BY: SR. RENEE YANN, RSM, D.Min.
Sr. Renee is senior vice president, mission, Keystone Mercy/AmeriHealth
Mercy Health Plans, Philadelphia.
On a beautiful day in May over 30 years ago, I left my alma mater with a cherished
BA in English under my arm. Little could I have imagined that elements of that
study would guide me one day on the path of elucidating and promoting Catholic
managed care as ministry. In my present role as senior vice president for mission
at Keystone Mercy/AmeriHealth Mercy Health Plans, Philadelphia, I have been
searching for a language and conceptual framework that could help me unfold
the power of Catholic managed care as ministry.
The character of Quasimodo, the "ugly monster" hidden in the cathedral
bell tower, seems to offer a promising symbol for this assessment. Please join
me in examining this ministry through a metaphor inspired by Victor Hugo's
1831 masterpiece, The Hunchback of Notre Dame.
Monster or Gentle Giant?
Throughout Hugo's novel, Quasimodo is perceived by others in a variety
of contradictory ways. He is both scorned and protected, feared and respected,
misunderstood and ultimately appreciated. His situation is not unlike that of
Catholic managed care.
A relative newcomer in the Catholic health care neighborhood, Catholic managed
care arrived bearing congenital scars and handicaps. Because it has been seen,
not as it really is, but as resembling for-profit managed care (with all its
negative connotations), Catholic managed care has always struggled to articulate
its intrinsic value, identity, and character in the Catholic health care context.
Health care is one of the few products that consumers do not purchase directly.
For example, yesterday, I bought a hot dog from a street vendor. I gave the
vendor $2 and she gave me a hot dog (with the works!) Done deal! Most sales
are structured in this direct "twin axis" exchange.
However, health care is most often purchased on a "triangulated"
basis. I (or someone acting on my behalf, such as an employer or government
agency) pay an insurer who then negotiates price and delivers payment to a provider
on my behalf.
It is as if a whole group of people wanting hot dogs were to pay a negotiator
to find the best and cheapest hot dogs. Even better, the group's members
would not be required to pay for the hot dogs when they ate them. Such a triangulation
naturally promotes tension and often conflict. Providers want to negotiate the
highest price. Insurers want to negotiate the lowest price, and they also want
consumers to be prudent even when services are "free" (or at least
seem that way). Consumers want high quality, low cost, and many choices.
In this triangulated situation, the buyer/seller exchange (money for hot dogs)
usually found in a market economy is disrupted. The consumer feels entitled
to free hot dogs, as often and as many as he or she wants. Providers find themselves
supplying services of increased frequency, cost, and complexity. This is often
done without reference to the total pool of resources or accountability of the
common good. When left in this unmanaged state, health care costs rise, resources
diminish, and those consumers who lack buying power lose access to care.
Managed care insurers, who consolidate the buying power of large numbers of
members, have significant ability to guide access, price, quality, and competition.
This often creates stress on the provider point of the triangle. Any entity
playing such a stressor role immediately invites unpopularity. Like Quasimodo,
Catholic managed care looks "ugly" when compared to traditional health
care. Add to that the catalogue of managed care excesses promoted by the media,
and we have a significant likelihood that Catholic managed care, just like Quasimodo,
will be judged and condemned long before the evidence is heard.
Self-Perception and Dream
Like all benign monsters of literature, Quasimodo knew himself to be different
from the public's perception. Far from an ugly, fearsome, and dangerous
threat, he knew himself to have identity, values, spirituality, a capacity for
love, a desire to serve, and the potential for accomplishing great good. It
is not a stretch to say that Catholic health care, heavily influenced by hundreds
of years of provider-based self-definition, may harbor immobilizing prejudices
regarding that "ugly monster," managed care.
In the novel Grendel, a more recent classic, John Gardner retells the
epic Beowulf from the viewpoint of the monster. The retelling creates
quite a different reality. Given the opportunity, perhaps Catholic managed care
might retell its own story as follows.
A Unique and Valuable Identity Managed care initiatives, when sponsored
by Catholic health care entities, often have been viewed primarily as financing
mechanisms — a way to establish captive populations for specific entity providers.
This limited conceptualization of managed care severely underdefines and restricts
its potential.
Catholic managed care is an integrated vehicle for the coordination and funding
of high-quality health care services. By consolidating medical management, resources,
data, and purchasing power for served populations, managed care exercises a
significant positive impact on quality, continuity, access, availability, and
cost in health care. For Catholic managed care in particular, the multiple benefits
of this impact are appropriately redirected to the poorest, sickest, and most
marginalized members of communities.
An Intrinsic Value that Activates and Underlies Decisions and Actions
The concept and practice of Catholic managed care are built on the foundational
principle of the common good in right relationship to the individual good. Since
the measure of common good is its benefit to all individuals, how does Catholic
managed care benefit all as well as one?
