eS eae s VOLUME 85

vs eg N ae | Number 1

yOu rnal of the ee | December, 1998

WASHINGTON

ACADEMY.-SCIENCES |

ISSN 0043-0439

Issued Quarterly

at Washington, D.C.

CONTENTS

| Articles:

Marilyn J. Henderson, Sarah Minden, et. al,

BLelicy Analyses for Transition to Health Care Reform” ............0.5222.-620200- 1

Mary Auslander, Dawn J. Moses, et. al,

s@onsumict Issues in’ Managed Behavioral Health Care” +. 2... 1. ee ee 15

Denise Noonan, Sarah Minden, et. al,

euamilyissuesim Managed Behavioral Health Cate”... .... oe fee eee ee cee ae 28

Susan Foster, Mary Armstrong, et. al,

Mnteeratine Services for Children in the Era of Managed Care” ............2.5..4.: 39

Susan Foster, Ann Detrick, et. al,

sintesration/ of Mental Health and Other Services for Adults” ...........s.5..02.:. 53

James O. Michel, John Allen, et. al,

“Partners or Antagonists: Medicaid and the Public Mental

Eicalihvaseney initine Exaiot Managed Care’)... icici eee eee de hee ce eee eae 70

Colette Croze, John Allen, et. al,

“Public Sector Purchasing of Managed Behavioral Health Care”.................... 83

James T. Winarski, Martin Cohen, et. al, “Issues Affecting Clinical

Practice ian Braiot Manased Behavioral Health Care’... 2.0. Kee eee ote e- 101

Denise Noonan, Robert Coursey, et. al,

elite diractice Gintennes, hes a Ne cena kas jes babe es be ea ee Hees 114

Sarah Minden, Jean Campbell, et. al

/ Measuring Outcomes of Mental Healtheate Services’ : .. 2.6 eee ee ee we ee 125

Meryl Friedman, Sarah J. Minden, et. al

miViCH PACA On O@AnGS oo. iee aie ace obey ecu ba ede eam as Se eee wale we ye 8 144

Washington Academy of Sctences

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Journal of the Washington Academy of Sciences (ISSN 0043-0439)

Published quarterly in March, June, September and December of each year by the Washington

Academy of Sciences, (202) 326-8975. Periodicals postage paid at Washington, DC and addition-

al mailing offices.

November 5, 1998

Special Centennial Issue of the Washington Academy of Science

From time to time over the past century, the Washington Academy of Sciences

has occasionally published works on science and technology which it’s then leaders

felt gave voice to important questions or issues. This special issue is one of those

occasions.

Within the theme of our centennial year, “Communications, Past Present, and

Future — Within and Among Entities in the Biological Hierarchy of Life,” the papers

Bin this volume are devoted to health care, particularly behavioral health care. Which

§ system of health care is best, sustainable, and affordable for in the next century is

discussed by many and concerns all Americans.

Our thanks to Fellow and Past President, Dr. Ronald W. Manderscheid for

assembling these papers and to the over 100 authors for sharing their work; and to

Fellow Thomas Bottegal and his editorial board.

fone H. Proctor, Hiv D.

Centennial Chair

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Introduction

Special Centennial Issue

Washington Academy of Sciences

As we move into the future, a greater focus will be given to how health care delivery

is organized into large scale systems. With the advent of managed behavioral health care,

this concern has become pronounced because of the potential for limiting access to care.

Enhanced communication among policy makers, payers of health care, health care

providers and health care recipients is critical to our understanding and advancement

of the behavioral health care field.

Since its inception, the Journal of the Washington Academy of Sciences has carried

a broad array of scientific findings applicable to the practice of medical science. The

present compilation of papers represents the concerns of these major stakeholders as

they consider the policy issues surrounding the increased focus on the organization of

care delivery systems. The expectation is that these papers will foster a dialogue around

behavioral health care and its future course.

Marilyn J. Henderson and Ronald W. Manderscheid

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Facing our Future Together:

Policy Perspectives on Behavioral Health Care

A collection of papers prepared for a Special Centennial Edition of the

Journal of the Washington Academy of Sciences

Edited by

Marilyn J. Henderson

Sarah L. Minden

Susan Foster

Ronald W. Manderscheid

September 1998

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Journal of the Washington Academy of Sciences,

Volume 85, Number 1, 1-14, December 1998

Policy Analyses for Transition to Health

Care Reform

Marilyn J. Henderson, Sarah Minden,

Susan Foster, Ronald W. Manderscheid

Introduction

The rapid expansion of managed care from the private to the public sector created

a critical need for an analysis of the issues confronting the behavioral health care field

B and suggestions for future directions. In the Fall of 1996, the Survey and Analysis Branch,

Division of State and Community Systems Development, Center for Mental Health

Services (CMHS) undertook a 2-year contract with Abt Associates to conduct a series

of focus groups and analyses to improve our understanding of the major managed behav-

ioral health care issues facing the field.

The project had several key components. The fact-finding phase consisted of an

extensive review of published and unpublished literature that illuminated key policy issues

in an era of transition from fee-for-service to managed behavioral health care (Minden

and Hassol, 1996); a series of 2-day focus group sessions with major stakeholders in

behavioral health care — consumers, family members, providers, managed care organi-

zations (MCOs), State mental health agencies, and insurers — that discussed the current

State of affairs in the public and private sectors (Foster and Minden, 1997); and a technical

expert workgroup that discussed current status of and future needs for data collection,

measurement, and information systems within the managed care context (Wurster, 1997).

The literature review, focus groups, and expert workgroup generated topics for 10

policy papers. These papers describe the state of the art in the various content areas and

recommend next steps toward improving the quality of care for persons with mental

illness. Each paper draws from the published and unpublished literature, as well as the

earlier focus group discussions, but is based primarily on the opinions of expert

panelists who convened to formulate the paper. The panelists participated in a 2-hour

discussion facilitated by the lead writer(s) and commented on the resultant draft papers.

In several cases, extensive conversations were held with individual experts around partic-

ular comments and issues (Foster and Minden, 1998). This special issue of the Journal

contains the 10 policy papers that resulted from the 2- year project. For each paper, the

facilitator/lead writer(s) are listed first, followed by the expert panelists and CMHS

program staff in alphabetical order.

2 POLICY ANALYSES FOR TRANSITION TO HEALTH CARE REFORM

The current paper provides a synopsis of the basic findings from this 2-year project,

the major issues that surfaced, and the needed next steps. It closes with a discussion of ongoing

and planned activities to advance the development of quality assessment for behavioral health

care, one of the areas identified by many participants as needing immediate attention.

Terminology

The literature review, focus groups, and policy papers all demonstrated the absence

of a uniform and consistent terminology for describing the new structures and proce-

dures that have emerged in this time of transition. Consider, for example, managed care

organization, managed behavioral care organization, managed behavioral health care (or,

healthcare) organization, MCO, MBCO, and MBHCO. The papers reflect this diversity

of terminology. Below we discuss some of the key terms used in this special issue.

Agency and authority. The terms “agency” and “authority” are often used inter-

changeably. The state, county or local mental health authority performs two distinct

functions: first, it operates facilities such as state hospitals and provides community-

based services such as housing, rehabilitation, and clinical care to some of its citizens;

second, it is responsible for the nature and quality of the care available to all its citizens,

whether received in the public or private sector. In performing the first function, we think

of the public mental health authority as an “agency,” implementing a variety of mandated

activities. In its second function, it manifests its “authority” to make rules and to review

and monitor the activities of others to ensure compliance and preservation of the public

good. Over time, the distinction between these two terms has blurred. We use “MHA”

to refer to the mental health agency/authority, and “Medicaid” or “Medicaid agency”

to refer to the single state agency that implements activities mandated by and operates

under requirements set by the Health Care Financing Administration (HCFA).

Because states vary so widely in how their mental health care systems are struc-

tured and function, we use the term “MHA” to include state, county, and municipal MHAs

who pay for coverage or purchase services on behalf of public mental health benefi-

Claries or consumers. We use “director” for the head of the MHA even though many

states call this person “commissioner.”

Consumers. Individuals who are or have been involved in the mental health service

system use various terms to describe themselves, such as consumers, survivors, ex-patients,

patients, clients, or recipients. While respecting individual preference, we use the term

“consumer” in this report since it implies the use of services and also reflects the trend

toward increased respect for the consumer’s point of view.

Mental and Behavioral. Stakeholders engage in lively debate over these terms, tending

to find one or the other unacceptable. The term “behavioral” was introduced as a term

that includes both substance abuse and mental health problems. While most of the papers

that follow focus primarily on mental health issues, many of them include this broader

POLICY ANALYSES FOR TRANSITION TO HEALTH CARE REFORM 3

perspective. Hence, authors use both terms.

Provider and Clinician. While “clinician” always refers to a person who providers

clinical services (e.g., a psychiatrist, psychologist, social worker, or nurse), “provider”

can be used to refer to a single clinician or to a group of clinicians who, together, consti-

tute a single entity that provides clinical services . “Provider” in the latter usage appears

in contracts for service delivery; it also is used to describe the public MHA as “the provider

of last resort.” We use only “provider” to describe groups and entities that deliver services;

and “clinician” and “provider,” interchangeably, for individuals.

Results from the Fact-Finding Phase

Participation

All focus groups stressed the need for a participatory approach to decision making

within managed care. They made it clear that all major stakeholders, particularly

consumers and family members, must play substantive and meaningful roles in struc-

turing and monitoring systems of care and in delivery of individual treatment. In order

to assure quality care with adequate resources, the various behavioral health care stake-

holders need to communicate clearly with one another, and work through issues as a

team. All groups expressed an interest in continuing to find opportunities to discuss and

collaborate on health care issues.

Quality of care

All focus groups emphasized quality of care, particularly the need for better outcome

measures, practice guidelines, and provider monitoring. They agreed that more work

is needed to develop clinical, person-directed (or -centered) outcome measures with

substantial uniformity across States and systems. Most groups wanted national-level

practice guidelines that would reflect individuals and their needs while still providing

comparable guidelines across systems. The extent of this flexibility within guidelines

was a source of tension in some groups.

Numerous issues abound in how to design, test, and move these quality measure-

ment systems forward in a timely way. Groups discussed the importance of developing

measurement tools as well as ways to pay for the development, testing and collection

of data and the data systems needed to support them, while stressing that this should be

done without reducing resources available for services.

Vulnerable populations

People who are particularly at risk require special attention. All focus groups agreed

that there should be a safety net mechanism but did not reach consensus on the roles

and responsibilities of the various levels of government. They highlighted the need for

4 POLICY ANALYSES FOR TRANSITION TO HEALTH CARE REFORM

culturally relevant services and for intensive services for individuals at high risk of falling

through the cracks of the care system. The literature review addressed this issue by

examining research on services for vulnerable populations and how the transition to

managed care might fail to meet their needs for comprehensive, integrated, long-range,

individualized services. It highlighted the importance of intensive case management in

the care of people with serious mental illness.

Contracting

Public sector contracting, including both the content and process of contracting, were

areas of great concern to all focus groups. Public sector contracts are one of the major

determinants of the shape and scope of services available to public sector consumers,

who are often those most in need of care. Groups identified short-term contracting as a

major problem and noted that State and local governments need more expertise and

technical assistance in the contracting arena. Major points of discussion centered

around the openness of the contract process to the public and the need for involvement

of stakeholders, particularly consumer groups, in contract design, negotiation, and

monitoring. The technical workgroup concluded that the contracting process should

include language about data requirements to ensure that data are available and acces-

sible to consumers and other stakeholders in need of information. The literature review

summarized several important unpublished reports on contracting issues.

Service coordination and integration

Many of the focus groups saw coordination between mental health and medical care

as necessary to reduce fragmentation and cost-shifting. From a clinical perspective, coordi-

nation was seen as especially desirable for mental health and substance abuse agencies.

Also noted was the need for better coordination and communication between the criminal

justice system and mental health services and for increased education of justice and school

personnel. The groups recommended increased ability to communicate effectively across

the systems with respect to records and funding.

Although coordination and integration were identified as critical elements of a good

service system, many were concerned that mental health issues might be lost within

an integrated framework. Data are needed across systems to monitor the impact of

managed care on comprehensive support services, since typically they are not provided

by managed behavioral health care. The research on integrated services including demon-

stration projects and evaluations of integrated service systems, was summarized in the

literature review.

Provider competencies

A well-trained workforce that can negotiate the system effectively and provide ethical,

high-quality treatment to persons in need was identified as a critical requirement. Where

POLICY ANALYSES FOR TRANSITION TO HEALTH CARE REFORM 5

providers are to come from and who will finance their training was an area of concern.

Groups noted a need for developing providers with specialized clinical and language

skills to provide care for consumers of all cultural and linguistic groups.

Consumer-run services

Consumer-run services are clearly used and needed. Accreditation and reimburse-

ment are major concerns, and tension exists between a desire for legitimacy within the

system and maintaining the essential qualities of consumer-run services that make them

a desirable and critical care component.

Information needs

Each focus group and the literature review recognized the need for high-quality, acces-

sible information to enable an assessment of the impacts of managed care on the behav-

ioral health care field. The technical workgroup (Wurster, 1997) specifically recommended

that immediate attention be given to a revision of the current MHSIP data standards in

FN-10 (Leginski et al., 1989) and the recommended children data standards (MHSIP, 1992).

They noted two papers addressing person-centered decision support systems (Campbell

and Frey, 1993; Buckley, 1993) as foundations. They also recommended development of

uniform outcome data for service systems and development and testing of performance

measures within the MHSIP Consumer-Oriented Report Card. Confidentiality of individual

consumer information is a critical issue that must be addressed in the development and

implementation of data systems. Similar issues were raised in the literature review.

Findings from the Policy Papers

Consumer Issues in Managed Behavioral Health Care - M. Auslander, et al.

Changes in the delivery of public mental health services present both opportunities

and risks for consumers of managed behavioral health care. Some of the most pressing

issues facing individual consumers and the larger mental health consumer movement

as they encounter, experience, and respond to the implementation of managed behav-

ioral health care include benefit design and service delivery, quality assurance and research,

consumer rights and protections, and advocacy.

Self-help and peer-run services are critical components of the service mix that needs

to be available to all consumers. It is important that the quality of these services be assessed

by consumer-developed standards rather than traditional accreditation procedures.

Consumers must be integrally and authentically involved in the design, delivery,

management, and evaluation of mental health services. The approach to services needs

to be a holistic, recovery-based, consumer-focused approach, including informed choice

as to whether or not to participate in services. Authors of this paper favor the passage

6 POLICY ANALYSES FOR TRANSITION TO HEALTH CARE REFORM

of federal and state laws that mandate consumer involvement. They want to assure that

such involvement is written into public-sector managed care contracts and honored by

providers.

Family Issues in Managed Behavioral Health Care - D. Noonan, et al.

Family mental health advocates have made great strides toward highlighting the impor-

tance of families in the care of persons with mental illness. They currently play a key

policy making role in some States. Yet challenges remain, particularly in light of recent

changes in the way mental health, medical, and social services are delivered.

Meaningful, proactive involvement of families and consumers in all decision-making

areas serves as the foundation for model advocacy, e.g., in legislation, practice guide-

lines, and contracts. To advance this involvement, families and consumers must collect,

analyze, and disseminate data, develop programs for education and legislative advocacy,

participate on advisory boards, and become involved in the development, oversight and

monitoring of contracts.

Major issues with respect to managed care settings include limitations on availability

of high-quality providers, access to services, and the quality and effectiveness of care.

The need for comprehensive, coordinated care delivered according to recognized

standards of quality is critical. Families stress the need for standards (with, perhaps,

sanctions) requiring consumer and family member involvement in the development and

monitoring of any contracts where public funds are expended.

Integrating Services for Children in the Era of Managed Care - S. Foster, et al.

The recognition that care for children with mental health and other social, educa-

tional, and medical needs is seriously compromised by fragmentation has led to impor-

tant efforts to coordinate services among agencies and to involve families in the entire

process. Service integration has been a goal for decades, but new opportunities are avail-

able as the public and private sectors transition to managed care. The paper outlines the

many issues that exist with respect to the integration of children’s mental health services

with education, health care, substance abuse treatment, and the juvenile justice system.

Recommendations for improving services for children and overcoming barriers to

services integration include the following:

States need to work toward an interagency focus and agreements. Their contracts

must purchase quality care based on specific positive outcomes, rather than being totally

cost driven.

Federal agencies need to provide overall direction through legislation, dissemina-

tion of guidelines and educational materials around service integration, collaborative

Federal activities, involvement of families in building systems of care, and increased

coordination and cross-funding for technical assistance centers.

Research should evaluate programs that track children through the managed care

system over time as well as study outcomes associated with blended funding and services.

POLICY ANALYSES FOR TRANSITION TO HEALTH CARE REFORM 7

Family and consumer involvement, including involvement by youth, should be integral

| to the activities of managed care companies.

| Clinical care must be consistent with the values and principles of larger systems of

| care, irrespective of the organizational culture or the individual clinician within the system.

Integration of Mental Health and Other Services for Adults - S. Foster, et al.

Little doubt exists that an integrated service system for persons with mental illness

| provides better care than a fragmented, duplicative service array. Such an integrated service

system offers comprehensive psychosocial services in an individualized, flexible manner

| by a multi-disciplinary team of providers.

/ System reform toward more effectively integrated services needs to reflect and include

| consumers and be driven by outcome assessment. Ongoing positive relationships

| among all persons — consumers, families, agencies, and policymakers — are critical.

Challenges to such efforts include the multiple agencies involved and their often

‘competing interests and the lack of integrated information systems to support service

| integration. Given the scattered nature of available services, rural areas, in particular,

face major service integration issues.

| Financial incentives through service contract requirements are needed to promote

and enhance integration across categorical agencies. Ultimately, it is the payers who will

be instrumental in assuring that such integration occurs. We also need additional

research that assesses the improved outcomes that result from integrated service

_ systems, particularly longitudinal studies of systems.

Partners or Antagonists: Medicaid and the State Mental Health Agency in the Era

of Managed Care -J. Michel, et al.

Medicaid managed care initiatives are intended to control escalating costs, expand

coverage and access to services, and improve quality of care. Behavioral health care has

been the most prominent specialty service to command the attention of Medicaid direc-

tors across the nation. At the same time, MHAs have been completing a process of

downsizing large public institutions, attempting to develop and consolidate community-

based systems of care, and supporting a burgeoning consumer movement — all while

coping with a rapidly changing business landscape.

Structural, procedural, and political aspects of the relationship between Medicaid and

the public MHAs affect the design and implementation of managed care initiatives. Of

| particular interest are the factors that influence how Medicaid and MHAs work together,

or at cross purposes, in setting public mental health policy and in approaching finan-

_ cial, administrative, and consumer issues. Examples of conflict areas include the defin-

_itions and use of the medical necessity criterion for service coverage, the structure of

basic versus long term Medicaid benefits, and the use of traditional community provider

organizations versus open competition.

8 POLICY ANALYSES FOR TRANSITION TO HEALTH CARE REFORM

Strategies to enhance interagency cooperation include development of structures and

processes to support an ongoing interagency dialog; a collaborative and comprehensive

review of all functional areas of both agencies to identify priority areas for systems

improvement; identification of strengths, weaknesses, and areas of competence for each

agency and methods for building on strengths; development of an interagency action

plan to clarify roles, responsibilities, and relationships with key stakeholders; and devel-

opment of meaningful, manageable measures of system-level performance.

Public Sector Purchasing of Managed Behavioral Health Care - C. Croze, et al.

As is true for all governmental functions, publicly sponsored mental health services

are being transformed in an attempt to manage limited resources. Public MHAs are incor-

porating managed care strategies into their service delivery and entering into risk-sharing

arrangements with private organizations. Public sector purchasing decisions have

considerable impact on public systems of care. Before moving to change the public system

or supporting the status quo, the MHA must complete a thoughtful risk assessment that

includes defining the public interest and the government’s role within this definition;

examining the local and state support for privatization versus government programs;

honestly evaluating current system functioning, with consumer input as a critical

component of this evaluation; setting up purchasing specifications to address problems

and identified strengths; assessing the potential impacts of system change; assessing the

relationship among funding streams and setting up a coordinated plan for the use of public

behavioral healthcare funding; strategically evaluating the risks accompanying action

or inaction; assessing and addressing the skill level of the MHA to undertake systems

change; and conducting an environmental scan of political forces.

Public MHAs do not always have the controlling role within systems change; there

have been power struggles between the State Medicaid agency and the State MHA. It

is critical for MHAs to be honest with stakeholders concerning areas they do control

and those they do not. This allows stakeholders to seek and obtain entree with those in

power and have the opportunity for meaningful input in all areas of system change.

Once the decision for system change has been made, a number of issues must be

considered: the role of the purchaser/care manager; whether to use an internal or external

agent for risk-based care management; statewide or regional/local design; role of the

MHA as payer, purchaser, or provider; level of risk bearing/transfer; and linkage of profits

to performance.

