AACP Newsletter, Volume 13,
Number 4, Autumn 1999
President's Column:
Ethics in Managed Care
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We will award it to our dear friend and second President Clif Tennison. Clif's example will dispel any questions as to whether we were falling into an oxymoronic trap. As many of you know, Clif was heavily impacted by the poorly conceived and erratic attempts of TennCare and TennCare Partners to bring managed care to Tennessee. Those of us close to Clif saw him suffer the agony of seeing programs and staff he had carefully nurtured for 25 years dissolve in the face of outrageous cost cutting and program restrictions. Yet Clif faced the disappointments with a practical spirit that was the very model of an adaptable and relentless community psychiatrist. He helped his center invent new programs with new funding and participated in a nearly miraculous salvaging of his beloved Helen Ross McNabb Center in Knoxville. But Clif neither quietly suffered indignities nor did he join the ranks of those who ineffectually bellow against managed care. He used the opportunities afforded him in AACP presentations to deliver blisteringly effective and factual accounts of the massive failure in his home state to deliver on the promises of their Medicaid waiver. Known to some as the Garrison Keillor of community psychiatry for his self-effacing speaking style, and his basic kindness and lack of invective, he spread the news of Tennessee around the country and greatly hastened the critical reviews of his state's mental health system by HCFA. Our friends in Tennessee say things are beginning to get better and Clif has been a big part of why. The AACP finds his behavior in the face of chaos in his corner of the health care revolution to be exemplary ethnical practice. We are very proud of Clif and delighted to have had an opportunity to honor him. His is indeed an inspiring story.
I have worked for King County's mental health authority in Seattle for the past five years. Our state and county also have a Medicaid waiver. I have been part of a county team that has tried to figure out how to do it well. With my grave reservations, King County hired a managed care company, on a non-risk bearing contract, to operate our system while we at the county set policy and provided direction. My experience has been very different than Clif's. The managed care company we have worked with has been a constructive force as we have struggled to move from a fee for service to a case rated system. We really haven't done half bad considering inadequate resources and an old history of complex relationships between our many providers and the county. I, too, have many painful stories of neglect and poor care, but I also have some wonderful stories of great work done by treatment teams and devoted community psychiatrists who have prospered under our system. What I have learned is that there are few really bad guys in the managed care revolution, just some very poor practices and bad ideas that lead to systems which are impossible to manage. How do we face such situations? What do we do as individuals faced with very tangible catastrophes with our patients who stand to lose their housing, lose a program that has sustained them or who have to prematurely say good bye to a beloved staff member? Who do we yell at and what good would it do? Way too many of us get disgusted and leave community practice, but even more are leaving worse situations battling managed care in private practice looking for a better deal in the public sector.
It is clear to me, after my nearly 25 years in Seattle's system, that problems ebb and flow as reliably as the tides. The prevailing sad reality is that a number of our fellow citizens will suffer from serious mental illness and will extract services from our communities one way or the other. My former office partner now works in the Washington State prison system full time because he wants to serve the most severely ill and gets to do it in that system with no restraints on his time. He gets to really know his clientele and can be very effective with patients who have been grossly misplaced and neglected by the system. He is an adaptable community psychiatrist who has gone to where he can gain access to clientele for whom he has passionate devotion. It is our task as community psychiatrists to hang in with our systems as they lurch along in this era of reform. We must speak up as direct witnesses to the impact of someone else's bright ideas on the best care for our patients. We need to criticize when things go wrong but we also need to be open to laudatory innovation, help capture the good ideas and see them promoted as policy. We need to speak up in support of good practice. We need to help our administrators, our politicians and our citizenry see that quality practice is the only way to be truly cost effective and resource conserving. We need to unabashedly promote the idea of best practices because it is the right and humane thing to do. This is how we can be truly ethical in the face of confusion and chaos in our system reforms. We as community psychiatrists are the ones who must guard the vision of ethical practice. I am so grateful to our former Board member Steve Moffic for his generosity in promoting this principle within our organization through the establishment of the Moffic Award. Please help him and the Ethnics Committee search our country for others who, like Clif, have found their ethical way in the fact of the managed care revolution.
Charles Huffine, MD
President
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