FELDMAN, STEVEN A. M.D.
Before I took my present position as a medical director at a managed care company (ValueOptions Massachusetts Behavioral Healthcare Partnership [MBHP]), I was a psychiatrist specializing in childhood and adolescence, practicing in the public and private sectors. Before that, I was a behavioral developmental pediatrician specializing in adolescent medicine and addictions. And long before that, I was a history major at Dartmouth College. I confess that I was unaware of an essay by Oliver Wendell Holmes 1 that analyzes the factors affecting medicine in 1861. He wrote:
The truth is that medicine, professedly founded on observation, is as sensitive to outside influences, political, religious, philosophical, imaginative, as is the barometer to the changes of atmospheric density.
In my 33 years as a physician, I have experienced politically and philosophically induced professional barometric lows similar to those measured during the hurricanes that strike the New England coast infrequently but with great impact. One such “hurricane” has been the prescription of psychostimulant medication to children, especially young children. Robert J. Haggerty, 2 an outstanding pediatrician, wrote a few years ago:
The needs of children in the 21st Century can be predicted fairly confidently. They will be the same as today: the need for loving adults, usually parents; a biological, social, and environmental milieu that includes access to integrated and coordinated health and human services; a supportive and safe neighborhood and community; a school system that allows each child to achieve his or her full potential, and the promise of a job as an adult that will pay a living wage and yield a sense of satisfaction.
For many years I have prescribed psychostimulant medications to children, including preschoolers. I have also been actively involved in the development of public sector managed care in mental health and substance abuse treatment. If I were to believe what I have read in the press and heard in polemics over the past few decades, I would stand accused of ignoring the needs of children, so eloquently enumerated above. I would be guilty of “drugging America’s children into submission” to minimize problems caused by poor schooling, poor parenting, and a poor social environment. I would thus be complicitous in making obscene profits for the pharmaceutical houses and managed care companies, such as the one that now employs me, by “pushing pills” rather than opting for more expensive comprehensive care. The shame I would feel would almost make me give up reading. It is uncertain how much of a loss this would be; a distinguished surgeon once told me “I don’t go by what I read; I go by what I’ve seen. Go observe for yourself.”
My powers of political observation may be inadequate. As a student in college and medical school during the 1960s, I hardly noticed the debates about and the passage of Lyndon Johnson’s Great Society Medicare and Medicaid legislation. I was more concerned about being drafted and going to Vietnam. I was more interested in Chairman Wilbur Mills’ (of the House Ways and Means Committee) nonlegislative exploits than in his crafting of a federal-state model for Medicaid and its administrative grafting onto state public welfare authorities. 3
I did, however, pay close attention to the family influences that gave me a rather special historical perspective on the birth and formative years of pediatric psychopharmacology. When World War II ended, my maternal uncle Eric Denhoff returned from the Pacific theatre to open his pediatric practice in Providence, Rhode Island, and to continue his collaboration with Maurice Laufer, a child psychiatrist. During our preschool years, my brother Bob and I would sit in the office waiting room, not because we were ill, but because my mother wanted her brother’s fledgling practice to look busy. Thus began my association with the office that would later become my first private practice setting.
As a teenager growing up in the mid-1950s, I would watch my stay-at-home mom type away on an old 1918 L.C. Smith typewriter, editing Eric’s papers for submission to medical journals. Those articles by Denhoff and Laufer 4,5 are considered by many to be classic descriptions of a behavioral syndrome responsive to psychostimulant medication. Others held them responsible for the invention of a nonexistent disease. 6 I didn’t know then about the validity of their etiologic theories for hyperkinesis, but I could vouch for the accuracy of my mother’s grammar and spelling. I remember spending summer vacations at a lake in New Hampshire, listening as the two doctors fished for bass and discussed their observations on the diencephalon and children’s behavior. They were, in fact, pioneers in the early years of modern pediatric psychopharmacology.
