Tales from the Dark Side: The Diary of a Managed Medicaid Behavioral Health Medical Director.Part I

By Sosunmolu Shoyinka, M.D.

This blog is about my introduction to the world of Managed Care. It is about one individual’s gradual transformation from junior faculty into business executive, from clinician-educator to administrator. It is about learning to function in the world of health care financing - a world of politics and of policy, of rapidly-shifting alliances, priorities and strategy. It is a world of oft-difficult decisions and of confronting stark realities. Yet it has also proved to be an unparalleled learning opportunity, one in which politicians, bureaucrats, clinicians, business and data analysts, media, policy and lobbying experts sit together to hammer out strategy for ensuring that the health needs of a very vulnerable population are taken care of. And it is home to some of the most hardworking, talented, dedicated and genuinely caring people that I have ever met.

Over the next several posts, I will share with you some of the lessons I’ve learned and continue to learn. My hope is that these posts will serve as a road map or guide for some other idealistic young clinician who believes that population care is the wave of the future, and is foolish or brave enough to believe that, applied judiciously, a little influence can make a big difference.

When I first announced my intention to accept the position of Medical Director for Behavioral Health with a Managed Medicaid Organization, my boss, colleagues and mentors thought I had lost it. No matter how hard I tried to explain my reasons for taking the role and what I hoped to learn from doing so, no one seemed to really understand. At times I wondered if I actually HAD lost it. And for the first 3-4 months after actually beginning to work in that role, I truly feared that I had made a mistake.

I had graduated from my Ivy League fellowship training a few years before, dewy-eyed and with intentions to change the world. My strategy was simple and straight out of a line in Jim Collins’ book “Built to Last”. In it he’d described how most successful companies, such as Google, find their niche. That strategy was summed up in one statement: ”Try a lot of stuff, and see what works”. So I did. Over a 3 year period, I exposed myself to as many diverse practice environments and roles as possible, to test out what really fit and what didn’t.

I’d heard that the best way to learn was to teach, and so I took a teaching job. I accepted a job on faculty at a university in the rural Midwest, where I spent the majority of my time teaching Psychiatry and Family Medicine residents Community Psychiatry. In the same vein, in my clinical practice, I took all comers. I supervised residents in several community clinic settings, via live encounters and tele-psychiatry. I consulted in a primary care clinic. I set up my own buprenorphine clinic, and developed a training program for addictions in conjunction with a substance abuse treatment provider. I conducted trainings with the Police Dept. Crisis Intervention Team. I gave talks at the Institute for Psychiatric Service, to NAMI, to Medicaid Directors and the Primary Care Association. I collaborated with a wide variety of providers to strengthen existing services and develop others. I took shifts in a forensic hospital and worked in Corrections. I took the board exams in Addiction Medicine and Community Psychiatry and was certified in both. I served on state and hospital committees and worked with some extremely talented thought leaders on state quality - improvement projects. I also worked with residents to develop community psychiatry projects aimed at filling some of the gaps of care in our local system. I loved every minute of it.

I discovered a love for treating individuals with complex problems. The more complicated, the better. Perhaps it was the clinical challenge or perhaps it was the gratification when working together with a multi-disciplinary team. Or perhaps it was the thrill of working with the individual to find a formula that finally worked for them and seeing hope rekindled in their eyes. It was the most rewarding sense I had ever felt. I similarly discovered a love for teaching. Or perhaps more accurately, mentoring. It was a similar sense – seeing what was in my students and helping them pull it out, develop it, and then master it. One thing never did stick, however: I never learned to love research, despite the urgings of both my father and my old mentor. My eyes simply seemed to glaze over every time the subject came up and I eventually gave it up as a career path. In its place, I discovered a knack for identifying gaps in the system of care and designing programs that could plug them.

As time went on, I began to gain a reputation as a clinician and teacher in my community. So I decided on the academic clinician-educator track. I had picked an area of interest: the integration of substance use/co-occurring disorder treatment into primary care. I planned to work with collaborators to carry out some basic health services research, to do direct clinical service, to write and to teach in that area, maybe run a service. In short, I was set, both I and everyone else thought, on a traditional academic path and would stick to that well-worn road. But something kept cropping up.

You see, I was beginning to realize that all that we did - clinically, in teaching and in research - all boiled down to one thing: money. As the old adage went, “you get what you pay for”. Well, we had what we were paying for, or maybe more accurately, were being paid for, alright. The way services were structured had a lot less to do with the needs of our patient population and a lot more to do with what someone was willing to pay for, and how much of it they would pay for. It was no one person or agency’s fault – just the reality of our current situation. And doctors were just another resource to be factored into the calculations on how to balance the books. So much for all I’d learned in training. In the real world, money talked and... well, you get the idea. The alternate path seemed similarly unappealing: to treat only individuals who could pay cash and turn others away. I could not envision such a career. Instead, I yearned for an opportunity to do what I’d seen my mentor, also a psychiatrist, do: namely, to influence policy in the direction of bringing fragmented, episode-based service delivery systems into alignment with the needs of our population. From what I’d seen, the best way to do that seemed to be to a “follow the money”, which meant tracking high-needs individuals and enveloping them in coordinated, anticipatory and assertive comprehensive care programs, such as the Missouri DMH 3700 program, or the Health Home. In order to achieve this, doctors needed to be present at the table when care delivery systems were being designed. It was a major epiphany.

