PSYCHIATRISTADMINISTRATORNewsJournal of theAmerican Association of Psychiatric Administrators

Volume 1, Issue 3 Fall 2001

Editor:

Sy Atezaz Saeed, M.D.

Editorial Board:

Boris Astrachan, M.D.Carl C. Bell, M.D.Gordon H. Clark, Jr., M.D.Mary Jane England, M.D.Gloria Faretra, M.D.David Fassler, M.D.Christopher G. Fichtner, M.D.Daniel Luchins, M.D.H. Steven Moffic, M.D.Paula G. Panzer, M.D.William J. Reid, M.D.Pedro Ruiz, M.D.Paul Rodenhauser, M.D.Steven S. Sharfstein, M.D.Wesley Sowers, M.D.John A. Talbott, M.D.

AAPA Past Presidents..................................................................................... 58

From the Editor .............................................................................................. 59

Presidents’ Column ........................................................................................ 60

It’s Different Nowby Chris E. Stout, Psy.D., MBA .................................................................... 62

Psychiatry After Managed CareSteven S. Sharfstein, M.D. ............................................................................. 64

Commentary on Dr. Steven S. Sharfstein’s Paper“Psychiarty After Managed Care”Boris M. Astrachan, M.D............................................................................... 68

Perspective on Parity: Part IISteven Kouris, DO, MS, MPH ...................................................................... 70

Ethics ColumnSteve Moffic, M.D. .......................................................................................... 75

Instructions for Authors .................................................................................. 81

AAPA Council Members ................................................................................ 82

Application for Membership ......................................................................... 83

AAPA PAST PRESIDENTS

1961-1962 Archie Crandell, M.D.1962-1963 M. Duane Sommerness, M.D.1963-1965 William S. Hall, M.D.1965-1966 Herman B. Snow, M.D.1966-1967 Donald F. Moore, M.D.1967-1968 Francis Tyce, M.D.1968-1969 Harry Brunt, M.D.1969-1970 Walter Fox, M.D.1970-1971 Dean Brooks, M.D.1971-1972 Georg Zubowicz, M.D.1972-1973 Emanuel Silk, M.D.1973-1974 Hubert Carbone, M.D.1974-1975 Hayden H. Donahue, M.D.1975-1976 Ethal Bonn, M.D.1976-1977 George Phillips, M.D.1977-1978 John Hamilton, M.D.1978-1979 Tom T. Tourlentes, M.D.1979-1980 Mehadin Arefeh, M. D.1980-1981 Roger Peele, M.D.1981-1982 Stuart Keill, M.D.1982-1983 Gloria Faretra, M.D.1983-1984 Darold A. Treffert, M.D.1984-1985 Thomas G. Conklin, M.D.1985-1986 John Talbott, M.D.1986-1987 Dave M. Davis, M.D.1987-1988 Robert W. Gibson, M.D.1988-1989 Robert J. Campbell, M.D.1989-1990 Stephen Rachlin, M.D.1990-1991 Haydee Kort, M.D.1991-1992 Boris Astrachan, M.D.1992-1993 Gerald H. Flamm, M.D.1993-1995 A. Anthony Arce, M.D.1995-1997 L. Mark Russakoff, M.D.1997-1999 Paul Rodenhauser, M.D.1999-2001 Gordon H. Clark, Jr., M.D.

NEWSJOURNAL OF THEAMERICAN ASSOCIATION

OF PSYCHIATRICADMINISTRATORS

Editor Sy Atezaz Saeed, M.D., MS, FRSH

Published 4 times a yearWinter • Spring • Summer • Fall

COUNCILExecutive Committee

President Christopher G. Fichtner, M.D.

President - Elect Thomas W. Hester, MD

Secretary & Marc Feldman, MDMembership/Comm. Chair

Treasurer & Wesley Sowers, MDFinance Comm. Chair

Immediate Past PresidentNominating Committee Chair

Gordon H. Clark, Jr., MDMDiv, FAPA, CPE, FACPE

Councilors

David Fassler, MD Paula G. Panzer, MDMarc Feldman, MD Raman C. Patel, MDShivkumar Hatti, MD Pedro Ruiz, MDBeatrice Kovasznay, MD Steve Sharfstein, MDLouis Mini, MD Wesley Sowers, MDSteve Moffic, MD William G. Wood, MD

Webmaster Tom Simpatico, MD

Archivist Dave M. Davis, MD

APA/BMS Fellow Marc E. Dalton, MD

CHAPTERS New York, PresidentRaman C. Patel, MD

Executive Director: Frances RotonP.O. Box 570218

Dallas, Texas 75357-0218Ph.: (800) 650-5888

Fax.: (972) 613-55329Email: frda1@airmail.net

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FROM THE EDITOR 59

Having just returned from the APA FallComponent meetings in Washington DC, I hadalmost finalized our next issue and was planningon getting all the materials out to our ManagingEditor on September 14. On the morning ofSeptember 11, I was in my car between two ofmy work locations when I heard on NPR whathad just happened in New York and WashingtonDC. The horrific events of September 11, 2001will forever have an impact on us. The huge lossof life is touching virtually everyone. Many of usare going through some of the same feelings -disbelief, fear, grief, loss, and anger.

Many think that the psychological effects ofthe terrorist attacks on the World Trade Centerand the Pentagon are just beginning to be felt,and will grow in the coming weeks to months.As a clinical, administrative, and academicpsychiatrist, I struggle with this tragedy on severallevels: my own reaction to the tragedy, how ithas impacted people I work with, how it is likelyto affect the systems I work with, and how will,and can, we react to the challenges? Some havespeculated that it is likely that the prevalence ofmental illness among children and adultsthroughout the nation will rise in the wake of theattack. Some fear that the United States does nothave the mental health infrastructure in place tocope with this increase.

Grief and loss are normal and universal humanreactions, and each of us will cope with the lossin our own way and in our own time. Whileacknowledging that psychiatry as a medicalspecialty has no unique knowledge of how acountry can recover from such trauma, in astatement from the American PsychiatricAssociation President Richard K. Harding, M.D.offered these suggestions for individuals andcommunities:

· Acknowledge your feelings of fear, angerand grief; talk with others about the tragedy andyour feelings.

· Talk with your children or other childrenabout the disaster and assure them that they aresafe and protected in a strong nation. Limittelevision watching; don’t allow children to view

the repetitive scenes of destruction over whichthey have no control. Instead, help children gainmastery over situations they can control such ashomework or sports. Talk with children about hateand prejudice.

· Participate in community ceremonies thatwill be held across the country to remember andhonor the dead and wounded, and rededicateyourself to the principles in which our nationstands.

· Contribute in some way to the rescue workand rebuilding effort through donations of time,money or other assistance to victims and theirfamilies. Write sympathy and support notes toaffected individuals and groups. Give blood nowand at regular intervals.

· Draw strength from your spiritual or religiousbeliefs and traditions.

· Resume your normal routine as quickly aspossible. Be informed of unfolding events, butavoid wallowing in the gruesome detail.

· Understand that the strong feelings of griefcan resurface sporadically even months after theevents, and that such feelings are normal. Consulta medical or mental health professional if feelingsof grief and loss or fears stemming from the eventbecome chronic and impair your daily activitiesand relationships.

· Know that the tragedy will pass, buildingswill be repaired and rebuilt, life will go on, andour nation will remain strong, but, as with a deathin the family, life will never be quite the same.

In this issue we invited Chris E. Stout, Psy.D.,MBA to offer his thoughts in a guest editorial that hehas titled It’s Different Now. Dr. Stout is noted forhis work on terrorism, war, trauma, and civiliancasualties. He served for a year as a consultingSpecial Representative to the United Nations for theAmerican Psychological Association. He has workedaround the world. His works have been translatedinto 5 languages. He is currently working on a booktitled The Psychology of Terrorism (Praeger, 2002).

Sy Atezaz Saeed, M.D.Editor

Coping with A National Tragedy

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PRESIDENT’S COLUMN - FALL, 2001Christopher G. Fichtner, M.D.

The tragic events ofSeptember 11 havechanged the context ofworking, reflecting andliving for all of us.Some issues seemlarger, others smaller,and still others barelyregister in ourconsciousness against

the numbing reality of this new era. Members of theAmerican Association of Psychiatric Administrators(AAPA) are experiencing the impact of this realityin both their clinical and administrative work.

Mental health professionals have commentedon the likelihood that mental health needs willbecome greater in the setting of this unfortunatenew reality. The mental health needs of thosemore directly affected by the events have beenrecognized, mobilizing professionals to helpaddress the associated psychological trauma. Andeven at a distance, practitioners are now seeingthe impact of these events reflected clinically inthe presentations of their patients.

While for some this may engender expectationsof a new era of funding for mental healthprograms, a more wary view would be that theimpact of recent events on psychiatricadministrators will likely be to challenge yet againthe manager’s capacity to do more with less. Itseems at least intuitively clear, reinforced for meby recent budget discussions in an executiveretreat setting, that re-prioritizations of resourceallocation in the aftermath of 911 will push mentalhealth further to the back burners than before. Ifso, the tasks of the psychiatric administrator willhave the discouraging feature of presenting in theface of constricting resources, and leadership inthe mental health systems of this era will not be forthe faint of heart. Yet, for those inclined to take upsuch challenges–as many of our AAPA members are–

there will be opportunity to have a reasoned impacton these systems.

