Volume XXXII - Number 19 - October 3, 1997

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American political leaders have failed miserably, as have many medical specialty societies including APA, at educating their constituencies about the need to set priorities in the allocation of resources for health care.

For this reason it has fallen by default to individual psychiatrists and other clinicians working in managed care settings to educate patients about the necessity of making hard choices, said James Sabin, M.D., at the Ninth Annual Behavioral Healthcare Tomorrow conference in Washington, D.C., last month, sponsored by the Institute for Behavioral Healthcare.

Sabin spoke during a plenary discussion on the following question: "Should we allocate the most resources to those in greatest need or to those who can benefit most from treatment?"

"With the notable exception of the State of Oregon," Sabin said in reference to the state that has established a prioritized list of covered health services for Medicaid patients, "our political leadership has tried to duck the painful issue of making choices and setting priorities.

"In effect, they pretend that behind-the-scenes dialogue between employers, payers, and representatives of managed care companies can replace an open, but difficult, moral process," said Sabin, who is codirector of the Center for Ethics in Managed Care and staff psychiatrist at Harvard Pilgrim Health Care and Harvard Medical School.

This failure on the part of political leadership has left the decisions about rationing, or prioritization, to leaders of managed care, who cannot fail to be vilified for their actions in a competitive market system, Sabin said.

"This is really not an issue that individual managed behavorial health care programs are going to want to get out in front of," Sabin said. "The media will say ‘HMO execs restrict access, ration care, and deprive people of valuable benefits.’

"We can’t expect leaders of a [managed behavioral health care] program in a competitive marketplace to take on the kind of political heat and carry out the acts of leadership that public leadership is all about."

Sabin extended his criticism of political leadership to APA.

"APA does a terrible disservice by simply blasting bad managed care practices without also saying that we must manage care well for ethical reasons on behalf of populations," he said. "By focusing exclusively on the most noxious aspects of managed care, APA is committing itself to only half a strategy."

Responding to Sabin’s comments, APA Medical Director Steven Mirin, M.D., said, "Not all caregivers agree with a population-based approach to care delivery, and we as a society must decide whether quality health care is a commodity to be rationed or a right of all citizens. Until this is addressed head on and resolved, APA will continue to advocate on behalf of patients who, all too often, are being denied the care they need."

In his remarks at the IBH conference, Sabin added that in the void left by political leadership, it may fall to individual psychiatrists and clinicians working in managed behavioral health care settings to talk to patients about choice making in health care.

"We have a great opportunity to shape the way the public thinks about these things," he said.

By way of example, Sabin recounted the process by which behavioral health care clinicians in the Harvard Pilgrim Health Care plan allocated finite resources.

Following an extensive strategic planning process in which members of the insured population played a substantial role, Sabin said, a decision was made to remove outpatient limits and escalating copayments for the sickest patients in the plan. Additional costs, it was decided, would be made up by imposing a higher copayment after eight outpatient sessions on those who were less sick. Determinations of severity of illness were not made solely on the basis of diagnosis, but included measures of suicidality, level of function and its change over time, availability of social supports, and presence of substance abuse, he said.

"This was a very clear instance of resource allocation with relative winners and losers," he noted. "When we put this into effect, I and my colleagues had hundreds of dialogues" with patients.

The conversations were conducted in a spirit of "good news - bad news," Sabin said.

For the sickest patients, the bad news was that they had a serious ailment; the good news was that both the care provider and the patient no longer had to worry about the benefit structure, he said. For those deemed less sick, the good news was that they didn’t have a serious ailment; the bad news was that after the eighth session, they had to pay more.

"This [discussion] happened in the course of clinical practice," Sabin said. "I literally encountered no one, among those who had to pay more, who thought that this was unfair.

"They weren’t happy about having to pay more," he added, "and for some the increased copay was a serious issue. In those circumstances, we had to seek creative solutions and do our best within the limits."

Sabin noted, "For the process to be seen as legitimate, the priorities don’t have to be beloved. They won’t be. If there aren’t people who are unhappy about the priorities, those aren’t real priorities."

Sabin suggested three rules for setting priorities. The first is that special priority should be given to the most impaired. "Not absolute priority, but relative priority," he said. "This is what distinguishes a human society from a Hobbesian jungle."

The second is that some relative priority should be given also to those who can benefit the most from treatment, regardless of the severity of their illness.

He noted, however, that it is not necessarily true that those who will do better are always those with milder diagnoses. "Every clinician in this room has worked with patients with schizophrenia or bipolar disorder who do fabulously," he said, "and patients who have mild personality disorders where even with a sledgehammer we couldn’t produce change."

Third, Sabin said, a wise resource allocation system considers potential cost-offset in setting priorities, since cost-offset makes funds available for the care of other members of the population.

Such priority setting can hardly be avoided on the national level either, Sabin suggested, though the fragmented system of care in the U.S. renders such global decision making nearly impossible.

"In setting priorities, we have to ask: What is the population for which the priorities are being set?" Sabin said. "Priorities don’t just exist in the ether; they are for populations. In our current system, responsibility for the population is fragmented . . . .We have carved out the elderly in Medicare, the poor in Medicaid, and the self-employed.

"There are multiple populations for which even the term we use - ‘covered lives’ - captures how confusing it is to conceptualize for whom the priorities are being set," Sabin said.