AMHA - Operating Principles and Current State

Peter Gumpert, Ph.D

From a speech given to the National Mental Health Foundation, Spring, 1998

Perhaps I can help frame part of our discussion by telling you about AMHA, its fundamental principles, how it's supposed to operate, and its current state. The problems of industrialized mental health care --- so-called "managed behavioral health care"  --are probably well known to most people here--olld news, so to speak. But I do think I should say a few things about that set of issues as well. It was, after all, the context that stimulated AMHA's development.

I'll start with two brief anecdotes to set the stage. The psychologist-lawyer Bryant Welch has been saying in public speeches for some time that managed mental health care is already dead - it just doesn't know it yet. Recently I've been hearing some things from a variety of highly-placed sources that seem to corroborate Bryant's assessment. A number of people in related industries believe that the HMO experiment has failed, and that professionals are soon to regain control of the health care system. Some companies are actually positioning themselves for this eventuality.

So Bryant may not be right quite yet. But I believe strongly that the managed care experiment has indeed already failed, and that the system continues to grow partly out of inertia, and partly because it is, overall, so cash-rich that it doesn't know that the end is in sight. (Let me add, however, that we must continue to help insure its demise.)

On the other hand, a couple of weeks ago I read a paper that came out in a public health journal, written by a couple of health policy analysts one at HHS in Washington and one at Johns Hopkins. The paper presented arguments in favor of changing utilization review policies for outpatient mental health. Writing as if they had made an astounding discovery, the authors reviewed the literature on the use of mental health services, and concluded that these services do not have to be restricted or managed to control costs--because they are both seldom used and inherently self-limiting. After rehearsing many persuasive arguments, however, the authors seemed to take it all back, and to suggest that managing outpatient mental health care was a good idea despite everything. The notion that doctors and other professionals run amok and must be managed by others seems to die pretty hard.

So I'll go through some fundamental problems with the case that managed care companies try to make. They may not all be obvious to you. The argument in favor of managed care consistently confounds the question of how to provide effective treatment with the motivation to reduce costs. The two are, obviously, not the same. This confusion of purposes is played out in many ways, including the way treatment approaches and service delivery systems are designed and implemented, and the way research is done and interpreted. The only costs in mental health treatment that have increased beyond the rate of inflation in the past 30 years were the costs associated with the inpatient treatment of two populations adolescents; and patients with chemical dependency problems. The evidence seems clear that for the most part, these populations are equally well or even better treated with outpatient strategies of various sorts. We can thank managed care for teaching us that we should not be hospitalizing these patients. But the managed care movement, as a way of establishing its market position, painted the remainder of mental health services with the same brush--as if the entire system were out of control and in need of external management.

The facts are that outpatient mental health treatment has been very inexpensive and cost-effective. Its cost is both highly predictable and self-limiting--more than 25 years of research tells us consistently that only a small proportion of the population uses it (about 5-6%), that most people use only a little, and the small number of people who use more treatment use more of it because they need more. Outpatient treatment does not require either external management or externally imposed limits. Despite occasional counterexamples and many bold assertions to the contrary, there is ample research evidence that psychotherapists cannot hold patients in treatment beyond what the patient needs or desires. Furthermore, one kind of psychotherapy does not work for everyone. Most of us have seen patients whose treatment by some method or other has failed.

The managed care argument does not address the value of providing effective treatment tailored to the needs of the person treated--it mainly addresses controlling cost. Indeed, the value of good treatment spreads out well beyond the patient him- or herself--to the family, the community, the workplace, and to reductions in general medical costs. While the medical cost offset literature does not suggest that the cost of mental health treatment is fully offset by medical cost reductions, it does show that the cost of adequate mental health treatment is indeed partly offset by reductions in general medical costs.

