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Changing paradigms in correctional mental health care: Georgia DOC meets the challenges of the new managed care.

Managed care is dead. Long live managed care. The traditional figure of the Rockwellian country doctor single-handedly managing the care of generations of Americans is no longer part of our way of life. Advances in science and technology have promoted the use of specialist care, which not only has made the country doctor obsolete, but has put the cost of medical care out of the reach of many Americans.

We have regulated and credentialed ourselves into a very expensive health care system. Part of that expense stems from legal costs as physicians, hospitals and government agencies try to minimize liability while remaining competitive. But even as our standard of living has improved, the percentage of our money going to health care has increased. Having developed a sense of entitlement to the provision of quality health care, we have come to think of access to health care as a right similar to life, liberty and the pursuit of happiness. It naturally follows that we have come to desire and expect that all but the most cosmetic options in health care be available to us.

And so we arrive at the death of managed care as we used to know it, and the birth of the new managed care, in which accountants, lawyers, stockholders and politicians decide what used to be exclusively the province of physicians. The autonomy of physicians as providers has dissolved. There is increasing pressure on providers to give more health care service for less money. The cold hard edge of capitalism has brushed up against the caring legacy of Florence Nightingale and left most of us longing for the good old days.

Georgia's Experience

Under the leadership of Gov. Zell Miller, the Georgia Department of Corrections (DOC) has made a serious commitment to managed care in the form of privatization of most health care services. Since the early 1980s, the DOC has contracted with Correctional Medical Services (CMS) to provide some of its primary health care services. In 1995, Prison Health Services (PHS) was contracted to provide all of the physical health care for the state prison system's 37,000 inmates. In 1997, the contract was awarded to the Medical College of Georgia under the name of Georgia Correctional Health Care (GCHC).

Prior to last year, mental health in the Georgia state correctional health care system had been administered primarily by the DOC. About 75 doctorate-level mental health providers operated in Georgia prisons, many of them as part-time independent contractors. The DOC would likely have continued to provide mental health care in this format for the foreseeable future were it not for two developments: a class action lawsuit and the intervention of the Internal Revenue Service ORS).

The DOC has been part of a class action lawsuit known as Cason v. Seckinger for more than 10 years. While the specific issues of the lawsuit are varied and cover a broad range of concerns, the most important issue at stake is the overall quality of health care.

To assure continued improvement in the quality of care, and to satisfy the court, the DOC has wanted to keep close control over the delivery of mental health services. In Georgia, a careful yet collegial relationship has developed between the state's chief administrators, chief clinicians and the federal court monitors. The result has been a collaboration of administrative will and clinical effort that has improved the level of mental health care in Georgia prisons.

The IRS also intervened by giving the DOC notice that it would face stiff penalties if it did not change its policies regarding full-time versus contractual workers. And so, in July 1997, when the provision of physical health services was turned over to GCHC, the provision of psychiatric and psychological services was turned over to MHM Correctional Services, a division of MHM Services of Vienna, Va.

Managing Change

New paradigms of care require changing some of the most fundamental elements of our way of doing things. Rock Welch, regional manager for MHM and the hands-on administrator overseeing the daily operations of the contract, has found managing the pace of change to be perhaps the most sensitive aspect of bringing the new managed care to Georgia corrections. Often, the private sector is more efficient than government, because it can change more quickly and thus respond to market demands more rapidly. Bringing the new private sector managed care into government operations demanded that private business slow down and that government speed up. This was no easy feat.

New computer software was developed to assist in managing the mental health care of inmate patients. GCHC Director of Pharmacy Charles Peterson developed a program that would help the DOC target pharmacy utilization. Psychologist Marcel de la Serna also developed a userfriendly assessment program. These locally developed tools will allow the DOC to adapt them as needed to Georgia's needs.

Two issues critical to the management of mental health care are: 1) who should take on the mental health caseload, and 2) the cost of medications. There are approximately 36,000 inmates within the jurisdiction of the DOC, with about 3,500 inmates on the mental health caseload. As we consider other paradigms, we may find many more or many fewer inmates being classified as mental health inmates.

Mental health professionals both in and outside of prisons have a high degree of success in treating serious mental illness. According to the National Institute of Mental Health, the outcomes for treatment of illnesses like schizophrenia, manic-depression, serious and psychotic depressions, and serious anxiety disorders like panic disorder, obsessive-compulsive disorder and post traumatic stress disorder are as good as any treatment outcomes in medicine.

