The Case of Sam

To the Editor:I read with interest the case of Sam in the October 2001 issue and the case discussions by eight authors from various disciplines (1). Fortunately or unfortunately, it is cases like Sam's, discussed from a multidisciplinary perspective, that have helped support the exponential growth of managed care (2). In the case of Sam, it is obvious that a lot of money has been spent and little benefit obtained.

As Commissioner Marylou Sudders stated, an outside review could have—and should have—been done. Outside reviews are part and parcel of managed care in the form of utilization reviews. Such a review surely would have questioned a 20-year history of unspecified weekly psychotherapy with unclear goals and unclear results, a list of medications without dosages or duration, and the absence of any documentation of Sam's desires, which is part of the reason patients are usually asked to sign managed care treatment plans. Such a review would be unlikely to approve a long-term hospitalization, assuming that this option was available. At best, managed care would have suggested something different, such as the assertive community treatment recommended by Dr. Munetz in his discussion of Sam's case. A managed system would also likely have tried to clarify who was in charge of the multidisciplinary team, or it would have assumed control itself through the review process.

As the presentation made clear, Sam's is a very difficult case with a very dedicated staff. However, what seems to be missing is accountability, and the results obtained appear to be minimal. Such a case calls for another form of management. That a managed care system might do better can be readily seen in another article in the same issue, which summarizes the Baltimore Capitation Project, a program that received a Significant Achievement Award from the American Psychiatric Association (2). This program has provided improved care for patients like Sam at lower costs. Isn't that what everyone would like?