Jerome Lance, M.D., medical director of quality management at the Ventura County, Calif., Behavioral Health Department, has received the Profile of Courage Award from the APA Assembly for his attempts to correct what he perceived as serious deficiencies in his department.

He received the award when the Assembly met in Washington, D.C., in November.

While working as an outpatient physician at the Ventura County Behavioral Health Department, Lance noticed important lapses in the quality of patient care—namely, that medical decisions and clinical direction were being determined by nonphysicians. He attempted to educate the clinic’s treatment team regarding his concerns. However, due to the team’s viewing the determination of "medical necessity" as a participatory decision-making process in which the physician was only one vote among the others, rather than as the physician’s sole purview, his concerns were ignored or ridiculed.

As if that was not upsetting enough for Lance, he learned of billing irregularities in the department as well—for example, psychiatrists’ special provider identification numbers being used where psychiatrists had no oversight over treatment or had perhaps not even seen the patients in question. He and colleagues attempted to inform department administrators of the peril the department faced. But to no avail. Finally Lance filed a lawsuit to protect psychiatrists on staff from the consequences of a probable federal audit. The lawsuit led to a federal investigation. The investigation confirmed billing irregularities, mismanagement, and lack of medical oversight. During this time, Lance’s trashcan was searched, and death hreats were left on his car, he told Psychiatric News.

Nonetheless, the investigation findings resulted in a fine of $15 million against Ventura County and the imposition of an integrity agreement and code of conduct on the department.

In a letter recommending Lance for a Profile of Courage Award, Timothy Tice, M.D., a Ventura County psychiatrist, wrote: "It is uncommon in our experience to meet persons with the character to speak up in thoughtful opposition to the majority, especially when personal risk is involved. It is rare to meet an individual with the courage and commitment of Jerome Lance, M.D., who has made considerable personal sacrifices, over an extended period of time, in an effort to improve and protect the lives of patients. Furthermore, it is remarkable to note that even after being a ‘whistleblower’ and enduring all the hardships he has, Dr. Lance has chosen to continue working for the system of care that he exposed."

Back in 1998, Ventura County voted to merge the Ventura County Behavioral Health Department and Welfare Services into a Human Services Agency, which was managed by social workers. Some psychiatrists, consumers, and two county supervisors expressed their concerns that this merger was not in the best interests of the mentally ill.

Did this merger contribute to the problems that Lance subsequently encountered and attempted to fix? "Without question," he said in an interview. "Because what happened was, in order to do this merger, they had to deal with the problem of the county hospital license, so they got into complex licensure issues that brought HCFA [Health Care Financing Administration] in. And once HCFA came in, HCFA was looking at everything, and so it was just a matter of time before the billing problems [which dated back to 1992] would have been exposed."

When Psychiatric News asked Lance what one of the most difficult aspects of being a whistleblower in his department had been, he replied: "The whole thing was kept under federal seal for a year, so that I couldn’t say anything. The seal was a great protection for the investigation, but it also made it difficult to change things that you knew needed to be changed because you couldn’t really say, well, ‘This is being looked into and it will change, so let’s get on with it.’ One had to wait until things unfolded at their own pace."

Have things improved at the department because of his efforts and the investigation? Indeed, Lance replied. "It has been remedicalized. We have, I think, a very fine master treatment plan."

Finally, is there a lesson for other psychiatrists in what he endured? Absolutely, Lance answered. "My word of encouragement, or counsel, or caution to all psychiatrists is to protect [the physician’s sole right to determine] ‘medical necessity.’ It is their intellectual product, it is their copyright, so to speak."