Eric Denhoff and Maurice Laufer worked with Dr. Charles Bradley at the Emma Pendleton Bradley Home in East Providence, Rhode Island. The home was named for the only daughter of its founders, Mr. and Mrs. George Lothrop Bradley, and opened on April 8, 1931. Its mission was to care for children with convulsive disorders, children with brain disorders after attacks of epidemic encephalitis, children with cerebral palsy, and children with behavior disorders so severe as to necessitate their removal from the community.
According to my Uncle Eric, the facility was organized as this country’s first neuropsychiatric hospital for children. From its inception, there was active research as well as patient care. Dr. Laufer told me about the serendipitous association of pneumoencephalography and psychopharmacology. After a pneumoencephalogram, it was common practice for a child to be placed on bed rest for 24 hours to avoid a postlumbar puncture headache. However, children were not to have idle time on their hands and were expected to do their homework even after undergoing such a procedure. Benzedrine, an amphetamine, had recently become available in this country, and Dr. Bradley reasoned that if he gave it as a vasopressor, he could increase the production of cerebrospinal fluid and thereby shorten the duration of the children’s headaches. He did this and was quite surprised when children began asking him for the “smart pills” or the “arithmetic pills.” The children noticed that they were better able to do their schoolwork while on the medication. For some it was the first time they were able to do it at all.
Dr. Bradley followed-up on these initial observations. Over time, he became quite familiar with the use of stimulant medications in children, but his work was largely unnoticed. Drs. Denhoff and Laufer worked with him and were impressed with the dramatic responses to Dexedrine and Benzedrine they observed. Dr. Bradley used the term “paradoxical” to describe his patients’ reactions to the medications because the children became emotionally subdued without losing interest in their surroundings. My uncle told me that he often witnessed spectacular improvement in the academic performance of children who were already placed in a school with specially trained, sympathetic teachers providing instruction on an individual basis or in very small group settings. He described the amphetamines as “magic bullets” for many of his patients. Denhoff and Laufer liked to joke that Bradley’s critics believed that the medications were effective only in Rhode Island. As a teenager listening to them, I did not understand all of what they were saying, but I knew how important their work in psychopharmacology was to them at a time when psychoanalytic thought and play therapy were dominant in the world of child psychiatry.
Dr. Denhoff went on to cofound the Meeting Street School Children’s Rehabilitation Center, a facility focused on the care of children with cerebral palsy. Most of the funding for the school came from an Easter Seals telethon. Later, Denhoff and Laufer formed a multidisciplinary private practice and special-education school for the treatment of children with learning disabilities and a variety of behavior problems.
Dr. Laufer stayed on at the Bradley Home. Building on the 1950 work of Gastaut, Laufer used the photo-Metrazol test to study children with hyperkinesis. He determined the amount of Metrazol needed to evoke a stroboscopic electroencephalogram spike-wave burst and a myoclonic jerk of the forearms. He studied two groups of children at the Bradley Home and observed that the threshold amount could be favorably influenced by amphetamine administration. He concluded that what he called the “hyperkinetic impulse disorder” had an organic component, specifically damage or dysfunction in the diencephalon.
According to Denhoff and Laufer, the hyperkinetic impulse disorder or hyperkinetic behavior syndrome was characterized by a set of behaviors attributed to organic causes. These included hyperactivity, short attention span, poor powers of concentration, variability in behavior with unpredictability and wide fluctuations, impulsivity and inability to delay gratification, irritability with lowered tolerance to frustration, easily provoked fits of anger, explosiveness with almost volcanic reactions, and poor schoolwork. Denhoff used the photo-Metrazol test to assess the possible causes for aberrant behavior in children with cerebral palsy and other neurological conditions. He believed that drug therapy could help control convulsions, allay fear and anxiety, reduce hyperkinesis, and favorably influence spasticity, dyskinesia, or imbalance. He also felt medication made it easier for families to deal with their child’s behavior, as well as problems with sleeping and eating. Denhoff described his multidisciplinary treatment approach for preschoolers in a monograph. 7 Central to his program was his faith in the ability of parents to carry out a home-based program woven into the daily life of the family. He hoped to achieve a responsible interdependency between parents and therapists that would allow the child to attain a full measure of autonomy as an adult within the community and to avoid long-term institutionalization. Denhoff believed that decisions about treatment, the appropriateness of the treatment, and whether and when it should be changed, augmented, or discontinued should be made by a team of specialists working under the direction of a physician competent in developmental medicine. Denhoff would have brooked no third-party interference in the relationship between doctor, patient, and family!
