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From the Editor

I think I know why Irish Setters are so frenetic. So many points of interest and only one nose. If I force myself to rank order my points of interest, I would start with immediate past-president Moldawsky's assertion that the tide is turning against managed care. Russ Newman's article in this issue outlines some of the reasons to hold that point of view.

Secondly, the managed care industry (aka the Merchants of Menace - that's MoM) has been shooting itself in the foot lately. The New York Times for Dec 31 ran a lead story in the business section about how Columbia/HCA crashed and burned. One paragraph reads: "ever since Federal agents began raiding Columbia hospitals with search warrants, starting in El Paso in March, and accusing Columbia of a 'systematic corporate scheme' to defraud Government health insurance programs, anxiety has plucked at the emotions of the company's 285,000 employees". As for its ability to manage cost, which everyone acknowledges to be MoM's primary mission, that isn't going well, either. The January 11 edition of the NY Times ran a front page story under the headline, "HMO PREMIUMS RISING SHARPLY, STOKING DEBATE ON MANAGED CARE."

On other fronts, President Clinton appointed a commission to draft a Patient Bill of Rights. (I hope they acknowledge Dorothy Cantor's pioneering work). Unfortunately, the commission takes as a given that managed care is here to stay and only needs to be regulated.

But there is bad news as well. Kal Heller, writing in the National Psychologists (Nov/Dec, 1997, page 14) notes that managed care as an industry had a 19% increase in covered lives last year. He also notes that three giants, Magellan, Value Behavioral Health, and Merit Behavioral Care control 50% of the market or 84 million of the 168 million Americans who are covered by managed care. MoM has a bleeding toe ro two, but that does not incapacitate a centipede.

Meanwhile, under the category of Mixed News, MoM is subjecting itself to standards of care promulgated by its own watchdog, NCQA. One of the largest behavioral health managed care companies in America, HAI, now part of Magellan, reported in its fall, 1997 house newsletter that it was adopting NCQA standards and went on to say that "Accreditation by the National Committee for Quality Assurance (NCQA) has become essential to a health plan's ability to compete in the 90s". The iron fist inside the velvet glove appears midway through the story. NCQA requires 20 items of information in patient charts. We supply that data on our own time, of course, without compensation. A final slap in the kisser is contained in their "Practice Standards" Column where they tell us what medications to sue for Panic Disorder.

Pat DeLeon, always upbeat, turns our attention back tot he good news in his column, which lets Elizabeth Cullen, JD, of the Practice Directorate, updates us on the momentum that prescription privileges have accumulated. As Pat likes to say, very impressive.

Lest the good news go to your head, let me voice my own personal version of some bad news that is quietly looming on the horizon. Russ Newman mentions that 40% of the hospitals in this country are contracting directly with payors, thus cutting MoM right out of the market. Hurry. But the hospital in my community is using its own staff network of providers, many of them undertrained and most of the unlicenced, to provide behavioral health care to the citizens covered by those contracts. This same hospital is forming alliances over a four county area with other hospitals, which are doing the same thing. The result is enormous pressure on those of us still in private practice. More than 80 primary care docs are now employees of this hospital. Some of them used to refer patients to me. Now they refer tot he hospital's own network of behavioral health care providers. The hospital is part of a healthcare holding company that numbers five entities, four of which are for-profit. It has already formed a PPO, an HMO, and a PHO (physician-hospital-organization). AS a private practitioner in the hospital's shadow, I participate only in the PPO. All of the entities in the holding company are served by the hospital's own network of behavioral health providers. This trend is sweeping the nation. Hospitals are playing King Kong to MoM's Godzilla. While the gorilla does in MoM, it will also inadvertently trample us. Anti-trust suit, anyone?