Our mission in the AAPA continues to be topromote medical leadership in behavioralhealthcare systems, and to do so primarily byproviding a forum within which psychiatristadministrators can engage in collegial dialoguewithin and across public and private settings, andlearn from one another about how to provide thebest possible services for our patients. Of thenumerous seeds that have been so industriouslyplanted in AAPA soil under the leadership of PastPresident Gordon Clark, M.D., we continue toemphasize those that have the greatest potentialto further our mission. This NewsJournal,Psychiatrist Administrator, is an excellentexample. Editor Sy Saeed, M.D. continues hiswork of compiling excellent contributions frompsychiatrists working to solve administrativeproblems and achieve systems and servicedelivery improvements. In this issue, he hasincluded an article by Chris E. Stout, Psy.D.,M.B.A., reflecting on the impact of the recentdisasters from the perspective of a mental healthadministrator and author on the subject ofterrorism. Dr. Stout is Chief Psychologist forthe Illinois Department of Human Services, Officeof Mental Health.

We continue to develop the AAPA websiteunder the direction of Webmaster ThomasSimpatico, M.D. The site now includes manymore links to websites concerned with mentalhealth and medical administration issues. Dr.Simpatico continues actively to seek input fromany AAPA members who would like to beinvolved in website development, especially ascontent experts. In the area of education,traditionally a priority for AAPA, we haveundertaken the development of a new program. Atthe request of the American Psychiatric Association’sCommittee on Psychiatric Administration and

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Management, we have submitted a proposal to offertwo full-day CME courses which, as a package,provide an overview of the basic concepts inadministrative psychiatry addressed through the APAcertification process. Collectively, the two coursesdraw upon contributions from eleven facultymembers, and will address the areas of administrativetheory, human resources, fiscal management,psychiatric care management, law and ethics. Theywill also address the areas of career developmentfor administrative psychiatrists and the future ofadministrative psychiatry. We expect to offer thesecourses at the APA Annual Meeting next May, andhope that they will be helpful for psychiatristsdeveloping administrative aspects of their careersand contemplating certification.

Although the AAPA Council did not meetformally at this year’s Institute for PsychiatricServices, we are actively working on our priorityagenda items including especially those initiativesdiscussed above. We have consolidated somecommittees to facilitate working relationships inoverlapping areas, and we are involving our finance

committee in multiple areas to explore fundingoptions as we further develop and expand our currentprojects. Suggestions from AAPA members as tohow we can better serve your needs are of coursealways welcome. One innovative forum that hasbeen well received is the PsychiatristAdministrator Ethics Column edited by Dr. SteveMoffic, which in case-presentation format providesan opportunity for discussion and consultation oncomplex issues involving ethical dimensions ofpsychiatric administration and management. I knowthat the Editor will welcome your suggestions forhow the Psychiatrist Administrator can continueto develop as a useful and informative publication.

I look forward to working with you, the AAPAmembership, to carry out our current initiatives,to create new learning opportunities in psychiatricadministration and management, and to make thisorganization work better for you and ultimatelyin the service of our patients.

It’s hard to know how to start a piece like this.I have presented and written on terrorism, andwar, and trauma, and civilian casualties, a fairamount. I’ve worked with tortured children,talked with traumatized refugees, broken breadwith former political prisoners. I’ve seen theaftermath of atrocities - exhumed corpses, massgraves, and murdered infants. I have gone onmedical missions to far off places around theworld. I have slides and statistics, bar graphs andcitations, I can quote numerous facts and figures.But prior to 11 September 2001, all of that wasdone with a certain degree of clinical detachment.I would go somewhere else, and then come home.I have not ever been in an active war zone, nor avictim of a terrorist attack. After 11 September, Ifeel a bit different. I suspect you may, too. Isuspect our colleagues, our patients, our friends,our families, and our staffs may as well.

We may rightly, or wrongly, presume theseattacks will have a vast psychiatric impact. Withperhaps greater certainty I believe there is apsychic impact that well extends beyond USborders. The rub is that many may confuse thetwo. I have seen much discussion on many ListServs as to dealing with PTSD after this, andwhile at first blush this seems quite reasonable,my only point is that grief, sadness, and fear,under these circumstances are indeed quite normaland to be expected. We need to thus not over-react in therapeutic zealousness and start topathologize the grieving process.

I have also been amazed at the diversity, if notdownright division, of some of the opinions andresultant debates posted as well - if one were togeneralize from a sampling of the clinical practiceList Servs I have frequented. There are debatesas to violent and aggressive responses versusforgiveness and passivism, evil versus goodness,behavioral reinforcement versus socialpsychology theories, isolationism versusglobalism, “we are victims” versus “we brought

IT’S DIFFERENT NOWChris E. Stout, Psy.D., MBA

this on ourselves,” and my favorite dichotomy -“this is a start of the end” versus “this is the startof a new beginning.” It seems the name of religionis used to support all opinions (it comes in handythat way in such debates I have found).

Locally, it has again become in vogue to calllocal state psychiatric hospitals or courthouseswith a fictitious, but nevertheless disruptive andfreshly upsetting bomb threats. Some years ago,I was involved with the emergency evacuation ofan entire psychiatric hospital due to a flood. Itwas variably impactful on patients, their families,and the staff (Stout and Knight, 1986). Butgeneralizability from that time and event transferspoorly to today.

Many non-colleague friends have asked “Dothese recent acts of terrorism effect yourpatients?” There is no need to differentiate sucha question along the lines of patient age ortreatment venue (in- or outpatient, public orprivate). And with the exception of those patientsunaware of the external environment, I simplysay, “Yes, of course - everything that goes oneffects everything that goes on.” A quick surveyof the complexity sciences literature bears thisout, but we may not typically think of such as wemay have become so insular to our specific work.Maybe not for everyone, I pray, but it surehappened to me. With all my travels, missions,advocacy, and research, I still was insulated fromperceived evils as such didn’t really effect me,my family, or my children. I became a bitcalloused; perhaps jaded.

A friend and colleague, Jordan S. Kassalow,OD, MPH, from the Council on Foreign Relationsin New York wrote a wonderful white paper on“Why Health Is Important to U.S. ForeignPolicy.” It offers excellent examples of the oftenunseen relationships between health and politicalstability or war. For example, he notes, “Researchshows that low or declining average health statuscorrelates over time with a decline in state

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capacity, leading to instability and unrest (Price-Smith 1999). According to Andrew Price-Smith’sresearch, high prevalence of disease in a stateundercuts national prosperity, generates inter-eliteconflict, exacerbates societal income inequality,and significantly depletes human capital”(Kassalow, 2001).

As for war, it is not difficult to understand therelationship between war and health status - “warskill and injure soldiers and civilians, but they alsodestroy infrastructure and social structures, in bothcases with adverse effects on the population’sgeneral health. Medical facilities are often singledout for attack in ‘new wars’ because they providevaluable loot, easy victims, and a way todemoralize civilian populations. War also causesexceptional mobility, and armies, peacekeepers,and refugees act as vectors for the transmissionof disease” (Kassalow, 2001).

“There is also evidence of the reverse effect,that of health on war. Combatants in new warsare often the socially excluded, even if they onlyact as proxies for more socially advantagedgroups. Poor health shortens people’s timehorizons, making them more likely to engage inrisky behavior; conversely, strong democracieswith broad support from healthy populations areless likely to engage in conflict, at least with eachother (Doyle 1983)” (Kassalow, 2001).

My point? I would like you to keep in mind thatthrough the work you do, the impact you haveeffects not only the individuals you work withdirectly today, but also their families, andpotentially thereafter for generations. I have fileboxes filled to the brim with the medical costoffset literature supporting such, but somehowthe numbers seem a little less relevant today andtheir lives more so.Dr. Stout is the Chief Psychologist with the Officeof Mental Health in the Department of HumanServices, State of Illinois.

References

1. Doyle, M. (1983). Kant, liberal legacies, andforeign affairs: Part 1. Philosophy and PublicAffairs, 12, 213 - 215.2. Kassalow, J. S (April, 2001). Why Health IsImportant to U.S. Foreign Policy, White paper,Council on Foreign Relations, NY, NY.3. Price-Smith, A. T., (1999). The health ofnations: Infectious disease and its effects on statecapacity, prosperity, and stability. Dissertation,University of Toronto.4. Stout, C.E., and Knight, T. (1986). Impact ofa natural disaster on a psychiatric inpatientpopulation: An empirical study. The PsychiatricHospital, 21(3), 129 - 135.

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In the decade of the 1990s, the United Statesembarked on an unprecedented social experimentto re-balance costs, quality, and access of healthcare through a rationing process called “managedcare.” Payers, employers, government, theinsurance industry, and some hospitals utilizedmanaged care to decide who gets what from thehealth care system. This experiment is aneconomic success but has become a politicalfailure (1). The essential strategy of managedcare has been characterized as “giving with onehand while taking away with the other,” that is,offering comprehensive benefits with low costsharing but restricting access through utilizationmanagement, gatekeeping, networks, and otherrationing techniques. This strategy has provokedoutrage from patients, physicians, and virtuallyeveryone involved in the health care system. Thereaction against restrictive physician panels,gatekeeping, utilization, and capitation has ledto a full retreat by managed care so that choice ofpatients is now broadened, utilization reviewrelaxed, and fee-for-service payment (albeitdiscounted) is back in vogue.