It is unclear where public sector managed behavioral health care activity will move

in the future. It exists within a political and governmental environment in which State

budgetary problems have receded somewhat from the recent past. We may see more region-

alization, greater use of Administrative Services Only arrangements, and more integrated

funding as States seek to maintain some level of control.

POLICY ANALYSES FOR TRANSITION TO HEALTH CARE REFORM 9

Issues Affecting Clinical Practice in an Era of Managed

Behavioral Health Care - J. Winarski, et al.

The role of clinicians is changing. Managed care has had an enormous impact on

| the practices of “higher cost” providers, the length and locus of care, and standardiza-

| tion of practice. Clinicians accustomed to operating autonomously under a fee-for-service

| system are adapting to an array of new demands that affect practice, documentation, and

| the clinician-consumer relationship. In response, they are developing new skills: brief

| treatment, group work, care management, partnering with MCOs, negotiating for

| service and advocating for consumers. Training clinicians in these competencies is

adversely affected by a lack of resources for such training, an educational system resis-

| tant to facing such market realities, and a lack of reimbursement for clinical training

_ programs.

As clinicians adjust to managed care environments tension arises between provider

views of managed care and the economic necessity of adapting to it. Ensuring that

| providers will have the special skills required to treat persons within the public sector

and to preserve quality of care over profits requires participation by clinicians in system

_ development and change. The need for quality care is universally agreed upon; however,

_ measures of quality are not universally agreed upon nor available. Issues around quality

management include the need for clinician involvement in developing outcome and best-

_ practice data and for clinical guidelines that are accurate, reliable, and flexible. Clinicians

_are responsible for quality even without guidelines, and the issue of linking financial

_ rewards to clinical outcomes is problematic. Credentialing programs need simplifica-

_ tion and should include consumer and paraprofessional providers of services.

| A number of ethical issues exist for providers, particularly with respect to maintaining

| privacy and confidentiality when sharing information with MCOs, payers, and case managers.

A unique challenge exists in balancing cost savings with providing high-quality care.

Clinical Practice Guidelines - D. Noonan, et al.

| The proliferation of clinical practice guidelines in recent years has produced a lively

_ debate on their uses, merits, and risks. While guidelines are a valuable tool for managing

| complex clinical situations and for assessing the components of service delivery

| systems, a variety of issues affects their full acceptance by providers and consumers.

Limitations with current guidelines include the proprietary nature of many guidelines,

the lack of consumer input into guideline development, the tendency to produce overly-

_ complicated guidelines that cannot be used in real practice, the lack of agreed-upon guide-

lines among multiple stakeholders, and the lack of guidelines that address many of the

most important issues faced in the public sector — dual diagnoses, difficult-to-treat

problems, and multiple treatment settings.

The issue of sanctions for failure to adhere to guidelines is highly controversial. Many

view this as ill-advised, stressing the need for guidelines to inform rather than control

10 POLICY ANALYSES FOR TRANSITION TO HEALTH CARE REFORM

decision making. Educational programs should accompany guidelines, targeted at

practicing providers and consumers and family members. Guidelines are useful compo-

nents of quality improvement programs when linked to consumer outcomes, but linkage

must be done carefully and collaboratively by researchers, consumers, family members,

clinicians, and health care administrators.

To be valuable, guidelines need to be developed systematically and collaboratively.

They must meet high standards of quality and be nonproprietary, brief, and easy to follow

with supporting educational material. Guidelines should be applicable to both primary

and specialty care settings, available to clinical trainees, updated regularly, and devel-

oped for high-risk conditions. In addition, a need exists for guidelines that address optimal

quality of life for persons suffering from serious disorders, regardless of the cost. With

such guidelines, decision-makers will have the tools to balance quality and cost concerns.

Measuring Outcomes for Mental Health Services - S. Minden, et al.

Determining the outcome of an individual’s treatment is crucial to improving quality

of care and enhancing the accountability of those who provide it. Examining outcomes

for whole populations and communities shows how well entire systems are performing

in regard to the quality of care they provide and where their performance needs

improvement. The key issues in outcome measurement include attention to differences

among stakeholder groups, appropriate use and interpretation of outcome data, standard-

ization of outcome measurement, and technical considerations in designing the outcome

measurement system.

The ideal outcome assessment system should meet the needs and interests of all

constituencies. Involvement of all stakeholders in the development and implementation of

the system will help promote culturally competent results. The system should include both

generic and disease-specific measures and collect both quantitative and qualitative data.

Implementing outcome measurement systems in actual practice requires several

carefully planned steps: building strong political commitment to use the system for both

accountability and quality improvement applications; establishing a clear vision of system

objectives and process; spending time in realistic planning; getting the commitment of

providers, consumers, and staff who will work with the system; obtaining information about

consumer and family member experiences directly from them; selecting outcome domains

and indicators reflecting the needs of the users of the system; combining data from multiple

sources; establishing clear procedures for collecting and analyzing data; ensuring that what

is measured is what actually occurred; integrating outcome information with other

measures of quality; and using outcome data to improve the quality of care.

Many projects are currently underway on outcome measurement at both the

consumer and the system level. As a field, we need to systematically build upon past

and current efforts, and standardize and integrate outcomes with other efforts. We need

to include consumers at all levels of planning and implementation and collect and inter-

pret information that adheres to scientific standards of quality.

POLICY ANALYSES FOR TRANSITION TO HEALTH CARE REFORM 11

Mental Health Report Cards - M. Friedman, et al.

Report cards are published collections of empirical measures that allow for the evalu-

ation of specific aspects of MCOs and mental health service delivery systems and their

management structures. They include, but are not limited to, assessments of clinical and

service quality, access, consumer satisfaction, cost-effectiveness, and outcomes. While

consensus exists on the value of report card data and the importance of public account-

ability of managed care organizations and provider networks, there is less agreement

on what constitutes a “good” report card. Specific issues that affect mental health report

card development efforts include standardization, confidentiality, interpretation of data,

and consumer choice.

| Several constituencies require report card data: consumers, MCOs, providers, and

public and private purchasers of care. For each of these groups, different types of perfor-

‘mance indicators are needed. Development of a core set of items that all constituencies

are concerned with and additional items specific to each constituency may make it feasible

to develop useful tools for all groups. An ongoing forum around report card issues

‘involving all major constituencies will advance the state of the art.

}

| Future Directions

The major areas of agreement among the focus groups and the policy papers that

‘resulted from this project were on the need for the following:

e Participation by all major stakeholders, particularly consumers, in all areas that were

addressed, including system reform, outcome measurement systems, clinical

guidelines, State contracting, and report cards,

e Delivery of quality services and ways to measure them;

| ¢ Moving forward proactively to effect change.

Less than perfect agreement existed on several issues:

e Whose perspective should drive quality tools such as outcomes — consumers,

| clinicians, service administrators, or payers?

¢ How much flexibility is needed to reflect individual needs and choices?

e Exactly what should the role of government be with respect to legislation and

sanctions?

It is clear from the issues raised in this project and from other ongoing activities

‘that the mental health field desperately needs tools to measure the quality of care and

that such measures should be consensually based with meaningful input from all major

stakeholders. At present, financial supports for mental health care are declining dramat-

ically in both the public and private sectors. Consensus does not exist on system and

ee ae ge

12 POLICY ANALYSES FOR TRANSITION TO HEALTH CARE REFORM

clinical practice guidelines, outcome measures, and report cards that can assess and

document mental health care quality. Without these quality measures, negotiation for |

resources 1s greatly hampered. In the absence of consensually based assessment systems, |

price has become the only measure of quality of care and the only focus of account- |

ability.

Manderscheid (1998) outlines the following critical steps that should be taken in }

the quality process once overall goals are set:

e Discussions about values

e Evolution of principles for action

e Development of guidelines for interventions

eSystem guidelines

eClinical guidelines

eEthical guidelines

e Performance measurements

Outcomes

¢Report Cards

e Feedback processing

A crucial step in support of this process is building consensus around and testing a |

model for the comprehensive data system to assess quality of care. Such a system could |

be built on the public health model as outlined in Manderscheid and Henderson (1996).

It would allow for assessment of performance at the population level through health status

measures; at the system intervention level through system- and clinical-level practice |

guidelines and enrollment, encounter, and cost data; and at the person-intervention level |

through clinical outcome measures. To continually improve assessment, information would |

be fed back into the system through the use of report cards and performance indicator

systems. All of these components must be linked into an integrated data system.

Clearly, to make progress in this area, input and cooperation are essential for all the major

stakeholders in the field.

In response to this need, CMHS has initiated a two-year follow-on project that will |

help speed up the development of the comprehensive integrated data system just

described. The project has several major parts. Because the whole area of broadly based _|

system and clinical practice guidelines within the behavioral health care field is poorly |

developed, the first part of the project will obtain information on the status of guide- |

lines through a literature review and focus groups. Information learned will be incor- }

porated into the later tasks of convening a technical workgroup that will set up the model

data system and conducting case studies at natural sites to look at adherence to the model

or components of the model in actual practice. Policy analyses will be prepared that present

POLICY ANALYSES FOR TRANSITION TO HEALTH CARE REFORM © 13

our current understanding of how to measure system and clinical guidelines and how

they fit into the overall data model that evolved from the project. Lessons learned from

this project will feed back into ongoing CMHS developmental activities, including the

current MHSIP efforts to develop a framework for a new set of data standards for mental

| health (MHSIP Ad Hoc Group, 1997).

CMHS is also continuing to move forward with other projects that will advance the

development and implementation of quality tools. In the area of outcomes, workgroups

on content and methodological standards for both adults and children are ongoing. Drafts

of principles and standards have been prepared (Adult Outcome Measurement Standards

‘Committee, 1997; CMHS Outcomes Roundtable, 1997; Smith et al., 1997) and will be

fed into the comprehensive data model.

The area of report cards has witnessed considerable progress, including the MHSIP

-Consumer-Oriented Report Card (MHSIP, 1996) which is being tested within State grants;

support to the American College of Mental Health Administrators to develop a core data

set for report cards; and initiation of a project to bring major report card developers together

to develop a pilot study of the common core set of items required for a population-based

‘report card.

In the area of performance indicators, CMHS awarded grant supplements to five

‘States (Colorado, Illinois, Massachusetts, South Carolina, and Texas) to complete a feasi-

bility study that has resulted in a set of core indicators for performance (NASMHPD-

‘RI, 1998) that will then be piloted by a larger number of States through additional grants.

Multiple projects are ongoing in the field to develop specific data items and

‘processes within the quality arena. We hope to draw upon and build upon this past and

| ongoing work. It is critical that the various pieces be linked together into an integrated

framework that includes the range of types of data needed so that we can begin to see

quality improvement throughout our system.

To make major strides in this area, ultimately, we need to increase our focus consid-

erably and put forth major initiatives centered around the development, testing, and imple-

mentation of quality tools. This represents a major challenge to the behavioral health

\care field at present. Rapid progress is critical if the field is to compete in this era of

accountability.

References

‘Adult Outcome Measurement Standards Committee: Methodological Standards for Outcome Measures - January

1997 Draft. Rockville, MD: Center for Mental Health Services, 1997.

‘Buckley, S. M. (1993). Moving MHSIP toward a person-centered paradigm. Concept paper to CMHS and the

MHSIP Ad Hoc Advisory Group. Rockville, MD: Center for Mental Health Services.

Campbell, J., & Frey, E. D. (1993). Humanizing decision support systems. Final Draft Report to CMHS and the

_ MHSIP Ad Hoc Advisory Group. Rockville, MD: Center for Mental Health Services.

Center for Mental Health Services (CMHS). (1997). Outcomes roundtable for children and families. Assessing

service delivery population, interventions and outcomes in child mental health and child welfare services -

Working Draft 12/31/97. Rockville MD: Center for Mental Health Services.

14 POLICY ANALYSES FOR TRANSITION TO HEALTH CARE REFORM

Foster, S., & Minden, S. (1997). Managed behavioral health care: A summary of seven focus groups - Final

Report. Prepared for Center for Mental Health Services. Cambridge, MA: Abt Associates, Inc.

Foster, S., & Minden, S. (1998). Service analyses for transition to health care reform - Final Report. Prepared |

for Center for Mental Health Services. Cambridge, MA: Abt Associates, Inc.

Leginski, W., Croze, C., Driggers, J.. Dumpman, S., Geertsten, D., Kamis-Gould E., Namerow, M., Patton, |

R., Wilson, N., & Wurster, C. (1989). Data standards for mental health decision support systems. (DHHS_ |

Pub. No. ADM 89-1589). Washington, DC: U.S. Government Printing Office. ]

Manderscheid, R. W. (1998). From many into one: Addressing the crisis of quality in managed behavioral health 4

care at the millennium. The Journal of Behavioral Health Services & Research, 25(2): 232-236. |

Manderscheid, R. W., & Henderson, M. J. (1996). The past, present, and future of data standards. In Trabin,

T. and Freeman, M. (Eds.) The computerization of behavioral health care: How to enhance clinical practice, |

management, and communications. San Francisco: Jossey-Bass.

Mental Health Statistics Improvement Program (MHSIP) Ad Hoc Group. (1997). The handbook of mental health |

data — a reference manual for anyone who wants to collect, find, report, understand or use mental health data |

— Draft 5/23/97. Rockville, MD: Center for Mental Health Services. |

Mental Health Statistics Improvement Program (MHSIP). (1996). Report card phase II task force. The MHSIP_ |

consumer-oriented mental health report card. Rockville, MD: Center for Mental Health Services. |

Mental Health Statistics Improvement Program (MHSIP). (1992). Task force on enhancing MHSIP to meet the |

needs of children. Enhancing MHSIP to meet the needs of children - Final Report. Rockville, MD: National |

Institute of Mental Health.

Minden, S., & Hassol, A. (1996). Final review of available information on managed behavioral health care. |

Prepared for U.S. Center for Mental Health Services. Cambridge, MA: Abt Associates, Inc.,

National Association of State Mental Health Program Directors Research Institute, Inc. (NASMHPD-RI). |

(1998). Five state feasibility study on state mental health agency performance measures - Draft Final Report \

- June 1998. Prepared for Center for Mental Health Services. Alexandria, VA: NASMHPD-RI, Inc. {

Smith, G. R., Manderscheid, R. W., Flynn, L. M., & Steinwachs, D. M. Principles for assessment of patient |

outcomes in mental health care. Psychiatric Services, 48(8): 1033-1036, 1997.

Wurster, C. R. (1997). Changes in data needs and requirements for cost-effective mental health services ina managed

care environment. Prepared for Center for Mental Health Services. Cambridge, MA: Abt Associates, Inc.

| Journal of the Washington Academy of Sciences,

Volume 85, Number 1, 15-27, December 1998

Consumer Issues in Managed

Behavioral Health Care

Mary Auslander, Dawn Jahn Moses, David Granger,

Marilyn J. Henderson, Johnette Johnson, J. Rock Johnson,

Edward Knight, Kathy Lynch, Ronald W. Manderscheid,

Garret Smith, Laura Van Tosh

Introduction and Background

Pressing issues face mental health consumers and the larger mental health consumer

movement as they encounter and respond to the implementation of managed behavioral

health care. Toward that end, this paper reports on adult consumers’ experiences with,

concerns about, and suggestions for improvement on, a variety of public managed behav-

ioral health care issues.' Issues facing children and family members are addressed in

separate papers in this volume.

It is important to note that the consumer movement includes a broad diversity of

views and opinions. We have done our best to capture the thoughts and concerns of many

‘of those involved. The specific issues discussed in this paper include:

¢ consumer involvement in the design, delivery, and evaluation of mental health

Services;

¢ care and treatment philosophies;

e benefit design and service delivery;

e quality assurance and research;

¢ consumer rights and protections; and

° systems advocacy.

Responding to inadequacies in the mental health service system and concerns over

mistreatment and injustices within the system, the contemporary mental health consumer

‘movement began to take shape in the early 1970s. Over time, this grass-roots effort devel-

oped into a coherent and powerful movement that has been effective in making mental

health service systems more responsive to the needs and desires of the people they serve.

' Given that most of the efforts of the mental health consumer movement have been directed toward

public systems of care, this paper will focus, in large part, on the implementation of managed behavioral

health care within public mental health systems.

16 CONSUMER ISSUES IN MANAGED BEHAVIORAL HEALTH CARE

Finally, those who were considered unable to speak for themselves demanded that they

be heard — they pushed to be treated in a humane manner, to be given treatment choices,

and to be included as active participants in the design and delivery of mental health services

(Chamberlin, 1990, 1984; Zinman et al., 1987; Smith and Ford, 1986).

The mental health consumer movement has significantly influenced the public mental |

health service delivery system over the past three decades. Some of the most profound |

changes that have occurred as a result include:

¢ enacting Federal and state laws mandating consumer participation in state and |

local mental health planning activities;

e recognizing consumers’ rights and establishing systematic procedures to protect

these rights;

e acknowledging the value of consumers as providers of services and developing |

and funding an array of consumer-run and other alternative services;

e establishing offices of consumer affairs within many public mental health |

authorities;

* creating positions for consumers on boards and committees that guide mental |

health organizations;

° increasing awareness of the demonstrated value and importance of involving |

consumers at the individual, program, and systems level; and

e educating the public about the experiences of mental illness, its treatment, and

the effects of stigma.

The emergence of managed behavioral health care within public mental health systems _

has presented opportunities and challenges for mental health consumers and the broader

consumer movement. The current reconfiguration of mental health systems, with its focus j

on effective, cost-efficient service interventions may provide greater opportunities for |

the development of consumer-run and other alternative services. Managed care’s |

emphasis on outcomes and quality assurance may also provide consumers with more |

effective vehicles for voicing their opinions about the usefulness and quality of the services |

they receive. |

The implementation of public managed behavioral health care and the trend toward

contracting with private for-profit and not-for-profit organizations to manage publicly-

funded services also raises concerns for many mental health consumers. Consumers face, |

once again, having to justify and ensure their central involvement in all aspects of the |

mental health service system. It is not clear whether the values of inclusion, recovery, |

empowerment, and self-determination, which are critically important to consumers and |

have been adopted by good public mental health systems, will be incorporated into the

contracts creating these new, ““business-oriented” systems of care. The emphasis many |

CONSUMER ISSUES IN MANAGED BEHAVIORAL HEALTH CARE 17

states are placing on cost-cutting raises concerns about access to care, the quality of care,

and the existence and effectiveness of client protection and grievance procedures.

Consumers must also learn how to navigate new delivery systems with new rules and

new players. Finally, it is important to note that these changes are occurring at the same

time as key public programs that provide critically important financial support for people

with disabilities (Supplemental Security Income - SSI, Social Security Disability

Insurance -SSDI, Aid to Families with Dependent Children - AFDC) are being radically

altered as well.

Consumer Involvement In the Design, Delivery, and Evaluation of Mental

Health Services

Active involvement in the design, delivery, and evaluation of mental health services

is acentral tenet of the mental health consumer movement (Fisher, 1994; Van Tosh, 1993;

Chamberlin, 1978). On the individual level, consumers want to have control over deter-

mining what services they need, and how and where they will receive these services.

On the program and systems levels, consumers want to actively participate in planning,

delivering, and assessing the effectiveness of programs and the larger mental health

system. Many consumers want recipients of services to be the sole determiners of these

issues, while others prefer to be placed on equal footing with policy makers, program

officials, and providers. Involvement is seen as critically important in generating needed

knowledge for effective program design and improvement. It is especially valuable

regarding issues of respecting individual rights, designing services that are responsive

‘to consumers’ needs, empowering individuals, and supporting recovery.

Over the past three decades, consumers have worked to ensure their involvement in

public mental health services and systems (Chamberlin, 1990, 1984; Smith and Ford,

1986, Stroul, 1986). This participation has been facilitated by laws requiring consumer

involvement, growing acceptance of consumer-run services as critical components of

any mental health system, and increased awareness of the importance of involving

‘consumers in their own rehabilitation and recovery. Although not always sufficient, most

‘public mental health systems have developed mechanisms to ensure at least some level

of consumer involvement. For example, state mental health systems are required to involve

consumers in state mental health planning efforts (Public Law 102-321, formerly P.L.

/99-660) and in the development and ongoing advisement of Protection and Advocacy

| agencies to investigate patient rights abuses (P.L. 99-319) (Van Tosh, 1993). Local planning

and oversight boards now often involve consumers as well.

In general, private managed behavioral health care organizations do not have a history

of working directly with mental health consumers in these ways (Judge David L. Bazelon

Center for Mental Health Law, 1996, 1995). Many are accustomed to involving and

reporting to the payers of services (e.g., employers) and company stock holders, but not

18 CONSUMER ISSUES IN MANAGED BEHAVIORAL HEALTH CARE

recipients of services. Again, consumers express concerns about whether the gains they

have made in this area will be diminished or lost as public mental health systems transi-

tion to managed care. Given that recipient involvement is historically not a central part

of this business culture, public mental health systems must preserve the few mechanisms

currently in place to facilitate such interaction.

