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Since Alan Stone, M.D., began his letter "The Race to the Bottom," which appeared in the November 21 Readers React column by stating that "there is nothing more bracing for the mind than a critical exchange of views," I’d like to add to that exchange. My intent is not to defend the letter of Dr. Shadoan, which Dr. Stone rebuts. Rather, it is to question some of Dr. Stone’s points, so that if indeed there is a "race to the bottom," at least let’s try to have some clear water to see what’s there.
I wish Dr. Stone had stopped after reminding us of the power and problems of the federal ERISA law and that the most helpful managed care legislation may need to come from Washington. However, then he goes on to complain about quality in managed care, completely ignoring the substantial quality problem before managed care. I wish he would have explained how he (or patients) ever got "good information about the quality of medical and surgical specialists and the care they provide." At least managed care seems to be stimulating outcome studies about systems and individual practitioners. Contrast Dr. Stone’s comments to careful comments made in the November 19 theme issue of the Journal of the American Medical Association on quality of care. The title of one article may say it all: "Managed Care Is Not the Problem, Quality Is." Maybe someday we’ll really know who provides quality for what.
Then Dr. Stone goes on to take some potshots at community psychiatry and community psychiatrists. If "the community mental health movement was something less than a success," was that so because mainstream psychiatry was silent about the rationing that existed due to limited public funding, only becoming concerned when the same rationing came to the middle class? I wonder if "patients were the losers" when so many who would have remained in state hospitals are now thriving in the communities. As to community psychiatrists, while some indeed "become the mercenaries of managed care," many others have not, and the still thriving American Association of Community Psychiatrists recently published an updated version of Locus, which is probably the best instrument that any managed care company clinician can use to decide on level of care.
Finally, Dr. Stone should know that not all managed care companies are traded on Wall Street. Maybe the academic institutions entering the race, along with the remaining not-for-profits, can change the direction of the race. Otherwise, Dr. Stone, please tell us what the alternative is.
H. Steven Moffic, M.D.
Houston, Tex.