"If we don’t hang together, we’ll all hang separately." -- Mark Twain (paraphrased)

Managed care has achieved swift and stunning success in seizing control of mental health dollars, services, and treatment decision-making by organizing into behemoth corporate entities; marketing "quality"; and holding down cost increases through draconian service limitations and increasingly lower payments to "service providers." To date, as mental health professionals, we have lost ground in our attempts to respond to the rapid deterioration in services, fees, and more significantly, our autonomy as independent practitioners. Authorizations are required with increasing frequency over shortening intervals, patient records are more widely subject to audit, and the number of Americans with coverage outside of managed care or with any mental health coverage at all continues to decline.

The success of managed care may be attributed to its achievements in holding down cost increases -- and also to their success in appearing to address (and in some cases successfully addressing) other weaknesses in our mental health service delivery system. Uneven or ineffective quality assurance mechanisms, the lack of integration among allied health services, and confusing variations in treatment are valid concerns to employers and consumers. The Tobacco Research Institute look-alike, NCQA (National Committee for Quality Assurance) has made impressive strides in convincing health care purchasers that these issues are successfully addressed through managed care. Managed care has also achieved success by raising significant capital and competing against independent professionals with the resources of large organizations. Historically weak in support of our own professional organizations and precluded from collective bargaining by law (and perhaps by our own ethical principles), we have exercised little clout against well-funded and politically well-connected public relations and marketing departments.

There is, however, some legitimate cause for optimism. We are witnessing an increasing ground-swell of public dismay, and political and legal initiatives vis a vis managed care; our professional organizations are actively addressing issues of privacy, freedom-of-choice, and false advertising through public education, legislative advocacy, and promising litigation. But these are largely reactive efforts. What about proactive efforts?

In response to the alarming and continuing erosion of mental health services, some California licensed psychologists are proposing a state-wide (and national) pro-active alternative to managed mental health care: the American Mental Health Alliance (AMHA). A national not-for-profit, multi-disciplinary organization, AMHA represents a fresh paradigm of egalitarian cooperation across mental health disciplines (i.e., psychologists, psychiatrists, social workers, marriage and family counselors, and psychiatric nurses). Nationally, there are so far thirteen state chapters, representing every region, with a total membership of over two thousand mental health professionals.

The AMHA model offers healthcare purchasers and consumers freedom-of-choice, accessible information about member professionals (permitting informed choice), privacy, and the assurance of authentic quality assurance practices – at reasonable fees. Professionals are offered the hope of practicing independently, within the ethical guidelines or our professional associations and without the conflicts-of-interest inherent in working with managed care – at reasonable fees. The proposal was initially developed by Boston psychologist Peter Gumpert, Ph.D. (Gumpert, 1996) with the support of the Boston Consortium of Psychotherapists. Several years ago, the California Coalition of Ethical Mental Health Care, an organization originally sponsored by the Managed Care Task Force of the San Francisco Psychological Association, invited Dr. Gumpert to present the plan in San Francisco. His plan was well-received and inspired the rapid formation of the American Mental Health Alliance-California, Inc. (AMHA-CA).

Unlike AMHA chapters in other parts of the country where all mental health professionals join as members in equal standing, complex California health laws required AMHA-CA to incorporate as an Independent Practice Association (IPA). Further, CA law requires majority ownership by only one mental health profession. For practical, political, and public relations reasons, we psychologists were selected by AMHA-CA members to assume this responsibility. Hence, 51% of the shareholders must be psychologists. To remain compliant with the law, AMHA-CA has a three-tier membership structure:

The California chapter of AMHA is inviting dialogue with and seeks the support of California psychologists. AMHA-CA aims to support independent mental health professionals in practicing ethically and, eventually, to contract with healthcare purchasers to offer the full range of mental health services without outpatient utilization review. Administrative overhead costs are expected to be minimal, keeping costs for services and fees to professionals reasonable. "Profits" will be used only for relevant clinical research and for clinical services. Quality of service is enforced by legally empowered licensing boards and enhanced by a self-managed system for cooperative mental health care delivery: For example, non-binding consultations with senior clinicians elected by the membership are to be required at 26-session intervals and prior to hospitalization. Outpatient benefits are to be flexible so that, if indicated in particular cases, intensive outpatient treatment can be utilized rather than hospitalization. Participating hospitals and treatment programs are to be selected based on their cost, quality of treatment, and willingness to include the primary therapist in the treatment. Members are encouraged to support each other.

In addition to functioning as a comprehensive, carve-out mental health services plan (which an insurance company in Minnesota has expressed interest in underwriting), AMHA is also pursuing (or interested in pursuing) simpler, more immediate options such as forming alliances with EAP’s (which often suffer significant constraints by managed care), offering a discount plan to organizations and consumers (pending approval by the California Department of Corporations), allying with other groups and associations (and web-site provider marketing groups) working toward the same goals and adequately respectful of mental health ethics.

Consumers who use the AMHA plan benefit from reasonable costs of services, freedom to select from a wide range of mental health services/professionals, privacy protection (records remain with treating clinicians, except at the request of the patient or as required by law), and the use of other resources available to them (e.g., a useful mental health web-site). Employers, and especially Employee Assistance Program staff, like the plan because of the reasonable cost (comparable to managed care), and because of the flexibility, quality, and protection offered to their employees. For employers, however, the switch to AMHA is a significant undertaking; and, before they commit to AMHA, employers want to see a larger membership, state-wide coverage, and stronger financial resources.

The AMHA-CA now has 150 members. In order to insure that consumers have the broadest possible choice of providers, licensed mental health professionals in "good standing" with $1M/$3M malpractice insurance coverage are eligible to join. Membership contributions are set reasonably so that large numbers of therapists can participate. As membership increases, the associated increases in geographic coverage, types of service, organizational finances, and resources increase the probability of success.

From AMHA’s viewpoint, we cannot rely on legislatures, on the courts, nor on consumers to devise the "best" mental health services delivery model. As clinicians and as psychologists, we must assume a leadership role in developing a workable, affordable alternative to managed mental healthcare. The public, healthcare purchasers, and the legislatures are looking for solutions. Join with us and help us create an alternative we know serves our communities.