Managed care's purpose is to prevent disease, promote health, and provide
access to care more equitably and more affordably than fee-for-service practice
can do. It should serve to improve service, care, and access. As in all relationships,
the bonds between and among Catholic managed care plans and their members and
providers are guided by fundamental ethical principles. Essentially, managed
care exercises these important ethical roles as a partner with its members and
providers.
Ethical managed care should:
- Promote member rights, care, and preventive health
- Provide accurate, data-driven evidence for health care decisions
- Educate members and providers for best outcomes
- Exercise good stewardship of available resources
- Support and reward clinical excellence
- Discover and correct clinical inappropriateness
An Underlying Theology, Mission, and Ministry We are used to such historical
images of health care ministry as a nurse at the bedside, a physician tending
a small child, a therapist supporting a person in rehabilitation. We are perhaps
less accustomed to such images as an administrator laboring over elements of
the strategic plan or a human resources director terminating a lackadaisical
and therefore dangerous caregiver. But these too are essential expressions of
the ministry of Catholic health care.
What then does Catholic managed care look like as ministry? It too may
be expressed in images that differ from our traditional stereotypes, but these
expressions are no less distinctive of ministry. Catholic managed care "looks
like":
- An outreach coordinator scheduling transportation for a mammogram appointment
- A physician analyzing practice patterns among plan physicians to determine
excellence
- A pharmacist using data to avoid contraindicated prescriptions
- An accountant creating budget tools for better stewardship
- A provider contractor ensuring that elements of a contract are in the best
interests of members
These and many other similar services create the seamless fabric that allows
a member to receive timely, coordinated, appropriately priced, excellent health
care services. How is their work different from the work done by a commercial
insurer? In Catholic managed care, as in all Catholic health care, otherwise
identical actions are differentiated by the explicit faith-based context which
motivates, sustains, analyzes, affirms, and corrects all actions, choices, behaviors,
and relationships.
All Christian ministers must return frequently to the well of the Gospels to
fill the reservoir of their own meaning. Healers draw grace from the compassionate
words and actions of Jesus toward the blind, lepers, and paralytics. Counselors
find replenishment in the strength and tenderness of Jesus toward the possessed,
the arrogant, and the disenfranchised. Sponsorship in the Catholic tradition
provides that essential context of meaning for Catholic managed care as well.
Those who work in this ministry find meaning in the Gospel values, tradition,
and ethical construct of Catholic heritage.
For example, managed care ministers may be renewed by the parable of the loaves
and fishes. In the light of this story, we may say that we experience the ministry
of graced administration and management of resources, in which right relationship
is achieved for the whole community, not only for individuals within it. The
parable of the loaves and fishes shows us a specific kind of ministry. Jesus
does not, in the parable, directly feed the hungry. He issues a challenge, the
response to which brings forth riches from the community itself. Distributive
justice, based on a balance of need and possession, allows all to be fed. Distributive
justice is the administrative face of compassion.
Managed care ministry, at its heart, is about this kind of distributive justice.
It is about the administration and promotion of resources for the healing of
the whole community. It is about setting the challenging context in which individuals
who possess more than others divest and share so that all may have an equal
"some." Managed care ministry, as in all ministries of administration,
is about keeping before us the difficult and essential question of distributive
justice: To whom do things really belong? At its best, managed care ministry
asks this question of itself, of the delivery side of health care, and of the
corporate and civic communities that it influences.
Managed care ministry, framed and sustained by Catholic sponsorship, possesses
the potential to effect systemic change through self-discipline, advocacy, and
mutuality. It has an opportunity unparalleled in the history of Catholic health
care. The emergence of the Catholic managed care ministry offers tremendous
potential to exercise the precious gift of the Holy Spirit that reflects the
mercy and justice of God for our times.
An Esmerelda for Managed Care
Like the more traditional provider-based model of health care, Catholic managed
care cannot sustain a value-driven ministry without the sponsorship of the faith
communities whose heritage, experience, and practice have shaped them to the
mind and heart of Christ. Quasimodo sought stability in Esmerelda, the novel's
beautiful heroine, who treated him kindly. He wanted her to recognize him for
his true self, love him, change him, and thus free him. Although his expectations
concerning her may have been inappropriate and naive, his recognition of his
need for a life-sustaining relationship was accurate and well founded.
Managed care too needs its perfect Esmerelda — that construct of mutual
truth, understanding, and motivation we call sponsorship for mission. Catholic
managed care seeks equilibrium through the anchors sponsorship provides: faith,
tradition, service, self-examination, and conversion.
In order for this relationship to achieve its potential for the sake of God's
people, sponsors and systems must move beyond any perception of Catholic managed
care as an ugly stepchild. They must work harder to understand its unique power
for mission and ministry, to call its practitioners to the continuous examination
of values-based practice, and to articulate the mission structures and supports
that will effect its strengthening as an essential and valued health care ministry
for today and for the future.