In order to ensure active consumer participation in public managed behavioral health

care services, it is essential to involve consumers in all aspects of the new systems of |

care including:

e developing and reviewing public contracts including input on benefit design,

outcome measures, clinical protocols, rate setting, and grievance procedures;

e selecting the managed behavioral health care organizations who receive public

contracts;

e providing testimony at public hearings and facilitating consumer focus groups

on mental health needs and services;

e serving on company and provider agency boards and committees with decision-

making powers;

e participating in the training of providers contracted by managed behavioral health

care organizations;

e delivering self-help and other consumer-run services;

e developing, implementing, and monitoring quality assurance/improvement

activities;

e providing consumer education and advocacy services;

¢ developing, implementing, and monitoring appeal and grievance procedures;

e designing and implementing research projects on processes and outcomes

relevant to treatment, choice, and recovery; and

e serving in management positions in public mental health agencies and managed

care organizations.

Consumer involvement must be protected through Federal and state laws and specif-

ically included in contractual arrangements between states and managed behavioral health

care companies. It is imperative that consumer participation be authentic. For example,

consumers should not be asked to approve policy after it has been developed, but should

be centrally involved in all aspects of its development. Consumer participation also must _

be representative of the population to be addressed (e.g., people of color and young and |

elderly adults). Finally, it is important to recognize that consumers serving in these roles _

are working as professionals with unique expertise as a result of their experiences and

it is essential to appropriately compensate them for the services they provide.

CONSUMER ISSUES IN MANAGED BEHAVIORAL HEALTH CARE 19

Care and Treatment Philosophies

Over the past 25 years, consumers have worked to expand and redefine the mental

health community’s understanding of mental illness and stigma (Blanch et al., 1993;

Estroff et al., 1991; Chamberlin, 1984). First, many consumers believe that there are

multiple factors, not just biology, that contribute to what is considered mental illness.

Biology may be a factor (and many consumers would agree on its importance), yet it is

only one of many that lead to diagnosis and treatment in the mental health system. For

example, histories of trauma and sexual and physical abuse have recently been

documented to be significant factors in developing symptoms that appear to be mental

illness (Muenzenmaier et al., 1993; Herman, 1992; Rose et al., 1991). Consumers believe

it is necessary to see individuals holistically and as being influenced psychologically,

socially, spiritually, and biologically. Care and treatment philosophies that consider only

one aspect of a person, without thought to its interaction with others, is found by consumers

to be incomplete, devaluing, and often damaging.

In addition, many consumers and some professionals embrace the view that recovery

from psychiatric diagnoses is possible (Anthony, 1993; Deegan, 1988). Recovery is based

on the goal and reality that people heal and go on to lead full lives integrated in their

communities. Recovery is consumer-defined, consumer-centered, and consumer-driven.

The belief that people can recover creates care and treatment that looks quite different

from what is designed for people who are expected to remain ill.

Most mental health systems, including managed behavioral health care service

_ delivery models, are still based on medical, illness-based approaches to diagnosis and

- treatment. These models are provider-centered and driven and heavily emphasize

diagnosis, symptom reduction and management through medication, treatment complhi-

ance, and standardization. Many consumers find these approaches to be limited, deficit-

focused, paternalistic, and controlling (Chamberlin, 1995).

It is important for managed behavioral health care organizations to embrace a holistic,

recovery-based, and consumer-focused approach to mental health services. To do so would

profoundly alter the management and delivery of services. Specifically:

e service delivery systems would be based on the knowledge and expertise of

consumers;

* consumers would be the primary determiners of their own care and services would

be individualized to meet the stated needs and desires of each consumer through

the development of personal treatment plans;

e benefit packages and definitions of medical necessity would include a broad array

of non-medical, support services such as education and career counseling,

permanent housing, and transportation;

20 CONSUMER ISSUES IN MANAGED BEHAVIORAL HEALTH CARE

e services would be provided in ways that foster recovery and focus on strengths

and autonomy by expanding consumer choice, promoting wellness, and elimi-

nating coercion;

¢ services would be assessed for their effectiveness in producing recovery-oriented,

positive, consumer-defined outcomes;

e increased collaboration would occur among mental health, social service,

housing, education, legal, and other systems; and

* reinvestment strategies would ensure the development of community-based

services that are run by and for consumers.

Benefit Design and Service Delivery

Following from care and treatment philosophies centered around recovery, it is imper-

ative that the benefit packages being designed under managed behavioral health care

initiatives promote wellness, empowerment, and person-centered care. Consumer

involvement in developing mental health benefit packages is imperative. Services

identified by consumers as essential include: self-help, mutual support, and other

services that are designed to empower individuals; rehabilitation services; outreach and

crisis services; counseling services; medical services; and adjunctive services such as

housing and transportation (Penney, 1997). In addition, many consumers have found

holistic and alternative interventions (e.g., acupuncture, nutritional regimens, body work)

to be extremely helpful.

Benefit packages must be flexible and not force consumers into a standardized service

progression or pace. For example, some individuals might prefer and benefit from services

provided on an intermittent basis, as opposed to successively; other individuals might

wish to participate in a combination of individual and group sessions as opposed to only

group therapy. Consumers should be educated about their benefits, rights, and appeal

and grievance processes. Most consumers believe that no limits should be placed on the

amount of services available, and at a minimum, coverage should be sufficient to meet

the long-term needs of consumers.

Although critically important, having a mandated comprehensive benefit package

is not sufficient to ensure access to quality services that meet individual needs. In addition

to a comprehensive benefit package:

* consumers must be able to choose whether to receive services at all and what

services to receive;

e services must be individualized;

° criteria used to determine the provision of services must be broad enough to

meet a range of treatment and support needs;

CONSUMER ISSUES IN MANAGED BEHAVIORAL HEALTH CARE 21

e services must be offered in a variety of settings by a variety of providers;

¢ services must be readily available (no waiting lists) and accessible (physically

convenient, language appropriate, and provided in ways that are sensitive to age,

gender, ethnicity, and culture); and

e spending limits must support the appropriate provision of services.

For many consumers, self-help and peer-run services are the cornerstone of their

recovery and empowerment (Felton et al., 1995; Chamberlin, 1978). Concern exists that

these types of alternative services may not “survive” the transition to public managed

behavioral health care. These non-traditional programs may be at risk because they have

_ not always been included in private or publicly funded mental health benefit packages

and because they often do not have formal management structures and in-depth admin-

istrative capacity.

It is essential that self-help and peer-run services be included in managed behav-

ioral health care packages and that they be promoted by both management and tradi-

tional providers. Requirements placed on professionally licensed providers (e.g., state

certification examinations) must not be applied to these alternative programs. Instead,

_ consumer-developed standards to assess the quality and competence of peer-run services

can be implemented. Peer-run services must be reimbursed at competitive rates to allow

for their continued existence.

It is important to ensure that peer-run services included in managed behavioral health

care arrangements are truly peer-run. In an effort to promote consumer-run programs,

some states have created incentives for their involvement in the new systems of care.

Anecdotal information suggests that some programs have portrayed themselves as peer-

run when they are not, in order to gain entrance into the system. For example, a program

that is fully staffed by consumers, but where major decisions still rest with a profes-

sional board, is not truly peer-run.

Quality Assurance and Research

With substantial changes taking place in the management and design of public mental

health services and the new emphasis being placed on cost containment and reduction,

consumers are concerned about the quality of the care that will be available to them under

new managed behavioral health care arrangements. In order to safeguard and protect

consumers, it is critically important to have public contracts require that procedures be

in place that accurately evaluate, from the consumers’ perspective, the quality, appro-

priateness, and effectiveness of services being provided.

Many managed behavioral health care organizations possess experience in the areas

of quality assurance and outcome measurement. The field also has a track record of

investing resources in sophisticated cost and care monitoring technologies. However,

22 CONSUMER ISSUES IN MANAGED BEHAVIORAL HEALTH CARE

these technologies have not been used in public mental health systems with individuals

who have long-term or intensive mental health needs, nor have they been developed with

consumer input. Consumers worry that managed behavioral health care systems will utilize

definitions of quality that are not responsive to their needs and values, and measures and

assessment procedures that do not accurately assess their experiences (Campbell, 1997).

In order to ensure that high quality managed behavioral health services are avail-

able, public mental health systems and managed behavioral health care contractors must:

e actively involve consumers (from the state contracting process through imple-

mentation and evaluation) in the definition of quality and in the design of all quality

assurance activities, the collection and assessment of all relevant data, and all

monitoring efforts;

e establish internal (overseen by the managed behavioral health care organization)

and external (overseen by the public mental health authority and outside

consumer “watch-dog”’ organizations) quality assurance procedures that are confi-

dential and easily accessible to clients;

e utilize quality assurance efforts that go beyond measuring the structure and process

of care and focus on client outcomes (Mental Health Statistics Improvement

Program Task Force on a Consumer-Oriented Mental Health Report Card,

1996);

e develop outcomes and outcome measures that are consumer-defined and

accurately capture consumers’ needs and priorities (Campbell, 1996);

e ensure that information from all quality assurance activities is readily available

and accessible to consumers; and

e guarantee privacy and confidentiality of all individual data collected.

While issues of privacy and confidentiality are of concern to consumers in all types

of managed care arrangements, for individuals receiving mental health care services it

is of the utmost importance. This is due, in part, to the pervasive stigma and discrimi-

nation against people who have received mental health services. While it is recognized

that data must be collected for quality assurance purposes, it is imperative that individual

level data be kept confidential.

Finally, Federal, state, and local mental health systems and managed behavioral health

care organizations must initiate research projects to determine the impact of managed

behavioral health care on the recipients of services. It is important to learn about

consumers’ experiences with access to and the quality of public managed behavioral

health care services and the outcomes associated with these services. Consumers must

be involved in formulating the questions and issues to be considered, creating study

designs, conducting research, and analyzing and interpreting findings. This involvement

will insure the relevance and usefulness of research findings (Campbell, 1993). In fact,

CONSUMER ISSUES IN MANAGED BEHAVIORAL HEALTH CARE 23

excellent examples of research conducted solely by consumers and in collaboration with

other researchers exist and have begun to appear in mainstream literature (Campbell,

| 1997, 1996; Carpinello et al., 1992).

| Consumer Rights and Protections

Historically, individuals diagnosed with mental illness have not been afforded the

same rights and protections as those seeking and receiving other kinds of health care

services (Sundram, 1995; Chamberlin, 1990). This is due, in large part, to a once

: commonly held belief that individuals with mental illness could not think clearly and

make decisions for themselves. These beliefs resulted in the creation of service inter-

' ventions that often ignored the wishes of the consumers of services and the establish-

ment of laws that allow state and local authorities to involuntarily commit and treat individ-

‘uals with mental illness against their will (Appelbaum, 1996).

| Consumers have fought hard to enact laws and regulations that require states, local-

ities, and individual providers to observe and protect consumers’ basic human rights and

| to implement mechanisms to ensure that these protections are provided. Much of the

work that has been done in this area has focused on protecting the basic civil and human

| rights of individuals in inpatient settings. Attempts are currently being made to expand

these protections to include individuals with psychiatric labels residing in the commu-

nity. In some states, consumers have taken this one step further and developed mental

| health consumer “bills of rights” that outline an even broader set of individual rights

including rights to both utilize and refuse services, to choose providers and care

| settings, and to receive services in a confidential manner (Consumer Managed Care

| Network, 1996; Judge David L. Bazelon Center for Mental Health Law, 1996, 1995).

Consumers are wary that implementing managed care in public mental health systems

and the corresponding reduction in the traditional roles of public mental health author-

ities may result in situations where consumers’ rights are violated and that individuals

will not be afforded proper protections or mechanisms for recourse (Fleischner, 1994).

It is important that consumers’ rights be outlined and protected in Federal and state law

and in managed behavioral health care contracts. In addition, appeal and grievance, media-

tion, and arbitration procedures must be in place to provide consumers with appropriate

and safe options for recourse when they feel their rights have been violated. It is criti-

cally important to:

e establish and publish understandable and accessible appeal and grievance proce-

! dures;

° ensure that consumers are not retaliated against (e.g., disenrolled, denied refer-

rals) for exercising their rights (e.g., refusing treatment) or filing a complaint against

a provider or a managed care organization;

24 CONSUMER ISSUES IN MANAGED BEHAVIORAL HEALTH CARE

¢ provide internal advocates/ombudsmen who can help consumers through appeal

and grievance procedures;

e provide external advocates who are not funded by or tied to managed behavioral

health care organizations who can help consumers advocate for their rights;

e facilitate access to outside mediation services;

¢ educate consumers on their rights and the appeal and grievance processes using

a variety of mechanisms (e.g., written materials, video tapes, role playing, peer

advocates)

e empower consumers to advocate for themselves and to utilize the protections that

are in place when necessary; and

¢ continue necessary services while disputes are being resolved.

Above all, consumers should be full participants in all these activities.

Systems Advocacy

As stated previously, the advent of public managed behavioral health care presents

significant challenges to the mental health consumer advocacy movement. Consumers

must establish new contacts, fortify previous gains, and advocate for change in a new,

for-profit, business-oriented culture that has little experience working directly with the

primary consumers of their services. Public contractors and managed care organizations

have a responsibility to become educated about the consumer movement, self-help and

consumer-operated services, and the philosophical underpinnings of recovery. This work

must be done quickly as systems of care are rapidly transforming (Rodwin, 1996).

Consumers insist that they must continue to speak and advocate for themselves and

many feel the movement would benefit from a single national consumer advocacy organi-

zation. In order to advocate effectively, consumers assert that they must have: access

to information; the ability to provide information to managed care plan enrollees; freedom

to monitor these new systems; and open channels to communicate with managed behav-

ioral health care leaders.

Many in the movement also believe that managed care presents an opportunity for

increased collaboration with other groups concerned with the availability of accessible,

high quality health and mental health care services. On issues of mutual concern, collab-

oration with family members, providers, health consumers, and broader consumer protec-

tion advocates could help effect meaningful change. These collaborations must be done,

however, with great thought in order to maintain the integrity of the movement and protect

it against exploitation.

CONSUMER ISSUES IN MANAGED BEHAVIORAL HEALTH CARE 25

Conclusion

Implementing managed care technologies within public mental health systems is

profoundly changing the way services are organized, delivered, and financed in the United

States. These changes present both great opportunities and risks for mental health

- consumers and the larger mental health consumer movement. To ensure that the service

system is responsive to its clients, it is imperative that mental health consumers be involved

in system redesign efforts and in all aspects of the new managed care systems. This involve-

ment must be mandated by Federal and state laws, included in all public-sector contracts,

and respectfully honored by managed behavioral health care organizations and providers.

Involving consumers in meaningful ways will result in effective, cost-efficient services

_ that are sensitive to the needs of the individuals they are intended to help.

Information Resources

For more information on consumer issues in managed behavioral health care, you

' may wish to contact some of the organizations listed below.

The Center for Mental Health Services (CMHS)

Knowledge Exchange Network (KEN)

P.O. Box 42490

Washington, DC 20015

800-789-2647 (voice)

301-443-9006 (TDD)

800-790-2647 (Bulletin Board)

http://www.mentalhealth.org

American Managed Behavioral Healthcare Association (AMBHA)

700 13th Street, NW, Suite 950

Washington, DC 20005

202-434-4565

http://www.ambha.org

Judge David L. Bazelon Center for Mental Health Law

1101 15th Street, NW, Suite 1212

Washington, DC 20005-5002

202-467-5730 (voice)

202-467-4232 (TDD)

http://www.bazelon.org

National Alliance for the Mentaily Ill (NAMI)

200 North Glebe Road, Suite 1015

Arlington, VA 22203-3754

703-524-7600 (voice)

703-516-7991 (TDD)

26 CONSUMER ISSUES IN MANAGED BEHAVIORAL HEALTH CARE

800-950-NAMI (Helpline)

http://www.nami.org

National Association of Consumer/Survivor Mental Health Administrators

c/o Darby Penney

Director of the Bureau of Recipient Affairs

New York State Office of Mental Health

44 Holland Avenue

Albany, NY 12229

518-473-6579

National Empowerment Center

20 Ballard Road

Lawrence, MA 01843

1-800-Power-2-U

National Mental Health Association (NMHA)

1021 Prince Street

Alexandria, VA 22314-2971

703-684-7722

800-969-NMHA (Mental Health Information Center)

http://www.nmha.org

National Mental Health Consumers’ Self-Help Clearinghouse

1211 Chestnut Street, Suite 1000

Philadelphia, PA 19107

800-553-4KEY

http://www. libertynet.org/~mha/cl_house.html

National Technical Assistance Council for State Mental Health Planning

(NASMHPD)

National Association of State Mental Health Program Directors

66 Canal Center Plaza, Suite 302

Alexandria, VA 22314

703-739-9333

http://www.nasmhpd.org/ntac

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‘

{

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Journal of the Washington Academy of Sciences,

Volume 85, Number 1, 28-38, December 1998

Family Issues in Managed Behavioral

Health Care

Denise Noonan, Sarah Minden, Dawn Anderson, Curtis Flory,

Joyce Friedman, June Gross, Laura Lee Hall, Marilyn J. Henderson,

Ronald W. Manderscheid, Felicita Nieves, Eleanor Owen

Introduction and Background

Increasingly, people with serious mental illnesses receive services in managed behav-

ioral health care settings, whether in the private or public sector. Managed care holds

out the promise of better coordination of services, more accountability, and cost savings.

There is, however, great concern that inadequate or inappropriate care may result from

cost cutting measures such as restricting access to services or employing less qualified

providers to deliver care. Families of consumers have been in the forefront of efforts to

hold mental health providers accountable for quality care. This paper summarizes many

of the concerns families express about the mental health care system in our country today

and describes the advocacy efforts that have arisen from these concerns.

It was not so long ago that families of adults with serious mental illness and children

with serious emotional disturbance were widely perceived as having caused the disorder.

This was particularly true for schizophrenia. Some theorists (Bateson, et al., 1956; Lidz,

1973; Wynne and Singer, 1977) observed dysfunctional communication patterns among

people with schizophrenia and concluded that these patterns were learned within the

family. Families were faced not only with the anguish and stress of a loved one’s illness,

but the added burden of being held responsible for it by professionals.

There has been some shift in attitudes about families with mental illness due to

biogenetic research, improved understanding of the emotional and behavioral impact

of a chronic stress such as mental illness, and the effects of the deinstitutionalization

movement. The biogenetic roots of mental illness are better understood, as is the role

of social environment in triggering or discouraging relapse (Goldstein and Doane, 1982).

In recent years, families have more fully participated as partners in the recovery of

a person with mental illness. This trend began with deinstitutionalization and the return

of many people to their communities. It has continued with improvements in medica-

tions to treat serious mental illness and with the changes in mental health services brought

about by managed care. As hospital stays have shortened, mental health care providers

have increasingly turned to families as sources of shelter, support, and advocacy for their

family member. (Lefly, 1989)

FAMILY ISSUES IN MANAGED BEHAVIORAL HEALTH CARE 29

Families find themselves on the front lines of advocating for their loved ones’ best

interests with health care providers, police, judges, and employers. At times they may

_ have to take positions that are opposed by their relative, such as supporting involuntary

commitment in an effort to ensure safety. Too often, families must face these challenges

_ without advice or help from professionals.

While many families are eager to be included in the care of their loved ones, they

are also fully aware of the burdens this participation entails. There may be additional

demands on time, interference with family routines, and disruption of relationships with

other family members and friends. Financial strain can be severe since many families

care for their family member with little or no support from the public system. Regardless

of health care insurance coverage, families incur many unreimburseable expenses. The

requirements of caregiving leave many family members fatigued, stressed, and sometimes

feeling helpless and overwhelmed (Lefly, 1989).

It can be extremely difficult for families to reach out for help despite their clear need.

The stigma of mental illness and serious emotional disturbance deters many from

disclosing their problems to extended family, friends, or professionals. Men may have

a particularly difficult time accepting mental illness in their family member and

receiving support. Families can become quite isolated.

Unfortunately, while health care providers may look more to the family for assis-

tance, they often do not provide the supports families need to succeed as caregivers.

Information about the illness, inclusion in treatment planning, and access to resources

such as respite care and financial planning are invaluable to families. The family advocacy

movement has arisen in response to such needs and has emerged as a powerful force

for change. Through advocacy organizations families become better informed and more

able to promote their interests.

Strategies for Family Advocacy

Family advocacy usually begins on a very personal level: trying to ensure that a

loved one gets the help he or she needs. For some advocates, these efforts eventually

extend beyond their family member to helping others at the community, state or

national level. But no matter how far-reaching their efforts, family advocates share a

vision of “a comprehensive, integrated system of health care for mental illness that respects

the rights and dignity of consumers and their families” (Laura Lee Hall, Deputy

Director, NAMI, personal communication).