For psychiatry, the 1990s was characterizedby phenomenal growth of behavioral carve-outcompanies, which specialized in restricting accessand containing costs for psychiatric hospitalizationand access to psychiatrists, as well as other mentalhealth professionals. A great majority ofAmericans enrolled in health insurance plans havetheir psychiatric benefits managed by one of threefor-profit, behavioral carve-out companies(Magellan, Value Options, and United BehavioralHealth), creating a special backlash from patients,families, and the mental health professions (2).

Managed care for psychiatry was given aspecial boost during the 1980s by the expansionof for-profit, private psychiatric hospitals. Thescandals involving one or more of these hospitalchains, well-publicized fraud and abuseinvestigations, and large monetary penalties from

government led to the universal recognition byemployers of the need to manage ever-growingpsychiatric benefits. These problems of the 1980scentered around hospitalization of adolescents andsubstance abuse (28-day programs especially).The impact of managed care was much broaderand more dramatic for psychiatry than the rest ofmedicine. In the decade of 1988 to 1998, onestudy demonstrated for private employers a55 percent reduction for mental health benefitsin contrast to a seven-percent reduction for generalhealth care benefits (3). Access to psychiatrichospital care was greatly restricted; many patientshad to shift to public programs such as Medicaidand Medicare to continue having any level ofexpensive psychiatric hospitalization. In addition,care was restricted to psychiatrists for medicationmanagement visits (often of brief duration) andpsychotherapy limited to a handful of visits. Bothinpatient and outpatient benefits for psychiatriccare declined dramatically, and all of this occurredin the era of ever-expanding parity.

Parity for mental health services has been therallying cry for patients and the professions foralmost 20 years. In the past few years, paritylegislation has passed in numerous states, and anational parity bill based on annual and lifetimebenefits passed the United States Congress in1996. Parity, however, underscores the politicalfailure of managed care.

The strategy of providing comprehensive,non-discriminatory “parity” benefits on the onehand while insisting on strict managed care bythe behavioral health care carve-out companieson the other has undermined the trust betweenpatients, their clinicians, and the government. Ithas confused everybody on the workings of thesystem, and infuriated many. Now the rallyingcry in state legislatures throughout the country isfor “non-discriminatory utilization review,” andbehavioral carve-out companies are now in retreatdue to the outcry of patients, families, and media

PSYCHIATRY AFTER MANAGED CARESteven S. Sharfstein, M.D.

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exposés of the consequences of managed caredenials. Panels of clinicians are being broadenedeven as more and more clinicians refuse to takemanaged care fees. “Phantom networks” are acommon complaint of patients trying to find aclinician on one of these panels. What will bethe role of psychiatrists in an emerging brave, newmarketplace after managed care?

In order to predict and ascertain the role forclinician and administrative psychiatrists in thisemerging era, it is useful to review various rolesof the other power centers in the health careindustry that impact on the financing of psychiatriccare. These sectors include employers, insurers,government, and consumers.

The fact that in America employers retain acentral role in the design and financing of medicalcare is an historical accident reinforced byextraordinary tax subsidies and a bygone era oflifetime employment. Who would design auniversal health insurance system today thatplaced the CEOs of major corporations,entrepreneurial capitalists, and small businessowners in charge of health benefits for the greatmajority of Americans? And yet, that is the rolethey continue to have. Let’s not forget that it wasemployers who sought to control the costs ofhealth and mental health care by moving millionsof employees into health maintenanceorganizations and hired the for-profit behavioralhealth care carve-out companies. Now faced withthe threat of litigation and the backlash of veryangry employees and their unions, employers areretreating from managed care and embracing anapproach that provides information and incentivesfor employee choice combined with more costsharing on their part as the primary method ofemployer health benefits policy.

Insurance and the insurance industry wereinvented to pool risks and spread them across abroad population, predict cost trends, and setpremiums. They play a significant role in thedesign and pricing of various products thatconsumers are encouraged to buy. They played

a major role throughout the 1990s in creatingmanaged care mechanisms for employers andgovernment to control health care costs. Theycould not control the major epidemiological andcultural trends that created this strong consumerbacklash, epitomized in popular media and nowleading to a federal Patient’s Bill of Rights.Insurers no longer want to be the bad guys andare trying to identify their true customer (theindividual consumer) and want to facilitate ratherthan frustrate consumer choice.

Government plays the role of the employerin providing health benefits for those who are notemployed (the elderly, retirees, and the poor) andalso serves as a major insurer through theMedicare and Medicaid programs. Governmenthas an important role in ensuring the safety andeffectiveness of medical treatments, underwritingresearch and training, limiting fraud and abuse,but because of the nature of democracy, they arenot in a good position to dictate who gets what,from whom, and how much. Politicians havediscovered that to be in favor of managed care isone way of losing elections. The backlash to theClinton health proposal of the early 1990s showedthe natural American reluctance to concentratepower and authority in Washington, DC, for thefinancing and delivery of health care.

And so we are left with consumers who wantto direct their own health care, financiallysubsidized by employers and government. Theseconsumers have been empowered by the newinternet-based information revolution, directconsumer advertising by pharmaceuticalcompanies and other health care providers, andhave much greater access to the latest informationon the science and art of medicine. They alsowant advice from their physicians, but more andmore want to retain final authority over theirmedical decision making.

So then what is the role of physicians, inparticular physician psychiatrists, in this new era?

The natural role of the physician is being anadvocate for the doctor-patient relationship;

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serving as an agent of the patient; and offeringinformation, advice, services, and support.Physicians naturally advocate for more resourcesto be devoted to health care, especially for theirpatients, and do not want to consider the patientswho are not in their office as well as the balancingof patients’ needs with other economic prioritiessuch as education or national defense. Physicianorganizations that try to manage care have beenconspicuous failures in the marketplace ofmanaged care. What about the future ofpsychiatrists in the new post-managed caremarketplace?

The Adaptation of PsychiatristsPsychiatrists have been improving their

position in the non-managed, private, out-of-pocket marketplace. Many Americans havediscretionary income where they can afford topay $2,000-$20,000 a year for outpatient mentalhealth care. Psychiatrists with the competitiveadvantage of being able to provide bothmedication and psychotherapy in a variety ofsubspecialty arenas have thrived, especially inthose areas of the country where there is a shortageand clear need. This has been especially true inthe subspecialty of child and adolescentpsychiatry.

Further, the robust epidemiology of mentalillness simply cannot be “managed away.” Evenwithin the insured and managed care marketplace,there are many opportunities for psychiatrists tothrive and grow. The emerging trends in the healthcare marketplace to develop highly-subspecialized enterprises (“niche” services) ledto the creation of diagnostic-specific treatmentcenters such as for anxiety affective or obsessive-compulsive disorders as well as specialized carefor children, adolescent, and geriatric patients.Combining psychotherapy and psychopharmacol-ogy as part of a comprehensive treatment plan,working closely with primary care practitionersand other mental health professionals, demandfor skilled psychiatric clinicians currently and forthe foreseeable future exceeds the supply.

Psychiatrists are clinical innovators, working

with patients in the public sector, caring for spe-cial populations such as children under MedicalAssistance or AIDS patients, developing specialinitiatives to reduce Workmen’s Compensationpayments and dealing with the tremendous coststo employers of worker disability, forensics suchas child custody work and medical legal services,children with emotional and learning disorders atschool at all ages, prevention programs such assmoking cessation, wellness programs, stressmanagement. All are examples of recent inno-vations led by psychiatric clinician entrepreneurs.

Psychiatrists are also natural leaders of teamsand systems of care. Again, with the robustepidemiology, there is the need for many differentdisciplines and subspecialties in trying to deal withthe large number of Americans who can benefitfrom effective psychiatric intervention.

Psychiatrists perform leadership roles in avariety of managed and unmanaged settings, andwill continue to do so.Psychiatrists have always worked in more thanone setting and will continue to have a variety ofopportunities to treat patients and deal with thepublic health needs of communities (4).

Final CommentRecently, Robinson asserted that “the

consumer era in health care is emerging due tothe rejection of governmental, corporate, andprofessional dominance” (1:p 2628). We’ve seenrecently the power of the consumer to shape themanaged care marketplace in the strong push fora Patient’s Bill of Rights in the Congress.Consumers definitely want quality care and value,that is, high quality tempered by costconsiderations. Psychiatrists as physicians mustbe relentless advocates for quality. How that’sdefined in the marketplace and who defines it isa political issue that will pit psychiatristsagainstinsurance and managed care interests andpossibly the government in the next few years.Working closely with employers to understandtheir needs and their definition of quality as wellas paying attention to patients as “customers” willhelp psychiatrists lead the march toward

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developing quality standards and systems of care.The practice guidelines will then replace medical-necessity decisions by third- and fourth-partyreviewers. The Hippocratic Oath compelsphysicians to put their patients’ needs first andforemost. Leadership in the health caremarketplace requires psychiatric leaders to assertthemselves with renewed vigor beyond theimmediate necessities of income and practice.

Dr. Sharfstein is Medical Director and CEO ofthe Sheppard and Enoch Pratt Health System,and Clinical Professor of Psychiatry at theUniversity of Maryland Medical School,Baltimore, Maryland.