The implementation of Obamacare confirmed my impressions. In mid-2012, I began researching and reading on the effects that the implementation of Obamacare would have on the health system and realized that this would change everything about how medicine was being practiced. My findings led to an op-ed piece, which was published in a nationally-circulated newsletter. I realized that, as it so often seemed to be, my profession was at risk of falling behind the times. For some time, it had been my observation that physicians tended not to want to bother with the business aspects of medicine, leaving that role to be eagerly filled by non-clinician administrators. I had also observed that, while physicians as a group tended to complain about being marginalized, very few were willing to step out of their clinical roles and actually get their hands dirty in making tough, fiscally sound decisions. It was not part of our training and made most of us uncomfortable. The physicians that I knew that DID understand money and how it worked in healthcare, such as my dept. chair and my mentor, had a huge advantage over those that did not. In the new/rapidly changing landscape brought on by health care reform, with talk of value-based reimbursement, accountable care organizations, of reimbursement being tied to patient satisfaction, this reluctance to become accountable not just for clinical but fiscal and other outcomes was likely to prove inimical to our profession. It was the choice of evolving or going the way of the dinosaur. I chose the former. I realized that, in order to learn the skills that I lacked, I needed to be in a different environment - one in which fiscal realities permeated every fiber of the decision-making process. Perhaps I could learn some of that by osmosis.

And so, when the opportunity to go work in the managed care industry arose, I decided to take it. It was a rather hesitant step, for I was unplugging myself from a world in which I was comfortable, acculturated, relatively skilled and connected, and venturing into a world that was totally alien. Not only would it require a rapid adjustment to a totally different culture, but it was also a potentially career – derailing move. There was also the possibility of being seduced into what I then-believed was the soulless, ethic-less world of managed care, where serious decisions about individuals’ lives were reduced to how well they could contribute to a positive bank balance for a “money-grubbing MCO”. The potential for failure was great. Nevertheless, I felt I owed it to myself to try. I felt that I was early enough in my career that I could recover, if I didn’t linger, should the job prove to be a dead-end, and could simply plug myself back into academia and pick up where I left off. So, with some trepidation, I gave notice, bade farewell to my beloved colleagues, students and mentors and took up my new role.

Any Given Weekday

I arrive in the office early and immediately get to work. Experience has taught me that, once the work day begins, I am unlikely to get much of my to-do list accomplished, given the frenetic non-stop pace of work on most days. Indeed, many of my co-workers start their workdays well before 7am. I quickly scan my Outlook calendar. I will attend the executive team meeting, and then meet with my behavioral health team lead staff, including managers and supervisors. We will review issues pertaining to our team and plan for the weeks ahead. Between 10 and 11am I will conduct a training on the medical complications of drug abuse for a sister health plan. At 11am I will attend weekly inpatient rounds, when we will discuss members in inpatient settings with long lengths of stay, rapid read missions and disposition issues. Over the lunch hour, I will meet with the Health Home team to discuss updates on the program.

This afternoon, I will follow up on issues identified in rounds. I will contact providers to discuss our members’ care and discuss strategies to optimize their treatment and identify issues that the health plan case managers and care coordinators can help with, such as after-care planning, transportation and linkage with community resources. I’ll meet with state officials to discuss gaps in the system of care and program ideas to fill them. I will also meet with my special project workgroup/task force and outreach to our collaborators. And at some point, I’ll need to complete some work-related training and reports. All in a day’s work.

My duties are focused on 2 primary goals:

1. To ensure appropriate, cost- effective utilization of services. 
2. To ensure that our members receive the highest quality care: appropriate level of/locus of care, in the right quantity, at the right time, and for the right duration.

My strategy includes the following:

1. Resource the behavioral health team through training, support and supervision. 
2. Resource the medical case management teams in the same way.
3. Resource our provider network through provider engagement, feedback, education/training and collaboration on program development.

As a payer, I can have significant input into what happens with regards to our members’ care, and I intend to use that to their benefit. One way to do that is to incentivize best practices through creative contracting and shared risk, tying payment to specific targeted outcomes. This rewards good care and outcomes and creates shared risk with the provider. It also dis-incentivizes poor care, all of which is consistent with the goals of health care reform.

In order to accomplish those goals, I’ll need to build strong collaborative relationships with providers, within the health plan executive team and with state policy makers. This will allow me to participate in developing strategy and policy in our company and at the state level. It’s a lot of responsibility but a job I relish. Interestingly, the clinical skills that I worked so hard to master find excellent use in this environment - assess a problem/situation, come up with a plan, (of necessity, often based on partial information), and implement the plan. Rinse and repeat.

To be continued…..