Family advocates have begun to articulate a model for advocacy that will promote

the changes necessary to achieve this comprehensive, integrated system of care. The

foundation of the model is meaningful involvement of families and consumers wherever

and whenever decisions are being made that affect their well being. This means inclu-

sion in advisory boards in health care organizations, schools, and state and local mental

30 FAMILY ISSUES IN MANAGED BEHAVIORAL HEALTH CARE

health authorities. It means involvement in writing clinical practice guidelines that will

shape the treatment plans of consumers. It means working hand- n-hand with legisla-

tors to write and promote legislation to ensure that consumers’ rights are protected and

their needs are met. Family advocates do not want merely to react to decisions, policies

or legislation that have been finalized. Rather, they want to be in a proactive position in

which their knowledge and expertise can shape the matter at hand.

The personal story is one of the most powerful tools family advocates have for

advancing their message. Advocates find that when the public, administrators, and legis-

lators can hear firsthand about the challenges, failures, and successes of consumers and

families, they are more likely to respond. It is especially important that successful policies

and programs be held up as models so that there is a clear message that positive outcomes

can be had with collaboration, creativity, and proper allocation of resources.

Family advocates recognize both the power of the individual voice telling his or her

story and the power of the collective voice in promoting its ideals. The collective voice

can be even stronger if consumer and family advocacy groups collaborate with others

who have similar goals. Groups committed to quality health care for all, advocates

for people who are developmentally and physically disabled, homeless, or incarcerated

and groups interested in preventing and treating substance abuse all offer possibilities

for collaboration.

Key Tasks for Family Advocates

Family advocates identify five key tasks as vital to the advancement of their cause:

data collection, education, legislative advocacy, participation on advisory boards, and

involvement in the development, oversight, and monitoring of contracts. These activi-

ties have become increasingly important as the public systems have moved to managed

mental health care.

Data Collection. Good data are essential for good advocacy because they contribute

to more informed discussions and better decisions. Possession of compelling data enhances

power at the bargaining table. Advocates need information on who is being served, where,

and how. The “where” should include jails, prisons, homeless shelters, and detoxifica-

tion facilities where mental illnesses affect a substantial percentage of the population.

Information on processes, outcomes, quality and costs of care is also critical.

Outcomes of care include information on suicide rates, employment, incarceration,

housing, and quality of life as well as standard clinical measures. Collection of this type

of information will require comprehensive, integrated information systems in the

private and public sectors. It is essential that such data are nonproprietary so that advocacy

groups can have access to it. There must also be stringent guarantees of confidentiality

for any information that could identify a particular individual.

i I a

FAMILY ISSUES IN MANAGED BEHAVIORAL HEALTH CARE 31

Family advocates also want information about the difficulty consumers and families

face in acquiring quality services so that problems can be identified and addressed.

Consumer-oriented report cards offer families and consumers the opportunity to make

informed choices among managed behavioral health plans and providers.

Education. A broad public education effort is essential to widespread support of

the goals of family advocacy. Not only do citizens need to understand serious mental

illness and its implications, they need to see that it is in everyone’s interest to have the

best, most cost-effective health care.

More narrowly focussed educational initiatives are important as well. Consumers

and families need information to help them navigate the increasingly complex and

managed systems of care. Legislators need to be informed about research demonstrating

that mental illnesses are treatable disorders. They also need documentation of the cost

effectiveness of various treatment approaches.

Legislative advocacy. Legislation that is in the best interests of people with serious

mental illness and their families should be proposed and actively promoted. Advocacy

groups around the country are working on issues such as parity coverage in private insur-

ance for mental health treatment, standards for involuntary treatment, and inclusion of

the new antipsychotics in formularies. Comprehensive, reliable data and compelling

personal stories are both important elements of effective communication with legislators.

Participation on advisory boards. Family advocates seek meaningful participation

| on advisory boards of managed care organizations and state and local mental health author-

| ities. They want to be involved in the process of identifying needs, designing programs,

and remedying deficiencies.

Involvement in development, oversight, and monitoring of contracts. Family

advocates are interested in meaningful involvement in activities related to contracts

between purchasers of mental health services such as Federal, state, and local govern-

ments and private managed care organizations. Opportunities for participating in the devel-

opment of RFPs (requests for proposals) and contracts are especially important so that

family and consumer priorities are represented. Oversight and monitoring are also impor-

tant, although public purchasers must ultimately be held accountable for these activi-

ties. Family advocates insist that contract language be precise in identifying specific goals

to be met within specific time frames and that these goals be linked to outcome measures.

Specificity of financial, clinical and system outcomes is critical.

Barriers to Family Advocacy

Effective family advocacy requires accurate information, a clear sense of purpose,

excellent communication skills and, of course, time, energy and dollars. A number of

barriers can make this work especially challenging. These include competing demands

on time, insufficient skills for complex tasks, insufficient financial resources, language

barriers, cultural barriers, and lack of interest.

32 FAMILY ISSUES IN MANAGED BEHAVIORAL HEALTH CARE

Competing demands on time. Family advocates often devote considerable time to

the care of a family member with serious mental illness. This is especially true for families

whose child is affected and who must coordinate medical care, mental health services,

and educational programming. The emotional, financial and physical strains experienced

by family members may make it difficult for them to contribute to advocacy efforts that

go beyond their family’s boundaries.

Insufficient skills for complex tasks. Reading technical reports, collecting and

analyzing data, drafting and promoting legislation, actively participating on advisory

boards, monitoring adherence to contracts and the like require sophisticated knowledge

and skills. While family advocacy groups may not perform all of these tasks themselves,

they must determine who is responsible for them and be able to assess the competence

of their performance. Advocates recommend that managed behavioral health care

organizations and public mental health authorities offer training to consumers and family

members to enhance their effectiveness on boards. Training would include issues such

as understanding technical language, analyzing data, and reviewing contracts.

Insufficient financial resources. Much of the work of family advocates is uncom-

pensated. There can be additional hardship for advocates whose children have serious

emotional disturbances and who must pay for child care when they are attending meetings.

In recognition of this barrier to involvement, a number of states have begun to compen-

sate families and consumers for their participation on advisory panels. Advocates suggest

that a percentage of the budgets of public mental health authorities and private managed

behavioral health care organizations be set aside for such purposes.

Language and cultural barriers. Information that families need for effective

advocacy is sometimes unavailable in their native language. Family advocates who work

in school settings complain that language and cultural barriers can make it difficult to

access appropriate services for children. Proposals, contracts, guidelines, program

descriptions and the like must be made accessible to all interested parties.

Advocates point out that bureaucratic culture can also create a barrier to the

involvement of families and consumers. Bureaucracies such as managed care organi-

zations or public mental health agencies have their own cultures that can seem closed

and intimidating. It is strategically important to know how to operate effectively in these

settings.

Lack of interest. Family advocates would like to see more families become actively

involved in advocacy efforts. They are concerned about some apparent disinterest, but

also acknowledge that other factors such as a sense of powerlessness or social stigma

may discourage participation. Family advocates emphasize the importance of presenting

information to families in ways that are not only easily understood, but also inspirational.

The certainty that active engagement will lead to better lives for consumers and families

can provide that inspiration.

1 |

FAMILY ISSUES IN MANAGED BEHAVIORAL HEALTH CARE 33

Family Advocacy in the Era of Managed Care

Over the years, family advocates have taken on scores of issues relating to the well

being of adults and children with mental illness. Health care, housing, education, rehabil-

itation services, and employment are just a few of the concerns that family members

have addressed. Perhaps one of the most galvanizing issues of the past decade has been

the impact of managed care on aduits with serious and persistent mental illness and

children with serious emotional disturbance. This is a phenomenon that reaches beyond

community and state borders and has therefore stimulated new conversations and new

| alliances in the hopes of assuring quality care.

While many deficiencies in the mental health care system predate managed care,

some have clearly been exacerbated. Family advocates observe that in the public sector,

| downsizing of state mental hospitals and shortening of hospital stays have not been

balanced sufficiently with increases in community-based care. Crisis beds, assertive

community treatment programs, housing services, psychosocial rehabilitation, and

employment services are essential to reaching and maintaining stability within the commu-

nity. Even when services such as these are available, they may be poorly integrated with

mental health and medical care. This is especially true for people with combined mental

health and substance abuse problems.

Key Issues for Families in Managed Care Settings

Families of consumers who have been treated in managed care settings identify a

number of limitations, which they associate with risk to the well-being of their family

|| member. The most prominent of these are concerns about providers, access to services,

and quality and effectiveness of care.

Provider issues. Managed care providers often do not have sufficient training and

experience in treating serious illness. Consumers and family members are rarely offered

choice in either the type of provider or the specific provider they will see. Moreover,

when a change of provider is necessary, the transition to a new provider may be chaotic.

Access to services. Gatekeepers in managed care organizations are often not

educated in or familiar enough with serious mental illness to make appropriate refer-

rals. Criteria for “medical necessity” lack clarity and are not uniformly applied. As a

result, services that families think are necessary may be denied, and services are often

not made available until there is a crisis. Finally, costs are shifted to consumers and families

who can often ill afford them.

Quality and effectiveness of care. Many factors interfere with high quality, effec-

tive care: discharge from hospital may be premature and planning for post-hospital treat-

ment inadequate; coordination among components of care such as housing, clinics, and

day programs is generally lacking; formularies are restrictive, the newest medications

34 FAMILY ISSUES IN MANAGED BEHAVIORAL HEALTH CARE

are not available, and decisions about medication are inappropriately driven by cost.

Managed care companies have not yet developed services to replace the programs closed

by public mental health authorities. In all of this, the process of appealing denials of

services or making complaints is cumbersome and intimidating.

Families raise additional concerns specific to the care of children and adolescents

in managed care organizations. They believe there has been widespread degradation of

the quality of care at all levels. The goal of care seems to be stabilization rather than

treatment for optimum functioning. Among the primary concerns of families with children

and adolescents are the quality of providers, the involvement of families in the care of

their child, the array of services available to families, and the integration of services.

Quality of providers. Providers often lack sufficient training or expertise in treating

disorders of childhood and adolescence. This is especially true for pervasive develop-

mental disorders, obsessive compulsive disorders, eating disorders, and other serious

disorders that require highly specialized treatment. Shortages of well-trained clinicians

can lead to unacceptably long waits for appointments, particularly in rural areas.

Involvement of families in the care of their child. Parents may not be meaningfully

and respectfully engaged in the treatment process. They are sometimes treated in a patron-

izing or hostile manner and may be blamed for their child’s problems. Families may

feel coerced by the threat of having their child taken away by child protective agencies.

The information that parents need to participate in a helpful and knowledgeable way is

often not provided.

Comprehensive array of services. Treatment planning for children needs to take

into account not only the diagnosis of the child but also the functioning of the family

as a whole; only then can appropriate decisions be made about necessary services.

Unfortunately, a comprehensive range of services including early intervention, home-

based treatment, school-based treatment, residential treatment, and respite care is often

unavailable, especially in rural communities. Respite care is nearly impossible to obtain

and is an invaluable resource, especially for single parents.

Integration of services. Mental health treatment is not well integrated with other

services provided to the child by the medical team, school personnel or others with substan-

tial involvement with the child.

Key Features of a Quality Mental Health System

There is strong consensus among families with respect to key features of a mental

health care system. These include access, appropriateness and quality and should be

present regardless of whether a system is public or private, managed or not.

Cea ser nn eeeeaece cee

FAMILY ISSUES IN MANAGED BEHAVIORAL HEALTH CARE 35

Access

Gatekeepers must have the experience and training to make appropriate decisions

| about the necessity of services and be able to advise consumers and family members

| about how to obtain help. Care should be available as close as possible to the commu-

| nities in which the consumers/families live and should be delivered in a timely fashion.

Appropriateness

Specialists. Providers should have the experience and training necessary to care for

adults with serious mental illness and children and adolescents with serious emotional

| disorders. Expertise in treatment of combined diagnoses of mental illness and substance

abuse is essential.

Sensitivity to language and cultural issues. Consumers and families should not be

prevented, by language or cultural issues, from receiving the information and care they need.

Quality

Standards of care. Care should be delivered in accordance with recognized

_ standards of quality such as clinical practice guidelines. The processes and outcomes

_ of care should be monitored and continuously improved.

Comprehensive care. Care for serious mental illness should be comprehensive. It

should extend beyond traditional services such as psychotherapy, medication, and acute

| hospitalization. Day programs, employment assistance, residential services, treatment-

_ oriented after school and summer programs for children can contribute enormously to

the quality of life of consumers and families.

Coordinated care. Services within and among systems of care should be coordi-

nated to maximize their effectiveness. Funds should be allocated specifically for the

purpose of coordinating existing treatment resources. Coordination is critically impor-

tant for people with combined diagnoses of mental illness and substance abuse. Special

attention should be paid to the coordination of medical and mental health care since

individuals with serious mental illness have a higher rate of premature death than the

general population due to medical problems as well as suicide. The role of the case

manager is vital and should be carefully defined. Some advocates prefer the title “care

coordinator” because the use of the word “care” implies a standard of quality. (Eleanor

Owen, NAMI, personal communication) The standard can be specifically defined and

evaluated by objective criteria.

Education. Consumers and families need accurate, understandable information about

mental illness and the services that exist to treat it. Information should be presented in

a manner that is sensitive to cultural and religious differences and in a variety of languages.

Collaboration with consumers. Consumers should be engaged more fully in treat-

ment planning and collaboration around issues of ongoing care. Mental health delivery

36 FAMILY ISSUES IN MANAGED BEHAVIORAL HEALTH CARE

systems must recognize that while many consumers can anticipate recovery and may |

not need long term services, there is a significant minority who may have frequent relapses |

and will not be well served by transitional supports. They often need the structure and

consistency of long term programs.

Collaboration with families. Providers, consumers, and families should work |

together whenever possible to assess family and community resources and to design and |

implement a comprehensive treatment plan. Family input can be crucial, not only in deter- |

mining the consumer’s needs and level of functioning, but also in recognizing the |

consumer’s strengths and assets. Appreciation of skills can help to foster a more

hopeful and respectful alliance among consumers, their families, and their care providers.

The Future of Family Advocacy

The energy, resourcefulness and dedication of families working on behalf of those |

with mental illness are remarkable and inspiring. Their efforts to increase public aware- |

ness of these disorders and to reduce the stigma associated with them have led to improve- |

ments in early identification and treatment.

Family advocates have an ambitious agenda for the future. Their efforts to this point

have taught them the value of collaboration with one another, with consumers, and with |

other advocacy groups who attempt to speak for those whose voices may go unheard.

Sometimes these collaborations, while expedient, are difficult due to differences in |

approach, philosophy, and priorities. For example, consumers and family members may |

have divergent opinions on issues such as involuntary treatment or confidentiality. Opinions

may also differ about whether it is productive for consumers and family members to

serve together on panels such as advisory boards for managed care organizations, although

there are many examples of successful joint participation. As with any partnership, there

must be a fundamental respect for the unique needs of each member as well as a commit-

ment to mutual goals.

Advocacy Goals

Legislative advocacy. Issues including parity for mental health and substance abuse

treatment, involuntary treatment, and inclusion of the most effective medications in formu-

laries in the public and private sectors are paramount. Legislation to hold state govern-

ments and managed care organizations accountable for the services they provide and

for divulging information about processes and outcomes of care are also sought.

Advocates believe that consumers and families need legal protections to ensure that they

will get needed services. Codifying these protections provides people with a mechanism

for redress of grievances.

Federal guidelines. Advocates strongly believe that there should be nationwide guide-

lines requiring consumer and family involvement in developing and monitoring contracts

FAMILY ISSUES IN MANAGED BEHAVIORAL HEALTH CARE 37

|| for delivery of services whenever public dollars are concerned. They suggest that the

| guidelines be strengthened by sanctions for noncompliance. Development of guidelines

|| for the treatment of mental illness in the correctional system and serious emotional distur-

| bance in the juvenile justice system are also considered priorities.

__ Data collection, analysis and dissemination. Advocates need access to high quality,

| timely information about who is being served in the mental heath system, where, and

how. Longitudinal data regarding the outcomes and costs of care are essential. Guidelines

specifying the types of data to be collected across systems of care would be ideal. Sources

of information should include the Federal government, public mental health authorities,

‘departments of public health, public assistance, and correction, as well as managed care

organizations. There should be an evaluation of what happens to individuals within and

between systems of care. Data collection raises important ethical concerns about confi-

‘dentiality: the goal of gathering data must not create a barrier that deters consumers

from reaching out for the help they need.

Education. Advocates argue that education is key to reducing the stigma associated

' with mental illness. They urge ongoing work with the media to educate the public about

issues of concern to consumers and their families and with school systems to identify

| children at risk for serious emotional disturbance and develop preventive strategies.

_ Education can enhance recognition of mental illness as a disability and ensure protec-

/)tions against discrimination. Informing taxpayers of successful programs such as the

Child and Adolescent Service System Program (CASSP) and Program for Assertive

|Community Training (PACT) will provide support for funding.

| Educating families to seek help before a serious crisis emerges and developing

consumer/family handbooks for each state, describing systems of care and available

! | resources in the areas of housing, psychosocial rehabilitation, employment are impor-

| tant educational goals. Advocates also want to enhance communication among families

of consumers. (e.g., NAMI is developing a web site with chatrooms and references.)

Education for advocates about the economics of mental health care will help them

| understand the forces that shape decisions so that they can make better-informed proposals.

| Similarly, creating coalitions among groups working on behalf of those who are strug-

| gling with homelessness, substance abuse, loss of health care benefits will advance all

advocacy efforts.

This list hardly does justice to the hundreds of initiatives promoted by family advocates

| across the nation. Advocates believe that their message could be strengthened at this

point by carefully considering their priorities and creating a document that expresses

_ their philosophy and sets forth their agenda and suggestions for public policy.

The rapid changes in the delivery of mental health services have created new

challenges and new opportunities for family advocacy. The greatest concern is that the

historical mission of the public mental health system to care for the most vulnerable

and underserved will be eroded by privatization and managed care. Family advocates

38 FAMILY ISSUES IN MANAGED BEHAVIORAL HEALTH CARE

have worked tirelessly to create alliances with other advocacy groups, mental health

providers, mental health system administrators and the public to ensure that the needs

of people with mental illness are understood and responded to appropriately. Increasingly, -

family advocates are seen as legitimate partners in the design and delivery of quality |

mental health care for adults and children.

References

Bateson, G., Jackson, D. D., Haley, J. & Weakland, J. H. (1956). Toward a theory of schizophrenia. Behavioral

Science, 1:251-254.

Goldstein, M., & Doane, J. A. (1982). Family factors in the onset, course, and treatment of schizophrenic spectrum —

disorders: An update on current research. Journal of Nervous and Mental Disability, ¥70:692-700.

Lefly, H. (1997). Family burden and family stigma. In L. Spaniol, C. Gagne & M. Koehler, (Eds.), Psychological

and social aspects of psychiatric disability (pp. 246-253). Boston: Center for Psychiatric Rehabilitation.

Lidz, T. (1973). The origin and treatment of schizophrenic disorders. New York: Basic Books.

Wynne, L. C., & Singer, M. Thought disorder and family relations. Archives of General Psychiatry, 9:199-206.

Journal of the Washington Academy of Sciences,

Volume 85, Number 1, 39-52, December 1998

Integrating Services for Children

in the Era of Managed Care

Susan Foster, Mary Armstrong, Cliff Davis, Mary Fleming,

Gretchen Graef, Marilyn Henderson, Mario Hernandez,

Barbara Huff, Lois Jones, Steve Kukic, Ronald W. Manderscheid,

Patric McCarthy, Alan Spader, Dorothy Webman

| and Background

| Complex issues surround the integration of children’s mental health services with

| other critical child- focused services in this era of transition to managed care and welfare

‘reform. This paper reflects the perspectives of practitioners, advocates, and policy experts

| representing the fields of mental health, juvenile justice, child welfare, substance abuse,

“and education. Issues addressed include:

¢ a definition of service integration;

e major service integration efforts to date;

e benefits of service integration;

e the impact of managed care on service integration;

| ¢ strategies for child service integration;

e barriers to service integration;

¢ recommendations for the field.

Definition of Service Integration

| There is no question that the development of a system of care for children across

estezorical agencies is a laudable idea. Stroul and Friedman’s “systems of care”

| monograph (Stroul and Friedman, 1994) includes a definition along with a core set of

values that are generally accepted in the field:

t A system of care is a comprehensive spectrum of mental health and other neces-

‘sary services which are organized into a coordinated network to meet the multiple and

changing needs of children and adolescents with severe emotional disturbances and their

families.

“Services,” it is important to note, connote partnerships between health, mental health,

/education, substance abuse, child welfare, juvenile justice, children, youth, and families.

40 INTEGRATING SERVICES FOR CHILDREN

This notion of partnership harks back to the values associated with systems of care such

as the central role of the family and the child, the value of serving families and children

within their own communities and in natural settings, the provision of a comprehensive,

flexible array of services, culturally competent care, and provider accountability that is

based on child and family outcomes rather than the provision of a given service. In a

managed care environment, questions remain as to whether or not these values can be

retained, whether model mental health service delivery systems for children can be repli-

cated, and whether systems of care improve child outcomes while containing costs. While

system of care proponents have never claimed cost savings from this approach, the question

of cost savings will arise in any managed care reform effort.

