Managed Care in Iowa

In Reply: We agree with Dr. Rohland that the contracting process is crucial for accountability and high-quality care. As she indicates, neither the state nor the managed care organization adequately anticipated the start-up problems, and the program start-up was tumultuous. One of the key lessons the turmoil in Iowa teaches is that responsible purchasing involves more than writing a contract. The public purchaser and the managed care organization must act more like a married couple than arm's-length contractees.

When the program foundered, the state and the managed care organization negotiated the way well-functioning couples do. This process is better described as one of collaborative diagnosis of problems and design of options than as "implementation of regulatory standards." Contracts and regulations are static. A successful human service program requires a more dynamic and nuanced interaction than those terms connote.

Dr. Rohland's suggestion that simple outcome measures be incorporated into contract specifications is excellent, but deciding which areas of the program to monitor and what kinds of measures to use can itself become a focus of conflict. Caring for needy individuals within limited public budgets requires trade-offs among values. Seeking a reasonable balance of values inevitably entails tension between different stakeholder positions.

A recent report from the Bazelon Center for Mental Health Law and the Milbank Memorial Fund provides empirical support for Dr. Rohland's emphasis on the importance of monitoring outcomes (1). Outcome data will enrich debate among competing political agendas. It will not, however, eliminate the need for moral and political deliberation about program goals and alternative choices (2).