As a consultant and educator for various stakeholders in the delivery of managed mental health services, I see confusion, skepticism and demoralization in the mental health professions about the direction health care is taking. Many doubt their ability to achieve the objective of the managed care mantra: Better care at less cost. To the clinician delivering care, it feels as if there is no stable ground to stand on, or, in the words of a 1960s female R & B group: "Nowhere to run to baby, nowhere to hide."
Our profession seems to be either frozen in fear or disorganized in struggle, not grounded and coordinated in response to the changes that are upon us. I described this "fight or flight" mentality in an early paper (Glazer 1992) and it still abounds in various locations across the country. A medical director of a regional Midwest managed mental health care company quipped, "Everyone is talking about improving quality, but they are really focusing only on cutting costs." In another venue, a former psychoanalyst who had taken a position as a medical director for a local program owned by a national managed mental health chain told me (apologetically), "If I were not in this job, the decisions would be made from a corporate, nonmedical perspective." Or how about the academic psychiatrist, a director of a prestigious residency program, who asked me, "What does managed care have to do with psychiatry?"
Physicians are talking about unionization (Adelson) while Harold Eist, M.D., immediate past president of the APA, previously rallied members with a call to remove the money launderers from the sacred temple of medicine. In this article, I want to suggest that the quality assurance model offers a viable alternative to the fight or flight response.
At least five factors need to be considered: market forces, government regulation, service delivery coordination (including oversight of clinical decision-making), benefits limitations, and consumer expectations. Within the rank and file of both APAs, it seems that the emphasis has been placed mainly on the political aspects of these factors rather than the science. Our guild organizations are suing for restraint of trade, teaching the membership to develop managed care- oriented clinical practices and lobbying for legislation against managed care. Meanwhile, practicing clinicians, on smaller and larger levels, are struggling to get into the fight for the mental health care dollar that has been (sadly) dominated by hospitals and insurance companies. But where is the substance in all of this? Where is the effort to insure that the newly emerging structures will be any better than the ones they seem to be replacing? Where is the assurance of quality?
Early efforts to set standards and drive assurance of quality exist. Of course, the Joint Commission on Accreditation of Health Care Organizations has pushed for the use of the quality improvement process in mental health care facilities for years.
The American Psychiatric Association and the American Academy of Child and Adolescent Psychiatry have issued practice guidelines by diagnostic categories. These will only serve as a sketchy overview, a clinical road map that will steer but not pinpoint standard treatments for mental disorders.
The Agency for Health Care Policy and Research (AHCPR) issued an excellent "pathway" guideline for primary care physicians to follow in the treatment of depressive disorders. The National Committee for Quality Assurance's HEDIS 3.0 standards, which apply to care covered under commercial insurance policies, includes a few specific standards pertinent to mental health, e.g., continuation therapy for depression. The American Managed Behavioral Healthcare Association's (AMBHA) performance measurement tool called "PERMS 1.0" was introduced in September 1995 and has been under study ever since. Thirteen managed behavioral health care companies participated in the first phase of development, and as of this writing it appears that they need to refine their data collection process and work on a consensus in the face of one large carve-out company having dropped out of the process (they are returning!).
The Center for Mental Health Services report card has target outcomes for seriously mentally ill populations, but has yet to publish success in promoting the consumerism process. The National Alliance of the Mentally Ill's report card surveyed consumers, families and managed care organizations on practice guidelines and access to community services. Recently, they issued a scathing report calling for reform in the service delivery practices of the major psychiatric carve-out companies, including, CMG Health, Green Spring Health Services, Merit Behavioral Healthcare Corp., Options Health Care Inc., Pacificare Behavioral Health Inc., United Behavioral Health Care, Value Behavioral Health and others.
One of the main deficiencies they noted was the absence of efforts by these companies to measure outcomes. AMBHA's response (most of the managed care companies surveyed are members of AMBHA) was to suggest that NAMI was making a political statement and should have entered into a dialogue about the findings prior to going public about them (Mental Health Weekly). This response seems defensive and is notably lacking in a public statement of a willingness to engage in a dialogue with NAMI in response to the report-an example of a "fight" response at its best.