Just as Laufer and Denhoff had learned from Bradley, I, in turn, learned from them and their colleagues at the Governor Medical Center and Governor Center School in Providence, Rhode Island. They had a multidisciplinary practice, composed of specialists in pediatric neurology, child psychiatry, neuropsychology, speech and language therapy, developmental optometry, special education, and family therapy. They used a comprehensive approach to assessment and treatment. I was taught that stimulant medication had an important role to play in the treatment of children properly diagnosed with hyperkinetic impulse disorder, including very young children. Laufer liked to see a child’s response to therapeutic trials with Benzedrine, Dexedrine, and Ritalin before deciding on a final selection. Denhoff preferred Dexedrine and changed the medication only if it was not effective. In children who did not have a good response to any stimulant, Denhoff would try an anticonvulsant, whereas Laufer would use a phenothiazine. Both physicians believed strongly that medication was only one component of the treatment program.
Often, the Ciba representative, Mort, would visit the office. He and Dr. Denhoff were friends, but Mort never was able to persuade Eric to use Ritalin as his drug of first choice. When I asked why the detail man from Abbott Labs did not come by to push Cylert (pemoline), my uncle told me a very interesting story about drug company money, research, and the Food and Drug Administration (FDA). In 1971, Abbott Laboratories submitted the results of two studies purporting to demonstrate the safety and effectiveness of Cylert. The results of the studies were questioned by Carol Kennedy, an FDA medical officer who did not recommend the drug’s approval. Eventually, the FDA appointed an outside committee that included my uncle and his former partner in general pediatric practice, Gerald Solomons, who was then director of the University of Iowa’s Child Development Clinic. Abbott, having invested significant sums in pemoline, was not pleased with the committee’s report. However, the drug did eventually make it to the market.
At the Governor Medical Center, I specialized in the developmental and behavioral problems of adolescents, but I had to make a living and saw children of all ages. I often had referrals of children with academic and behavioral problems at school. After a thorough multidisciplinary evaluation, if I believed that a trial of stimulant medication was indicated, I had to defend my recommendation before Dr. Harry S. Novack, a professor of special education. Dr. Novack told me that the results of research with some medications were quite nebulous and inconsistent: the populations were small and vaguely described, the age range was too heterogeneous, and the methods of handling and reporting data were vague. He had the audacity to use articles by Bradley, Laufer, and Denhoff to make these points. He emphasized that “the plural of anecdote was not data.” As an educator, he cautioned me not to prescribe medication without making a good faith effort to obtain firsthand observations of the child’s behavior in the environment where the problem occurred. He taught me that schools are often unkind to children who do not learn readily. He reminded me that beginning in the early 1950s, local educators had learned about the psychopharmacological aspects of behavior modification and had begun to encourage parents to seek help for school problems from physicians. It was apparent to him that these drugs were being used indiscriminately in some settings. Getting a prescription would depend primarily on a description of a child’s behavior by a teacher or parent. This was not going to happen at the Governor Medical Center or Governor Center School on his watch. The center was a challenging place to work when Denhoff, Laufer, and Novack did not agree on a treatment plan. They did agree that data, not Talmudic argument, would be needed to answer theoretical questions, but while they waited for the researchers to catch up, they would do the best they could to help alleviate the burden of suffering experienced by the troubled children and families seeking their expertise.
I learned that decisions concerning the evaluation and treatment of a child were embedded in the child’s social and cultural milieu and reflected judgments made by individuals from a variety of disciplines and backgrounds. Hyperactivity was in the eye of the beholder.
