By Anil Godbole, M.D.

The APA elections have just been held. Psychiatric News publishes candidates' position statements, and each year I allocate a whole day to reading and sorting out the directions and themes emphasized by the aspiring leaders.

This year I was dismayed to note that although psychiatry has moved significantly toward a biological orientation, politically we still haven't identified ourselves as an integral part of mainstream medicine. Although there were comments by several candidates about collaboration with medical colleagues and organizations, it certainly was not a priority.

The choice of leadership should not be based on who can reach the highest decibel in their attack on managed care, but on who can also articulate and pave the way for an alternate practical, humane, and caring vision of care.

Managed care threatens to further the divisions that exist within our ranks. It separates us from our other medical colleagues. The large national carveout companies are redefining our roles to be simple medication dispensers. Breakthroughs in psychopharmacology will lead to the introduction of safer psychotropics, increasing ease of administration, and requiring minimal monitoring, which will probably lead the behavioral managed care companies to encourage or require primary care physicians to take over responsibility for patient care after psychiatrists evaluate and stabilize a patient.

We are fast losing ground in the area of psychotherapy privileges within managed care settings. The splitting of these two most important interventions, namely medication management and psychotherapy, has been the most damaging consequence of behavioral managed care.

Some experts predict that in the not-too-distant future providers such as doctors, therapists, and hospitals will develop organized systems of care and learn to manage risk, both clinical and financial, by developing rigorous scientific treatment protocols correlated with outcomes and by using information technology to improve access, early detection, and education. APA President Harold Eist has worked tirelessly to raise questions about the current model of managed care and has attempted to forge a coalition of providers and consumer advocacy groups.

A chasm continues to grow separating physicians violently opposed to any kind of managed care from those who either have embraced it or at least reluctantly accepted it.

It is only recently, as a result of payer and consumer demand and a backlash from organized provider groups, that managed care leaders have begun to pay attention to quality standards. While recent public scrutiny prompted by the consumer advocacy groups and the media has led to questions about the ethics of the managed care companies and their modus operandi, it appears that for the health field as a whole, some form of managed care will remain with us for quite a while.

In light of this reality, if we are to be forceful proponents for mental illness parity on the basis that these disorders are legitimate medical illnesses and can be diagnosed and treated effectively in a predictable scientific way, we must make every effort to integrate behavioral health services with general health services. We cannot have it both ways, saying on one hand that mental illness is similar to medical illness but then on the other hand participating willingly in a separate delivery system like carveouts for the mentally ill.

Several challenges confront psychiatrists--to convince decision makers about the justice of and necessity for parity; to demand that behavioral health care be integrated with general health care; and to convince our medical colleagues to allocate a large share of health-care dollars to behavioral health on the basis that it reduces the overall cost of medical care, reduces disability, and improves patient compliance.

A large number of medical disorders are caused or perpetuated by risk-based behaviors. Our profession, by working with general physicians, can have a major impact on the management of medical illness and reduction of the high cost of treating them. We caregivers must organize to develop health care delivery systems for both insured and public-sector patients that are cost-effective, accessible, and outcome-driven and provide a full continuum of services.

The concept of provider-sponsored networks assuming full risk-bearing responsibility for defined populations is being supported by the AMA. We should heartily join in such an effort and bring decision-making authority and commensurate responsibility back within our own organized medical systems.

APA leaders should undertake a massive education program to inform members about issues such as health financing, delivery system models, provider networks, quality-outcomes standards, and consumer-payer expectations. The managed care seminars arranged by APA around the country as well as the publication of "Psychiatric Practice and Managed Care" are worthwhile efforts, and we need to build on them.

It may sound heretical, but I would even suggest that APA invite the national managed care companies to cosponsor free workshops and symposia, some of them run concurrently with our annual meeting, on topics such as ethics and confidentiality, network development, medical necessity criteria, treatment algorithms, provider profiling, and outcome measures. The pharmaceutical companies routinely organize such free educational programs in conjunction with our annual meetings. Instead of investing our time and energy on frontal attacks on managed care, we would be better off maintaining our focus fighting for three basic principles--parity, integration with general medical care, and allocation of a larger portion of premium dollars to mental health.

Our medical colleagues are fast organizing themselves in groups, fostering alliances with hospitals and other health care entities, and developing managed care capabilities. We need to do the same, first within psychiatry, and then in conjunction with other physicians to provide a comprehensive health package.

There are things we can learn from managed care, particularly regarding access, information systems, marketing, provider and facilities linkage, and accountability to payers and patients. I am by no means suggesting a surrender or even a truce with managed care, but merely recommending a redirection of our energies. This is also not meant to be a diatribe against managed care, but instead an attempt to point out that the current way we relate to it is grossly dysfunctional, and that as physicians we must step up to the plate and accept the challenge. I am calling on our newly elected leader to lead the way.

Dr. Godbole is medical director of behavioral health services at Ravenswood Hospital Medical Center in Chicago and a clinical associate professor of psychiatry at the University of Illinois.

(Psychiatric News, April 4, 1997)