February 5, 1999

One of the difficulties that APA faces in serving the needs of all its diverse members is illustrated in a new and challenging wrinkle in the health care delivery scene: A psychiatrist was hired by the psychiatry department's managed behavioral health organization (MBHO) in an academic health center (AHC) to train and supervise nurses to prescribe for, manage, and treat psychotic patients. What ought to be the position of APA on that? What might APA say if an HMO did that? A government? A provider-controlled MBHO (PCMBHO)? This is a tough call.

This AHC has developed a network of affiliated hospitals, health care facilities, and primary care and multispecialty satellite clinics; purchased group and individual practices; and merged with another AHC doing the same. It competes with similar AHC networks as well as with HMOs, MBHOs, and PCMBHOs.

But AHCs carry heavy burdens that are nowhere found at HMOs and MCOs: hospital salaries; administrative costs; cost of deans, academic department chairs, and full-time faculty; medical and graduate education and research expenses; and a heavy debt burden. The AHCs, as safety-net hospitals, often in urban settings, serve a disproportionate share of the uninsured and underinsured, then must deal with Medicaid managed care's preferentially sending patients to lower-cost community hospitals and clinics, leaving only the most complex cases for the AHCs.

Further complicating the picture, there are three factions within AHCs: the hospital, its president and administrators, sometimes employing full time primary care practitioners; deans, academic chairs, and the full-time faculty under them; and the voluntary staff in individual or group practices or PCMBHOs. These factions have interests that diverge, setting one against the other. Frequently it is the hospital (wanting to fill beds and lower costs) and academia (protecting the specialty) against the voluntary staff.

Usually that affects medicine, but here it impacts psychiatry, with the hospital and academia training ancillary personnel to make the AHCs more competitive in the marketplace. They are less costly than, and eliminate the need for, residents and private attendings. However, nonmedical personnel could see this as credentialing them to practice independently, collaborating with primary care doctors, and therefore competing with private psychiatric practice.

So with regard to this issue, what is the place of APA, whose membership includes all players in the game: HMO and MBHO administrators, reviewers and panel members, all factions in AHCs, PCMBHOs, and private practitioners? It is not clear, but one thing is certain. APA and its district branches and state organizations may support but cannot own or be PCMBHCOs; otherwise, they will become as fractured as the AHCs and will be similarly pressured in the marketplace. Aside from legal, financial, conflict-of-interest, and membership problems, APA must remain apart from managed care to carry out its mission: setting standards; monitoring HMOs, AHCs, MBHOs, and PCMBHOs for quality; and litigating, promoting public relations, and legislative and regulatory initiatives to increase oversight and regulation of this rapacious, uncontrolled, vulgar marketplace, ultimately to level the playing field so that better organizations can successfully compete with poorer ones.

Herbert Peyser, M.D.
APA Area 2 Trustee