Dr. Novack was too much of a gentleman to say “I told you so” when in 1970 all hell broke loose. On June 29, 1970, Maynard 8 wrote an article in The Washington Post informing the readership that some 5% to 10% of the 62,000 elementary-school children in Omaha, Nebraska, were being treated with behavior-modifying drugs to improve classroom deportment and increase learning potential. On September 29, 1970, Congressman Cornelius E. Gallagher of New Jersey convened a hearing to look into the “drugging of America’s youth by America’s doctors.” He was appalled that after 35 years of use, there was little to no long-term follow-up data available on the outcomes of psychostimulant treatment in children. The media storm continued for a while and then died down. (Talk about short attention spans.) Mental health care and children’s issues belong to a category of public policy issues for which public and political interest is episodic and fleeting. Usually they reside on the “back-burner.”
At the time of his death, in 1982, on my 40th birthday, Dr. Denhoff had left behind a legacy of service for children with special needs. As most physicians, he was comfortable being on the side of his patients, advocating for more resources. He had escaped managed care during his professional career, and he could not teach me about a managed care medical director’s moral and contractual obligation to provide care to a defined population as well as to the individual patient. 9
At Dr. Laufer’s urging, I had completed my training in psychiatry and child psychiatry during the late 1970s and early 1980s. I now spent most of my time consulting in schools, adolescent mental health units, mental health centers, and substance abuse programs. Managed care was not a dominant factor in the mental health field when I started out, and I had to learn about it by living with it.
Managed care embodies an effort by employers, insurers, and some physician organizations to establish priorities, balance competing goals, and decide who should get what from the United States health care system. 10 The management of behavioral health care services is also a creature of the drive for cost containment and for system accountability in terms of quality and value. 11 Managed behavioral health care is considered to be “carved out” when the insurance risk for mental health and substance-abuse services is covered separately from the overall insurance risk. This means that certain specific covered benefits are administered and funded separately from general health care services.
I remember vividly when I lost my managed care “virginity”—it was not consensual. I was treating a suicidal adolescent in an inpatient unit when the nurse told me I had a telephone call. I found myself speaking to a psychiatrist named Harold who told me that Blue Cross had asked him to review the case to determine whether the patient needed to be in the hospital. I presented the case in what I thought was an erudite and compelling manner and was told that I was “lying.” I told Harold that because this was the first time we had ever spoken, he did not know me well enough to know whether I was lying or not.
I was introduced to managed behavioral health care carve outs when I saw patients for two psychiatrists who managed mental health and substance-abuse benefits for an independent practice association (IPA) in Rhode Island. All members of that health plan who needed outpatient mental health services received them in one of the two doctors’ offices. If care was not rendered, then the “physician contractors” would make a profit on the capitation rate. If care was rendered, then they would make a profit by delivering it in their own settings. When a patient was admitted to a mental health inpatient unit, the psychiatrists would provide the treatment and step them down to a lower level of care as soon as it was safe to do so. Both of the psychiatrists were savvy, experienced clinicians and “never” made clinical mistakes. They hired good nurse managers and very experienced therapists and administrators—they ran a tight ship. Rumor has it that they later sold their managed care business for a tidy sum. Needless to say, they did not create a very positive image for managed mental health care in Rhode Island as far as those professionals who were not part of their closed network were concerned. However, I am certain that the employer groups who contracted with the IPA were happy that costs were under control at a time when private psychiatric hospitals were advertising their services.
The many companies originally doing managed behavioral carve-out work had achieved initial success with commercial accounts by using new expensive information systems and technology, elaborate case management policies and procedures, a provider-credentialing system with an extensive network of contracted providers, and a highly qualified staff of well-trained professionals who could work as a team to integrate their different functions. I was soon to discover how well-managed behavioral health care would do in this nation’s first statewide Medicaid carve out.
In the public sector, state mental health authorities have guaranteed the safety net for those persons who are uninsured or underinsured, usually through community mental health centers and state hospitals. Although they have always operated with insufficient resources, they have carried out their mission as best they could, usually by employing gatekeeping and waiting-list strategies. 12 There are a variety of managed care models in various states that reflect diverse approaches to mental health financing, service delivery, and differing Medicaid policies. 13 To know one managed care system is not to know another managed care system.
