ABSTRACT
After seeing the evidence in favor of MCHT and learning about various successful examples in different countries, readers may wish to try their hand at starting their own program; but, they will likely encounter many obstacles on the journey, such as the Valley of Faint-Hearted, Uninspired Planning and the Slough of Conflicting Values (to borrow from John Bunyan). “Why don’t the knuckleheads use common sense?” asks Gary B. Melton, who attempts to answer the question why innovative services have not become conventional…if an innovation is cheaper but more effective than current practices, why wouldn’t it be quickly and widely adopted? (Melton, 1997). He says policy makers are influenced by values that conflict with the innovative program, such as a desire to maintain institutional jobs, third-party payers not reimbursing policy holders, and a preoccupation with symbolic issues (e.g., focusing on who has the authority to decide about treatment.) Also, planning and implementation are inadequate in many ways. There is a failure to differentiate between individual and aggregate effects (the hue and cry that ensues from a few cases going sour obscures an aggregate benefit to the community as a whole). Although ideas underlying innovative service design are often simple, implementation is complex because of the ripple effect throughout the whole health care system. Demonstration programs are usually small scale and treatment flexibility cannot always be maintained as programs grow and become bureaucratized. Administrators have a desire for certainty and want additional replication of research on new service models even when the relevant research is already much stronger than for traditional institutional models. They are reluctant to take risks-con-ventional practices are the norm, and they don’t want to attract condemnation or civil liability. New treatment models require new money, usually from institutional programs, where the lion’s share of the budget
is. But downscaling facilities may not result in savings; costs of buildings are largely fixed (unless closed), and they are so overcrowded that merely giving adequate care to the remaining patients may consume any money saved. Of particular concern to managed care companies is that the availability of new, less restrictive programs may widen the net to serve patients previously not served by institutional services (Kwakwa, 1995).