References1. Robinson JC: The end of managed care.

JAMA, 285:2622-2628, May 23/30, 2001.2. Iglehart JK: Managed care and mental

health. N Engl J Med, 334:131-5, 1996.3. Hay Group for the National Association of

Psychiatric Health Systems, AssociatedBehavioral Group Practices, NationalAlliance for the Mentally Ill. Health careplan design and cost trends: 1988-1997.Philadelphia, PA 1998.

4. Sharfstein SS, Schreter R: Psychiatrists inthe new medical marketplace. Journal ofPractical Psychiatry and Behavioral Health,5(4):132-142, May 1999.

CALL FOR PAPERSThe Psychiatrist Administrator invitesarticles on all areas of psychiatricadministration and management with a focuson the roles and perspectives of psychiatristsin leadership and management roles. Pleasemake submissions and inquires to:

Sy Atezaz Saeed, M.D., EditorPsychiatrist AdministratorDepartment of Psychiatry & BehavioralMedicineUniversity of Illinois College of Medicine@ Peoria5407 North University Street, Suite CPeoria, Illinois 61614-4785Tel: (309) 671-2165Fax: (309) 691-9316E-mail: SASaeed@UIC.Edu

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Welcome! New Members

August 2001

Morton Albert, M.D.Tiffany Ho, M.D.

September 2001

Adekola O. Alao, M.D.Mustafa Hussain, M.D.

Marianne Klugheit, M.D.Eric Lavender, M.D., MPH

Nurun N. Shah, M.D.

Psychiatry is a unique medical discipline.More than any of our sister medical specialties,we in psychiatry extend our practice into areasof habilitation and rehabilitation, social controland individual development.1 For many of ourpatients, effective care requires that we accessand work with families, the schools and theworkplace.

Psychiatrist administrators working in publicsector settings always have been involved inmanaging care. Our work in attempting toorganize a panoply of services to treat andrehabilitate our patients is constrained byrelatively fixed budgets and fixed expenses(personnel costs, contracts for services, etc.).Within constraints we struggle to meet the needsof those we serve.

Increasingly the term “managed care” withinpsychiatry has come to represent the effort ofcorporations, largely in the for-profit sector, toconstrain expenditures for psychiatric services,and through that process to generate profit. Themajor strategies utilized include discountedpayments to providers, limiting use of servicesand provider substitution strategies. Thedevelopment of information systems (IS) hasprovided an infrastructure for managed care. Butefforts to use IS to support clinical psychiatriccare remain limited.

Sharfstein in his informed and well-writtenarticle notes that an accident of history has givenindustry, abetted by government, the major rolein providing for health care benefits throughinsurance programs. But while corporations maybe “retreating from managed care and embracingan approach that provides information andincentives for employee choice combined withmore cost sharing”, they will surely seek newdirections if these strategies fail to keep costs fromrising once again.

Sharfstein identifies the growth of an

Commentary on Dr. Steven S. Sharfstein’s Paper,“Psychiatry After Managed Care”

Boris M. Astrachan, M.D.increasingly informed and assertive consumermovement, and sees promise in working togetherwith employers, consumers and government toenhance quality, to develop practice guidelines.

He describes how we in psychiatry adapt to achanging environment, dealing with thatpopulation which can afford to pay for care,seeking niche opportunities and working todevelop quality standards. He helps usunderstand where we are going in health care,and what are the opportunities.

Sharfstein identifies the reluctance ofgovernment to engage in meaningful discussionon the shape of health care and issues of accessand cost. Such failure is a failure of government’sobligation to address the needs of the uninsuredand underinsured members of our population.Such a failure of obligation reflects the absenceof our national will to provide at least minimalhealth care coverage for all.

And in the face of government’s failure, whatof our obligations? Psychiatrist administratorswho serve public sector patients have theobligation to act prudently in the political worldto attempt to support the needs of those whorequire our services; to seek alliances with othergroups in this process, and to press for greaterdiscourse about the needs and responsibilities ofthose we serve. We have professional obligationsto question what we do. There is always more tolearn, more to do and new ways to organize ourservices. Sharfstein addresses the what is, andonly touches on our obligations. We are notwithout influence if we chose to speak for care.But our obligations to patients and professionwould also insist that we need engage in a largerdialogue about managing care.

As psychiatrist administrators andpractitioners, we too often act as if we do notknow what services our patients require as wellas what they want. And at times we seem to

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forget the importance of understanding theecological context in which care is delivered.Substance abusing patients generally requirespecialized services and coordinated care withother physicians. Depressed patients who do notrapidly respond may need medication andassessment for group treatment. Schizophrenicpatients may be well served by working withfamily members and through referral to AssertiveCommunity Treatment programs. Practitionersand psychiatric programs and facilities haveobligations to engage with patients in managingcare. Managing the use of these specializedservices raise questions about privacy andconfidentiality. How can we best respectlegitimate individual rights and concerns whileproviding enhanced services? How do we useinformation systems to enhance quality? We needto think about and address such questions.

We have the obligation to develop enhancedinformation systems so that our programs maybecome more effective as well as more efficient.And a further obligation to identify how suchsystems may legitimately link to other data, sothat children may be better served not only in ourpractice, but in the schools, etc. We haveobligations to our employees, to keep themlearning, to keep them focused on service to

others, and to see that they are adequatelyrewarded. And we have an obligation toourselves, our profession and our patients toengage in dialogue about patient needs, treatmentstrategies, and how we may improve what wedo.

And when we cannot deliver all of the servicesthat we should (regardless of the reasons), wemust seek such consolation as we can from theknowledge that we have sought to utilize ourresources as best we can, to serve those who areour patients; that we have tried to serve ourorganizations, profession and employees well.These are, and have always been our obligations.As psychiatrist administrators, we need to beleaders in managing care.

Dr. Astrachan is Distinguished ProfessorEmeritus of Psychiatry at the University of IllinoisCollege of Medicine, Chicago, Illinois.

Reference

1. Astrachan BM, Levinson DJ and Adler DA.The impact of national health insurance onthe tasks and practice of psychiatry.Archives of General Psychiatry 33:785-794,1976.

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During the past decade, the quest for mentalhealth parity has intensified on both the state andfederal levels. Part I of this review brieflychronicled the history behind efforts at the federallevel, up to the passage of the Mental HealthParity Act of 1996. Part II begins with anoverview of the Act, examines the state of paritysince the bill’s implementation, and takes a lookat more recent initiatives.

THE MENTAL HEALTH PARITYACT OF 1996

President Clinton signed the Mental HealthParity Act of 1996 into law on September 26,1997, and with the leadership of Senators PeteDomenici (R-NM) and Paul Wellstone (D-Minn),this landmark law received unprecedentedbipartisan support. The parity provisions did notcompletely eliminate discriminatory coverage,however, it nonetheless represented an historicfirst step toward equalizing health insurance plancoverage for treatment of mental illnesses andother medical conditions.

Key ProvisionsThe Mental Health Parity Act of 1996

amended the Employee Retirement IncomeSecurity Act (ERISA) and the Public HealthService Act. The law equalizes aggregate lifetimelimits and annual limits for mental health benefitswith those for medical and surgical benefits(Typical caps for mental illness coverage are$50,000 for lifetime and $5,000 for annual, ascompared with $1 million lifetime and no annualcap for other medical disorders). The law coversmental illnesses (i.e., “mental health services,”as defined under the terms of individual plans); itdoes not cover treatment of substance abuse orchemical dependency. Existing state parity lawsare not preempted by the federal law (i.e., a statelaw requiring more comprehensive coverage isnot weakened by the federal law, nor does it

PERSPECTIVE ON PARITY: PART II*Steven Kouris, DO, MS, MPH

preclude a state from enacting stronger paritylegislation). The law applies only to employersthat offer mental health benefits; it does notmandate such coverage. The law allows for manycost-shifting mechanisms, such as adjusting limitson mental illness inpatient days, prescriptiondrugs, outpatient visits, raising co-insurance anddeductibles, and modifying the definition ofmedical necessity. (Therefore, lower limits forinpatient and outpatient mental illness treatmentsare expected to continue, and in some cases,actually expand to help keep costs down.) Thelaw applies to both fully insured state-regulatedhealth plans and self-insured plans that are exemptfrom state laws under ERISA. It has a smallbusiness exemption which excludes businesseswith 50 employees or less. The law allows anincreased cost exemption; employers that candemonstrate a one percent or more rise in costsdue to parity implementation will be allowed toexempt themselves from the law. Also includedis a directive to the NIMH Advisory Council toprepare yearly reports on the impact of parity.The law took effect on January 1, 1998, andexpires on September 30, 2001.

What’s not coveredThe Mental Health Parity Act of 1996 does

not provide a mandate for mental health benefitsto be offered in health insurance plans; coveragefor treatment of substance abuse or chemicaldependency; rules for service charges, such asco-payments, deductibles, out-of-pocket paymentlimits, etc.; designations for the number ofinpatient hospital days or outpatient visits thatmust be covered; coverage in connection withMedicare or Medicaid; restrictions on a healthinsurance plan’s ability to manage care; orprovisions for business with 50 or feweremployees.*Part-I of this article appeared in our previous issue(Psychiatrist Administrator, Vol. 1, Issue 2, pp. 38-42)

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POLICY PERFORMANCEThe primary purpose of parity legislation is

to ensure the availability of services by removingthe disincentive to seeking treatment that limitedcoverage produces. Moreover, the greateravailability of comprehensive and flexibletreatment options holds the promise of more cost-effective treatment. This in turn can be expectedto reduce medical costs, disability costs and avariety of indirect costs to society. Additionalimportant benefits sought from mental healthparity include reduced discrimination and socialstigma, reduced financial burden on consumers,and prevention of adverse selection for thosehealth plans and public service organizationsalready providing care for the most severelyaffected populations.