In Massachusetts, the Division of Medical Assistance (DMA) is the state agency responsible for the Title XIX Medicaid Program and the Children’s Health Insurance Program. Expenditures for mental health and substance abuse services within the Massachusetts Medicaid Program soared from $70.1 million in fiscal year 1989 to $184.5 million in fiscal year 1992. Although the specialty area of mental health accounted for only a small part of the Medicaid budget (∼5%), it was one of the fastest growing components. 14
In 1992, under the leadership of Charles Baker and Bruce Bullen, Massachusetts began MassHealth Managed Care and carved out some of the administrative oversight of mental health and substance abuse services to a private for-profit managed care corporation. With the advent of Medicaid managed care, the states had an opportunity to expand access to mainstream providers and to save money. However, in managed care, it was imperative to confront the real scarcity of resources. The state had to decide which group of potential consumers would be enrolled in the system and to predict how much it would cost to cover their mental health and substance abuse services. They would have to navigate successfully between limited resources and unlimited expectations at a time when citizens believed they had a right to unrestricted access to ever more convenient, personalized, high-quality services.
The state had to define which persons were eligible to receive services, what treatment services would be covered, how service use would be managed, who would be responsible for providing services, how the endeavor would be funded, who would assume the financial risk, and how service quality would be determined and monitored. 15 It was hoped that the rapid transformation of the public mental health delivery system into a system of public contracts for privately delivered care, if done well, would improve care for a vulnerable population and give the taxpayers more value for their money. It was feared that if done poorly, Medicaid-managed behavioral health care could turn out to be a public health disaster. Using a shared risk contract that capped profits and losses, DMA shifted from being a payor asking little of service providers to a purchaser focused on quality and value received for premium dollars. The publicly stated goals of the program were to expand the accessibility of preventive and primary care services, to improve the quality, continuity, and appropriateness of health care delivery, and to improve the cost-effectiveness of the Medicaid program. According to the terms of the contract, the managed care company would become responsible for authorizing care for its enrollees, reviewing utilization of services, negotiating reimbursement rates for a selected network of hospitals and clinics, and expanding existing diversionary services such as crisis stabilization and residential care.
In 1996, Massachusetts awarded its carve-out contract to the Massachusetts Behavioral Health Partnership (MBHP) and structured the agreement to allow the company to earn profits by meeting administrative targets and performance standards selected by DMA after considerable input from consumers, providers, and other interested parties. There were 11 performance-based incentives (performance standards ) accounting for over 40% of the partnership’s potential earnings in the first contract. In subsequent contracts, psychopharmacology for children and comprehensive assessments done in the community were included as performance standards. According to MBHP’s chief executive officer, Richard Sheola, the performance standards allowed MBHP to do “well financially by doing good clinically.”
Critics charged that this amounted to little more than asking the company to answer the phones, pay the bills, and perform routine administrative functions. They alleged that there was no real commitment by the state to provide the necessary resources to fund mental health and substance abuse services at an appropriate level, particularly children’s services, and that MBHP was colluding with the state by “fostering the illusion that the system works.”16
It is well recognized that managing only the Medicaid portion of a complex funding system that includes mental health, special education, child welfare, and juvenile justice funds can only do so much. There have been many studies and reports examining children’s mental health services in Massachusetts. The system has been called “fragmented,” with unmet expectations at many levels. The problems have been described as deeply rooted, not easily isolated, and compounded by a chronic mismatch between resources and needs. 17 The Massachusetts Psychiatric Society has testified that there is a crisis in providing appropriate services to children and adolescents in the least restrictive setting, partly because of inadequate funding, lack of interagency coordination, and a shortage of certain types of providers such as child psychiatrists and in-home support services. At a national level, it is recognized that the system of care for infants, toddlers, and preschool children is different from the system of care for school-aged children because different specialists are often involved in early childhood services. Mental health is usually the last intervention to enter into the care of very young children after physical health and child welfare issues have been explored. 18
As a behavioral health care medical director, I spend a great deal of time dealing with complex systems issues while hearing about individual heart-wrenching problems. I wonder what advice Denhoff, Laufer, and Novack might have offered if they were sitting on my shoulder watching me at work. I would ask them how to implement a system of care that would allow the providers in the network to have adequate time for good history taking and consensus building. I would want clinical judgments to be based on knowledge from multiple domains (biological, cognitive, temperament, and psychodynamic). I would expect that when clinically indicated, interventions would be focused in the here and now, targeting specific and well-defined problem areas within the different domains of function. They would probably tell me that societies have been dealing with such quality and payment issues for centuries, and they would remind me that I did study history in college. In the Code of Hammurabi it is written, “If a physician open a tumor over the eye with an operating knife and saves the eye, he shall receive 10 shekels in money. If he cut out the eye, his hands shall be cut off.”