High-quality integrated service systems should have certain characteristics in

common. To name a few: a single point of entry; multi-disciplinary assessment; individ-

ualized treatment; flexible programming; integration of acute and long-term benefits;

and integration among multiple child-serving agencies (Stroul, 1993). Common

outcomes are defined by all entities in the system based on the literature, current practice,

and the capacity to collect outcomes-related data across systems (Epstein et al., 1996).

Major Service Integration Efforts to Date

Efforts at the local, state, and Federal level to integrate services for children have

been underway for two decades, not only in mental health, but also in child welfare,

maternal and child health, mental retardation/developmental disabilities, and related fields,

but have not become commonplace until recently. Some have improved access to care,

enhanced communication between providers and families, and demonstrated that

agencies can work together creatively to improve service delivery. Several examples of

initiatives in the broader child mental health field are described below; service integra-

tion efforts operating in managed care environments will be discussed later in this paper.

Little systematic research exists on the effectiveness of community-based systems

of care, and none on programs developed specifically under a public managed behav-

ioral health care system. There have been, however, a few significant national system

reform efforts focusing on children with mental health needs. The demonstration

projects of the Child and Adolescent Service System Program (CASSP) sponsored by

the National Institute of Mental Health in the 1980’s led to the development of a set of

guiding principles for systems of care that are adhered to today (England and Cole, 1995;

Stroul and Friedman, 1994). The Mental Health Services Program for Youth was a Robert

Wood Johnson initiative that funded experiments in developing care management

networks and in interagency restructuring to create partnerships among the categorical

agencies responsible for children (Cross and Saxe, 1997). Although capitation was

employed as a strategy at some sites, this project preceded the widespread adoption of

managed behavioral health care at the state level. Whether or not the principles behind

—

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— ————S——E—EEE 7

INTEGRATING SERVICES FOR CHILDREN 41

these projects can be incorporated in a managed service delivery system is a subject of

discussion in the field.

The Fort Bragg Experiment (Bickman et al., 1995) was a demonstration project that

attempted to create a system of care for children with mental health needs. The project’s

comprehensive evaluation found that while the program succeeded in improving access

to and fluidity of care, reconfiguring the system did not necessarily lead to improved

child outcomes. Critics of the demonstration and its evaluation (Friedman and Burns,

1996) argue that Fort Bragg was neither a “system of care,’ at least according to the

Stroul and Friedman philosophy on which it was based, nor a managed care system, as

| there were no incentives within the system to control costs.

Demonstration projects associated with Medicaid waivers and those funded by the

| Center for Mental Health Services (CMHS) are exploring capitation and other alterna-

' tives to fee-for-service that allow for more flexible service planning for children. CMHS,

through its Comprehensive Community Mental Health Services for Children and Their

Families Program, for example, provides funding to grantees to implement and evaluate

systems of care for children with severe emotional disturbance (U.S. Department of Health

and Human Services, 1996).

Legislative changes both at the Federal and the state level are blending funding streams

and promoting programming that enhances interagency communication and planning

in partnership with children and their families. Amendments to the Individuals with

Disabilities Education Act passed in 1997 include enhancements regarding non-school

providers and payments from other agencies such as Medicaid. Parental involvement

also increases under the new law. (U.S. Department of Education, 1997)

Benefits of Service Integration

The primary benefit of service integration for children’s care is that it addresses

egregious problems in the system as it functions today. Currently, most care for children

with multiple needs is too limited and fragmented. Overemphasis on expensive service

providers, reactive, crisis-oriented interventions (often by removing the child from the

home), insufficient focus on prevention, early identification, and timely treatment are

due, in part, to categorical funding which narrowly focuses how dollars are spent. The

lack of community and family involvement in service planning also plays a role in the

misappropriation of service dollars (Friedman, 1994). Children with mental health needs

may be served in a wide array of service settings, but rarely do these systems commu-

nicate, share information or resources, or transition children smoothly among themselves.

The consequences of fragmentation are manifold — and sometimes tragic. Juvenile

justice and child welfare systems are often the recipients of children with extensive service

needs, but are ill-equipped to address their mental health, educational, and social problems.

The costs of caring for these children are too often passed off from one agency to another.

42 INTEGRATING SERVICES FOR CHILDREN

When a troubled child arrives in the emergency room on a weekend night, for example,

it too often happens that no one agency will take fiscal responsibility for placement.

Uninsured children end up in the child welfare system when their parents have to give up

custody in order to obtain placement in a residential therapeutic setting. The stress on families

as they weave their way through an increasingly complex patchwork of services to obtain

the care their children need can be overwhelming, exhausting, and financially draining.

The potential benefits offered by an integrated service system speak for themselves:

simplified access to a broad array of services and supports via a single point of entry;

multi-disciplinary assessment; better family understanding of intervention approaches;

individualized treatment; a continuum of care across multiple child-serving systems;

flexible use of resources; a single point of accountability to the family; and integrated

record keeping and data collection activities. Integration enhances accountability by

ensuring that a specified provider is assigned responsibility for each interaction a child

has with the service system. It also prevents cost-shifting, expands the range of services

beyond those provided in any one service category, and eases the burden on families to

coordinate their children’s care.

The Impact of Managed Care on Service Integration

Depending on one’s perspective, managed care presents either an opportunity or a

barrier to the integration of children’s services. Some advocates say that there are no

models for integration within a managed care system, while others assert that managing

care presents a unique chance to pull services together into a seamless whole. Still others

suggest that an integrated service system is a managed care system.

When child-serving agencies at the state level design parallel managed care

programs, each with their own mandate and contractual agreements, services continue

to work in parallel rather than in concert, and the service system continues to be fragmented

and confusing to consumers and their families. Parents and foster parents find it diffi-

cult to figure out where to obtain services and how to pay for them. Without an integrated

managed care model that puts structures in place to coordinate multiple initiatives for

children, confusion and fragmentation will result. (Osher et al., in press)

Many of the public managed care reform initiatives do include devices to promote

or ensure service coordination, most notably case management for children and families

with the most intensive service needs. Questions remain, though, as to the impact managed

care will have on the poor and children of color and their families. Even though managed

care organizations under contract with public mental health authorities are expected to

promote community-based treatment, will the quality of care improve so long as cost

savings is of paramount interest to the organizations and payers? As decision-making

about care for children with mental health service needs shifts from states and counties

to managed care organizations and other providers of managed services, children with

INTEGRATING SERVICES FOR CHILDREN 43

| mental health needs (as many advocates have urged) are being treated more frequently

| in their homes and other community settings. Still, concerns are rife among families,

youth, advocates, and providers that much that has been achieved with regard to stake-

| holder involvement and the provision of culturally competent services will be lost unless

| states and counties require that managed care organizations incorporate these values into

| service delivery. One particular fear is that as managed care organizations build service

systems and provider networks, children with dual diagnoses will not receive the full

| range of mental health, substance abuse, and social services they need. Mental health

| and other services to people of color and linguistic minorities are often provided by ethnic-

| specific grassroots agencies. Some of these organizations will not survive in a business-

| oriented health care environment, thereby leaving their constituents without access to

|| consumer-oriented care. Many are concerned that as states stop providing direct

| services, the needs of different cultural and socioeconomic groups will be ignored.

The desire to manage care has, in some cases, resulted in positive steps toward pulling

| services together and closing service gaps. In Arizona, for example, the state’s managed

| behavioral health care organization altered its credentialing requirements to allow tradi-

| tional healers to work with Native Americans. As a result, they increased capacity in a

| tural area with few services and increased access to culturally competent providers at

the same time. The transition to managed care has also precipitated a much-needed

| dialogue regarding service integration at state and local levels among government officials,

i providers, advocates, and consumers. The reasons for this are complex and range from

| aneed to survive economically in a changing health care market by pooling resources

| to a desire to improve the quality of care.

| The question arises as to who is responsible, in the current health care environ-

) ment, for integrating services. Is it the role of managed care organizations? Many argue

: that the behavior of managed care organizations and others contracted to provide managed

service delivery in the public sector is determined by the expectations and actions of

government and will assume the culture of the purchaser. Managed care organizations,

for example, cannot alone create a care network for children entering the juvenile courts

without a mandate from the state to do so. Moreover, managed care organizations cannot

bring key players to the table to create service systems. Managed care organizations

can create the networks to serve children with multiple needs, but they are limited to

managing the system once it is integrated. Government, then, must play a role in

| promoting service integration. Some experts surmise that state officials are frustrated

| by the obstacles to integrated care and want managed care organizations to take over

_ the work of service integration, to do the job that government cannot politically do.

Unless both managed care organizations and government work together, fragmenta-

tion will persist.

The tools of managed care, such as utilization review, quality management, and

procurement of networks, applied in the context of an integrated management system for

tf INTEGRATING SERVICES FOR CHILDREN

services for children and their families, have the potential to increase overall system effec-

tiveness and improve child and family outcomes. Developed for adults, however, such tools

may not prove useful or appropriate in developing integrated services on behalf of children.

Strategies for Child Service Integration

Service integration activities need to occur at three levels:

e the client level, via case management and other therapeutic models

e the system level, via structural and financial strategies

¢ the policy level, through community organizing, legislation and other activities

at the highest governmental levels

No single strategy integrates a service system; rather, it is the cooperative efforts of

providers, agency directors, local and state governments, managed care organizations,

and families opting for an array of complementary strategies that promote service integra-

tion. For example, as much as case management can help children and families cope

with and obtain access to and cope with a complex service system, case management

alone will not integrate systems, per se. Without local government initiative, interagency

collaboration, and appropriate fiscal incentives, service integration cannot occur.

Client-level Service Integration

Two direct service strategies that attempt to link services on behalf of children and

their families are case management and wraparound interventions. Case management,

often the primary direct service strategy employed in service integration efforts, refers

to arange of activities from service authorization and utilization review over the telephone

to direct contact with children and families, intensive coordination, brokering, assertive

inter-provider planning, and advocacy. The classic managed care approach, aimed

primarily at managing the system, consists of utilization review with a focus on control-

ling costs and does not necessitate in-person contact between the case manager and the

child or family member. The human services approach, on the other hand, is aimed at

improving access to care and outcomes for children and families while decreasing both

gaps and overlaps in service.

Although many advocates and providers would like to see all children with mental

health needs have access to a case manager who follows their care over time, has a positive

relationship with the child and family, and ensures strong educational efforts that involve

the family at every level, this “intensive” case management model is generally employed

only with children with serious emotional disturbance and children in residential and

foster care who are likely to use a variety of services over a long period of time. Some

INTEGRATING SERVICES FOR CHILDREN 45

states currently support the cost of intensive case management provided by managed

care organizations. Other states initiated case management programs across agencies in

the era prior to managed care. In Utah, for example, the state set up an integrated educa-

tion, health, and human services system for special needs children at the elementary school

level using a case management approach and a flexible pool of resources with which to

provide appropriate services. The program is perceived by many as successful in identi-

fying and addressing the needs of children and families as early as possible.

Managed care experience in private sector health care has demonstrated that the

administrative, or gatekeeping form of case management, consisting of ongoing case

monitoring and coordinated planning, applied to the most expensive portion of the popula-

tion, can be effective at controlling costs. On the whole, efforts to evaluate cost savings

attributable to case management have been problematic. Conducted by categorical

| agencies with a vested interest in proving that such a strategy is financially viable, savings

| may have been achieved through cost shifting. In order to objectively evaluate cost savings

_ across systems, further study is needed; data must be shared and research efforts must

be collaborative.

Wraparound is an integrative strategy that combines case management with an inter-

disciplinary team led by the parent or other primary caregiver who designs and approves

the intervention. The team includes not only formal support persons but those individ-

uals identified by the family as instrumental to the child’s development. The model also

requires that community teams composed of local stakeholders including parents,

advocates, educators, juvenile court representatives, child welfare, health, and mental

health personnel meet regularly to plan for the care of children and families in their

communities. Such a labor-intensive model requires financial support from states and

counties above and beyond categorical funding streams to support coordination activi-

ties that are otherwise not reimbursable.

System-level Service Integration

Systems-level strategies to achieve service integration involve financial strategies,

structural and organizational strategies (e.g., staff outsourcing), identification of

outcomes, and child tracking.

Financial strategies. One of the primary barriers to service integration is a line-item,

compartmentalized approach to funding the agencies that serve children. Such funding

drives virtually every aspect of system structure, manifesting an administrative burden

replicated in each system. Categorical funding streams generally are mandated to cover

narrow service responses to narrow populations, and such restrictions bar the way to

service integration. Community agencies, therefore, are limited in what they can do and

whom they can serve, which can bring them into conflict with community partners with

similarly narrow funding boundaries. Recent waivers have begun to break this pattern.

46 INTEGRATING SERVICES FOR CHILDREN

A key to integrating services to children and, at the same time, achieving desired managed

care efficiencies is to alter the structure of funding to support these services at the commu-

nity level where people live and receive almost all of their services.

Key Federal funding for services to children such as Medicaid, Social Security, and

Maternal and Child Health Services Block Grants determine the manner by which Federal,

State, and local agency activities are structured, documented, and reimbursed. Financial

strategies that allow for flexible, cross-agency planning for children with mental health

and other needs, that contribute to service integration, and that assist in the achievement

of certain valued goals such as home vs. residential placement (National Technical

Assistance Center for Children’s Mental Health, 1996) include:

° Case-rate funding. A fixed dollar amount is set per child per day and given to

programs to provide an array of services. Milwaukee Wraparound, a system of care funded

by CMHS, serves children in the juvenile justice system and those needing mental health

services. The program uses a case-rate approach in which the child welfare agency certi-

fies these children as “residential” and transfers a set dollar amount per child to the program

to promote their return to the community.

¢ Capitation (full or partial). This commonly employed approach provides a fixed

dollar amount for the care of an entire target population. North Carolina’s Carolina

Alternatives program has provided capitated contracts to ten pilot sites around the state

to provide mental health, substance abuse, and other social services to children and

families. The sites, predominantly community mental health centers, act as managed

care entities; thus far, the program has seen a reduction in hospitalization among children

with serious emotional disturbance.

Blended funding is considered the optimal strategy for achieving service integra-

tion. Using mechanisms such as capitation or case rate funding, agencies combine

resources on behalf of children whose care they share. As a result, they optimize resources

and demonstrate their commitment to service integration.

Numerous efforts toward blending funding streams are underway, but they require

commitments from local and state governments and administrators at the highest levels

to ensure that the systems work. Also known as “decategorization,” these experiments

in mental health services funding are being pursued by several states. In Iowa, decate-

gorization boards were given the authority to spend money from 32 different funding

streams for children, including child welfare, juvenile justice, and mental health

(Friedman, 1994). The local boards kept the savings achieved by retaining children in

the community (rather than in residential settings) and used them for creative program-

ming to support the children in their homes. As a result, there has been a decrease in

foster and residential care and an increase in dollars committed to keeping families intact.

This program could not have worked without the commitment to the idea of integration

that existed at the state level. Moreover, since this statewide initiative was in place prior

to the advent of managed care, there was a well-established local mechanism, with funding

INTEGRATING SERVICES FOR CHILDREN 47

behind it, to negotiate with managed care organizations.

Structural and organizational strategies. Many programmatic efforts can bring

children’s services closer together organizationally: outsourcing staff to bring services

from one agency into another; using interagency boards to bring key agency players

together for joint program planning; and forming vertical (among multiple provider types

such as hospitals and clinics) and horizontal (among mental health providers) networks

to improve efficiency (Murphy, 1995).

Identification of outcomes. Functional outcomes, such as school attendance and

independent living, appear thus far to be the most concrete and measurable markers used

by localities responsible for certain child populations. Incentive-based outcomes that

are geographically based have proven essential in promoting service integration at the

local level. In several California counties, local agencies are working closely together

to ensure that they improve outcomes for children because government payers have made

_ the receipt of monies for children’s services dependent on achieving agreed-upon

outcomes. Other states and localities are working to identify common outcomes across

service systems to determine whether interventions have an observable benefit. The

Michigan Outcome Identification Project (Hernandez, et al., 1996) seeks to prioritize

outcomes for the children’s mental health system and to assess the level of agreement

about outcomes from stakeholders inside and outside the public mental health system.

Child tracking. A clear goal of service integration is to be able to pinpoint the location

of a child within the system and the services he or she is receiving and to ensure that

the child does not get lost in the process. As systems of care are developed by states and

counties, attempts are being made to track children across the service system. Tracking

children from one system to another is essential to understanding where the gaps

and duplications in service are, whether or not cost-shifting is occurring, and whether

or not some children are slipping through the cracks. Current systems collect and store

identifying and service data on consumers but, with little capacity for cross-walk among

domains or across agencies, child tracking is difficult (Marzke, 1994). The Mental Health

Statistical Improvement Program (MHSIP) developed data standards for children

(MHSIP, 1992). It recognized that many children with mental health needs were not served

by the specialty mental health system and therefore called for an expansion in data content

to the entire system of care. To date, the MHSIP’s recommendations have not been

widely adopted.

At the Federal level, efforts are underway to create a prototype integrated informa-

tion system for managed behavioral health care. States and localities are initiating data

coordination efforts, some specifically for children and youth, to remove the informa-

tion barriers to comprehensive service delivery. How these efforts will be coordinated

with private sector managed care organizations with proprietary information systems

of their own remains to be seen.

48 INTEGRATING SERVICES FOR CHILDREN

Better information across systems will improve care coordination and continuity of

care as a child transitions from one system to another. Research to date on children’s services

has focused on individual sectors of the service system; at times this has resulted in

misleading findings because it does not account for cost-shifting and for services provided

by other systems. Integrated information systems will prove useful for collecting data for

outcomes research and for evaluating the quality of care across the entire service system.

Policy-level Service Integration

Recent Medicaid waivers have increased flexibility to use funds to reduce out-of-

home placements and provide community-based services, but such demonstrations are

too early in implementation to be evaluated. Clear direction and incentives from all levels

of government are required if agencies serving public sector clients are to work together.

In Cincinnati, Ohio, for example, the county government combined funding streams from

child welfare, juvenile justice, and mental health and contracted with a private, not-for-

profit organization to which children with multiple needs were assigned for compre-

hensive service delivery. While this was a pioneering attempt by policy makers to blend

funding, the contribution from each system was unequal, resulting in an assignment

process that favored the larger contributors. An ideal blended funding initiative would

ensure that all participating agencies contribute equally, conduct needs-based identifi-

cation, and engage in collaborative intake, thereby guaranteeing that the most appro-

priate children were served.

California, where mental health services are administered and delivered at the county

level, offers numerous examples of experiments in system of care development. In Ventura

County, longstanding efforts at service integration were further supported by key legis-

lation which promoted system of care development and provided fiscal incentives to serve

youth at risk for out of home placements in the community. Legislation enacted in 1984,

AB 3920, established a two year demonstration project to develop a model for a compre-

hensive, coordinated children’s mental health system that could be replicated in other

counties. The work in Ventura County is considered by many to be a model for the country.

Some local governments have undertaken integration efforts without divesting their

responsibility for mental health service delivery to managed care organizations. A polit-

ical movement toward service system reform underway in San Diego is being watched

closely around the country. Three features make it unique: the county board of super-

visors is driving the integration of funding for children with severe emotional distur-

bance in foster care and in residential treatment; families are equal partners along with

government payers and providers; and the county has maintained its authority for the

care of children and not divested it to a managed care entity.

Another policy-level means of integrating service delivery involves the creation of

interagency agreements to provide a set of services to a given population. In Massachusetts,

INTEGRATING SERVICES FOR CHILDREN 49

| the state Medicaid Bureau, motivated by a need to contain costs, and the state mental

| health authority drew up an Interagency Service Agreement to combine their dollars for

| acute care. These kinds of relationships are very difficult to forge, but they must be fostered

| to increase efficiency, make declining resources go further, and ensure that they continue.

Barriers to Service Integration

While everyone agrees that service integration for children is essential, in the real

world itis difficult to implement and maintain. Federal and state legislatures have created

| multiple systems with narrow mandates. Each system feels accountable for its own

mandated outcomes and fears that too much collaboration will limit its ability to fulfill

| its mandate and maintain its funding. Some categorical agencies are more difficult to

pull into integrated service systems than others. Juvenile justice, for example, is often

the point of system-entry for children with mental health needs, but, except for first time

_ offenders who may get drug education, rarely do such children receive psychiatric evalu-

ations. For all the children who do not commit violent crimes, a gap in the system exists.

Society’s punitive attitude toward children who commit crimes 1s a barrier in itself to

treatment. A few courts do have their own mental health clinics or mental health providers

they can call upon; linkage with other agencies, however, remains only rudimentary and

is seen as one of the major impediments to service integration.

