November 20, 1998

The advent of managed care has created new ethical dilemmas for both psychiatric clinicians and administrators, but whether a given decision by a managed care reviewer is ethical or unethical is not always clear, according to panelists in a session at APA's 1998 Institute for Psychiatric Services last month in Los Angeles.

The session group was led by H. Steven Moffic, M.D., executive vice chair for managed care at the Medical College of Wisconsin in Milwaukee and author of the recently published book The Ethical Way: Challenges and Solutions for Managed Behavioral Healthcare.

Under managed care, the "two big issues that have to be balanced are cost and quality," said Moffic. Quality of care issues include "overuse, underuse, and mistreatment," he added.

Audience participant Alan Sandman, D.O., noted, however, that "quality of care is a gray area" because two clinicians may use different treatments and because shorter lengths of stay in hospitals under managed care may be perceived as desirable by patients who wish to be discharged as soon as possible. Sandman is a psychiatric reviewer for Community Behavioral Health in Philadelphia.

Defining quality is difficult, Moffic agreed. He noted that Medical College of Wisconsin Behavioral Health Services, which he directs, is undergoing a National Committee for Quality Assurance (NCQA) accreditation, and to facilitate that process, he has designed a set of brief practice guidelines for daily use. Behavioral Health Services acts as a corporate carveout through its contracts with several managed care companies.

Moffic said he referred to the APA practice guidelines in designing his guidelines, using the APA guidelines as a resource. He devised a short series of guidelines that run about 5 to 10 pages per disorder. He also consulted people in other companies who were developing in-house guidelines to get further ideas.

There are numerous guidelines from many sources, including guidelines on levels of care, said Moffic. Those guidelines deal with criteria related to whether a patient should be hospitalized or treated through partial hospitalization or as an outpatient.

The American Association of Community Psychiatrists has developed very detailed guidelines, while managed care companies have developed very short guidelines, Moffic observed. "So there's a lot out there, but it's very disparate."

Physicians are always free to deviate from his company's in-house guidelines, he noted, "but if you deviate, you have to chart why you're deviating from [them], and then you can individualize your care." His company will "try to accept what you're saying as long as you can give a rational explanation as to why you're deviating from the guidelines. . . . But if you don't follow them, and you don't tell us why you're not following them, we probably won't pay for care."

Jonathan Book, M.D., chief medical officer for Magellan Behavioral Health in Columbia, Md., commented, "I don't feel myself caught on a day-to-day basis. . .between the need for the company to make a profit for its shareholders [and the need to provide quality care]." But he said he does believe it is valuable to have a clinician in the role of managed care reviewer to bring the values of good clinical practice into play in the corporate setting.

In his prior job as superintendent of a large state hospital, said Book, he found himself confronted with many of the same issues regarding limited resources and high demand that he now sees as a managed care reviewer. In neither case can the physician do exactly as he or she likes, he noted.

"One of the ethical issues is there aren't unlimited resources in any system that I'm aware of," Book added.

Despite the proliferation of practice guidelines, managed care reviewers suffer from a lack of clarity regarding a clear standard of care in psychiatry, according to Book. "Part of the problem for us all is the paucity of clear clinical guidelines in the industry."

Seymour Gers, M.D., the Area 2 representative to APA's Committee on Public and Community Psychiatry, echoed Book. Gers noted that well before the advent of managed care, state hospitals applied strict rules on resource allocation.

"I am struck by all of the guidelines," said Gers. "Everybody says [the guidelines] are going to do good; how come we don't see good being done?"

There is an inherent conflict between the need for profit and the primacy of the patient, Gers contended. "There is concern for making a profit in managed care, and when that concern interferes in the delivery of [quality] managed care, you have a conflict."

A major difference between contemporary managed care and his prior experience in a state hospital, said Gers, was that despite limited resources in the state hospital, he was left alone to do the best he could do. His every decision was not subject to utilization review.

"Are you arguing for a system where clinicians are not accountable?" asked Book. Replied Gers: "I believe in accountability. I want to be accountable for the work that I do, and I want everybody to be accountable for what they do," including managed care reviewers.

Richard Normington, M.D., a psychiatrist from Reno, Nev., questioned whether utilization review can be conducted rationally. Given a limited amount of money for patient care, the result is that the rationing of care "becomes tighter and tighter," he contended. Normington recalled a case in which a patient with 85 days of inpatient benefits remaining was involuntarily discharged from the hospital and committed suicide the following day.

It is often difficult to know if managed care has adversely impacted care, said Moffic. Utilization review is "a medical process" and should be conducted by physicians, he added. Even if physicians are the reviewers, it is necessary to have an external appeals process to ensure impartiality, he said. Internal reviews involve inherent conflicts of interest.

The ultimate ethical issue under managed care, according to Normington, is how the clinician responds to what he or she deems inappropriate care limits set by managed care administrators.

Finally, said Moffic, care reviewers are faced with the dilemma of determining what constitutes adequate payment for clinicians and how that can be tied to quality of care.