Managed care companies assert that any treatments they pay for should be supported by solid research evidence. The outcome research that is being done by managed care organizations to support their preferred methods is, for the most part, poorly conceived, poorly designed, and poorly analyzed. Studies often use unvalidated measures and research designs with the wrong controls; Ivan Miller's excellent review papers, published recently, also point to gross misreading and misinterpretation of research results. A large body of research data points clearly to the idea that psychotherapy works, and works well. Outcome research that is specific to treatment type is in its infancy, however, and the arguments being made for its applicability to choice of treatment are tendentious to say the least. I'll say it again the "scientific" basis for comparing the effectiveness of different treatment modalities is exceptionally weak and oversimplified; we are a very long way from being able to use psychotherapy research to make such decisions. The primary reason there isn't much research to support longer- term treatment, by the way, is that such research takes a lot of time. Most of the patients who start out in the samples drop out of treatment along the way, because most people simply don't stay in treatment for long. So the whole enterprise requires that researchers wait a long time before they can publish. Virtually all solid psychotherapy research that is based on more than a few cases has investigated short-term treatments of 20 to 30- session duration (not the ultra-brief treatment that managed care prefers for cost reasons). A related "big lie" is that mental health treatment can be protocolized--made into a linear technology that can be delivered by people with limited training if you see this, do that. Treatment protocols can be narrowly useful in dealing with acute crises or emergent problems such as a manic episode or a suicidal gesture. Outside of such emergencies, however, protocols are useless. We treat patients, not diagnoses. People who fit into the same diagnostic category differ enormously from one another, and often have very different treatment requirements. Diagnosis is largely a theoretical fiction, and one type of treatment does not fit all. I am quite sure that psychotherapy of any modality depends for its effectiveness on the intimate relationship created between patient and treater, on enormous respect for the patient's unique history and needs, and on the intuitions of experienced clinicians.

Managed care systems tend to devalue and de-professionalize the people who give care to patients, and often to devalue the patients themselves. This does not help anyone, except perhaps the managed care companies. It certainly doesn't enhance treatment, and most probably gets in the way.

One more big lie sponsored by the managed care industry is that utilization review contributes to treatment quality. If I took a little more time today I think I could convince you very easily that third party "utilization review" of clinical work (whose industrial analogue is called inspection) does not assure or even assist quality. Instead, it tends to interfere with quality improvement, and mainly adds both cost and adversarial relationships to the enterprise. In modern manufacturing, the removal of inspection departments is often an early step in achieving true quality improvement. Three strategies actually enhance quality in industry: empowering people to make decisions about their work; providing them with the information and resources they need to do the job right the first time; and encouraging cooperative effort among workers toward common goals. These methods must also work in health care. The methods and atmosphere created by managed care systems do the exact opposite of what is needed. They do not contribute to quality--they add cost, create adversarial relationships, infantilize and disempower people, and violate patient confidentiality and privacy. Remember--we as professionals are supposed, first of all, to do no harm. There is a solid argument in favor of the proposition that the undermining of confidentiality hurts people, and makes good treatment virtually impossible.

___ Still another wrongheaded notion promoted by these companies is that quality is assured by "credentializing" practitioners. My own experience is_and years of research shows--that credentials assure nothing. Treatment quality is determined by a good fit between patient and treating professional, and by solid collegial resources available to clinicians who are willing to use them as needed.

___ Another big lie created by MCOs for-profit care delivery systems lead to treatment efficiency and effectiveness, which so-called "providers" are unable or un-motivated to create. The truth is that for-profit managed care systems divert a huge amount of money from service to administration and profit--on the average, only 50% to 60% of the premium dollar goes to service. These companies are in the business of making money by withholding care from patients. Care delivered is considered a loss. In their own literature, MCOs refer to the cost of service delivered as a "loss ratio."

The so-called "second generation" MC that uses sub-capitation to small groups of professionals puts the onus of withholding care--and taking on liability for care-- completely on the professionals. The sub-capitated contracts of this sort that I have seen make it literally impossible to deliver an effective level of care. The therapist is invited to be the bad guy who withholds care, and the MCO continues to rake in profits.

Finally, I want to say that as a social policy experiment, the professional disaster spawned by managed care is expanding in an unexpected way the industrialization trend is hurting the graduate education of psychiatrists, psychologists, social workers, and others. If these young professionals are taught only medication and brief "solution- focused" and other cognitive-behavioral approaches to treatment, how will the practitioners of the next generation even understand what they don't know?