Despite concerns by opponents that the costsassociated with adopting parity are necessarilyhigh, recent studies and early experiences withparity have proven this assertion incorrect.According to the 1999 study, Effects of the MentalHealth Parity Act of 1996, the effects are positive,with employer sponsored health plans reportingminimal or nonexistent cost increases. As a result,the majority had not taken nor planned anycompensatory actions to control costs. Improvedsubstance abuse coverage was an unintendedbenefit reported by many plans responding to thesurvey.

A subsequent report by the U.S. GeneralAccounting Office (GAO) last year indicated 86%of employers reported full compliance with thenew law by the end of 1999. Employee access tomental health services was not reportedly altered.While compliance with dollar limits of coveragehas continued to climb, some plans have counteredwith more restrictions on the number of coveredhospital days and office visits, or other benefitdesign features. Only 3% of employers report thatcompliance with federal parity has increased theirclaims costs. None have dropped mental healthbenefits. Published estimates of costs associatedwith federal parity are typically less than 1%. Instates with the most comprehensive parity laws,

estimated cost increases range from 2 to 4%.Opinion on whether the Mental Health Parity

Act of 1996 was truly successful varies in largepart on the observer’s perspective regarding theintent of the bill’s passage. If the bill had beensubstantially stripped of its teeth by the politicalprocess, why was its passage still viewed as suchan important step? Supporters, including manylegislators motivated by family or personalstruggles with mental illness, believed that tosupport parity was to begin to reverse adiscriminatory and unjust situation. The NationalAlliance for the Mentally Ill (NAMI) and othermental health advocacy groups believe that theparity issue is less about health care than aboutcivil rights. Viewed in that light, the passage ofthis bill had very important symbolic impact. Italso was an acknowledgement of the incrementalnature of policy change. Passage of the bill, itwas hoped, could lead to a change in the nationalview of mental disorders and create a climate inwhich further changes are possible.

One measure of this effect is the subsequentpassage of parity laws at the state level. In 1996,only 6 states had parity laws for mental health orsubstance abuse. Currently 32 states have paritylaws and virtually all are expected to have someform of legislation soon. There is, however,considerable variation in how individual statesdefine eligibility standards and set servicelimitations. Parity in Maryland, for example,includes all mental and substance abuse disorders,while New Hampshire’s law specifies coverageonly for severe biologically based mentaldisorders. Exemptions also vary from state tostate. Maryland’s parity law excludes companiesthat are self-insured or that have fewer than 50employees.

The economic impact of implementing stateparity laws is beginning to appear in the literature.Minimal increases in annual costs are reported inCalifornia, Colorado, Minnesota, andPennsylvania, whereas decreases are seen inMaryland, North Carolina, and Texas. At the sametime, service access and utilization are reported

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to have been enhanced. Also worth noting is thegranting of mental health parity to millions offederal employees by the Clinton administration.This affects health plans all over the country andis a critical and large pilot for mental health parity.Unfortunately, implementation problems underthe Bush administration have thus far served onlyto frustrate providers.

The fear of high costs associated with theimplementation of parity led to the watering downof the original federal parity bill and still hamperslegislative efforts at state and federal levels. Earlyestimates of skyrocketing (over 10%) costs werebased on what is now considered inappropriateeconomic and actuarial models. Recent empiricalstudies and economic simulations show thatwithin a managed care environment any increasedcosts of parity are modest and access to care isincreased. A 1998 NIMH-supported study byHarold Varmus reported that: (1) in systemspreviously using managed care, implementingparity results in less than 1% increase in costs;(2) in systems that introduced parity and managedcare together, costs actually went down; (3)introducing parity in any system leads to increasedmanaged care activity.

The Washington Business Group on Healthhas reported on the experiences of eight largeemployers, representing 2.4 million covered lives,who early on had made the decision to offergenerous mental health benefits (consistent withthe current definition of full parity) and continuethis practice because they believe that it is actuallyhelping their “bottom line” by decreasingabsenteeism, disability payments, and lostproductivity. Using an even broader perspective,Burnam and Escarce reported that despite theonset of parity during the late 90’s, the escalationof costs due to mental health coverage in amanaged care environment slowed to such adegree that the actual percentage of an HMO’scosts devoted to mental health care was only 3-5% vs. 10% for the overall health care budget.Thus, mental health parity laws did not cause amassive increase in dollars spent. In fact, the

major effect of parity might only have been toincrease the use of managed care cost-containment practices.

Other investigators have looked at the effectsof parity on access to mental health care in adifferent manner. Rather than focusing on dollarsspent on mental versus physical health care, theyreported on changes in the types of servicesprovided in the new parity plus managed careenvironment. Mechanic and McAlpine (1999) areperhaps the only investigators to address the issueof whether managed health care plus parity, hasaffected not only frequency of visits but also otheraspects of care. These authors confirm that dollarsspent on behavioral health care are decreasing asa percentage of employers’ health costs. Theypoint out that it is hard to square this decrease inspending with the large body of data that showpoor, inadequate treatment for most mentaldisorders in most systems. Nonetheless, they statethat dollars spent is not a good proxy for quality.The authors do point out that the greatest overallreduction in inpatient days occurred in the areaof mental health. This might arguably have beenappropriate. However, these reductions in daysdo not seem to relate to severity of illness. Onewould also expect reductions in inpatient care tocorrelate with increases in alternative (i.e.outpatient, residential) means of care. In one case,a large employer using a behavioral health carve-out plan was shown to substantially increaseoutpatient payments and to modestly increaseresidential care payments during a period ofdeclining inpatient use related to managed care.Studies of other managed care plans, however,showed significant decreases in overall utilizationof mental health services, including number ofoutpatient visits, despite dramatic decreases ininpatient care. Moreover, decreases were alsoseen in outpatient visits for the most severelydisordered. Thus, parity laws, by triggeringincreased managed care cost-containment activity,might have actually decreased the amount of careprovided for mental disorders. Interestingly, thereis no clear evidence of decreased usage leading

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to poorer outcomes. The few data available onlyhint at this possibility. If one measures the impactof mental health parity law on increasing accessto mental health care, one would have to concludethat the 1996 federal law has achieved no benefit.

Recent Federal EffortsSenator Domenici and other staunch

proponents of mental health parity did not simplyaccept the compromise legislation and forgetabout the parity issue. Efforts to amend the federalparity law have continued. In March, SenatorsDomenici and Wellstone introduced The MentalHealth Equitable Treatment Act of 2001 (S. 543).This bill would require health plans that offermental health coverage to provide full paritybetween mental health and other health servicesby prohibiting unequal treatment limits orfinancial requirements. Specifically, it preventsthe use of more restrictive limits on hospital daysor outpatient visits, and higher co-payments ordeductibles or out-of-network charges. It alsoeliminates the exemption currently permitted foremployers who show more than a one percentrise in premiums due to compliance with parityrequirements, and it eliminates the sunsetprovision of the original 1996 Parity Act slatedto occur September 30, 2001. The bill originallydecreased the small business exemption to onlycompanies with less than 25 employees, however,in committee, this was expanded to includecompanies with 50 workers or less in order togain needed support. This bill was sent to theSenate Health, Education, and PensionsCommittee in July and unanimously approved onAugust 1, 2001. Some committee members,however, predict a contentious debate when thebill comes to the floor of the Senate.

The Medicare Mental Health ModernizationAct of 2001 was introduced April 4th into boththe Senate (S. 690) and the House (H.R. 1522)by Senator Wellstone and Representative Starkrespectively. These identical bills establish parityby amending title XVII (Medicare) of the SocialSecurity Act to provide for elimination of the

current 190-day lifetime limit on inpatientpsychiatric care and a reduction of the 50% co-payment (to 20%) for outpatient treatment. In anattempt to increase access to community mentalhealth services it ensures coverage of intensiveresidential services under Medicare part A andintensive outpatient under part B. It also providescoverage of marriage and family therapist andmental health counselor services under Medicareand excludes clinical social worker services fromcoverage under the Medicare skilled nursingfacility prospective payment system. Both billsare currently in committee.

Another related proposal was introduced intothe House in January by Representative Roukema.The Mental Health and Substance Abuse ParityAmendments of 2001 (H.R. 162) amends thePublic Health Service Act, Employee RetirementIncome Security Act of 1974 (ERISA), and theInternal Revenue Code of 1986 to prohibit healthplans from imposing unequal limits on coverageof not only mental health services but alsosubstance abuse/chemical dependency services.This measure was referred to committee whereno action has yet been taken.

