Many psychiatrists who work at the intersection of public psychiatry and managed care find themselves in an environment in which cost concerns often appear to trump patient care. For those psychiatrists who have found innovative ways to put their ethics and patients’ needs first—sometimes at great risk to their careers—there is the Moffic Award for Ethical Practice in Public Sector Managed Behavioral Health Care.

The award, established by H. Steven Moffic, M.D., and the American Association of Community Psychiatrists (AACP) in 1998, is presented each year at APA’s fall meeting, the Institute on Psychiatric Services. The AACP Ethics Committee reviews nominations and designates one or more winners, presenting a certificate and $2,000 to each. Although psychiatrists have most often won the award, mental health professionals and organizations can be recipients.

Moffic, who is executive vice chair for managed care in the department of psychiatry and behavioral sciences at the Medical College of Wisconsin, decided to recognize psychiatrists who work in the public sector under managed care because "the ethical risks seem even higher for the poor, and the most seriously ill are seen so often within that sector."

When confronted with managed care systems that sometimes threaten the quality of patient care and patients’ right to confidentiality, none of the award winners to date has quit his or her job or passively accepted the system. Instead, each has found ways to work under new constraints.

Tennison, with a 19-year tenure at the Helen Ross McNabb Center in Knoxville, where he is now the chief clinical officer, wouldn’t give up so easily. "Our jobs, our professional interests, and our personal lives changed dramatically during this time of change, doubt, self-assessment, and renewal," Tennison told Psychiatric News. "Coping with the massive losses in resources required not only organizational survival, but also the development of strategies grounded in professional ethics."

Adaptation became the status quo for staff at the McNabb Center. "We adjusted our hours, our expectations, and our staffing patterns, withstanding losses of 50 percent to 60 percent in funding and staffing of most programs—others were eliminated entirely," he said.

Tennison avoided closure of the McNabb Center with the help of his staff by aggressively pursuing other sources of funding to reduce dependence on Medicaid funding and creating new services as the old ones disappeared. These included five Medicare-based, partial-hospitalization programs and a new alcohol and drug abuse program, which came about as a result of a merger with the Detoxification and Rehabilitation Institute in Knoxville.

The staff also created new interagency collaborations with local training and advocacy programs, for instance, to develop alternative ways to serve the community.

Tennison consistently served as a voice for his patients, according to Moffic. Tennison "returned patient phone calls promptly, referred clients to advocates when a dispute in treatment arose, and took patient appeals as far as they would go," he said. In other words, when TennCare did not authorize a treatment plan for one of Tennison’s patients, he pursued all paths available to him to get each patient the care he believed was necessary.

When he accepted the Moffic Award for himself and the McNabb Center, Tennison credited the center’s staff, management, and board of trustees.

"The award was a meaningful and timely recognition of hard work, perseverance, and difficult decision making," Tennison said. "It recognized what is for me the most important set of concepts and dilemmas in the whole struggle to cope with sudden and terrifying changes in our service delivery system."

Tennison also said that although there have been improvements in TennCare’s services, "there remain awful deficits in psychosocial intervention, rehabilitation, recovery, and prevention."

Andres Pumariega, M.D., the 1999 award winner, called attention to yet another problem with managed behavioral health care systems—the lack of attention to the cultural concerns of both clinicians and patients.

As chair of the department of psychiatry and behavioral sciences at Eastern Tennessee State University in Johnson City, Tenn., Pumariega spent some time researching and writing about the general lack of cultural sensitivity in managed behavioral health care systems.

"The managed behavioral health care industry was developed and is run mainly by Caucasian males," Moffic said. "With the prominence of poor ethnic minority patients in the public sector, the lack of cultural competence in managed care has become even more of a concern."

Pumariega led the development of a 1996 document, titled "Best Principles for Managed Care Medicaid RFPs: How Decision Makers Can Select and Monitor High Quality Programs," which included recommendations for states setting up managed care systems that included culturally competent assessments and certain ethical standards in contracts between managed care vendors and providers.

That same year, as chair of the National Latino Behavioral Health Workgroup, Pumariega oversaw the production of cultural competence guidelines, titled "Cultural Competence Guidelines in Managed Care Mental Health Services for Latino Populations."

In the guidelines, Pumariega advised that "a culturally competent individual at the executive level should be appointed to take responsibility for and have authority to monitor implementation of the cultural competence plan."

Moffic said that the National Committee for Quality Assurance, the accrediting body for managed care companies, now requires that managed care companies implement cultural competence standards, largely due to Pumariega’s influence.

The following year saw another strong advocate for culturally competent care receive a Moffic Award. Michael Hoge, Ph.D., chief operating officer of Yale Behavioral Health, helped to design the program that serves diverse Medicaid populations and addresses not only patients’ psychiatric needs, but social needs as well.

Moffic explained that because many people with severe or chronic mental illnesses have unstable living situations, they must receive social or residential services to be able to find adequate housing, learn work skills, and acquire social supports. Often, the systems that provide psychiatric care and social care are different, and the two don’t necessarily communicate well with one another.

Staff at Yale Behavioral Health helps patients find housing and build social support systems while they are in treatment. "There have been few systems that take care of psychiatric and social needs under one funding source, and this system has been successful," said Moffic.

According to Ezra Griffith, M.D., who nominated Hoge for the Moffic Award, the Yale system "was able to maintain a primary emphasis on client need, placing cost as a secondary consideration."

As associate professor of psychology in the Yale University department of psychiatry, Hoge has also used education as a tool to improve managed behavioral health care systems. He developed a successful curriculum for psychiatry residents at Yale that extends beyond the practice of managed care to the principles that underlie it. Residents learn how to develop relevant treatment plans, employ evidence-based treatments, and analyze the cost of those treatments, for instance.

"Hoge teaches how managed care has driven improvements within the field of medicine," said Moffic. He has also taught these principles to mental health professionals from other disciplines, administrators, politicians, and consumers. Hoge envisioned an "integrated system that would provide high-quality, cost-effective mental health care," Moffic continued.

Nominations are now being invited for the Moffic Award. Moffic can be reached by phone at (414) 456-8950 or by e-mail at bpernitz@mail.mcw.edu. ▪