Over reliance on managed care organizations to pull services together constitutes

| another barrier. Managed care organizations have no inherent incentives to expend the

_ resources necessary to bring child-serving agencies together; insofar as they do so, they

| simply carry out the expectations of public authorities. Some states, in an effort to save

money, have shifted responsibility for children’s mental health, have adopted pre-packaged

benefits, and have failed to think more creatively, more holistically about the needs of

children and their families.

Providing integrated mental health and other services to children in rural areas has

its special challenges because there are often few services to integrate, few child-focused

mental health providers, and large geographic distances to overcome. Moreover, people

often avoid seeking social and mental health services in rural areas because it is more

difficult to do so anonymously.

A final barrier resides in the lack of scientific evidence that service integration is

| efficacious and saves money. Proving both is particularly difficult. Data that exist are

| neither sophisticated nor integrated enough to provide proof of cost savings that can be

_ linked directly to service integration efforts. Moreover, children are often factored into

| managed care contracts in the second or third year, making it impossible to collect longi-

) tudinal data. Where mental health care is provided by non-mental health professionals

such as primary care physicians, school counselors, and non-reimbursable support persons,

cost and outcome data are hidden.

50 INTEGRATING SERVICES FOR CHILDREN

Recommendations for the Field

The following recommendations for improving mental health and other services to

children through service integration apply to states, the Federal government, researchers, |

families and consumers, and providers.

State Agency Responsibilities. States must promote and implement an interagency

focus and interagency agreements to coordinate service provision and to avoid the prolif- }

eration of multiple managed care systems serving the same children. They should purchase |

high quality products that produce positive outcomes. Quality should take precedence

over cost considerations. Their managed care contracts should set profit margins and |

mandate reinvestment pools for creative community-based programming. States and |

counties must identify those outcomes that are the most meaningful. Contracts must hold

managed care organizations accountable for achieving these outcomes. Outcomes must |

include family satisfaction, maintaining children in school, providing neighborhood-based |

care, and using short-term therapeutic foster care.

Federal Agency Responsibilities. While innovation generally occurs at the local level, |

to maintain change, the Federal government can provide overall direction to states,

managed care organizations, and localities. The Federal government should write legis- |

lation, disseminate guidelines and provide other informational materials to support and |

educate about service integration. It should show the public evidence of collaboration |

between Federal agencies, as is beginning to occur when Federal agencies co-sponsor |

conferences and write joint documents on service integration that are widely dissemi- |

nated. Greater involvement of families in efforts to build systems of care could provide —

valuable insight to program planners in determining service array and in working with

families on an ongoing basis. Service providers and families could co-facilitate training

programs to enhance families’ knowledge of managed care.

Improved coordination of Federally-funded regional technical assistance centers is

essential. Continued funding is recommended for issue-specific (e.g., special needs, mental

health, child welfare) training centers, but the government should, in addition, fund

regional training centers with cross-system funding to disseminate information on the

“how-to” of integrating systems and building consensus. It should also promote other

technical assistance to state and community leaders, purchasers, and providers on how

to evaluate the various options for developing a managed system of care and how to keep

up to date with legislative changes. Providers need training on network development

and integrated information systems to improve communication. Grassroots organiza-

tions, often the best equipped to serve children and families of color, need training to

place themselves strategically in the market to ensure that they survive in a changing

health care environment.

Research. The research agenda in the area of service integration should include

rigorous evaluations of different types of systems and population-specific studies that

track children through the system. To truly understand what happens both to the

INTEGRATING SERVICES FOR CHILDREN awk

children and to cost, a group of children in a managed service system should be tracked

over a period of time. More research is needed into outcomes associated with blending

of mental health, juvenile justice, education, and child welfare services.

Family and Consumer Involvement. As managed care companies become more

involved in caring for children with mental health needs, families and children themselves

need to take an active role in determining the services that will be provided. Managed

care companies must truly incorporate families into the planning and implementation

process. Youth should have a voice in their own care. They can, and do, participate on

managed care organization boards.

Providers. Administrative strategies alone will not result in the highest quality

integrated service system possible. Providers across systems must deliver clinical care

that is consistent with the values and principles of the systems of care. This approach

requires that providers from very different organizational cultures rethink how they view

_ the people they serve to focus on child strengths, on all factors in the environment that

impinge on the child’s health, and on prevention. It is impossible to treat a child with

mental health needs successfully without intervening with peers and families. Providers

must listen to parents rather than assume that they are the cause of the child’s problems.

Clinical models that espouse such values should be applied across service systems and

incorporated into a continuum of care.

Conclusion

It is clear that the concept of systems of care for children is well accepted by experts

in the field and that efforts thus far in this direction have shown much promise in improving

overall care to children with mental health needs. The current mental health care climate,

as unsettling as it is to various constituencies serving children, presents an opportunity

to link services that previously functioned in a fragmented or parallel manner, to improve

overall efficiency, and to attend to quality and evaluation in a way never before experi-

enced. What form such systems will take, and whether they will involve family partner-

ships in care and culturally competent services, remains to be seen. To develop fully the

interagency partnerships that an integrated service system for children requires, each

responsible party must expand its definition of the child and family to incorporate their

multiple needs and strengths into service planning.

References

| | Bickman L., Guthrie P., Foster E. M., Lambert E. W., Summerfelt W. T., Breda C. S., & Heflinger C. A.

(1995). Evaluating managed mental health services: The Fort Bragg experiment. New York: Plenum Press.

Cross T. P., & Saxe L. (1997). Many hands make mental health systems of care a reality: Lessons from the mental

health services program for youth. In C. T. Nixon and D. A. Northrop (Eds.), Evaluating mental health services:

How do programs “work” in the real world? Thousand Oaks, CA: Sage Publications.

52 INTEGRATING SERVICES FOR CHILDREN

England, M. J., & Cole, R. F. (1995). Children and mental health: How can the system be improved? Health

Affairs 14(3), 131-138.

Epstein, I., Hernandez M., & Manderscheid, R. (1996). Outcome roundtable for child services. Department

of Child and Family Studies, University of South Florida.

Friedman, R. M. (1994). Restructuring of systems to emphasize prevention and family support. Journal of Clinical

Child Psychology, 23 (Suppl.), 40-47.

Friedman, R. M., & Burns, B. (1996). The evaluation of the Fort Bragg demonstration project: An alternative

interpretation of the findings. The Journal of Mental Health Administration 23:1, 128-135.

Hernandez, M.., et al. (1996). Michigan outcome identification project. University of South Florida: Florida Mental

Health Institute.

Hodges, S., & Hernandez, M. (1996). Local processes of outcome evaluation: A survey of CMHS grantees.

University of South Florida: Florida Mental Health Institute.

Marzke C,. Both D., & Focht J. (1994). Information systems to support comprehensive human services delivery:

Emerging approaches, issues, and opportunities. National Center for Service Integration.

Murphy A. (1995). Formation of networks, corporate affiliation, and joint ventures among mental health and

substance abuse treatment organizations. Rockville, MD: U.S. Center for Mental Health Services.

National Technical Assistance Center for Children’s Mental Health. (1996). Child welfare, children’s mental health,

and families: A partnership for action.

Osher T. W., Koyangi C., McCarthy J., Pires S., & Webman D. (1997). How to achieve success at managing

integrated systems for children and families. In press.

Stroul B. A., & Friedman R. M. (1994). A system of care for children and youth with severe emotional distur-

bances. CASSP Technical Assistance Center, Center for Child Health and Mental Health Policy, Georgetown

University Child Development Center.

Task Force on Enhancing MHSIP to Meet the Needs of Children. (1992). Enhancing MHSIP to meet the needs

of children. Final Report.

U.S. Department of Education, Office of Special Education and Rehabilitative Services, Communications and

Media Support Services. (1997). IDEA: Individuals with disabilities education act, amendments of 1997. An

Information Package.

U.S. Department of Health and Human Services. (1996). Comprehensive community mental health services for

children program. Fact Sheet.

| Journal of the Washington Academy of Sciences,

_ Volume 85, Number 1, 53-69, December 1998

Integration of Mental Health and

Other Services for Adults

Susan Foster, Ann Detrick, Stephen Eichler, Larry Fricks,

Marilyn J. Henderson, Joyce Jorgenson, Damian Kirwan,

Jeffrey Kushner, Ronald W. Manderscheid, Sandra Naylor-Goodwin,

|| Kirk Strosahl, Fred Volpe

- Introduction

There is little doubt that integrated services for persons with mental illness are prefer-

_ able to services marked by fragmentation, duplication, and gaps in care. Persons with

' mental illness have multiple needs that cross categorical agency boundaries. They require

an array of psychosocial services provided in an individualized, flexible manner by multi-

_ disciplinary groups of providers. Further, with the expansion of managed care, we are

| now in a period of major change that offers both opportunities for and barriers to service

_ integration. Many believe that with managed care should come an efficient, integrated

_ system of care that will meet the needs of persons who require multiple services. In an

_ increasingly competitive market with shrinking resources, the incentives are in place

' for services to be better streamlined and linked into the efficient whole that service integra-

| tion promises. Changes occurring simultaneously in health care, welfare, health care

delivery in prisons, and eligibility for insurance and other entitlement programs make

for more frequent movement from one system to the other — which, in turn, makes service

integration efforts all the more important today.

This paper provides a broad overview of service integration. It begins with a defin-

| ition of service integration and the characteristics of an ideal service system and then

highlights the debate between advocates for “structural” vs. “functional” integration and

_ describes models and methods to achieve both. Financial, contractual, and policy-level

Strategies for achieving better inter-organizational linkages are then discussed. A

Separate section is devoted to models for coordinating care between the justice system

| and the mental health system. Special issues including who needs to be involved in the

| process of designing and implementing systems of care, determining outcomes of care,

_ and the challenges to service integration are discussed. Finally, recommendations are

serving persons with mental illness.

| made for steps that should be taken to move toward more highly integrated service systems

54 INTEGRATION OF MENTAL HEALTH

Definition of Service Integration

Efforts to integrate services have existed for decades, initiated not only by mental |

health providers, but also by those in the areas of maternal and child health, substance |

abuse treatment, and social services. England and Goff (1993) define service integra- |

tion as an “integrated financing and delivery system using a multidisciplinary panel of |

providers selected for quality and cost management and which involves continuous quality

improvement principles.” In the ideal integrated service system, providers are able to |

offer a flexible array of often neglected and non-reimbursable psychosocial services |

(Mechanic, 1994), tailored to individual needs in partnership with the consumer. Cross- |

agency service planning and positive collaborations between mental health and other

relevant organizations serving the same population are essential steps to decrease fragmen- |

tation and create a system that functions seamlessly for each consumer. |

Service integration reflects a holistic, consumer-centered philosophy of care. It takes

into account the multiple needs of a person with mental illness, ensures parity between |

mental and physical health care, and focuses on prevention. Consumers nationwide insist

upon the value of a comprehensive, consumer-driven, individualized approach toward |

recovery that includes meaningful employment opportunities, affordable housing, self- |

help programs, and alternative therapies. It is based on the respect and dignity that each |

person deserves as he or she moves forward in the process of recovery. ?

An integrated service system ideally includes the following features:

¢ asingle point of entry into the system;

e multidisciplinary service teams of psychiatrists, nurses, social workers, and |

vocational rehabilitation specialists with consumers and families as integral

members of the team;

¢ information systems that allow easy communication and sharing of data between |

organizations;

e services that are provided in an individualized, flexible manner and that ensure |

the consumer retains choice of treatment options;

¢ streamlined financing that decreases fragmentation and increases the flexible use |

of resources; q

¢ a service array that includes mental health, health, vocational, social, self-help,

and housing services; |

¢ effective, ongoing partnerships among service providers, consumers, families and |

high level officials; |

¢ acontinuum of care from acute to community-based services with seamless transi- |

tion from one to another; and

e care that addresses consumer needs over the course of a lifetime.

—_

ae <2

INTEGRATION OF MENTAL HEALTH 55

| Strategies for Achieving Service Integration

Service integration is a process in which a variety of strategies are employed to create

| asystem of care. Integration of services should occur on three levels: the consumer level;

_| the system level; and the policy level. At the consumer level, services are generally linked

through case management. At the system-level, integration is based on interagency collab-

orative arrangements and relationships among providers that directly shape the delivery

of mental health and other services. Integration occurs when a variety of services are

available in one location, or when there are agreements between provider agencies in

|| different locations. At the policy level, service integration requires the development of

|, new service delivery structures, approaches, and financing schemes, the creation of new

services, and the legislation of multiagency budgets and service plans. Service integra-

‘tion efforts tend to be most successful when they are strongly developed at all three levels

(Teitelbaum Sie LOOT):

How to achieve service integration is an area of debate in the field.' Should services

|) be linked structurally, through location of services under one roof, or functionally, through

| a variety of strategies that do not require co-location? The following sections describe

| arguments for both approaches to service integration, methods for achieving both, and

_models currently in existence.

| Structural Integration Strategies

Advocates for structural integration point to numerous advantages to providing an

|| array of services in one setting (Strosahl, 1994; Feingold and Slammon, 1993). People

benefit from services delivered in the same location by providers with similar philoso-

|| phies who are in constant communication with one another and who work as a team

| under the same roof; at the same time, consumers are spared the burden of going to multiple

sites to obtain the services they need. With support from mental health specialists, primary

| care physicians, often the first point of contact for persons seeking mental health care,

| can detect and manage the majority of mental health concerns (Strosahl, 1994). In rural

| areas, where it is particularly difficult to move through society anonymously, there is

{

| stigma associated with going to a mental health center, whereas primary care is seen as

|) anecessary and “normal” service.

Many HMOs have, for some years, provided both primary care and mental health

|| Services, but the mental health consultant model at Group Health of Puget Sound in

‘ Much of the mental health policy literature on service integration focuses on the relationship between

primary care and mental health services, but this paper will also draw from the justice system, substance

abuse, and clinical literature to discuss other key systems that must be considered in any discussion of compre-

|| hensive service integration.

56 INTEGRATION OF MENTAL HEALTH

Washington State is considered by many to be a model for effective collaboration between |

mental health and primary care providers. This HMO serves a predominantly middle |

class, privately insured, population, but certain aspects of the model may have applic- |

ability to the public mental health system. Here, mental health consultants conduct treat- |

ment planning and brief interventions in mental health and substance abuse in concert |

with primary care physicians. The mental health consultant continues to be available to |

the consumer and to the physician, but the primary care physician directs the care. Specialty |

care is provided for persons with serious mental illness or during acute episodes. As Arons |

et al., (1994) have asserted, not only is it more effective to treat mental health and substance |

abuse in an integrated fashion, but “the ability to manage mental health and substance

abuse services is central to full integration.”

One rural initiative, the Bay Area Service Extension Project, in northern Michigan |

(National Association for Rural Mental Health, 1995) is considered to be a successful

integration of primary care and mental health. The project outsourced mental health practi- |

tioners to tribal health clinics. The key to the program’s success, however, was the recep-

tivity of the physicians to such an arrangement. Physicians found that they were better |

able to identify mental health problems among their patient populations because they

had the support they needed to ensure rapid access to consultation, crisis intervention, |

and ongoing treatment. :

It may be naive to assume that simply providing mental health services in primary

care settings is the answer to integrating mental and physical health. Over dependence

on primary care physicians to take the lead in the management of mental health needs |

can result in the under detection of mental illness. Wells and his colleagues (1989) found

that general medical providers, when operating solo, detected only about half of the |

depressed individuals in their practices, as opposed to mental health specialists, who |

identified almost all. There is also no guarantee that physicians will be aware of the

skills of mental health practitioners or receptive to bringing them into their practices ;

(Badger, 1997).

For structural integration initiatives to work, medical and mental health providers |

must share a common philosophy of care and operate in an atmosphere of mutual respect.

In such an atmosphere, mental health is not devalued; rather, emotional and physical

health are viewed as intimately connected. The package must also be tailored to the popula-_|

tion served. Services can be located together in a variety of settings, but should reflect |

the perceived health, mental health, and social needs of the community being served. |

For example, services could be offered in public housing developments, schools, ethnic-

specific organizations and other neighborhood settings. |

Finally, structural integration only works when there are services to locate in the |

same place. According to Damian Kerwin of the National Association for Rural Mental —

Health, there are over 1000 counties in this country with no mental health providers

whatsoever. Goldsmith and his colleagues (1997) found that while most rural areas had

INTEGRATION OF MENTAL HEALTH a

|| some form of ambulatory mental health services, there was a general lack of adequate

_ and appropriate care for persons with mental health needs at all levels of care. No managed

‘| care plan or integrative strategy can overcome the dearth of providers and geographic

isolation of individuals in rural and frontier locations with mental health needs; other

creative solutions must be sought.

Overall, the arguments for co-location as a strategy for developing integrated service

systems, are strong, but proponents recognize that this approach is not always feasible

and that it is more important to judge a service integration initiative by how well it works

rather than by how it is structured.

| Functional Integration Strategies

Advocates for carved out mental health services with “functional” integration argue

that the way a system functions is more important than how it is physically structured.

When organizational players work collaboratively, often assisted by case managers, they

_ achieve a “functionally integrated carve-out.” To Croze (1994), “integration is about elimi-

| nating boundaries, about productive collaboration; it does not require that specialty systems

of care be completely merged.” Proponents of functional integration express concern

that when mental health services are provided in medical settings, the medical model

| prevails, mental health services are devalued, and access to alternative and specialty

' services 1s limited.

Case management. While co-location of diverse services is a system-level service

integration strategy, case management is the most widely used technique at the consumer

_ level for linking consumers to a range of services in different locations. This strategy is

dependent on an individual, hired by an agency, to bring service system components

together on behalf of consumers, or to functionally integrate services for them. “Case

management” can connote a range of functions, from phone-based gatekeeping to

outreach, assessment, and long-term collaboration with consumers to enhance their quality

of life, social and occupational functioning, and recovery through supportive counseling

and service referral and follow-up. Managed care organizations have found the more

intensive forms of case management particularly useful with persons with severe and

persistent mental illness (Surles, 1992). The gatekeeping, or brokering, type of case

management, is employed more to control than to increase access to services and can

_ result in reduced choice on the part of the consumer and decreased flexibility on the

part of the provider.

Planners sometimes make the mistake of depending on a case manager to integrate

systems. Because they are closest to consumers and their families, case managers are

_more likely than other personnel to identify system-level problems, but they cannot change

systems. They usually have little or no contact with organizational and political leaders

who have the authority to effect systemic change. Service system implementation and

58 INTEGRATION OF MENTAL HEALTH

sustainability are most likely to be successful when administrators value case managers’

observations by including them in the decision-making process.

System-level Strategies. While case management seeks to coordinate care on behalf

of consumers and their families, various system-level strategies may be used to integrate

therapies and organizational functions to address the needs of the whole person and the

systems surrounding that person. These interventions require the service system to respond

collectively to individuals with mental health needs.

Organizational innovations require managerial level investment and planning across

agencies. They include development of common intake forms, shared access to records,

cross-agency needs assessments, integrated referral and feedback systems, formation

of multi-disciplinary and multi-agency teams which meet regularly to conduct joint care

planning, and interagency sharing of staff and other resources.

Certain treatment approaches are viewed as beneficial to persons served by several

service systems and those with co-occurring disorders such as mental illness and substance

abuse. Multi-systemic therapy (MST) (Santos et al., 1995) approaches treatment from

the perspective of the multifactorial nature of mental illness and recovery and focuses

on consumer strengths and prevention. Its values are consistent with those espoused by

managed mental health care (Henggeler et al., 1996). MST stresses, for example,

improving practice standards by providing incentives for those clinicians who achieve

positive outcomes. Advocates of this approach acknowledge that while such a model is

integral to providing consistent care across agencies, without a supportive system of care,

it will not be successful.

Another model, the Program for Assertive Community Treatment (PACT), has been

rigorously evaluated and extensively replicated. Widely accepted by consumers and

providers alike, assertive community treatment is viewed as an effective means by which

to address the multiple needs of persons with mental illness through intensive case manage-

ment within a multidisciplinary team (Gilbert, 1997). PACT began in Wisconsin in the

1970s as part of the Training in Community Living Model (Frank, 1997).

PACT stands out among community-based mental health programs because it contains

a number of elements considered important to mental health providers, consumers, and

advocates and to those who view service integration as essential to quality care for persons

with mental illness. First, case managers operate as part of a multidisciplinary team of

mental health clinicians, nurses, and vocational rehabilitation specialists. Rather than

brokering services scattered across many institutions and agencies, the case manager

works with a coordinated, cross-agency, and ongoing team that includes the consumer.

Second, the team performs all direct services for the consumer, including psychiatric

evaluation and treatment, medication management, drug treatment, nursing and social

support, and social and vocational rehabilitation. Third, consumers take an active role

in their recovery by living and working in the community and by partnering with the

team to determine the level of support they require. Finally, employment is a valued goal

ce = ee SS

INTEGRATION OF MENTAL HEALTH 59

_ in the program, and support for becoming and staying employed is considered essen-

| tial to recovery. The inclusion of a vocational rehabilitation specialist on the team is seen

_ by consumer advocates as essential to an integrated service delivery model.

