Catholic Managed Care

September-October 2004


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.


Copyright © 2004 by the Catholic Health Association of the United States
For reprint permission, contact Betty Crosby or call (314) 253-3477.

Catholic Managed Care

Copyright © 2004 by the Catholic Health Association of the United States

For reprint permission, contact Betty Crosby or call (314) 253-3490.