Changing Paradigms in Correctional Mental Health Care: Georgia DOC Meets the Challenges of the New Managed Care

Article excerpt

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. …