Finally, mental health parity has become anintegral part of a more sweeping effort at healthcare reform. In recognition that the United Stateshas the most expensive, but not necessarily themost cost-effective, efficient, comprehensive, orequitable health care system in the world, thereis a concurrent resolution before the House ofRepresentatives (H. CON. RES. 99) introducedby Rep. Conyers and over two-dozen colleagues,directing Congress to enact legislation by October2004 that provides access to comprehensive healthcare for all Americans. It states:

Resolved by the House of Representatives(the Senate concurring), that the Congressshall enact legislation by October 2004 toguarantee that every person in the UnitedStates, regardless of income, age, oremployment or health status, has access tohealth care that—

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(1) is affordable to individuals and families,businesses and taxpayers and that removesfinancial barriers to needed care;(2) is as cost efficient as possible, spendingthe maximum amount of dollars on directpatient care;(3) provides comprehensive benefits, includingbenefits for mental health and long term careservices;(4) promotes prevention and early intervention;(5) includes parity for mental health and otherservices;(6) eliminates disparities in access to qualityhealth care;(7) addresses the needs of people with specialhealth care needs and underserved populationsin rural and urban areas;(8) promotes quality and better healthoutcomes;(9) addresses the need to have adequatenumbers of qualified health care caregivers,practitioners, and providers to guarantee timelyaccess to quality care;(10) provides adequate and timely paymentsin order to guarantee access to providers;(11) fosters a strong network of health carefacilities, including safety net providers;(12) ensures continuity of coverage andcontinuity of care;(13) maximizes consumer choice of health careproviders and practitioners; and(14) is easy for patients, providers andpractitioners to use and reduces paperwork.

ConclusionPotential benefits from adopting parity

legislation appear to outweigh the economic risksinherent in expanded coverage. Successfulexperimentation among the States adds a degreeof comfort for legislators who are skeptical ofprevious study results. Within the context of largerhealth care reforms, momentum is now growingrapidly in Congress for passage of more extensivefederal measures during this session. As thestreams of health policy formulation, agenda

setting and years of advocacy merge into a strong,unrelenting force, a window of opportunity forsignificant health policy change has developed.Another perfect storm may be upon us.

Dr. Kouris is with the Department of Psychiatry, Universityof Illinois College of Medicine at Rockford, Illinois.

Sources1. Burnam, M.A. & Escarce, J.J. (1999). Equity in

Managed Care for Mental Disorders: Benefit parity isnot sufficient to ensure equity. Health Affairs, 18(5),22-31.

2. Congressional Bills: 107th Congress.U.S. Senate. S. 543, Mental Health EquitableTreatment Act of 2001.U.S. Senate. S. 690, Medicare Mental HealthModernization Act of 2001.U.S. House. H.R. 1522, Medicare Mental HealthModernization Act of 2001.U.S. House. H.R. 162, Mental Health and SubstanceAbuse Parity Amendments of 2001. ONLINE. GPOAccess. Available: http://www.lib.ncsu.edu/stacks/gpo/<107th Congress>. [August 2001].

3. Goldman, W., McCulloch, J., Cuffel, B., and Kozma,D. (1999). More Evidence for the Insurability ofManaged Behavioral Health Care, Health Affairs, 18(5),172-181.

4. Levin, B.L., Hanson, A. & Coe, R. D. Mental HeathParity; National and State perspectives 2001: A reportto the Florida Legislature. Tampa, Florida: The Louisde la Parte Florida Mental Health Institute, July 2001.

5. Mechanic, D. & McAlpine, D.D. (1999). MissionUnfulfilled: Potholes on the Road to Mental HealthParity, Health Affairs, 18(5), 7-21.

6. NAMI Home Page http:// www.nami.org Parity inInsurance Coverage, The NAMI Position.

7. Sturm, R., and Pacula R.L. (1999). State Mental HealthParity Laws: Cause or Consequence of Differences inUse? Health Affairs, 18(5), 182-192.

8. United States General Accounting Office: MentalHealth Parity Act: Despite New Federal Standards,Mental Health Benefits Remain Limited. Rockville,MD: The Office, 2000 (May).

9. Varmus, H.E. Parity in Financing Mental HealthServices: Managed Care Effects on Cost, Access, andQuality, Interim Report to Congress by the NationalAdvisory Mental Health Council, May 1998.

10. Washington Business Group on Health. Report to theOffice of Personnel Management: Large EmployerExperiences and Best Practices in Design,Administration, and Evaluation of Mental Health andSubstance Abuse Benefits. March 2000.

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ETHICS COLUMN

Is There An Ethical Way?Column Editor: H. Steven Moffic, M.D., Chair, Ethics Committee

COLUMN INTRODUCTION:At the end of our last column, we presented

an ethical question posed by Lawrence Beasley,M.D. That question will be the one discussed inthis issue’s column, along with the comments andexample which Dr. Beasley connected to thequestion.

ETHICAL QUESTION:Dear Dr. Moffic:

As is usually the case for Ethics Committees,there are typically more questions than answers.Please add the following one to your list:

Shouldn’t psychiatrists or psychiatricadministrators (note which comes first in this title)not administrators or similar non-medicalregulators make decisions on clinical care?

Much of what drives quality care in Psychiatryis the time we are able to devote to each patient.Administrators and fiscally driven systems willencourage (if not coerce or require) physicians tosee as many patients in as short amount of time asthey are willing to do. This decreases the quality ofcare and also removes the pressure on the system tochange and improve. Psychiatrists must, thereforebe the gatekeepers, or in essence dam-keepersagainst this flood of patients in order to preservequality care. To succumb to these pressures andconsequently condone this level of care is, it wouldappear – unethical.

Perhaps the Ethics Committee of the AAPAcould put forth specific recommendations regardingreasonable time allotments.For Example:

A new patient to require at least one (1) hourfor evaluation (1½ preferably) and a typicalfollow-up to be at least thirty (30) minutes. Afifteen (15) minute medication check shouldbe reserved for only the few most stable patientson maintenance therapy only.

Let’s float this for comment.

RESPONSE 1:Dear Steve:

Decisions about clinical care should be madeby physicians, and in mental health settingspreferably by psychiatrists, or by psychiatristswho are acting as Psychiatric Administrators.Time is an integral part of a psychiatrist’s, or anyother physician’s, interaction with the patient.While it is true that fiscally-driven systems willencourage physicians to see as many patients aspossible in a short time, it is the responsibility ofthe physician to make sure that adequate time isdevoted to each patient so that an evaluation canbe made, appropriate therapy can be delivered,questions can be answered, medications can beprescribed, possible side effects can beanticipated, the treatment plan can be updated,and future treatment can be planned. It is theresponsibility of the physician (psychiatrist, orother clinician) to preserve the quality of care forthe patient.

Physicians are sometimes pressured toperform tasks that are unethical. This wouldinclude such things as writing prescriptions forpatients that they have not seen, seeing patientswithout having adequate time for carefulassessment, signing off on the care of non-physician clinicians when they are not adequatelysupervising these clinicians, or acting assupervisors for other clinicians when they, in fact,are not doing so. This would only be a partiallist.

It would seem to me quite difficult to evaluatea new patient in less than an hour. Not only is theinitial session necessary for gathering information,and forming preliminary diagnoses, but also forsetting up a beginning treatment plan, establishinga rapport with the patient, and giving hope forthe future. Typical follow up visits should be forat least thirty minutes, if any psychotherapywhatsoever is to be rendered. Fifteen-minutes

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medication checks should clearly be reserved foronly the most stable patients who are onmaintenance medication therapy only, and it isunlikely that much real therapy could be done ina session as short as fifteen minutes. In fact, athirty-minute psychotherapy session wouldprobably be mostly (only?) for supportive therapy,or would involve a patient who had previouslybeen in therapy for quite a while with longersessions, such as forty-five minute sessions, andwas now reasonably stable.Sincerely,Dale M. Davis, M.D.

RESPONSE 2:Dr. Moffic:

Now to Dr. Beasley’s concerns, which arewell taken. One to one and a half hours doesindeed seem mandatory for a reasonable qualityinitial psychiatric evaluation which, I assume, alsoincludes relevant general medical history andperhaps limited assessment. All subsequentfollow-up visits MUST be at least 30 minutes;documentation has to be worked into this also.This timeframe should apply to all patients not inreasonable remission as determined by goalsagreed upon at the time of the initial evaluation.In fact, the first several of these 30 minutes visitswould probably involve further historyclarification as well as issues related to treatmentper se. I don’t see how we can deliver the requiredempathic dynamic verbal interchange withpatients more rapidly. To do so would force usto abdicate roles for which we have been trained,roles that set us apart from all other physiciansand which our patients expect (whether they areconsciously aware of it or not). Fifteen minutesessions would be only for patients clearly inremission, but who require long term follow-upand medication over time.—Roy Varner, M.D., Professor, UT MedicalSchool, Houston, Harris County PsychiatricCenter

RESPONSE 3:Dear Steve:

With regard to the question that Dr. Beasleyraises in his letter, my main focus would be tomake a clear distinction between clinical decision-making and administrative decision-making.There is no question that at times they come inconflict and because of this it is probably advisablenot to make one person responsible for both. Inone sense, this is the same conflict that comes upwhen a treating psychiatrist is asked to write anoccupational evaluation.

On time issues, it is always most advisable toemphasize quality of care and not get caught upin bottom line issues other than to say someoneelse has to make those decisions.

I hope this will be of some help and thesuggestion Dr. Beasley makes is too general sincepsychiatry is such a heterogeneous field. Thereare reasonable differences of opinion as well asinstitutional differences.Very truly yours,Gerald H Flamm, M.D.