To date, there is no single set of guidelines, no source, that is considered authoritative or comprehensive for the mental health profession. There is little evidence of collaboration among the stakeholders to develop such guidelines, and self-interest is a common and predominant theme in responses to efforts to date.
These efforts at defining appropriate treatments and setting standards of care are important, and will lead to clear standards and practice guidelines, but we need much more, and we need it soon. In spite of the early efforts described above, it appears to this observer that psychiatrists and other mental health practitioners prefer to fight for political position, argue with utilization reviewers, compete for administrative alliances, complain about the loss of our autonomy and struggle for financial stability (all important objectives) rather than own and forge a new clinical culture that embraces the quality assurance process. Yet, it is in this quality assurance process that the safety and stability of our profession ultimately lies.
Why is there such a lack of effort by mental health practitioners to incorporate clinical scales and tools to measure outcomes of treatment at the practice level? There are user-friendly tools out there (Sederer and Dickey). If we do not measure the impact of our treatments (a flight response) can we expect to be trusted and believed in the health care climate that we are in? I do not think so.
Where is the implementation of decision-support technology that is emerging in many areas of medicine? Decision support tools ground clinical decision-making within a scientific context. They do not drive or dictate decisions (Glazer and Gray), but rather place them within an objective and standardized context from which outcomes can be calculated, and decision-making can be refined.
Why have practitioners embraced practice software that accurately supports scheduling and claims data but fails to incorporate clinical measures that would allow for a clear and quantified description of case mix, outcomes, costs per patient per time and so forth? If we don't collect the data, we will not be able to report it in a way that will make us competitive. And when that happens, we are rendered ineffective when questioned or criticized. Why is it rare to see competition for mental health care contracts based on clinical and cost outcomes rather than political and pricing structures? In these areas, we are actively engaged in one huge flight response. Without such efforts to account for the effectiveness of selected treatments and to justify clinical decisions, we abdicate our professional dominance to benefits managers, accountants, attorneys and politicians. Why are we so weak in responding to these initiatives? Fear: the driving force of the fight-or-flight response. What is the basis of this fear? Is it competition? A sense of being "de-skilled," where our long-held assumptions have been discarded and replaced by other assumptions that many don't fully understand? There is adequate basis for fear, but also opportunities to overcome and strengthen our position in this emerging health care climate.
Recently, I described my concept of the "ideal" system of care for our patients (Glazer 1996) (Figure). This description helps to delineate the role of the individual practitioner in the measurement of mental health outcomes. The figure exhibits the system, with "inputs," i.e., treatments, from the program to the patient and "outputs" measured as clinical and economic outcomes. The information from these outcomes should inform the "controls" for the system, e.g., benefit design, network administration, program evaluation, formulary and so forth. These controls should, in turn, improve the programs and, it is hoped, subsequent patient outcomes.
Of course, this system reflects the "total quality improvement" process that we strive for, but in reality is rare. The major obstacles to attaining this ideal system include the absence of comprehensive, real-time data management systems, and the lack of administrative incentive (or culture) to consider the overall system. Practitioners should assess the degree to which they associate with programs that move toward this format. I predict that within the next five years an individual clinician's success will rest on the degree to which he or she has connected to a system of care that best approximates the one in the figure. While awaiting the emergence of such systems, practicing clinicians, whether on salary or not, can install and implement the necessary bridging technology, e.g., clinical data management systems and clinical rating scales to prepare for this inevitability.
It is time to clarify our strengths and our directions in this managed care environment. We should participate in the political and financial battles led by our guild organizations. But as individual practitioners, we must understand and come to terms with our fears, which have promoted the flight-or-fight response. In so doing, we take the necessary steps to be accountable for the treatments we deliver. We must overcome our fear of measuring treatment outcomes in our patients. We must recognize the value of sharing outcomes with responsible sources that organize the data and help define best practices for our patients' conditions. We must master the anxiety over collaboration with colleagues irrespective of degree or training. Failure to do so guarantees that we will be no stronger than we were before the managed care movement began.