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Objective: To better understand the strengths and weaknesses of systems of services for seriously mentally ill individuals in Canada and the United States, the quality and cost of services in the province of British Columbia (population 3.2 million) were compared with those of services in the 50 states., Methods: A survey of selected psychiatric facilities, data from the Canadian Ministry of Health, and information from families and consumers were assessed using methods similar to those used in a 1990 survey that rated services for individuals with serious mental illness in the 50 states. Separate scores were given for hospitals, outpatient and community support services, rehabilitation services, housing, and children's services., Results: British Columbia scored higher than any single state in the United States and more than twice as high as 40 states on the quality of services for seriously mentally ill individuals. Compared with the states, British Columbia ranked ninth in cost of services per capita. When ratings of quality and cost were combined, British Columbia appeared to be delivering services almost twice as good as those in New York State at about half the cost. However, recent trends, such as shortages of inpatient beds and increasing numbers of seriously mentally ill persons among the homeless population, suggest that British Columbia's services may be deteriorating., Conclusions: Probable reasons for the superior services for seriously mentally ill individuals in British Columbia include single-source funding, a strong mandate to treat such individuals, and a comprehensive approach to providing services. The Canadian health system, as implemented in British Columbia, has definite advantages for individuals with serious mental illnesses.

In attempts to contain mental health costs, administrators are increasingly using incentives, competition, and accounting strategies and are creating more complicated financing systems. Yet the costs of these strategies and their impacts on the efficacy and efficiency of mental health services have yet to be studied. The authors compare mental health payment systems in British Columbia and Oregon. In the Canadian system, the patient is isolated from payment, sources of revenue are consolidated at the provincial level, only one payment mechanism per service type is used, health care documentation is oriented more to clinical needs than to reimbursement, and more discretion is delegated to providers. As a result, Canadian overhead costs are substantially less than those in the U.S. Patients have universal access to medical services in the Canadian system, and providers in hospitals, agencies, and individual practices have high incomes with low overhead costs.

As a result of deinstitutionalization, acute care beds in state hospitals have become blocked by patients who lack access to appropriate community placements but who have derived maximum benefit from hospital care. To help plan community services for these patients, this study identified and described patients at an Oregon state hospital who were hospitalized longer than therapeutically necessary because no community facility could treat them. A total of 146 patients were identified during a three-month period, and 81 were described; 65 percent were men, 70 percent were schizophrenic, and 90 percent presented a risk to themselves or others. The patients exhibited few strengths, and one-third had a substance abuse problem, at least one counter-therapeutic attitude, or a need for medical monitoring. The authors describe how new community residential facilities can meet the needs of these difficult patients.