And there is more to worry about from our medical colleagues. More than half (some estimate are as high as 70%) of all psychotropic medications are handed out by primary care docs, many of whom have little training in psychopharmacology and no training in mental health. This growing trend simultaneously medicalizes mental health and trivializes our profession. The awful truth is that many of these docs have accepted capitated contracts from MoM. IF they medicate their patient's problems of living, they actually save capitated dollars fro themselves, while, at the same time, doing their patients' an enormous disservice. Never mind what they are doing to us.

Medicine was our nemesis when we were trying to win independent licensure. Now, they are not so much against us as just determined to grab as much of the health care dollar as they can. If they can supplant MoM, they will have tighter control of the market than they ever had int he good old fee-for-service days.

I attended a seminar at the hospital where I have privileges (Hah!) Given by a high-powered healthcare research firm. The hand-out was a 66 page trend analysis of the entire health care industry. It opens with the headline, "Managed Care Reform Sweeps the Nation". But it goes on to show how hospitals, PCPs, and nurses can control the flow of patients in the healthcare industry. Psychology's a mere footnote. If economics were the only consideration, I would scream, "We have to have prescription privileges." How else are we going to stay in the game?

We can gloat over the AMA's disastrous attempt to endorse Sunbeam medial products, but hat is yesterday's news and it has not made a dent in medicine's desire to recapture the entire health care industry.

So which one of these fast-flying birds does the setter focus attention on? My nomination goes to the formation of large practice groups that can compete directly with the other major players for contracts. Sharon Shueman, a psychologist with Pacificare Behavioral Health, Inc. Suggests that we keep our eye on the continuing evolution of managed care policies and procedures (1997). She notes that many managed care companies are backing away from internal case management. Instead, they are farming out utilization review to large, multi-disciplinary practice groups. That can be us, folks. I can hear Nick Cummings saying, "I told you so". Of course, Nick is too much of a gentleman to actually say that.

The Wall Street Journal for Jan 5, 1998 ran a lead article on page B1 with the headline, "A New Balancing Act for Psychotherapy". This is must-read article for all of us. Among other bits of information about the future of behavioral health care, we learn that a not-for-profit group of New York therapists, known as American Mental Health Alliance, has a contract with MoM to provide services to 370,00 0 union members. A group of therapists in Philadelphia, Access Behavioral Care, Inc., provides services to a pool of 3,000,000. In New Haven, Psych Management Inc., a for-profit entity owned by psychiatrists, provides mental health benefits to members of Anthem Blue Cross/Blue Shield of Connecticut. These group practices now do everything that MoM used to do. They still have to accommodate payor's concerns about cost, but they can structure the way that service is delivered to suit themselves.

A convenient way to tracking all of these trends appeared in the Jn/Feb.. 1998 edition of the National Psychologist (page 14). Dr. Charles cooper, executive director of Human Resource Consultants, a large mental-health group practice, shows us a flow chart that identifies most of the major trend lines in the continuing evolution of health care. In his analysis, bigger is better, because the number of patients left in the self-pay, fee-for-service, high-end, boutique market where private practitioners are being advised to relocate is rapidly shrinking. It is the large, vertically integrated, behavioral health practice that can survive and thrive.

Those of us who are thorough-going solo practitioners may shrink at the thought of giving up our autonomy. Is there nothing for us in this bewildering rush to the future? President Haber has focused her presidential year in demonstrating that there is. It all starts with the Passport Series, which will run for at least the next four issues. And I will sing harmony with an editorial next time titled: Welcome to the Niche Market.

Associate Editor Michael Brickey and I are pleased to announce the 1997 Best-of-Bulletin Awards. Award for the Best Feature Article goes to Laurie Kolt, Ph.D., for her article in the Summer 1997 issue titled "How to Build a Thriving Infertility Practice.". Award for the Best Continuing Education article goes to John Norcross, Donald J. Freeheim, Gary R. VandenBoss, and Julia Frank-McNeil for their article in the Spring 1997 issue titled "Responding Therapeutically to Patient Anger."

Jeff McKee
Saturday, April 25, 1998