Summer 1997 - Editor's Column - Interdependence Day: The New Revolution

xxAACP Newsletter, Volume 11, Number 3, Summer 1997

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Editor's Column - Interdependence Day: The New Revolution

It's the Fourth of July. Time to think about revolutions. I am at my computer because I have just been writing a piece to be incorpoated into the response by the Community Care Behavioral Health Organization (CCBH) to the request for proposals released by Allegheny County of Pennsylvania. The County is seeking a managed care company to partner with as Southwestern Pennsylvania moved into mandatory managed care Medicaid. It has been a mammoth undertakin to create CCBH, a not-for-profit organizatoin formed by some of the large psychiatric provider systems in the County. Even while I am writing this a home on a holiday, there are some ten or twelve people who have been working around the clock, as they and many others have been for over a week, putting the finishing touches on the response. It's a heroic effort and there are reasons people are willing to make it. One of them is that if CCBH is chosen by the County, and the State concurs with their decision, CCBH will manage about 80 million Medicaid dollars. That is enough money to keep many people working right through the holiday. But that is not the only motivator, or even the primary one.

Many of the people who have been working on this and other aspects of the transitoin to managed care get a bit dreamy when they talk about the effort. They see it as an attempt to refashion public sector psychiatry and as an opportunity to create a better service system using rational care management systems to ensure the provision of quality care. They are committed to services being truly held accountable to consumers and other stakeholders. They are proud to be associated with a not-for-profit approach to managed care, in which any savings are reinvested into improving services, rather than being extracted to profit shareholders in some distant part of the country. In short, they want to make a revolution in behavioral health care. I do not have a card yet, but I have signed on with them.

The truth, though, is that we in Pittsburgh are just an out post of the revolution. A few weeks ago, I was part of a delegation from CCBH to Communitey Behavioral health (CBH), the not-for-profit managed care company formed by the City of Philadelphia out of the community mental health care system that is now the Medicaid behavioral managed care company for Philadelphia. We were guests of Estelle Richmond, Commissioner of Health and Behavioral Health Services for Philadelphia and Charles Friedman, MD, CBH's medical director. In addition to showing us some of their inner workings and describing how they integrate Medicaid funding with other funding streams to create a comprehensive service system, they told us about the revolution they created and the counterrevolution they have so far weathered.

They emphasized the absolutely essential role played by the consumers, families and other advocates in making sure that the system remained focused on the needs of consumers and the community, rather than on the need to generate profits. The consumer's families and advocates have mobilized on a grand scale, organizing a sophisticated lobbying campaign and even multiple mass demonstrations in City Hall against the threat of for-profit managed care organizations displacing CBH.

All fit stuff for the home of the Declaration of Independence and the Liberty Bell. They remain vigilant and CBH staff remains anxious because in Philadelphia there is now a lot to lose -- a true, consumer-centered, community-oriented and community-based behavioral health care system AND some 400 million in Medicaid dollars. For that reason, the for-profit MCOs are still in the water, looking for a chance to bite. George III did not give up right away either. We talked in Philly of ways we can support each other in the State to create the space where CCBH and CBH can both flourish as not-for-profits tied to their communities. It is clear that tough cost-cutting, profit-seeking times will continue and we need allies, not just in the State, but across the country.

On another front, in the same struggle, is the predicament of the AACP itself. Who are our allies? At the board meeting in May in San Diego, we spoke with Ezra Griffith, a community psychiatrist at Yale, and president of the American Association for Orthopsychiatry, about prospects for joint work. In case you are unaware, Ortho is THE interdisciplinary association of mental health providers. They have a long and distinguished history as advocates for community mental health. Many of the great leaders in the history of community psychiatry have affiliated with Ortho. Times have been tough, though, on organizations like Ortho, and they are looking to regain capacity and membership they have lost in the conservative resurgence of the last fifteen years. They would like to connect with community psychiatrists across the country.

At the same time, new organizations are springing to life. One example of this is the Association of Clinicians for the Underserved (ACU - see an article on it in this issue) spawned from the womb of the National Health Service Corps. It focuses on connecting health care providers with a committment to providing care to marginalized communities, but has had little input from mental health and psychiatry. They too would like to connect with community psychiatrists around the country.

There is no doubt in my mind that we need to seek out such organizations as allies. We share common goals and we too are in need of greater strength to carry them out. The questions are, for me anyway, how do we go about the process of working together? What do we try to do and how do we do it? Who else do we ally with and to what end? In this country, we are good at declaring independence. But when you make revolution, you take the chance of hanging together or assuredly hanging separately. How good are we at declaring INTERDEPENDENCE?

Ken Thompson, MD
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