The National Alliance for the Mentally Ill has formed a partnership with PACT, Inc.

| _ to promote replication of the model and marketing to managed mental health care organi-

zations in the belief that this is the most effective community-based service delivery model

(Flynn et al., 1997). PACT’s strengths in a managed care marketplace include its cost-

| effectiveness for persons with severe and persistent mental illness. Research on the model

| has also shown that the greatest benefit is achieved when services are provided over the

long-term; hence, managed care organizations will be most interested in the model if

| they have long-term contracts with states and other payers.

Different models of integrated service delivery may be best applied to different popula-

tions. While PACT may be most effective as a long-term intervention for persons with

| ‘serious and persistent mental illness, the HMO model described earlier may be more

appropriate with persons who have less severe illness, intact support systems, and fewer

concrete needs. The implication for managed care is that an assessment of the severity

or chronicity of the illness, of culture, economic status, service availability, and

geography must be conducted before a service model, however integrated, is applied to

a given community.

Information Systems. It is believed by many that information systems and other

_telecommunications technology can “virtually” integrate systems. They have the

capacity to support collaborative planning and service delivery among service providers

at different locations via electronic and telephone communication, computerized

exchange of information, and interagency referral tracking, thereby precluding the need

to locate providers in one physical setting. The Internet is a source of information on

treatment modalities, support groups, not only for consumers but also providers. Some

group practices allow consumers to schedule appointments via the Internet (Trabin, 1996).

While some of these functions are already in place and accessible to many, an

integrated information system that provides real-time knowledge of consumer functioning,

service utilization, outcomes assessment, and system performance across agencies does

not yet exist. Such a system could assist providers and program planners to respond rapidly

to consumer-level and system-level problems and to assure that appropriate and timely

services are delivered to the consumer.

A fully integrated information system would allow all providers and administrators

access to consumer enrollment and utilization data. Providers and administrators would

use standardized performance measures, practice guidelines, and outcome measures.

Optimally, such a system would allow for consumer tracking across systems to identify

gaps and duplication in service as an indicator of level of service integration. Within the

information system, there would be linkages among areas so that analyzed together, these

data could be used for ongoing quality assessment and overall program evaluation.

60 INTEGRATION OF MENTAL HEALTH

Numerous efforts are under way at the Federal level to develop measurement standards |

and prototypes for each of these areas, but an overall information system strategy, involving |

cooperation between the private and public sectors, needs to occur simultaneously with

system reform.

The technology exists to create such systems, but the data systems and capabilities |

across public sector agencies and between public and private sector entities vary |

tremendously. Further, providers are often linked to multiple managed care networks, |

all with their own information systems and requirements. Numerous barriers related to

cost, confidentiality, standardization, measurement, and how data are used and inter- |

preted have to be overcome before truly integrated information systems can be imple-

mented. Consumers, family members, and other advocates have been and must continue |

to be involved in the design and implementation of such systems.

In rural areas, where services and providers are separated by great distances,

technology can facilitate consultation, medication monitoring, and care planning. |

Telepsychiatry has proven a useful means of bringing specialist consultation to remote |

areas and creating teams where none existed. One successful and creative example of

such networking is in Arizona where services were provided to Navajos using satellite |

technology for psychiatric consultation to Navajo healers who provided direct service |

on the reservation. Teams that travel from town to rural community mental health centers

or primary care offices achieve the same ends, but video technology saves the time and _ |

expense incurred through travel. |

Financial Strategies

Across the United States, numerous natural experiments are taking place in finan-

cial restructuring to effect service integration. Capitation, now widely practiced in the

public and private sectors, is a financial strategy that has great potential for facilitating

integration. Operating from a pool of funding for a focused population, providers techni-

cally have the flexibility to develop a spectrum of services, including prevention, employ-

ment coaching, and wellness services, applied individually according to need.

Organizations and provider networks, and even county mental health authorities, are

increasingly willing to use such arrangements to provide a continuum of services.

While capitation allows for creativity and flexibility, there is little research evidence

to suggest that it integrates services (Frank, 1997). Capitation may, in fact, result in

decreased access to specialty services because the provider organization bears financial

risk and therefore has the incentive to provide care at as low cost as possible. In today’s

competitive health care market, some organizations are accepting low capitation rates

to obtain contracts and are therefore forced to reduce the number of services, and to restrict

choice in the frequency, intensity, and types of services they use. For example, long-

term psycho-therapy or inpatient substance abuse treatment may not be available in a

INTEGRATION OF MENTAL HEALTH 61

| capitated plan. This is of particular concern for people of color and low income popula-

tions who may wish to seek services from ethnic-specific organizations, or require trans-

lation, outreach, and home-based treatment (Lipson, 1997). Other dangers include selec-

tion of the lowest risk client base and “dumping” potentially high-end users into other

_ payment systems. As long as selection and cost shifting occur, a service system cannot

be considered fully integrated. Safeguards must be in place in the payer-provider contrac-

tual arrangement to ensure that quality is maintained and that optimal outcomes,

standards of access, range of services, and availability of providers, are achieved. (Wells

et al., 1995; McGuirk et al., 1995)

Blended funding initiatives attempt to consolidate multiple funding sources into a

single stream to reduce fragmentation. In this way, the resources committed by various

agencies (e.g., mental health, substance abuse, and corrections) to a given population

are streamlined to provide a range of services in the most efficient way possible. Such

a process requires planning at all levels of government and cooperation between treat-

ment organizations and agencies to determine which funding streams should be consol-

| idated and to what end. Such initiatives are rare for adults, but have been piloted to integrate

| children’s services.

Contracting Strategies

A mental health service contract can be an integrative strategy when it builds in

requirements that the contractor demonstrate efforts toward linking services on behalf

of the population served. The contract enables the payer to obtain a service array that

is responsive to the needs of consumers and their families. At its best, a contract can

specify the mechanisms for integration between community organizations and systems;

fiscal responsibilities across agencies; instruments for measuring consumer satisfaction

with service array, availability, and access; interdisciplinary training requirements; and

specific outcomes measures.

| In the earliest days of managed mental health care carve-outs, states’ contracts with

} managed care organizations required little in the way of innovation to improve the quality

of care to persons with mental illness; states tended to accept the packages that were

offered to them. Experience coupled with increased competition for public sector contracts

has enabled purchasers to be proactive in specifying the populations that need to be served

| and the strategies that must be employed to enhance quality of care. A recent study of

} Medicaid managed care contracts (Rosenbaum et al., 1998) found that while state

Medicaid agencies have begun to consider the relationship between managed care organi-

zations and other agencies serving persons with mental illness (particularly between mental

health and drug treatment programs), their contracts with these organizations often use

ambiguous language to define “coordination,” none set standards for the achievement

of integrated service delivery, and few specify interagency fiscal responsibilities for the

62 INTEGRATION OF MENTAL HEALTH

populations they share. The authors warn that without specifications for interagency inter- |

action and proper monitoring of steps toward service integration, carve-out contracting |

can exacerbate fragmentation and gaps in coverage and service. While contracting has |

the potential to drive systems of care, its potential as a strategy has not yet been realized.

Policy Level Strategies

At the policy level, service integration involves building support for specific

programs and for collaborative and interdisciplinary approaches to care. States are increas-

ingly legislating the merger of categorical agencies that serve the same populations. City,

county, and statewide planning in conjunction with heads of public and private agencies,

task forces, and boards is also occurring. This kind of broad-based planning has the poten-

tial to build lasting support for institutional linkages and interagency/interdisciplinary

program approaches in policy-making circles.

In several states, shifts in responsibility and funding for mental health and other human

services from a centralized bureaucracy to counties and regions has given local planners

the autonomy to consider the unique needs of its vulnerable populations and to plan for

services across systems. The planning process can be tremendously complex and

requires collaboration among all stakeholders at all levels to make it a success. California |

is the most prominent example of a county-operated mental health (and recently, human

service) environment. As the state has also operated for a longer period of time than most

within a managed care environment, it offers some interesting service integration

examples. In Los Angeles County, Integrated Service Agencies (ISAs) were formed to |

provide all mental health and social services to individuals in their catchment areas 7

days a week, 24 hours a day. This initiative holds promise for truly integrating services |

because it employs an array of strategies: blended funding, capitation, and case manage- |

ment. It also involves a local planning process and identifies a locus of accountability |

for persons with mental health needs.

New York, which has been slower to move to managed mental health care, has

benefitted from observing other states make the transition. Rather than carving out mental

health services to a managed care organization, New York’s Department of Mental Health

regionalized the delivery of mental health services and recently issued a request for

proposals to regions to deliver mental health services to over half of the serious mental

illness population. In response to the request, providers formed multi-organization |

consortia to create networks that provide an array of integrated services.

Indicators of successful change at the policy level include: a commitment to change

on the part of key stakeholders; strong leadership at all levels of the service systems

targeted for integration as well as among the funding sources that support these systems;

and a planning team that is representative of the community’s different service provider,

cultural, and ethnic groups (GAO, 1992; Marzke and Both, 1994).

INTEGRATION OF MENTAL HEALTH 63

Coordinating Care Between the Justice and

Mental Health/Substance Abuse Systems

Prisons have become primary institutions in which persons with mental illness and

chemical dependency are housed (Torrey, 1995). Often jailed for non-violent or drug-

_ related offenses, persons with mental illness may receive medications and some form

of mental health treatment in jail, but rarely receive the follow-up and care they need

upon release. As a result, they become trapped in the revolving door between the mental

health and corrections systems. There are, however, two strategies for integrating

services, diversion and unified drug courts, that help retain persons with mental health

_ and drug treatment needs in the community.

Diversion is intended to prevent unnecessary incarceration and recidivism for

persons who commit non-violent crimes. Often, these persons have mental health and

substance abuse needs that are better addressed in the community than in a correctional

facility. The best diversion programs, according to a review by Steadman et al. (1995),

have mechanisms to integrate mental health and corrections functions (e.g., by placing

mental health professionals in courts) but also work within an integrated community-

based system of services and set aside resources (such as liaisons and case managers)

to ensure that those linkages take place.

Milwaukee’s Community Support Program serves individuals with severe and persis-

_ tent mental illness who have been released from prison and who are at high risk for reincar-

ceration, homelessness, and decompensation as a result of poor medication and thera-

peutic monitoring. A multidisciplinary team includes paraprofessionals housed in a small,

community-based setting that provides medical and therapeutic services, assistance with

money management and housing, and close monitoring. Staff also provide outreach to

local prisons and jails to identify and offer services to qualifying individuals. The program

has not been formally evaluated, but factors in its perceived success are its low-cost identi-

fication of persons with mental illness in prisons, and improved relations between agencies

involved with mentally ill persons within and outside the corrections system. (McDonald

and Teitelbaum, 1994).

Unified drug courts link the judicial, corrections, and mental health/substance abuse

service systems. Prior to conviction, an offender is referred by a judge to mandatory

drug treatment; upon successful completion of a drug treatment program (with no subse-

quent arrests), the criminal record is erased. In a St. Louis, Missouri unified drug court,

a combination of public health, judicial, and financial approaches from the local to the

state level makes it possible for individuals without health insurance to receive immediate

drug treatment. Moreover, pre-treatment, inpatient treatment, and aftercare, covering a

year of services, is included in the package.

In addition, certain managed care principles have been applied successfully to these

types of programs that include: contracts between the state and a network of providers

and managed care organizations for a case rate per member per month for pretreatment

64 INTEGRATION OF MENTAL HEALTH

and aftercare; measurement of outcomes to evaluate the performance for contracted |

providers (e.g., employment, sobriety, percent who graduate from treatment, and

percent who go to jail); levels of care criteria to appropriately place clients; a quality 1

assurance plan and monitoring; and a holistic approach to medical necessity.

Special Issues in Planning Service Integration

Who Needs to be Involved in the Process?

If one considers that system reform, in this case the development of integrated service |

delivery systems for persons with mental illness, is a process rather than a single event,

the process should reflect the needs and concerns of the population to be served. The |

creation and maintenance of such systems requires cooperation and positive working |

relationships among all involved parties from consumers to families, agencies, and policy-

makers.

Bruner (1994) notes that such a process involves partnering with consumers and

families at the local level, conducting community-based needs assessments to reach |

consensus on goals and objectives, and developing mechanisms for problem resolution. |

Families and consumers should be involved in the design, development, delivery, and

quality assurance processes of managed care services. Participants must also reflect the |

culture of the community served.

Some mental health specialists maintain that market forces and strategic purchasing |

of services will, without government intervention, do a superior job of creating well- |

functioning integrated service systems. Most, however, believe that government must

continue to play a vital role in maintaining safeguards that ensure that disenfranchised |

populations such as persons with severe mental illness, specifically those who are poor,

homeless, and people of color, receive the services they need.

Outcomes

A well-functioning integrated service delivery system must be outcome-driven. In

other words, outcomes for the population served must be linked to common goals that

reflect the diversity of customers served, the multiple services they receive, and the settings

in which they are served. Promoting an outcomes orientation and accountability

for achieving results are crucial steps in the process of implementing service integra-

tion (Schorr, 1994). Determining the means by which those agencies should be held

accountable for consumer outcomes is a challenge; one option is to provide fiscal incen-

tives based on outcomes such as job retention, consumer satisfaction, and maintenance

in the community.

INTEGRATION OF MENTAL HEALTH 65

Challenges to Service Integration

Service integration is not easy to achieve or sustain, which may explain why there

are no ideal service systems in place. Service integration requires collaboration among

agencies with different missions and funding sources; hence, it is not surprising that

_ integration is a difficult goal to reach. Moreover, philosophies that differ across agencies

and professional disciplines can hamper dialogue. For example, if the goal is to blend

funds to provide case management, it can be difficult to obtain the commitment of

resources from agencies that have different opinions as to its value.

| Categorical funding requirements from the Federal to the local level constrain

programs’ ability to work together by creating multiple systems with narrow mandates.

Moreover, as funding flows less freely, managing turf conflicts and competition among

_ organizations participating in service integration efforts presents a universal challenge.

At the policy-making level, a lack of commitment, support, and leadership, as well as

uncertainty over funding availability, can result in turf battles between state and local

_ officials who may see service integration as a threat to their programs and budgets. (GAO,

1992) |

Service systems will never be truly integrated without integrated information

_ systems, both within mental health and across agencies. Currently, data collected, instru-

| ments used, and level of computerization vary by agency, by area of jurisdiction, and

/ between the public and private sectors. At present, there is no integrated information

| system in existence, although components of such a system are being used by various

| organizations and government bodies.

| Proving that system reform leads to improved clinical outcomes remains elusive.

| While it is assumed that integrated service systems are better for the consumer, the field

| has not reached consensus on defining the most important outcomes across service

| systems. Finally, some service areas, particularly rural ones, have few services and few

service providers to integrate. Rural areas have unique needs (e.g., reimbursement for

| provider and client travel) that tend not to be addressed at the state level because of their

| low population density. There may also be resistance on the part of primary care physi-

| cians to working with mental health providers.

{

| Recommendations

The expert panel made several recommendations for service integration efforts in

' the future:

Funding Mechanisms. Financial incentives are a key method for changing models

of care for persons with multiple needs. Capitation and consolidation of funding

streams have great possibilities for the development of service systems that are flexible

and comprehensive. New funding mechanisms and risk arrangements must be accom-

66 INTEGRATION OF MENTAL HEALTH

panied by close monitoring and service requirements to ensure that an elastic, individ-

ualized system results. |

Public and private sector purchasers alike can change the shape of mental health |

service delivery if they set contract parameters for system of care development. The

contract is a powerful a tool for purchasing an integrated continuum of services. It is —

the payer’s responsibility to require the integration of mental health and primary care |

along with other key services, to remain involved in the design, delivery, and evalua-

tion of services, and to ensure that appropriate outcomes are identified.

Funding should be provided to states and localities to facilitate planning toward service |

integration. Such processes are time- and labor-intensive, requiring personnel to facil- |

itate interagency communication, cross-training, and other activities to initiate and sustain |

system reform. |

Research. As much as service integration is accepted as a worthy goal, there is insuf-

ficient evidence that increasing system integration improves quality of care or improves |

consumer outcomes. Tracking individuals across systems longitudinally would yield the |

best information as to whether or not integration efforts were closing gaps and reducing |

duplication in the system. Overcoming such barriers as creating common identifiers across

systems while still protecting consumer privacy are challenges researchers face in these

endeavors. There are several natural experiments in service integration in progress across

the country that could (and are) being studied using quasi-experimental designs and ethno-

graphic approaches. Not enough time has passed to assess the results of such initiatives, |

but it is clear that they must be thoroughly evaluated in order to determine whether or |

not programs are successful, which aspects of the programs have the greatest impact, |

and whether or not the results are generalizable. Various strategies are being employed |

to integrate mental health and other services, but in what combinations as applied to |

which populations requires further study. |

Rural Areas. In rural areas, use of primary care settings for mental health interventions

can be viable alternatives to mental health centers, which are viewed by some rural

residents as stigmatizing. But in order for this model to work, training for physicians is

required to enhance their ability to identify and treat mental illness and substance abuse.

Medical students and mental health trainees should be given rural practice opportuni-

ties in collaboration with professionals in both disciplines to introduce them to the model

of co-located mental health and primary care and to entice them to practice in rural areas.

Allocation of funds to rural areas tends to be limited, and consideration of the unique |

needs of rural providers for transportation funding should be made. Where services are |

few and far between, consultation, team meetings, referrals, and other activities that link _

different services can be achieved through satellite technology.

Rural counties can pool resources and join together strategically to advocate for better,

more creative means of delivering a variety of services to their constituents. Documentation

of rural service integration projects that seem to be making a difference should be dissem-

inated to communities and to state legislators.

INTEGRATION OF MENTAL HEALTH 67

Technical Assistance. Local governments need technical assistance to understand

managed care and to learn about creative program strategies under capitated systems. Local

stakeholders also need training in leadership, consensus-building, and other strategies that

promote interagency collaboration and commitment to persons with mental illness.

Information Systems. There are, at present, no fully integrated information systems

that can provide ‘real time’ consumer and program data for the improvement of service

delivery, and no system can be truly integrated without it. Technological experts, as well

as experts in mental health data, consumers, and epidemiologists must work together

to determine which questions are most important to answer so that information is gathered

purposefully. Consensus must be attained on content, measurement, and use of data; confi-

dentiality concerns must be addressed; and the infrastructure to support such a decision

support system needs to be built. Efforts to date such as MHSIP’s consumer-oriented

report card (1996) are important and need to continue.

Consumers and Families. If, indeed, service integration efforts call for a common

philosophy across agencies, consumers call for a focus on recovery, self-help, and reinte-

gration into the community. Consumers and families need to be involved as decision

makers throughout the design and implementation phases of service integration efforts.

Recognition of the right of these constituencies to meaningful participation will help

people recover from mental illness and become more fully participating members of

society. Twenty-five states now have offices of consumer relations.

Outcomes. Just as it is important to identify goals and objectives collaboratively,

outcomes should be identified that are tailored to specific populations. Clinical outcomes

may not ultimately be as important as functional outcomes such as job retention and

stable housing. If the mental health field can settle on consumer-centered outcomes with

realistic time frames for their achievement, it will be able to contribute to larger efforts

at bringing human services toward an integrated whole.

Conclusion

The financial strategies and contracting incentives associated with managed mental

health care have tremendous possibilities for promoting service integration. Capitation

can free organizations from strictures on the types and range of services that can be

provided and make flexible, creative programming possible. The efficiencies required

in an era of dwindling resources have reignited a movement toward community-based

care and have made policy makers and planners join with consumers and families to

advocate for comprehensive programs that sustain individuals in their communities. The

_ public mental health system is requiring the managed care entities with which it

contracts to demonstrate the ability to serve individuals with mental health needs across

systems such as corrections, primary care, and drug treatment. While there is insuffi-

cient evidence that service system reform improves the quality of care and outcomes,

68 INTEGRATION OF MENTAL HEALTH

it is clear that physical, emotional, and substance abuse issues are inextricably linked

and must be treated in an integrated fashion.

Ultimately, how successful service integration initiatives will be will not rest on finan-

cial incentives. Service integration is a process that requires collaboration, networking,

and compromise on the part of players in different systems and at all levels. A partici-

patory process that includes the public sector, the private sector, providers, consumers,

and families is crucial to ensuring that the most vulnerable populations maintain choice

and access to the range of services they require. There is no single strategy that will ensure

that service integration takes place; the best initiatives will combine financial, consumer-

level, technological, and other systems innovations to create systems of care that have

a lasting effect on the quality of care for individuals with mental health needs.