Treatment Pitfalls

Outcomes for the treatment of emotional problems and disruptive behavior are not well-known. It is not clear whether we have cost-effective treatments for personality disorders, mild chronic mood disorders like dysthymia and cyclothymia or other chronic and persistent emotional and coping problems. There is a fair consensus that we might actually worsen the course of antisocial personality disordered people or at least the subgroup of them who have a true sociopathic personality. Other areas where mental health professionals as a whole have not proven their worth is in the assessment and treatment of substance abusers, in anger management and in dealing with those who have been abused.

Correctional health care has increasingly come to rely on mental health to intervene with angry and disruptive individuals. Whether that behavior is the product of a serious mental illness is a matter that is interpreted very differently by mental health professionals. Some would tend to put most of the 36,000 inmates on the caseload. Others would limit the mental health caseload to the psychotic and those with the types of serious illnesses mentioned above. However, regardless of the lack of demonstrated cost-effectiveness in treating many disruptive behavior problems, there is a level of comfort others derive by assigning such problems to mental health and then letting mental health use its resources to change or at least address the behavior.

The outcome of mental health caseloads where there is a predominance of personality disorders, chronic mild, yet disruptive, mood disorders and substance abusers, is that the seriously mentally ill will get less attention. Those whom mental health professionals are trained to treat and whose care is their primary business take a backseat to the more vivid and nagging problems created by those without serious mental illness who often clog the caseload.

The problem of medications also is of concern and elicits both emotional and intellectual debate. When referring to which medications he as a physician would have access to, one psychiatrist vigorously stated, "Anything but the best is inferior, unethical and unconstitutional." This is an old and still cogent topic for debate. Who has a right to what and who should pay for it? If amoxicillin will do the same thing as Augmentin with no substantial difference in risk or benefit, would we use the more expensive Augmentin or go with the cheaper amoxiciilin? What if studies show that 15 percent of people get a stomachache with Augmentin but 25 percent get it with amoxicillin? The less expensive medication has 10 percent more risk of producing side effects. What if the difference is 75 percent more side effects, but they are minimal? What if there are only 3 percent more side effects, but they are dangerous?

These very questions are playing themselves out in correctional health care in Georgia. We currently are struggling with the role of the older, much less expensive antidepressants versus the newer, more costly antidepressants. It seems we have enthusiastically embraced the new antidepressants as unquestionably superior to the old while respectable studies indicate they are only mildly superior. The interpretation of these studies and their application to actual prescribing habits becomes monumental.

A second medication issue of interest concerns the role of valproic acid versus Depakote. With Depakote recently approved by the FDA for bipolar disorder and the advertising that has subsequently arisen, it is no wonder that Depakote has become the drug of choice for everything from true bipolar disorder to a tool for anger management. It is interesting to hear many prison health care providers say they've chosen Depakote because lithium wreaks havoc on the kidneys and valproic acid tears up the lining of the stomach - taken almost verbatim from the advertising campaign for Depakote.

Although the literature does not support these claims, providers are quick to prescribe expensive medications without examining the evidence. Clinicians are indeed susceptible to the same marketing strategies used to sell cars or to influence political votes.

Final Solutions

The final solutions to the questions of the new managed care - such as who gets on the mental health caseload, whether they should be treated with medicine or not, and what medicine to use - will not be answered by MHM, the DOC or the federal court. In fact, those questions are not likely to be answered at all, at least not definitively, for some time, as managed care evolves and correctional health care providers evolve with it.

The new managed care is succeeding. It is putting some business sense behind the emotional topic of the allocation of health care resources. The question of whether it is saving the state money may not be the correct question. The real question may be, is the health care system evolving into one that gives most value to the inmates, taxpayers and institutions. The ultimate success of the new managed care will depend largely on how freely those who govern it allow the marketplace to operate.

The greatest challenge for the leadership is in accepting radically new paradigms of delivering care while staying true to the most important element of leadership - trust. Trust, and the improved quality of care for inmate-patients that will result, will be achieved by each of us turning inward and developing our trustworthiness. Believing in the principles that guide natural law, determining your values and then setting your compass to align with those truths you have carefully unveiled, will be the rock upon which the next generation of improvements in correctional health care will be built.

Nelson C. Bennett, M.D., has been a psychiatrist for the Georgia Department of Corrections since 1992.
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Title Annotation:Department of Corrections
Author:Bennett, Nelson
Publication:Corrections Today
Date:Apr 1, 1998
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