RESPONSE 4:Dear Steve,RE: Shouldn’t psychiatrists or psychiatricadministrators not administrators or similar non-medical regulators make decisions on clinicalcare?”

I think there is no question of generalagreement on this point, whether from clinical ornon-clinical staff members in a system; thedifficulties seem to come in implementation ratherthan principle, particularly in the practicaleconomics of time allotment per patient perclinician, on which the most stringent pressuresgenerally fall on the psychiatrist; i.e., the personwith the most knowledge and experience, theleader of the treatment team, and the person(usually and hopefully) with the prescription padand the license to use it.

This leads to the even more important issueraised in Dr. Beasley’s next paragraph and to his

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suggestion for an ethical guideline to address theallotment of specific amounts of time for services:

“A new patient to require at lease one (1)hour for evaluation (1 ½ preferably) and atypical follow-up to be at least thirty (30)minutes. A fifteen (15) minute medicationcheck should be reserved for only the fewmost stable patients on maintenance therapyonly.”

Having worked from time to time incommunity mental health clinics and been facedwith what seemed a deluge of patients, all newto me and needing record review withconfirmation of data, if not complete evaluations,I am in total sympathy with the above concerns:however, a number of variables exist which cannotbe adequately addressed by the time issue. Afew are listed below.

1. The time required for an evaluation varieswith:a. the experience and skills of the

examinerb. the setting; for example, a quiet room

with adequate furnishings andventilation with no interruption mightshorten considerably the time required

c. preliminary work by other clinicians,its format, their expertise, reliability,and the legibility of their reports

d. patient factors such as coherence,intellect, cooperation

2. Time and economics fail to mesh whenthe notoriously poorly-reliable consumerof public services fails to show up.

3. Availability and accuracy of dictationsystems.

Some balance should clearly be negotiatedon an individual basis to allow adequate time forthe psychiatrist to fully and ethically evaluate thepatient, but I believe this is as a “free-standing”principle cannot be addressed as such.

We are left therefore with the content of thepsychiatric evaluation as a measure of medical,psychiatric, and administrative ethics. This

important issue is included, if not specified, in anumber of areas; first of all, in our allegiance toour patients addressed in Section 1: “A physicianshall be dedicated to providing competentmedical service with compassion and respect forhuman dignity” – we cannot provide care withoutadequate evaluation and information and there isno such thing as a “medication check” withoutthose two essential elements; then by thePRACTICE GUIDELINES FORPSYCHIATRIC EVALUATION, which defines(or suggests, if your prefer) the components of apsychiatric evaluation in a concise and easilymeasured format; thirdly, in the very core ofpersonal and medical ethics stated in Section 2:“ A physician shall deal honestly withpatients….”Yours, truly,June A. Powell, M.D.

RESPONSE OF EDITOR:Dr. Beasley’s query seems to bring up at

least two important ethical questions, which seemrelated to one another . Let’s address them oneby one.

1) Who should make the final decisions onclinical care, the clinical psychiatrist, apsychiatric administrator, or a non-medical administrator?

While our Ethical Principles for PsychiatricAdministrators only address the role of thepsychiatric administrator, it does imply what theanswer should be. The Preamble and itsconnected Annotation put the needs of the patientas the first priority. Therefore, who is in the bestposition to address these needs? While it mayseem self-evident that the person to do so wouldbe the clinical psychiatrist, since the psychiatristwould either have seen the patient and/orsupervised another non-medical clinician, such aresponse does not address the issue ofaccountability and outcomes. Given figures that30% or so of health and mental health treatmenthas been unnecessary or inappropriate (Moffic,

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1997), how can “competent medical service”(Section I) be assured? Here it seems that somesystem of objective monitoring must be in place,whether that is in the office of a solo privatepractitioner or a mental health system. Themonitoring can be done in several ways: patientsatisfaction surveys, the use of published clinicalguidelines and/or medical algorithms,supervision, chart reviews, and outcome studies.Usually, a psychiatrist who is also anadministrator, would be most likely to be able toset up a relevant, objective monitoring program.In a mental healthcare system, Section 5 andAnnotation 4 would seem especially relevant.

SECTION 5“A physician shall continue to study, apply,

and advance scientific knowledge, make relevantinformation available to patients, colleagues, andthe public, obtain consultation, and use the talentsof other health professionals when indicated.”

Annotation (4). Given both the unique as wellas occasional overlap of skills and training of thedifferent mental health disciplines, the psychiatricadministrator should strive to make the most cost-effective use of the apparent strengths of eachmental health discipline.2) Is the amount of time spent with a patientconnected to quality care, and if so, should therebe specific “reasonable” time allotments fordifferent clinical visits?

While it may seem self-evident that allowing“reasonable” and enough time is the ethical wayfor quality of care, there may be more here thanit seem at first glance. Perhaps because it seemsself-evident, to the best of my knowledge (and aliterature search), there are no published studiescomparing different time frames for evaluationor medication checks (or psychotherapy, for thatmatter). The lack of such comparison is onereason that managed care was able to challengeour historical time allotments and essentiallyreduce a med check under those systems to 15minutes (with some flexibility at times for time,though not payment, given no-shows). Given this

lack of research, the onus is then on psychiatricadministrators to use whatever information iscurrently available to set up the time allotmentsin their systems. Some of our “Ethical Principles”seem relevant to keep in mind when consideringthis challenge.

SECTION 1“A physician shall be dedicated to providing

competent medical service with compassion andrespect for human dignity.”

Annotation (1) for Psychiatric Administrators.Knowing that the quality of medical services canbe affected by a wide variety of variables,including the skills of clinicians, the organizationof the delivery system, and the adequacy offunding, the psychiatric administrator will strive,though may not always succeed to do what ispossible to have competent mental health servicesin the organization. “Competent” does not meanideal services, but rather refers to the averageexpectable outcomes given the current state ofpsychiatric knowledge and available deliverysystems.

Annotation (4). To substantiate that competentpsychiatric services are being provided, thepsychiatric administrator should support and/orfoster the development of relevant outcomestudies and strive for continuous qualityimprovement.

SECTION 5“A physician shall continue to study, apply,

and advance scientific knowledge, make relevantinformation available to patients, colleagues, andthe public, obtain consultation, and use the talentsof other health professionals when indicated.”

Annotation (2). The psychiatric administratorshould stay abreast not only of general psychiatricadvances in knowledge, but also relevantadministrative, political, and business knowledgethat may influence the functioning of healthcaresystems. Information relevant to others in theorganization and to the public should be sharedwith them.

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RESPONSE 5:Here we come full circle, both back to Dr.

Beasley and also to the last issue of PsychiatristAdministrator. About two months after hisoriginal ethics question, we received this letterfrom Dr. Beasley.Dear Dr. Moffic:

After writing to you on May 11, 2001 (copyenclosed) responding to your requests for EthicsQuestions, I read the April 2001 issue of“Psychiatrist Administrator”. Coincidentally, oneof the articles was very relevant to some of mysame concerns (a copy is enclosed for yourconvenience). I would borrow this to submit asa somewhat more elaborate, nonetheless pertinentanswer to my own question.

Why not formally adopt the recommendationslisted in the article or at least consider thepossibility.Sincerely,Lawrence B. Beasley, M.D.

To encourage readers to re-read Dr. Mini’s,et al article, we won’t quote any details, exceptto say that the recommendation (among manyothers in the article) for visit times in the articleis not at all far from Dr. Beasley’srecommendations. This unexpected“coincidence” may suggest we are considering amajor ethical issue for psychiatrist administrators.

INVITATION FOR FOLLOW-UPCOMMENTARY:

But what does our readership think about thisethical question and the recommendations.Should our organization take some public standon these matters? We welcome your comments,or other ethical questions, which can be published

in an upcoming issue of the PsychiatristAdministrator.INVITATION FOR OTHER QUESTIONS:

Given the current ethical challenges that facepsychiatrist administrators, we’re quite sure thereare many more questions to deliberate. Pleasesend them to us for consideration in futurecolumns.H. Steven Moffic, M.D.1200 E. Bywater LaneMilwaukee, WI 53217FAX: (414) 456-6343e-mail: rustevie@earthlink.net

Or to our NewsJournal Editor,Sy Saeed, M.D.Department of Psychiatry & BehavioralMedicine,University of Illinois College of Medicine @Peoria5407 North University St., Peoria, IL 61614-4785TEL: (309) 671-2165FAX: (309) 691-9316e-mail: SASeed@UIC.Edu

Thanks for your interest and participation.

Reference:Moffic, H.S.: The Ethical Way: Challenges andSolutions for Managed Behavioral Healthcare,San Francisco, Jossey-Bass, 1997.

Mini, L.J.; Hantoot, M.; Patel, M.; Reed, D.;Weinstein, S.: The role of psychiatrist in thecommunity mental health center: What shouldthey do? How many do you need?. PsychiatristAdministrator 2001, 1:19-25.

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The Psychiatrist Administrator is the officialpublication of the American Association ofPsychiatric Administrators (AAPA). Established in1961, AAPA is the premiere educational, networking,and support resource for psychiatrists interested inadministration and management. The AAPA promotesmedical leadership and medical excellence inbehavioral healthcare systems, including services formental illness, substance use disorders, anddevelopmental disabilities.

