Managed Care: Strengthening the Consumer Voice in Managed Care: III. The Philadelphia Consumer Satisfaction Team

On December 7, 1987, Governor Robert Casey announced the closing of Philadelphia State Hospital—widely known as "Byberry"—in the ringing moral terms that characterized the deinstitutionalization movement: "Today, we're taking action that is both strong and compassionate [to] ensure that Pennsylvanians with mental illness and mental retardation will no longer be left out, left behind, or forgotten" (3). By 1989 the deaths of two former patients and the attempted suicide of another prompted an intensive review of the closure plan (3). As part of the review, Joseph Rogers, who was then president of a consumer organization called Project SHARE, formed under the auspices of the Mental Health Association of Southeastern Pennsylvania, led a team of consumers that made visits to Byberry to interview patients about their needs and wishes for community care. Rogers proposed that consumers could be trained to gather data on the quality of services from users of the care system after the hospital's closure.

Rogers' proposal was the right idea at the right time. Estelle Richman, who was then Philadelphia's director of mental health services and is now the city's managing director, feared that "we might wake up finding that we had put money into the community without accountability." Richman was convinced that "the best way to assess your services is through hearing from consumers and families" (Richman EB, personal communication, Aug 3, 2001). Rogers' and Richman's ideas led to the formation of Philadelphia's Consumer Satisfaction Team in 1990, when Byberry was finally closed.

Consumer Satisfaction Team, Inc., has grown steadily from its initial team of four and a budget of $138,000 to its current staff of about 30 employees and a $2.8 million budget. Its growth has been dynamic, but its mission has been stable. From the start, it had four objectives:

• To promote the satisfaction with mental health and substance abuse services of individual consumers and people in recovery

• To serve as a link between consumers and the government entities that fund these services—the Office of Mental Health, the Coordinating Office for Drug and Alcohol Abuse Programs, and Community Behavioral Health

• To promote the accountability of funders and providers of services to the people who use and depend on these services

• To contribute to an effective and cooperative behavioral health system

In 1997 the Pennsylvania Department of Public Welfare decided to separate, or "carve out," behavioral health services for Medicaid recipients from the health maintenance organizations that were then responsible for such services. Each of the five southeastern counties was allowed to choose between contracting with a private managed behavioral health care organization or forming one of its own. Given its experience in managing the closing of Byberry and the expansion of community-based programs, Philadelphia County chose to form and run Community Behavioral Health, a nonprofit managed care program.

Community Behavioral Health is one of the three prongs of the comprehensive Philadelphia Behavioral Health System. The system brings the Office of Mental Health, the Coordinating Office for Drug and Alcohol Abuse Programs, and Community Behavioral Health under unified management. The objective is to bring together typically fragmented funding streams into a coherent, consumer-centered system. The Consumer Satisfaction Team is a crucial component of the system, from which it derives its annual budget.

In a previous column, we argued that consumer participation is vital for heightening a health system's accountability for the reasonableness of its practices and policies by enhancing transparency (making the inside of the black box of managed care visible), by improving deliberation (the give-and-take among stakeholders' perspectives), and by strengthening organizational learning (adopting a try-it-fix-it ethos) (1). Although the Consumer Satisfaction Team contributes to all three components of accountability for reasonableness, its most distinctive lessons pertain to organizational learning.

In many of the efforts to reform managed care, proposals center on the right to appeal and to bring suit. As important as appeals and litigation may be, they suffer from being episodic, inherently adversarial, and narrow in the sense that only a small subset of dissatisfied consumers appeal or sue. In contrast, in the 12 years since its inception, the Consumer Satisfaction Team has developed an approach that is continuous, collaborative, and broad. In 2000 almost 10,000 consumers were interviewed, and their comments were reported. Major sites are regularly revisited, and ongoing interviews are conducted. Most important, all the stakeholders we interviewed for this column exhibited the kind of cooperative and relatively nondefensive spirit that true quality improvement requires.

Although Philadelphia officials, led by Estelle Richman, have shown an extraordinary commitment to the value of consumer perspectives on quality, in principle their approach can be emulated by other public and private programs. It will not be easy, but it's not rocket science. "Voice" requires a speaker and a listener. The Consumer Satisfaction Team has learned to speak clearly and cogently. Providers and the public purchaser listen regularly and carefully. The next two columns in this series will further explore the "speaking" and "listening" functions in efforts to ensure the effectiveness of the consumer voice.

The authors thank Elizabeth Andl-Petkov, Valerie Byrd, Jonathan Delman, Laura Deriggi, Loretta Ferry, Leonard Hoffman, Dorothy Lynch, Lawrence Real, Estelle Richman, Joseph Rogers, Susan Rogers, and Jennifer Tripp for helping them learn more about the Consumer Satisfaction Team concept and the Philadelphia experience. They also thank the Greenwall Foundation, the Open Society Institute Program on Medicine as a Profession, and the Center for Health Care Strategies for their support.

Dr. Sabin, who is editor of this column, is clinical professor of psychiatry at Harvard Medical School and director of the ethics program at Harvard Pilgrim Health Care, 133 Brookline Avenue, Sixth Floor, Boston, Massachusetts 02215 (e-mail, [email protected]). Dr. Daniels is Goldthwaite professor in the department of philosophy at Tufts University in Medford, Massachusetts, and professor of medical ethics in the department of social medicine at Tufts Medical School in Boston.