AMHA as an example of an alternative

Let me stop this now, and spend a few minutes describing the American Mental Health Alliance (AMHA) to show you that it is possible to create sensible alternatives. AMHA is a full service mental health and substance abuse care system now being offered to employers It is in direct economic competition with managed care companies. AMHA in Massachusetts is wholly owned by its member-professionals as a not-for-profit cooperative. A member can own only one share, and can earn money only from providing service, not from share ownership. AMHA member professionals are cost conscious, but they cannot profit from withholding care.

AMHA is a self-managed system that functions by valuing and empowering both patients and professionals. Treatment decisions, including modality, are made by the clinician and the patient. Resources are made available to either or both in the event of problems or difficult decisions that must be made. Consultation by professionals with valued colleagues is encouraged in a variety of ways, and consultation is easily available to patients.

The AMHA panel is not "closed." Any licensed clinician who is willing to abide by AMHA's ethical treatment principles may join. So it does not limit patient choice of therapist. Quality is assured primarily by reducing the isolation of professionals, and making solid resources available to them.

Normal outpatient treatment limits--which are relaxed as an alternative to more restrictive treatment--amount to 50 sessions a year. Treatment duration and frequency are matters for the patient and the therapist to decide. This relatively generous benefit is cost-competitive with managed care because AMHA's administrative costs are very small, and shareholders who demand profit are not an issue. The benefit structure does require a co- payment from the patient, who should participate in paying for treatment anyway.

As with managed care, inpatient care is used primarily for safety and stabilization. In general, hospitals are no longer geared up to provide the extended treatment they provided earlier. So AMHA uses intensive outpatient care as much as is clinically sensible. But inpatient care is certainly available when it is deemed appropriate by the patient and the professional, who is asked by AMHA to consult with an expert who can help with alternatives to hospitalization, and with smoothing the way if the patient is to be hospitalized. AMHA uses a regionalized system of Clinical Consultation Teams - experts in suicidality, serious mental illness, and so on who consult on difficult cases. The decision, however, rests with the patient and primary therapist.

___ AMHA therapists remain a part of the treatment team during a hospitalization, providing continuity of care before, during, and after a hospitalization episode. Our hospital contracts in Massachusetts contain this requirement, and AMHA member-professionals have the equivalent of hospital priviledges.

___ A cooperative professional community is central to AMHA's quality assurance and cost effectiveness. AMHA therapists work under a covenant called Cooperative Mental Health Care, in which they agree to learn from each other--in effect, to be "in community." These days I like to go even further, and think of AMHA as a professional ecosystem  a set of

interlocking, mutually helpful relationships among professionals who differ in discipline and training, but share certain fundamental values that have to do with patient care, and work together to create knowledge and insure ethical and effective care.

In Massachusetts, AMHA has about 750 members, of which about half can now be considered fully active. AMHA is federated nationally as AMHA-USA. State AMHAs are autonomous, linked organizations, and are ready to provide service in several additional states, including Maine, New Hampshire, New York, New Jersey, Pennsylvania, Washington D.C. and Virginia, Ohio, Missouri, Arkansas, Montana, California, and Oregon.

AMHA-USA coordinates efforts, helps states get started, and is set up to make contracts with multi-state employers AMHA-USA is owned and governed cooperatively by the various states.

AMHA's structure and policies are guided by sound clinical practice. AMHA believes it is crucial to preserve (not restrict) choice of practitioner and treatment modality; facilitate (not hinder) access to services for patients; preserve (not violate) the basic rights of patients, including privacy and confidentiality; preserve (not undermine) the curative therapeutic relationship between patient and therapist; and encourage professionals to work in a way that is ethically responsible and consistent with their training and experience.

Since profit motives often create a conflict between shareholder interests and patient needs, AMHA surpluses are used to maintain needed reserves, enhance services, contribute to prevention, and conduct useful evaluation and good research on what we do.

So what are the basic principles underlying AMHA's structure and processes?

