By Craig W. Maumus, M.D.

Much has been written about the perceived evils of what is going on in our health care market and how we should fight many of the changes taking place. Less has been written about trying to understand and deal with all these changes. Two recent articles in district branch newsletters, however, seem to grapple with just this challenge.

In his president's column titled "A View from the Sea" in the August Central California Psychiatric Society Newsletter (Sam A. Castro, M.D., editor), CCPS President Allen R. Doran, M.D., explores these issues.

"We are definitely at a juncture in medicine. The decision about the juncture and where to go, however, has already been made. Many of us feel aloof and are wondering: 'just another problem to deal with, managed care,' and we go into our often used, albeit comforting, delayed gratification modes. Let's 'see what tomorrow brings,' or 'how long can I survive until retirement,' or 'why belong to CCPS; it can't help anyway.' "

Dr. Doran explains that he has problems with these modes of thinking. "I chose medicine, and finally psychiatry, because I really do want to help people. I also want each of us to help each other and maintain a high level of care. That has been synonymous with the quality care I can provide regardless of reimbursement. The interesting part is that somewhere along the academic route I learned the value of the dollar and became fuzzy about what I was 'missing' and my true passions. I jumped into private practice with both arms and legs and ran as fast as I could, not realizing that the 'Golden Years,' which were sagely discussed by my older colleagues, had already passed.

"Now that I have regained consciousness, managed care doesn't fit in too well for me. People can see value without too much trouble, and private pay for many of my patients doesn't seem outrageous, even when they have managed mental health benefits. . . . I tolerate it because one of my passions is inpatient work. Give me a good diagnostic dilemma, interpretive dynamics, and a useful psychopharmacologic result, and I'm in heaven. . . ."

Dr. Doran points out that the good news is that psychiatrists "are in this together," and he emphasizes the need for all psychiatrists to be "strong advocates for autonomy and physician control."

"We are good at what we do," he writes. "Our love for medicine has in its roots a knowledge base that by definition is in constant motion.The transition of the business structure of medicine is but one aspect; this change must also incorporate the explosion in our biological understanding of the brain and behavior. I yearn for more time with my patients so that they can accurately and more completely tell their story, and I can understand their real feelings. I want to tell my patients the ever-expanding story of their brain and how it functions (truly biopsychosocial). It is only then, when I make this connection, that I am satisfied and reap the rewards of our noble profession."

Also wondering about this "transition of the business structure of medicine" is David Hellerstein, M.D., editor of the New York County District Branch Newsletter. In a front-page editorial in the summer issue titled "The Health Club and the Candy Store," he describes a recent conversation with a friend who owns a chain of health clubs and tells us how this helped him understand the system changes occurring in his psychiatric practice.

"I was telling him about my department's first efforts at dealing with capitated mental health contracts," Hellerstein explains. 'You know,' he said, interrupting me, 'You and I are in the same business.'

"The more I thought about it, the more I realized he was right. Since beginning as director of a psychiatric outpatient service a number of years ago, I had thought about the business side of my job as analogous to running a candy store. Basic old-fashioned capitalism: every time one of my clinicians or I see a patient, we get paid. It's like selling a product, say bars of candy; the more candy bars we sell, the more money we make.

"But now that my department was about to get our first capitated health contract, all the rules were changing. No longer would we receive a certain (small) amount of money per visit; instead we would be paid a certain (even smaller) amount of money per member per month, whether or not that member actually used our services! Just like my friend's health clubs, we were signing up members we might never see. Whereas in the old days our best customers were those we saw one or more times every week, now our 'profit,' like that of the health club, would depend on members we rarely see, but who renew their 'membership' year after year. . . .

"The biggest jolt in capitation is that 'them' is now becoming us. We have gotten accustomed to dealing with 'them'_bad-guy managed care reviewers and companies that have reviewed treatment. We have gotten to be good at arguing for more sessions, at advocating for each patient we treat. Now with capitation, 'they' are 'we'! Not only are we providing the treatment, but we are at risk (financially) if we prescribe too much for our patients as a population!...

"Basically, that is what we (and other clinicians) are struggling with each time we try to decide when to see a patient next. The problem is, society is now telling us to keep in mind that 'medically necessary' can be defined relative to more than one standard.

"Try explaining that to your PGY-3's!"

(Psychiatric News, October 18, 1996)