The choice of “Psychiatrist Administrator” isintended to distinguish the NewsJournal from otherpublications in mental and behavioral healthadministration in terms of its focus on the roles andperspectives of psychiatrists in leadership andmanagement within evolving systems of care.

The purpose of the NewsJournal is to provide up-to-date, accurate, and easily understandableinformation to our readership and to contribute to thebody of scholarly work in the area of psychiatricadministration and management. Your article shouldbe written in a clear, straightforward style that ispleasant to read.

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they are cited in the text, with reference numbers typedas superscripts. References should be typed double-spaced beginning on a separate page after the textand acknowledgments. The NewsJournal uses theUniform Requirements for Manuscripts Submitted toBiomedical Journals (Vancouver group) as its guidefor reference style. Abbreviations of journal names mustconform to Index Medicus style; journals not listed inIndex Medicus should not be abbreviated. List all authorswhen there are no more than six; for more than sixauthors, list the first three, followed by et al.

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Authors will receive page proofs before publication.The author should return corrected proofs to FrancesRoton, Executive Director AAPA, within three daysof receipt; delays in returning proofs may result inpostponement of publication.

MANUSCRIPT SUBMISSIONManuscript submission is a representation that the

manuscript has not been published previously and isnot currently under consideration for publicationelsewhere.

Three copies of the manuscript should be sent toSy Saeed, M.D., Editor, Psychiatrist Administrator,Department of Psychiatry & Behavioral Medicine,University of Illinois College of Medicine @ Peoria,5407 North University Street, Suite “C”, Peoria,Illinois 61614-4785. The manuscript should beaccompanied by a transmittal letter giving the name,address, email address, and phone numbers of thecorresponding author. The letter should indicate thatall authors have seen and approved the manuscriptand that the manuscript has not been published or isnot under consideration for publication elsewhere. Adisk copy of the complete manuscript, including tablesand references, should also be submitted. Please labelthe disk with the name of the first author and title ofthe article and indicate what hardware and softwarewere used. You can also submit the manuscriptelectronically by sending it as an e-mail attachmentto the editor at SASaeed@UIC.Edu.

If you have any questions about specific details notcovered here, please e-mail SASaeed@UIC.Edu.

INSTRUCTION FOR AUTHORS

AAPA COUNCIL MEMBERSExecutive Committee

PRESIDENTChristopher G. Fichtner, M.D. (2001-2003)Chief Psychiatrist and Medical Services CoordinatorIllinois Department of Human ServicesOffice of Mental Health160 La Salle Street – 10th FloorChicago, IL 60601O: 312-814-2720H: 847-509-1836FAX: 847-509-1834Email: cfichtne@yoda.bsd.uchicago.edu.

PRESIDENT-ELECT AND BYLAWSCOMMITTEE CHAIRThomas W. Hester, M.D. (2001-2003)Georgia Department of Human Resources -Division of MHMR and Substance AbuseTwo Peachtree Street, NWSuite 4-130Atlanta, GA 30303-3171O: 404-657-6407FAX: 404-657-6424Email: Thester@dhr.state.ga.us

SECRETARY & MEMBERSHIPCOMMITTEE CHAIRMarc Feldman, M.D. (2001-2003)Medical Director, Center for Psychiatric MedicineVice Chair for Clinical ServicesUAB Center for Psychiatric Medicine1713 Sixth Street SouthBirmingham, AL 35294-0018O: 205-934-6737FAX: 205-975-6382Email: mdf@uab.edu

TREASURER & FINANCECOMMITTEE CHAIRWesley Sowers, M.D. (2001-2003)Medical DirectorAllegheny County Office of Behavioral Health206 Burry AvenueBradford Woods, PA 15015-1240O: 412-622-4511FAX: 412-622-6756H: 724-934-2201Email: minniemut@aol.com or sowers@sfhs.edu

IMMEDIATE PAST PRESIDENT ANDNOMINATING COMMITTEE CHAIRGordon H. Clark, Jr., M.D. (2001-2003)Integrated Behavioral Healthcare1 Forest AvenuePortland, ME 04101O: 207-761-4761H: 207-846-3683FAX: 207-780-1727Email: ghclark@maine.rr.com

COUNCILORS(including committee chairs)

David Fassler, M.D.Otter Creek Associates86 Lake StreetBurlington, VT 05401O: 802-865-3450FAX: 802-860-5011Email: dgfoca@aol.com

Shivkumar Hatti, M.D., MBA600 N. Jackson Street3rd FloorMedia, PA 19063O: 610-891-9024/104FAX: 610-892-0399Email: shiv@suburbanpsych.com

Public and Forensic PsychiatryCommittee ChairBeatrice Kovasznay, M.D., MPH, Ph.D.44 Holland AvenueAlbany, NY 12229O: 518-474-7219FAX: 518-473-4098Email: cocdbmk@omh.state.ny.us

Louis Mini, M.D.Associate Medical DirectorTinley Park Mental Health Center7400 West 183rd StreetTinley Park, IL 60477O: 708-614-4166FAX: 708-246-7581Email: louisjpsych@pol.net

Ethics Committee ChairH. Steven Moffic, M.D.Department of PsychiatryMedical College of Wisconsin8701 Watertown Plank RoadMilwaukee, WI 53226O: 414-456-8950FAX: 414-456-6343Email: rustevie@earthlink.net

Paula G. Panzer, M.D.500 West End Avenue, Suite GR-JNew York, NY 10024O: 212-799-8016FAX: 212-472-8840Email: pgp1@columbia.edu

APA LiaisonRaman C. Patel, M.D.Bronx Lebanon Hospital1276 Fulton AvenueBronx, NY 10456O: 718-901-8883FAX: 718-901-8863Email: ramancp@aol.com

Pedro Ruiz, M.D.1300 Moursund StreetHouston, TX 77030O: 713-500-2799FAX: 713-500-2757Email: pedro.ruiz@uth.tmc.edu

Steven S. Sharfstein, M.D.Sheppard &Enoch Pratt HospitalPO Box 6815Baltimore, MD 21285-6815O: 410-938-3401FAX: 410-938-3406Email: sharfstein@sheppardpratt.org

Academic Psychiatry Committee ChairWesley Sowers, M.D.Medical DirectorAllegheny County Office of Behavioral Health206 Burry AvenueBradford Woods, PA 15015-1240O: 412-622-4511FAX: 412-622-6756H: 724-934-2201Email: minniemut@aol.com or sowers@sfhs.edu

Psychiatric Practice and Managed CareCommittee ChairWilliam G. Wood, M.D., Ph.D.EVP, Chief Medical OfficerValueOptions3110 Fairview Park DriveFalls Church, VA 22042O: 703-208-8510FAX: 703-205-6749Mobil: 703-472-5415Email: william.wood@valueoptions.com

AAPA/BMS FELLOWSMarc E. Dalton, M.D.822 Williamsburg LaneCharleston, SC 29414O: 843-792-0037H: 843-769-0455FAX: 843-792-6894Email: Daltonme@muse.edu

WEBMASTERTom Simpatico, M.D.1150 Terrace CourtGlencoe, IL 60022O: 773-794-4207H: 847-835-5631Pager: 773-260-5650FAX: 773-794-4141Email: t-simpatico@nwu.edu

NEWSJOURNAL EDITORSy Saeed, M.D., M.S., F.R.S.H., ChairmanDepartment of Psychiatry & Behavioral MedicineUniversity of Illinois College of Medicine at Peoria5407 North University, Suite CPeoria, IL 61614O: 309-671-2165FAX: 309-691-9316Email: SASAEED@UIC.EDU

ARCHIVISTDave M. Davis, M.D.Piedmont Psychiatric Clinic1938 Peachtree Road, NWAtlanta, GA 30309O: 404-355-2914FAX: 404-355-2917

AACP LIAISONCharles Huffine, M.D.3123 Fairview EastSeattle, WA 98102O: 206-324-4500FAX: 206-328-1257Email: chuffine@u.washington.edu

ACPE LIAISONJohn M. Ludden, M.D.Harvard Medical School126 Brookline DriveBoston, MA 02215O: 781-259-8555FAX: 617-421-6219Email: healthcare@ludden.net

EXECUTIVE DIRECTORFrances M. RotonPO Box 570218Dallas, TX 75357-0218O: 800-650-5888H: 972-613-3997FAX: 972-613-5532Email: frda1@airmail.net

APPLICATION FOR MEMBERSHIP

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Preferred Mailing Address ___________________________________________________________________________

_______________________________________________________________________________________________

Telephone # ________________________________________________ Fax # ________________________________

Primary Organizational Affiliation ______________________________________________________________________

Position/Title _____________________________________________________________________________________

Email Address ____________________________________________________________________________________

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Applicant is invited to send a current Curriculum Vitae.

National Dues $ 40.00 Chapter Dues* $ 25.00 Dues waived for Members in Training.

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Please mail application and one year's dues (check payable to AAPA) to:

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Founded AMERICAN ASSOCIATION OF PSYCHIATRIC ADMINISTRATORS1961 "Promoting Medical Leadership in Behavioral Healthcare Systems"

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AMERICAN ASSOCIATION OF PSYCHIATRIC ADMINISTRATORS“Promoting Medical Leadership in Behavioral Healthcare Systems”

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