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I have read with some concern the articles in recent issues regarding the damage that managed care is allegedly having on the care of psychiatric patients. I am currently the medical director of a pilot Medicaid project consisting of a managed care company (OPTIONS Health Care, Inc.) and five mental health centers in the Tampa Bay area.
I came to this position from 21 years of private practice in psychiatry and with experience in the private and public sectors. The article in the October 17 issue about the managed care report written by NAMI [the National Alliance on Mental Illness] and comments by Dr. Eist in the same issue paint managed care with a global brush and without appreciation for the managed care projects and companies that are truly concerned with providing appropriate and medically sound psychiatric care for the individuals for whom we are responsible.
In this project over the past year and a half, we have significantly improved the psychiatric care of Medicaid patients and enhanced communication between mental health community providers and primary care physicians. We have moved care from a program focus to an individual focus, with flexibility of services made possible because of the capitated system and quality motivation of the providers and of OPTIONS. We have also eliminated waiting lists and focused care based on the needs of the patients instead of the funding streams.
In addition, our project has put in place treatment guidelines that are consistent with APA guidelines, and they do not restrict the use of the newer antipsychotic medications as reported by NAMI in its managed care report. In fact, one of our providers has the largest clozapine clinic in the area, and we are studying the use of risperidone in a joint project with Janssen Pharmaceutica. We are monitoring for polypharmacy and for multiple-provider prescribing. We have also initiated a specific primary care physician integration effort to improve the overall care of the patients we treat.
Our inpatient medical necessity guidelines, as well as those for other levels of care, are not restricted to the involuntary commitment criteria as indicated in the NAMI article. We focus our interventions on a "care first" philosophy that emphasizes the patients receiving the needed emergency care. We obtain efficiency and cost savings by assuring that our members receive timely, medically appropriate care in the most cost-effective setting consistent with patient safety. We do not deny any payment authorization without the medical director’s determination and then only after offering consultation with the treating physician.
In contradiction to the article, we are conducting several outcome studies and continuously provide information to our treatment providers on a monthly basis. We clearly define a suicide attempt as a medical emergency and have very clear policies on how we promote "care first" in these situations.
These issues reported in the article on the NAMI managed care report do not accurately reflect our company or this project and do an injustice to those of us who have dedicated our lives to the care of the mentally ill and their families.
I can say with certainty that there are abuses in the managed care system as well as in the fee-for-service (private practice) system. Under fee-for-service, however, Medicaid costs were rising at 20 percent yearly, and there was serious discussion among policymakers about reducing mental health benefits to save money. Due to the use of managed care, Medicaid costs are rising only about 3 percent a year, and there is no consideration of reducing mental health benefits.
To deify one system and vilify the other does an injustice to both and leads us further down the road of divisiveness and ignorance of the need for all of us - as psychiatric physicians - to find the best ways to advance the care of mentally ill individuals.