helping persons with serious mental illness recover their ability to live successfully in their home community. Department success should be measured not simply by how much funding the state provides, or how many contracts are let, but more importantly by how effective their programs are in bringing recovery to those who come in need. For that to happen, innovation must be welcomed as a friend, not shunned as a threat. In both the public and private sectors of mental health care, this requires visionary leadership. If the CEO, or commissioner, has a vision for providing innovative and effective evidence-based community services, it can happen. Dynamic leadership can provide the imperative that current market forces lack to change structures so that creative entrepreneurs can enter and exit the market as needed. When that happens, innovative and entrepreneurial clinicians will step forward with new treatments and services for persons with serious mental illness. Those clinicians who provide high-quality creative care will be rewarded with an ever-growing market share. Those who don’t will find their dwindling market share forcing them to either improve services or cease current efforts and move on to other opportunities. Avoidance of monopoly There must be an option for competitive mental health providers to enter the market and offer similar services at lower cost and/or higher rate of effectiveness . This is of course the key point of a nonmonopolistic market— that several providers can openly and fairly compete for the same customers . By so doing, market forces help ensure that services as effective and efficient as possible. A strong message must be given to all involved in the mental health care delivery system that monopolistic behavior will not be tolerated. There must be legal risk, both in the public sector and in the private sector, for those who would unfairly hinder the competition so as to protect market share or maximize profits. Antitrust laws must be enforced. According to Haas-Wilson (2003), the enforcement of antitrust laws must be carefully managed. She notes that antitrust enforcement must not be either too vigorous or too lenient. Ironically, either extreme has the same result—fewer...

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