Let me state from the outset that I didn’t suggest presenting on this topic. In fact, I was rather taken aback when Dr. Pumariega, the upcoming President of the American Association for Social Psychiatry, asked me to do so. After all, I thought I had written and presented about most every ethical aspect of managed care over the last 20 years, and was getting tired about being a lightning rod for all the emotional storms around this process. For almost a decade, I had left the belly of this beast, at least as far as administrative responsibility. But, somehow, the connection of human rights and managed care never came to mind.
Or, did I just repress that? Fairly quickly after this invitation, an intrusive memory flashed back into my mind. Back in 1990 or so, I had started a new job in Milwaukee, where I was directing a new academic not-for-profit managed care system, perhaps the first in the nation. This was around the same time that psychopharmacology was to take off. Not until much later did it become apparent how much managed care companies emphasized medication over psychotherapy and changed what most psychiatrists did.
For my very first presentation as part of a Wisconsin Psychiatric Association meeting, which actually was a debate on managed mental healthcare, my opponent compared managed care to Nazism. How dare he, I reacted at that time?! I am Jewish, and my whole extended family in Europe, other than my grandparents who left early enough, was apparently killed by the Nazis. This seemed to be a cheap shot at the time. Or, was it? And, how could doctors in managed care systems be equated in any way with the Nazi doctors that the renowned psychiatrist Robert Jay Lifton had interviewed and researched.
Then, another intrusive associative flashback occurred, to a former President of the American Psychiatric Association, Harold Eist, M.D., who deemed managed care to be “evil” and suggested in public that I was evil for being involved with it as a medical director. For that, I responded that I was involved as a participant/observer in order to try to understand the ethical aspects and challenges of managed care, and that our academic “company” was not-for-profit. Actually, to my wife’s chagrin, I was offered a significant percentage of any savings we achieved through our contracts, but I turned that down for professional ethical reasons.
OK, now I was wondering and worried. Maybe I was suffering from Post Managed Care Stress Disorder, and these memories were being triggered by this planned symposium. So, if I was not to intermittently suffer incessantly, maybe I needed to reassess if there was something to this linkage.
Then again, I had tried to be as fair as I could when I wrote the book from my experience in 1997, called “The Ethical Way: Challenges and Solutions for Managed Behavioral Healthcare”, which, for better or worse, got an unprecedented re-review in the January, 2010 journal, Psychiatric Services. However, there was nary a mention of human rights in the book, or in any of the reviews, then and now. I also didn’t mention any possible connection to Nazis and totalitarianism, though Dr. Lifton’s concept of “doubling” could fit, not only the harmful work of Nazi doctors, but the denials of managed care medical directors, who otherwise might seem like nice and compassionate people. In fact, many of the early medical directors in managed care came out of community psychiatry. One can extend this process to the frightening possibility that we all are vulnerable to “doubling” under the right social circumstances.
Now, after leaving managed care administration in 2003 and ending up in prison in 2009, and no, in case you are wondering, not in prison for being sentenced for something I did wrong in managed care. No, I ended up there as a part-time psychiatrist at a medium-security prison, somewhat like the one Madoff is in, curious to work in about the only mental healthcare system I had not led and/or worked in. There, I quickly became a bit more aware of human rights. Due to a federal lawsuit, prisoners became one of the few groups in the USA that had a human right to healthcare. We psychiatrists can have some pride that finally our APA Assembly recently passed an Action Paper declaring access to health care as a right.
Perhaps it was the impact of making mental healthcare in prison a human right that partially explained why I found out that I could provide better mental healthcare there than in my community mental health clinic outside of prison. I also knew that some prison systems, though not mine, were indeed run by private managed care companies. So, here was one unexpected connection between human rights and managed care. But this is the first situation that will indicate how complex this condition can be. Human rights for healthcare in prison is one thing; avoiding understaffing and overcrowding that limits security and the ability to provide enough healthcare is another. States can vary enormously in how they handle care, including mental healthcare, and security. Managed care companies would generally go only into the better funded prison systems.
Now, of course, having security as the first priority is reminiscent of many governments in history and in our time. It can also be reminiscent of the harsh and extreme mental health commitment laws of the past.
Poor or vindictive security in correctional settings per se can lead to interpersonal conflict, triggers to past trauma, abuse of the vulnerable, and solitary confinement, which can then lead to psychosis. This is often clearly a violation of our 8th Constitutional Amendment, Cruel & Unusual Punishment.
(To be continued in Part 3, which will turn to human rights after this initial discussion of my involvement in managed care)
Sad in Psychiatry: Affectionately called a "gadfly," and known as "da man in psychiatric ethics," Steven Moffic writes about what makes him sad about modern day psychiatry, and how to "treat" that condition so that we will become glad about what psychiatrists can do to help.