Cooperative Mental Health Care is rooted in the following ideas. First, the principle of isomorphism, which says, in effect, that the way some people are treated in a system affects the way other people are treated. If professionals are devalued by administrators or each other, patients will also be devalued. Thus the methods by which a human service is delivered become an integral part of the service itself, and affect it strongly. The managed behavioral health care delivery model is predicated on simple, linear thinking and centralized interpersonal control; it generates adversarial relationships and has oppressive consequences. The service it ends up making available to patients is inevitably affected by this broader orientation.

Self-managed systems work better than those that use central control to manage outcomes. In a self-managed system, each element affects the others. While there are pools of influence, the essential equality and variability of members provides the foundation for good decision-making and adaptation to change. The system functions on a broad spectrum of information, and the needs of the various stakeholders (employer, professional, and subscriber) are worked out in a fluid process. Thus AMHA professionals are conscious of cost issues at the same time that they care primarily about quality of care.

A third principles involves the establishment and maintenance of cooperative relationships. This notion is pretty simple, and fully backed by extensive research over more than thirty years cooperative relationships are more effective and productive than competitive, adversarial ones. AMHA emphasizes and creates cooperative relationships between itself and its corporate clients and member professionals, among the professionals, with hospitals and other agencies, and between professionals and patients.

A fourth principle is based on the proven organizational psychology notions of distributed power, participative leadership, and the empowerment of all parties to achieve common goals. The importance of this principle is very clear, both professionals and patients must be empowered to reach their goals, and the goals of all parties in the system must be congruent and aligned. By the same token, treatment decisions must be made by patients and professionals, not by third parties.

A fifth principle requires the establishment of a professional community for support and continuous learning Members, for example, organize themselves into peer consultation groups to discuss cases and learn, and consult respected experts in their regions when highly intensive treatment or hospitalization of a patient may be indicated.

What is our organization's present state?

We have had a number of problems in our 3-year history. First, every state AMHA is seriously undercapitalized, and we all work largely through member volunteer effort. My salary as CEO and board chair of AMHA-MA is $1.00 per year. I haven't been paid yet. Thus we are forced to move very slowly, and conserve capital very carefully to stay alive.

Second, the extensive volunteer effort generates a certain amount of burnout. People must make a living, and they are always in danger of over-extending themselves.

Third, when we started three years ago, the employer-managed care honeymoon was in full swing, and our marketing efforts largely fell on deaf ears. The ears are not so deaf now, but money from member-professionals is also harder to come by. Members become discouraged if they don't see contracts, and contracts have been slow in coming.

Fourth, mental health is a tiny part of the whole health care system _a maximum of 9%. Many companies are reluctant to change their benefit structure simply to change to our mental health carve-out system, because it is simply a nuisance to them to inform their employees of a new system.

Fifth, states vary greatly in their insurance laws and regulations. Until recently we have been restricted to offering services to self-insured companies operating under ERISA. This means that a substantial part of the market hasn't been available to us.

So the road has been rocky, and disappointing at times. Good news is also in the picture, however

1.   We have been hanging in there despite the difficulties. A couple of state AMHAs formed and then dropped out of the effort, but most are moving steadily forward.

2.   AMHA-NY has landed a very major contract, involving some 300,000 people. The contract is not all we would want, since it is restricted to outpatient mental health care and therefore doesn't help us test the full AMHA model. It clearly puts us on the map, however. We are no longer a "theoretical" organization.

3.   We believe we've solved our fully-insured market problems by hooking up with an indemnity insurer who is interested in allying with us --this company must, for the moment, remain nameless.

4.   We are in the process of making other strategic alliances that will open additional doors to us.

5.   The market is gradually moving toward what we offer. Since we are determined to be in this for the duration, we believe we will make it.

6.   We are very interested in conducting and encouraging solid research on treatment.

In conclusion, let me say that AMHA should be seen as more than a business. It is a part of a larger political movement. We have adopted an extended commercial strategy as our way of educating the public about what good mental health care is, and the importance of such care. In addition to this part of the political agenda, I am also aware that we psychotherapists must find ways to improve broadly the quality of the care we deliver. The AMHA model, because of its emphasis on community, offers a way to do that, and to demonstrate it to others. The political issues are not the whole story, of course. I hope it is obvious that we are very serious about what we are offering to employers and subscribers.