I do not know what the equivalent rate of reimbursement would be now, taking inflation into account, but the regulation did establish a quality outcome standard assuring the Babylonians that surgery was taken seriously. Physicians were probably motivated to perform high quality work and to develop good practice guidelines for patient selection and treatment. 19
I would want to employ a different “hands off” policy, however. I believe that in the future, using information systems, provider credentialing data, and multidisciplinary expertise, there could be a performance standard that will focus on the early childhood system of care and on preschool prescription practices. We could thereby answer Dr. Coyle’s questions about the diagnoses for which various medications are prescribed in our population of enrollees and about the professional identities of the prescribers. 20 However, for such a standard to be adopted, DMA and other involved groups would have to be convinced that it should be made a priority because over 200 standards may be suggested in the course of a year. If we are to have a service delivery system that is child focused and family centered, a system that respects cultural differences, it is imperative that those individuals advocating for children continue to make their voices heard. Under the leadership of Walter Harrison, M.D., the Massachusetts Academy of Pediatrics is initiating an effort to address issues of access to care and coordination of care in children’s mental health by working with all the payors and “stakeholders” in the state.
Are we on the right track with managed behavioral public sector carve outs?
Critics have charged that in the 9 years that mental health and substance abuse services have been managed by private for-profit organizations, DMA has commissioned only one independent study—in 1993. It is not known whether privatized management is in the best interest of consumers and taxpayers. The commissioned study results showed that mental health expenditures were reduced by $47 million or 22% of the levels predicted without managed care and without an overall decrease in access to services or in the quality of care. 21 The Heller School of Public Policy at Brandeis University and the Department of Public Management at Suffolk University have conducted annual surveys of mental health and substance-abuse providers from 1993 to 1997. From 1998 to 2000, Suffolk conducted mail surveys of mental health providers. Medicaid managed care in Massachusetts was judged to be a continuing success. 22
Yet, it has been pointed out that there is little or no solid information about the impact of managed care on the quality of mental health services. There is no empirical data for individual enrollees about the content of care delivered measured against an objective standard of care. There is a need for a comprehensive and empirical study of the program to provide more valid and reliable data to facilitate continuous quality improvement. The legislature has been asked to appoint a commission to review DMA’s arrangements with all managed care organizations to determine whether the continuation of those arrangements is in the best interest of the consumer. According to Sabin and Daniels:23
Showing that incentives are aligned with central clinical goals and that earnings correlate with achieving performance targets, not withholding services, does not prove that Massachusetts Behavioral Health Partnership is performing optimally.
Over the past 5 years, I have watched MBHP teams develop more sophisticated quality-improvement systems. We hope that these lead to better clinical outcomes. Yet I remember well my uncle’s words about treating preschool children with cerebral palsy. He said that although teams were important in diagnosis and treatment, it was imperative that a “special” physician play a role in the lives of these families; a physician who showed “special” interest and provided “special” services; a physician, who could listen, hear, and guide.
In the complex world of public-sector managed behavioral health care systems there is a role for the physician who will listen to children, families, and treaters, respectfully hear what they say, and guide the policy makers toward the best-practice models of care especially those affecting service delivery to preschoolers. Our company has been awarded the Massachusetts contract for an additional 5 years, with a possible extension of 4 more years. I hope to have the opportunity to follow in the footsteps of my mentors and to be a “special” physician in my role as a managed care behavioral health physician.
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© 2002 Lippincott Williams & Wilkins, Inc.