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This is the first of a two-part series.
Psychiatry and APA are facing an array of complex and sometimes conflicting choices as psychiatrist-run carveouts become increasingly common.
In response to such concerns, APA President-elect Herbert Sacks, M.D., convened a conference with help from the APA Office of Economic Affairs last month at APA headquarters in Washington, D.C.
"If I am not for myself, who is for me? And when I am for myself, what am I? And if not now, when?" This ancient quote from Rabbi Hillel frames the quandary of psychiatrists in the era of managed care, observed participant Edward Gordon, M.D., chair of APA's Committee on Managed Care.
Although carveouts have been around for several years, only recently have they become a focus of member concern. This concern came to a head following a report last November in Psychiatric News about the role played by APA's Consultation Service in helping a group of psychiatrists, who call themselves PsychCare, land a contract in Connecticut to provide psychiatric services to more than 140,000 people on a capitated basis. The contract is estimated to be worth $25 million to $30 million. Sacks said he continues to get phone calls from members on the subject.
"The heat has not subsided in Connecticut," he said.
Conference participants sought responses to seven questions that Sacks posed prior to the conference and used the responses to guide the discussion.
Whatever the proliferation of subspecialties and the diversity of interests within psychiatry, APA continues to play a key role in serving the "core needs" of the psychiatric profession, observed APA Medical Director Melvin Sabshin, M.D. This is not the first time APA has faced issues involving factional competition within psychiatry, Sabshin noted. But APA has tried to serve the predominant needs of its members while being fair to those in the minority, he said.
In the United States, the marketplace usually has primacy, observed Sacks. But "medicine is no ordinary market," he noted, with its highly skilled workforce and its tremendous impact on the national economy.
The advent of psychiatric carveouts and independent practice associations (IPA's) has had "a divisive effect on members," said Sacks, with some members seeing APA's central office as sometimes in conflict with district branches.
"Managed care raises a set of very serious concerns," observed Yale economist Mark Schlesinger, Ph.D. Issues of quality of care, of patient interest, and of psychiatry's economic interests are all in play and in some ways may be in conflict, he contended. Whether a carveout is well run and skillfully staffed may be irrelevant if gatekeepers bar most patients from ever reaching the plan.
It is also possible that a plan providing patients with "exemplary" mental health services ascribes a relatively small role to psychiatrists and hence is not good for the economic interests of psychiatry, according to Schlesinger.
Psychiatrists have responded to managed care by creating their own, psychiatrist-run carveouts, he noted, with the assumption that such plans would be better for psychiatrists and their patients than plans run by business managers. But in many cases, said Schlesinger, the doctor-run IPA's "are in fact more intrusive on the clinical autonomy of physicians" than plans run by business managers.
APA faces problems regardless of whether it chooses to become more involved in evaluating and facilitating such plans, said Schlesinger. This view was repeatedly echoed throughout the conference.
Another issue involves the perception that may be created by physician-run, for-profit IPA's, said Schlesinger. Such plans "inalterably shift the way policymakers think about" medicine and may seriously erode the view of medicine as altruistic rather than merely another business driven by the profit motive.
Given such dangers, what roles might APA play?, Schlesinger asked. It could serve as "an early warning system," as a "fair-minded adjudicator," or as a liaison between member-run IPA's and state regulators, he suggested.
"To the extent that APA is seen as playing a broad quality-assurance role," it may avoid creating a perception among policymakers of being merely a guild driven by "narrow self-interest," he observed. In this context, APA might consider serving as an accrediting body for IPA's.
But Lawrence Kline, M.D., chair of APA's Council on Economic Affairs, expressed skepticism about the capacity of APA to sway the perception and approach of policymakers.
"I am very cynical," said Kline. Policymakers are focused mainly on how to achieve savings, and there is little APA can do to alter this focus, he asserted.
Schlesinger insisted, however, that it was critical that APA, and other professional associations, play an active role. The alternative, he warned, is to abdicate all influence to the raw economic forces now driving managed care. The perception by policymakers that APA is concerned with the public good, as well as the interests of its members, is crucial, he insisted.
Managed care need not be antithetical to high-quality psychiatric care, once the looming issue of insurance coverage is resolved, he said.
Area 2 Trustee Herbert Peyser, M.D., was not persuaded. "Strict economic determinism" survives, he asserted.
APA Division of Government Relations Director Jay Cutler, J.D., wondered whether there was any evidence suggesting that APA's acting as an accrediting body for carveouts would have any effect on which carveouts were selected by managed care plans.
Schlesinger said while he knew of no evidence in psychiatry, in other specialties 30 percent to 40 percent of carveouts are selected with input from state-accrediting bodies that assess plan quality. Since such bodies do not now exist to evaluate mental health carveouts, it is possible that an APA "seal of approval" could exert a significant impact on market selection, said Schlesinger.
But Kline said that "the market at this time appears to be interested only in price, not quality."
Some members have suggested that there be an APA-run IPA, but this would involve numerous daunting ethical and practical concerns, Kline noted. Most of the respondents to the questions posed prior to the conference expressed opposition to an APA-run IPA.
While the issues are complex, APA members "are not standing still" and will continue to forge agreements and alliances on their own as they struggle to survive financially in the changing market, Kline observed.
While the goal is to hammer out deals more favorable to psychiatry, the inevitable outcome in the short run will be to create winners and losers, observed Chester Schmidt, M.D., chair of APA's Work Group on Codes and Reimbursements. In Baltimore, where Schmidt works, the battle is now under way, he said, and the winners and losers should be clear within the next few years.
Both Schmidt and Kline pointed to recent state and federal legislation designed to remedy some of the more egregious aspects of managed care. These include a compromise measure to equalize aggregate annual and lifetime limits for psychiatric services with those for other services and legislation permitting more generous hospital stays following childbirth and mastectomy.
Coverage of the conference on psychiatric carveouts continues in the next issue of Psychiatric News.
(Psychiatric News, May 16, 1997)