In the May/June Health Affairs, Julie Donohue asserts that the structure of the Medicare Part D drug benefit creates incentives for health plans to underprescribe persistently used and expensive medications such as psychotropic drugs. Donohue promotes close monitoring of the use of pharmacy management tools by drug plans, as well as improving the Part D risk-adjustment mechanism. She also suggests that Medicare should share risk with plans for prospectively identified high-risk beneficiaries, such as those with schizophrenia and other serious mental disorders.

Thanks to factors such as the spread of managed mental health care, new treatment technologies, and a growing supply of providers, the proportion of the gross domestic product spent on mental health care has been essentially stable over the last thirty years, Richard Frank and Sherry Glied report in the May/June Health Affairs. The authors say that dramatic shifts in the sources of financing for mental health care - toward public and private third-party payers and away from state mental health authorities - have spread costs more widely but led to the fragmentation of responsibility for people with mental illness.

Also in the May/June Health Affairs, Colleen Barry and coauthors conclude that mandating comprehensive parity between mental health insurance benefits and other medical benefits would have little impact on total spending. Cost control techniques associated with managed care give health plans alternatives to discriminatory coverage for containing costs, the authors say, but they warn that this can be a double-edged sword: "Parity in benefit structures means little if alcohol, drug, and mental health care is managed more stringently than other types of health care."