AACP Newsletter, Volume 12,
Number 4, Autumn 1998
Regional Reports:
Iowa
Iowa psychiatrists have not shared the Governor's enthusiasm for the Mental Health Access Program (MHAP). The technical term used by the Governor in classifying psychiatrist complaints was "squawking". Based on our experience in Iowa, the following suggestions are offered to psychiatrists in other states or programs who are in the process of developing contract specifications, implementing managed care programs, and providing oversight of the quality of care provided under these programs.
First, take advantage of every opportunity to have input into contract specifications, implementation, oversight and evaluation of clinical services in these programs. State Medicaid contracts are political processes and everyone involved in them has a potential conflict of interest. Psychiatrists should not be excluded from this process because of their conflict of interest in regard to program reimbursement. Our training as psychiatrists allows us to provide important and valuable contributions in the assessment of clinical quality. On clinical issues, we are more than an opinion of a special interest group. As psychiatrists, we have an ethical obligation to educate program administrators as to what constitutes appropriate standards of clinical care, even when our input is not specifically solicited.
Secondly, when asked for our input as psychiatrists, it is important to remain focused on clinical aspects of the contract in order to maintain our credibility as clinicians. In the Iowa Medicaid contract, input by psychiatrists into the content of the Medicaid contract or its oversight were marginal. Viewed only as a special interest group, concerns raised by hospitals and physicians were given little credence and psychiatrists had little input. Because of their predominant focus (and hostility) regarding reimbursement issues, their opinions on issues of clinical quality were often given the same (or less) weight as those offered by "other special interest groups."
Finally, it is important to maintain and enhance good working relationships with AMI and other patient and family advocacy groups. Their "conflict of interest" is going to be perceived more sympathetically than ours, even though we may be saying the same thing and are often working toward the same goals. The voice of the Iowa AMI has been critical in bringing concerns about the quality of care in the Iowa managed care program to the attention of legislators and to the general public. There have been many times that the best (and only) contribution that psychiatrists could make on behalf of patient care was to support AMI members in their role as advocates.
Are patients worse off under Medicaid managed care in Iowa? There is inadequate data to support or refute that they are or are not. For all of our concern, we don't know if cost savings to the state have reduced the quality of care in the public sector. In our independent evaluation of the quality of care in the Iowa Medicaid managed mental health care program in its first year of implementation, we concluded that the quality of clinical care could not be adequately assessed. The clinical data that were available for review was limited in both quantity and scope.
From my experience with Medicaid managed care in Iowa, I have become less sure of who the good guys are and what defines the right course of action from the wrong course of action. The state's motivation to contract Medicaid mental health care to a for profit vendor was cost containment, not improvement in the quality of care to the Medicaid population. While I may wish that quality of mental health care for persons with mental illness were a priority of the state government, it was not the driving principle for the state contract. Hence, inattention to issues of clinical quality in the Medicaid contract was ultimately the choice of the Iowa taxpayers. Blaming the contractor, DHS, or the Governor is overly simplistic.
Furthermore, there is no consensus on what constitutes quality of care in public sector mental health services. Even when defined, there is seldom agreement on how to measure it. It is difficult to hold the contractor accountable to measure something that we ourselves have not clearly defined.
Finally, and perhaps most importantly, there is no consensus on what the acceptable standard of quality of care in state Medicaid managed care program should be. As a society, our standards of quality, cost, or moral responsibility to provide care to vulnerable populations have yet to be determined. Perhaps our most important role, as psychiatrists and as citizens, is to take a proactive role in defining those standards.
Continue to the Ohio Regional ReportContinue to the Texas Regional Report
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