The People vs. Managed Care

Our analysis suggested that:

Groups 1 and 3 were likely to follow an APA presidential candidate who had experience in the organization, was expected to be involved in managed care, and considered the industry as a powerful ally.

Groups 2 and 4 were likely to follow Dr. Eist into victory.

Perusing publications of the early 1990s would show that many pro-managed care ideas were being presented at many settings, often contradicting the experience of those who were actually seeing patients.

The meeting of the American Managed Care and Review Association's (AMCRA) Managed Behavioral Health Conference in May of 1994(19) had been heralded as a gathering of those sponsoring "an established, institutionalized methodology for delivering mental health services to millions of Americans". The statements made at the conference would suggest that success was beyond doubt: "The future of behavioral health care is in universal coverage defined by integrated care delivery systems optimized for cost effectiveness with internal quality control mechanisms and which are coordinated with medical care plans."

The above required adequate access to care, adequate provisions for care, adequate understanding of quality, and adequate funding. At the same time, access was being increasingly restricted, provisions for adequate care were disappearing, studies of real quality were not being done, and payments for actual services were being reduces.

Clinicians knew that reaching a psychiatric diagnosis is a complex process that requires much more than the intervention of a non-psychiatric screener. Clinicians knew that many patients have several diagnoses at the same time. Clinicians knew that most patients need combinations of treatment. Clinicians knew that many treatments require great dedication and effort. None of this was anywhere in the managed care plans.

Communications in medical publications at that time presented another factor: "Computers have become indispensable tools for managing the rapidly growing body of medical information." For whatever reason, many started associating progress in computer communications with "progress" in managed care, as if better communications by themselves were part of managed care. The result of this confusion is that some saw the critics of managed care as "dinosaurs" who would not adapt to the communications revolution.

We all are for better communication of scientific knowledge, for better collection of clinical data, for better accounting systems and for better office practices. We are strongly against the use of computers to pry into people's privacy, to try to control people's lives, to try to separate patients from their doctors, or to try to circumvent people's right to confidential medical records.

Glowing statements by managed care companies and confusion about how progressive the adversaries of managed care were, helped limit the growth of opposition to managed care, but there were other factors:

Many physicians acquired heavy debts while attending medical school and had no desire to make trouble at a time when almost any job might appear desirable to them.

A large group of psychiatrists, namely the International Medical Graduates (IMGs) had developed an unfriendly relationship with the managed care companies. These companies often did not worry about trying to certify them (what about going all around the world looking for diplomas and other certificates), were ready to refuse them if they were not board certified, and were critical of the large number of poor, chronically ill and medically impaired patients the IMGs were treating.

The IMGs in turn found the managed care companies overbearing, rigid, unable to identify cultural differences and areas of competence, and dedicated mostly to non-medical issues related to money. Under these circumstances, there were hard feelings that forecast a permanently tense relationship between IMGs and managed care companies. It didn't help that the IMGs were rapidly becoming a major force in American medicine.

The managed care companies had helped create a new anti-medicine tool in the early 1990s: studies that tried to demonstrate that much fewer physicians would be needed in the future. The studies, based on projections by the managed care companies, predicted that, following managed care precepts, only 4 psychiatrists would be needed for each 100,000 people. This quota would suggest that in San Diego County we might do well with 100 psychiatrists. This projection gave San Diego fewer psychiatrists than those working for the University, the county and the Navy Hospital, which would leave no psychiatrists to help the remaining 2 million San Diegans. The idea sounded as harebrained as the quality assurance proposals (or non-proposals) of the managed care industry.

Physicians in the mid-1990s were not immune to the fluctuations in feelings about health care that existed in the general population. Health care was rated as the third most important issue by voters in the 1992 presidential election. Harris polls conducted between August 1994 (when 55% of Americans said health care was 1 of 2 important issues ) and April 1999 (when 10% said the same) showed much variation. In the 1998 national election-day exit survey, health care ranked as the sixth most important issue.(20)

A factor contributing to fluctuations in feelings may have been uncertainty about the consequences of managed care and lack of knowledge about potential alternatives.

The APA Annual Meeting in May 1995 provided the occasion for the consolidation of the two campaigns: Dr. Steve Sharfstein, APA Secretary, announced his candidacy to Dr. Eist. The answer, as expected, was the acknowledgement that they would run against each other.

Dr. Sharfstein had been an early participant in the debate about the future of psychiatric care, earlier as APA Deputy Medical Director, and more recently as Executive Vice President and Medical Director of the Sheppard and Enoch Pratt Hospital, as well as APA Secretary. He had written(21) that psychiatric facilities "must adapt proactively to the new managed care environment… Adapting clinical administrative structures to respond to the daily barrages of phone calls and other requests for information, communicating with onsite reviewers, and clearly and concisely justifying continued stay are critical management tasks for current and future survival."

Dr. Eist's response to managed care called for sturdy resistance, avoidance of compromise and refusal to cooperate in any managed care initiative.

The Summer of 1995 was spent by both camps in planning strategy. The observers expected Dr. Sharfstein to run as a mature APA leader with a logical right to the Presidency. Dr. Eist was to run as the anti-managed care candidate. It was to be a classical confrontation between establishment and populism, between conservative and liberal ideas, in which two opposite conceptions of the future were to be debated.

In 1995 and early 1996 the behavioral health carve-outs came to influence the patients of a large number of psychiatrists, the managed care companies consolidated their control of large sectors of health care, and their advance seemed to be unstoppable. This resulted in a progressive polarization among those who wanted to adapt and those who wanted to fight.

The campaign debates in late 1995 and early 1996 contributed to the progressive consolidation of positions. Dr. Eist's final victory was seen by his followers as an indication that the fight for the heart of the APA had been won, and the organization would take a strong anti-managed care stance.

Dr. Eist's campaigns have been considered by many as a turning point in the election of officers for the APA as he came from without the structure to gather popular support by introducing substantial issues that eventually changed the perceptions of many members.