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Journal of the Washington Academy of Sciences,

Volume 85, Number 1, 70-82, December 1998

Partners or Antagonists: Medicaid

and the Public Mental Health Agency

in the Era of Managed Care

James QO. Michel, John Allen, Bruce Bullen, Jack Callaghan,

Rick Compton, Marilyn J. Henderson, Gene Lovato,

Ronald W. Manderscheid, Noel Mazade, Candace Nardini, Lee Partridge,

Randy Poulsen, E. Clarke Ross, Marylou Sudders, James Wiley

The failure in the early 1990s to reach consensus between the Administration and

Congress regarding the shape of national health care reform has fueled the continuing

efforts of individual states to address an array of lingering problems, principally through

Medicaid managed care initiatives. These programs are intended to control spiraling costs,

expand coverage and access to services, and improve quality of care. The recent relax-

ation of waiver requirements in the Omnibus Budget Reconciliation Act is likely to

continue this trend. Within this environment, mental health has perhaps been the most

prominent specialty service to command the attention of Medicaid directors across the

nation. Although payments for mental health and substance abuse treatment services repre-

sent only about a quarter of total Medicaid expenditures, inflation rates for these services

have typically been higher than the already steep rate of medical cost increases. While

public mental health directors have been busy completing a process of downsizing large

public institutions, attempting to develop and consolidate community-based systems of

care, and supporting a burgeoning consumer movement, they have had to cope with a

rapidly changing business landscape reflected through changes in the Medicaid program.

The goal of this paper is to examine the manner in which structural, procedural, and

political aspects of the relationship between Medicaid and the public Mental Health

Agency (MHA) impact the design and implementation of managed care initiatives. Of

particular interest are the variables impacting the manner in which Medicaid and the

public MHA work together, or at cross purposes, in setting the course of public mental

health policy. Acknowledging the unique fashion in which individual states organize and

finance their public mental health systems, the current paper will:

e discuss the manner in which Medicaid and the public MHA typically take either

similar or divergent approaches to eligible populations, benefit design, purchasing

strategies, provider networks, quality management, financial management and

other administrative functions;

e identify areas of both collaboration and conflict, using examples of existing

managed care initiatives; and

PARTNERS OR ANTAGONISTS 71

° suggest possible strategies to enhance cooperation.

Payer, Purchaser, Provider

It is helpful to conceptualize the management of the public mental health system in

terms of three broad functional categories: governance, systems administration, and service

provision. Central to the governance function are the key political/public policy

decisions regarding who will be served and how much public money shall be allocated.

Governance is the true province of public policy makers, including the executive and

legislative branches of government, plus the direct stakeholders, especially consumers

and advocates. Systems administration refers to the set of operational activities required

_ to implement policy, i.e., network development and management, financial management,

information management, and quality management. Operating the public mental health

system has long been the (fairly exclusive) province of the MHA, but one of the major

questions today is whether some or all of the systems management tasks can be more

efficiently and effectively handled by for-profit or not-for-profit private sector managed

care organizations including managed mental health care organizations. In the public

_ mental health system, a mix of public and private, mainly nonprofit, inpatient and commu-

nity-based organizations have traditionally been responsible for service provision. The

manner in which service provider networks are selected and managed is another area

of debate regarding efficiency and effectiveness.

As a ‘mere’ payer for a discrete set of mental health services, Medicaid has not histor-

ically taken a great interest in the overall systems management function of the public

mental health system. Indeed many would describe Medicaid’s pre-managed care

participation in the governance function as fairly passive: in most states Medicaid allowed

itself to be a financing source for the deinstitutionalization/community development policy

which was shaped by the MHA. Two factors have significantly altered this state of affairs:

first, Medicaid’s financial stake in mental health services has increased significantly (to

the point where it is the dominant payer for certain services), and second, Medicaid has

begun to enroll increasingly larger percentages of its recipients into managed care plans.

During the 1980s, Medicaid came to represent a major source of funding for mental

health and substance abuse treatment services. As MHA directors began to pursue

mainstreaming campaigns, clients under their care who required inpatient services increas-

ingly were hospitalized in community general hospitals using Medicaid financing. At

the same time, many MHA directors began to collaborate with their Medicaid counter-

parts to implement optional clinic and rehabilitation services. By 1994, total Medicaid

reimbursement for mental health was $22.9 billion, accounting for almost half the funding

for public services (Oss, 1995). Other public funding of mental health included state

and local government ($21.7 billion), Medicare ($3.1 billion), and other Federal govern-

ment ($2.8 billion).

72 PARTNERS OR ANTAGONISTS

At the same time that Medicaid has increased its investment in the public mental health

system, its embrace of HMOs and other managed care plans has necessitated an internal

transformation from an indemnity payer organization to a purchaser of managed benefit

packages. Like employers and commercial insurers, Medicaid has been attracted to the

promise of more predictable costs and greater accountability offered by the plans. Posing

the central question, “Are we receiving value for our dollar?,’ Medicaid directors have

begun to work with organizations like the National Committee for Quality Assurance

(NCQA) to develop meaningful and appropriate measures of plan performance. Although

their main focus remains general medical care, this new approach combined with the greater

investment in mental health have resulted in Medicaid directors becoming active partic-

ipants in systems governance — formulating public mental health policy. Moreover, by

contracting with private for-profit or not-for-profit managed mental health care organi-

zations, Medicaid has also become a significant force in the systems administration function.

MHA directors have historically been active in all three functional areas. In most

states, the long standing tradition of setting public mental health policy (governance) is

the most common component of the MHA’s role. MHA systems operations show greater

variation from state to state, with centralized systems administration at one end of the

continuum, and regional/local (including county-based) at the other. There is also signif-

icant variation in the extent to which the MHA assumes a direct service provision role.

Although an ideological embrace of mainstreaming has led to a greater reliance on private

(mostly non-profit) providers, some state delivery systems remain largely within the public

sector, and virtually all state MHAs continue to operate a (reduced) number of public

hospitals. The issue here is whether the MHA, with a history in governance, systems

administration, and service provision should continue in all three roles, and if so, in what

manner, with which emphases. Is this history a qualification for future continuation, or

does it merely result in a resistance to necessary and worthwhile change? Furthermore,

if the activities of the MHA change — or even if they do not — what is the proper role

of the Medicaid agency? How ought Medicaid and the MHA work together in the future?

Organizational Mission

Mission statements are intended to help organizations think clearly about who they

serve — who their customers are — and how they serve them. Public mental health direc-

tors describe their mission in terms of providing systems of care for people suffering

from serious mental illnesses. With respect to their customers, there has been a change

of focus over the past decade: although persons with serious mental illness were the

priority, before the mid-1980s MHAs tended to assume responsibility for matters affecting

the mental health of all citizens in their states, regardless of their level of disability. The

narrowing of mission can, in part, be understood in the context of a changing political

environment that has sought to limit the role of government. Confronted with dimin-

me a a

SS ee

PARTNERS OR ANTAGONISTS 73

ishing resources and the fact that many citizens have access to some insurance coverage,

at least for episodic care, the MHA came to focus its resources on adults with serious

- mental illness and children and adolescents with serious emotional disturbance. Most

mental health directors see this as a positive shift that affirms a long standing commit-

| ment to the most vulnerable groups of citizens. It simultaneously releases them from

an inherently frustrating charge to “be all things to all people.” During this period, many

states developed specific legislative mandates which in effect determined (limited) eligi-

bility for services funded by the MHA.

While the ‘who we serve’ aspect of the MHA’s mission has narrowed, thinking about

‘how we serve’ has been expanding. With the downsizing of state operated institutions,

the locus of care is shifting to community-based systems of care. The ability to under-

| stand the continuing care needs of vulnerable populations and to plan, design, and monitor

innovative and responsive services is considered an area of MHA competence. Mental

| Health directors note that they developed many of the creative elements of a fully devel-

oped continuum of care, including intensive case management, rehabilitation services,

mobile crisis teams, and diversionary services. As part of their development of commu-

nity-based systems, MHAs have increasingly looked to the private sector for provision

of care. While there is significant variability from state to state, all MHAs now have a

mix of public and private providers in their service networks.

Medicaid directors describe their mission differently, as providing comprehensive

_ health insurance benefits for poor and disabled citizens. Following an era of runaway

growth, there is also a clear mandate for Medicaid directors to contain costs. They have

increasingly turned to managed care, with its promise of cost savings and improved quality,

_as the most viable solution. In 1993, 8% of the Medicaid population was enrolled in a

managed care plan; by 1996 that figure had grown to roughly 40%. In contrast to MHAs,

the trend with Medicaid programs has been toward expanded coverage. Although Medicaid

has not, as the “insurer for the poor,’ provided coverage to all citizens at or below the

Federal poverty level, several state Medicaid Agencies have taken a leading role in

attempting to address the national problem of more than 40 million uninsured individ-

uals. These states have sought to use savings from their managed care initiatives to fund

new eligibility criteria that now include persons meeting ever higher percentages of the

Federal poverty level guidelines.

The move toward managed care has also had profound implications for the manner

in which Medicaid agencies operate. As an indemnity insurance entity, they previously

focused on claims administration and regulations regarding provider clinical and admin-

istrative qualifications and practices. In a fee-for-service environment, financial manage-

ment was accomplished principally through pricing mechanisms that more often than

not set provider reimbursement at below-market rates. Under a managed care approach,

Medicaid agencies now strive to redefine themselves as value purchasers of benefit plans

for their enrolled populations. The emphasis now is on contracting with managed care

74 PARTNERS OR ANTAGONISTS

plans, including HMOs, often on a pre-paid basis. Medicaid staff have been at the forefront

in developing contract management skills and using vendor management as a primary

vehicle for program implementation.

While both the MHA and the Medicaid agency are units of government, and thus

ultimately share a common purpose to improve the welfare of the greater society, different

missions, multiple agendas, and differing priorities can contribute to different visions

of what constitutes the best public mental health policy. The mandate for Medicaid to

control costs is an area of tension in many states. In situations where interagency relation-

ships are less than optimal, MHA directors are skeptical about the stated purpose of

managed care initiatives, believing that ‘expanded access’ and ‘improved quality’ are

secondary to saving money. Carrying the concerns of primary consumers and advocates,

they worry that the cuts in spending are too deep. For their part, Medicaid directors

question the MHA’s commitment to sound management, particularly when it comes to

spending Medicaid funds for which the MHA is not held directly accountable.

Eligible Populations

MHAs primarily use diagnostic and functional criteria to determine eligibility for

services. Because the MHA has statutory responsibility to assure emergency services

for all citizens, eligibility determination has ordinarily come to mean eligibility for an

array of continuing care services, such as case management or residential rehabilitation.

Many adults with a serious mental illness and children/adolescents with a serious

emotional disturbance who are identified as priority clients by the MHA also meet

disability criteria used by the Social Security Administration for determining eligibility

for Supplemental Security Income (SSI). The Federal government has defined standards

for SSI that are used by the states. In addition to functional status, financial criteria, which

vary significantly from state to state, are also used to determine Medicaid (and SSP) eligi-

bility. For those clients who meet MHA criteria for service eligibility but are not Medicaid

eligible, i.e., whose income and assets exceed the limits set by their particular state, the

MHA is the payer of last resort, providing the safety net for this population.

While from the MHA perspective there is almost complete overlap between MHA

priority clients and persons eligible for Medicaid, adults with serious mental illness and

children with serious emotional disturbance are only a small percentage of the total

Medicaid population. Medicaid provides coverage for two broad categories of assistance:

those classified as Aged, Blind, and Disabled (ABD), and those qualifying for Aid to

Families with Dependent Children (AFDC). Roughly 27% of the total Medicaid popula-

tion fall into the ABD category, and less than half this group suffer from a psychiatric

disability. Within these categories, Medicaid is responsible for several high risk popula-

tions that tend to be significant users of mental health services, including persons with

developmental disabilities, persons with addictive disorders, and children suffering from

PARTNERS OR ANTAGONISTS 75

neglect and abuse. The majority of Medicaid-reimbursed mental health services are

consumed by recipients in the AFDC categories. However, penetration rates (i.e., the

percentage of eligibles who actually use services) and per capita expenditures are much

higher for ABD recipients. Under a managed care approach, this sub-group is an obvious

target for cost savings, potentially providing the greatest return on a per-case basis.

The fact that there are significant populations eligible for services from both

Medicaid and the MHA, but also important groups that are not shared, creates oppor-

tunities for both interagency conflict and collaboration. From the MHA perspective,

| Medicaid funding has become a critical financing element for the entire public system.

| Decisions by Medicaid directors to award contracts to HMOs or managed behavioral

| health care organizations are seen by the MHA as a potential threat to the very existence

_ of the public delivery system that must serve as the safety net for the uninsured consumer.

| However, to the extent that Medicaid is able to expand coverage to the working poor

_ and uninsured (i.e. the safety net populations), additional Federal revenues may become

| available to allay MHA financial concerns.

The volatility of Medicaid coverage is a complicating factor for interagency collab-

i oration. To remain eligible, Medicaid recipients must follow through with regular re-

| determination procedures; failure to do so results in termination of coverage. While

| coverage may be reinstated, even retroactively, if it is terminated for a period of time,

‘the MHA must act as the safety net and assume responsibility for services. Changing

_numbers of eligible users of services makes planning difficult for the MHA, and can

| result in unexpected demands on scarce resources.

) The perceived inability of MHA directors to specify exactly how many people they

| serve and how much service they receive also makes joint Medicaid-MHA planning a

| challenge. Because it is part of a national insurance program and must meet relatively

rigorous Federal information requirements, the single state Medicaid agency has years

of experience maintaining an accurate, standardized eligibility database — a prerequi-

site for developing risk-based managed care programs. Most MHAs have no such experi-

ence. As their mission requires them to make services available to all persons in need,

they have not traditionally thought of eligibility in terms of insurance coverage.

| Furthermore, MHAs have not had an oversight agency such as the Health Care Finance

\, Administration (HCFA) driving (and funding) the development of their information

| systems, which largely remain inadequate. Finally, although criteria may be well

| defined, in practice eligibility based upon diagnosis and functioning can raise serious

} questions regarding inter-rater reliability. The ‘messiness’ associated with MHA eligi-

| bility can thwart interagency efforts to integrate services through a blended funds approach.

| MHA directors, unlike their Medicaid counterparts, do not ordinarily think in terms of

per capita spending, because they are never certain either about the size of the benefi-

ciary pool, or what percent of eligibles actually utilize services — but these are

precisely the types of analyses necessary for developing actuarially sound rates.

76 PARTNERS OR ANTAGONISTS

Covered Services

In a public sector managed care initiative, the issue of which services are to be included |

in the benefit is obviously a critical design decision, one which presents opportunities |

for interagency collaboration or conflict. If in their respective approaches to covered |

populations, Medicaid’s mission has been relatively expansionary and the MHA’s more :

restrictive, the opposite seems to have been true regarding mental health benefits. MHA

directors have led efforts to expand the scope of services and the continuum of care for |

persons with serious mental illness. Unlike their Medicaid colleagues, MHA directors |

have not historically thought in terms of limiting benefits. Rather, they have been actively

involved in creating new service models and expanding the community-based continuum. |

The concept of ‘wraparound’ services perhaps best exemplifies the MHA approach:

providers are encouraged to work directly with consumers, to be creative and flexible

— to use services not traditionally considered mental health if necessary. The emphasis

is on doing whatever it takes to meet the needs of the client. |

As a national insurance program, Medicaid is required to take a more conservative |

approach to covered services, and is based largely upon a medical model. Indeed, one

of the chief and explicitly stated goals of Medicaid managed mental health care initia-

tives to date has been to bring greater flexibility to the use of Medicaid funds by expanding

the range of covered services. Title XIX mandates a standard benefit, after which states

have considerable leeway over final benefit design. Mandatory Medicaid mental health

benefits include standard inpatient' and outpatient services for adults, and a somewhat

broader range of EPSDT (Early Periodic Screening, Detection and Treatment) services

for children. States vary in their use of optional benefits, which may include targeted

case management, clinic, and rehabilitation services. In states with a broad Medicaid

mental health benefit, the optional services have been added to the state Medicaid Plan

in the last decade, typically as part of an interagency revenue maximization initiative.

One of the main challenges regarding managed care design facing both MHA and

Medicaid managers lies in clarifying responsibility for managing and financing a

comprehensive benefit package. Medicaid is more likely than the MHA to express

concerns about the inappropriate use of its funds to pay for services that do not fit strict

definitions of medical necessity. In one state, an explicit objective of the managed care

initiative is to curb the excessive use of residential treatment for adolescents for social

(i.e., protective) rather than for clinical reasons. Medicaid, the state purchaser, wants

managed care organizations to develop step-down alternatives to residential care.

Besides ‘inappropriate’ use of the Medicaid benefit, there are other related and non-medical

services needed to complete the continuum. In designing comprehensive services for

' Mandatory Medicaid inpatient benefits do not include services rendered in so-called Institutions for

Mental Diseases (IMD), i.e., hospitals in which over 50% of the residents are mental health consumers.

IMD services are an optional benefit for children and adolescents under the age of 21.

PARTNERS OR ANTAGONISTS V1

persons with serious mental illness, MHA directors have recognized the necessity of

providing housing supports, employment training, and other non-clinical services. While

_ there may be consensus between the MHA and Medicaid as to the value and necessity

of these non-medical services, there often are questions about service definition as well

_as funding responsibility.

The different properties of the Medicaid covered services can also be a complicating

factor for interagency relations regarding managed care design. Medicaid has two types

of covered services: the basic or mandatory services which cover acute needs, and the

additional, more comprehensive optional services, which generally target continuing or

long term care. The former are funded completely out of the Medicaid budget; the latter,

however, are not and states often use the MHA budget to supply the state matching funds,

while the single state Medicaid agency draws down the Federal financial participation

(FFP). In states where Medicaid has taken the lead in developing a statewide carve out

i program, the basic benefit has included only the mandatory Medicaid services; manage-

ment of the continuing care benefit has remained the province of the state or county MHA.

The challenge for both agencies in this design thus becomes one of coordinating benefits

to make the system as seamless as possible. One state placed all Medicaid and MHA

services (including the state hospital) under the benefit to be administered by a single,

statewide managed care organization, thereby hoping to avoid the potential vicissitudes

involved with benefit coordination across agencies — the managed care organization is

the single, accountable entity responsible for both acute and continuing care benefits.

| Network Providers

Except in those states where the provider network is predominantly state- or county-

operated, both Medicaid and the MHA tend to have separate contracts or agreements with

many of the same community-based direct services providers. The nature of their

| provider relationships are quite different, however. Where the MHA tends to buy whole

|| programs, often on a cost reimbursement basis, Medicaid pays for services as needed,

exclusively on a fee-for-service basis. The MHA approach is generally to make estimates

of needed service capacity and to then purchase accordingly, while Medicaid typically

allows the participation of any and all interested providers, as long as they demonstrate

the ability to meet regulatory requirements and/or credentialing standards. Thus the MHA

may, for example, cover the fixed costs associated with maintaining 24-hour emergency

response services (and thereby purchase “excess” capacity), while Medicaid will act as

-amarginal payer, reimbursing only for services rendered.

Perhaps the most important difference between these co-financers of the public mental

health system lies in their attitude toward providers. The MHA tends to view commu-

nity-based provider organizations as extensions of themselves; their missions are

congruent, and the MHA is usually the dominant customer. Senior MHA managers often

78 PARTNERS OR ANTAGONISTS

have been providers themselves, adding to the affinity between these entities. While MHA

directors may feel that they have developed and nurtured the provider system in their

own image, Medicaid’s provider relationships, including those with its mental health

providers, have been more formal, business-like, at arms length. Medicaid directors are

less concerned about the consequences of using a free market approach when they control

the managed care design, perhaps, in part, because they do not view the provider system

as their own.

The issue of free market versus protectionism relative to the ‘traditional provider’

is undoubtedly one of the more contentious areas of debate in the era of managed care.

Political fault lines are readily observable when a for-profit managed care company is

thrown into the mix. In its extreme forms, the rhetoric is characterized as pitting greedy

corporate executives lacking experience with adults with serious mental illness or children

with serious emotional disturbance versus committed, altruistic, clinically superior

providers (the provider/advocate perspective) — or as pitting efficient, quality-oriented

data-driven managers versus well meaning but inefficient, technologically-challenged,

politically entrenched monopolists (the for-profit managed care organization perspec-

tive). Conflict is not inevitable; there are many creative compromises available in terms

of network development. In some states, for example, equity partnerships between tradi-

tional providers and a private, for-profit managed behavioral health care organization

are seen as a vehicle for improving network efficiency while maintaining continuity of

mission. The point is that the MHA tends to experience a strong pull to advocate for partner-

ship with the community-based provider industry, while the Medicaid agency usually

does not. To the extent that providers are well organized politically and are perceived to

be competent and to hold the high ground as consumer advocates, they can become a

significant ally for the MHA. Policy makers in one state credit the support of the providers,

as well as consumers and advocates, for swaying the administration away from the original

Medicaid-sponsored carve-in design toward the MHA-proposed carve-out.

Quality Management and Approach to Customer Service

In theory, quality management represents an area of systems administration that may

afford Medicaid and the MHA some of the best opportunities for collaboration: all parties

can agree that improving quality is an important and worthwhile goal. The two agencies

have somewhat complimentary strengths in their approaches to quality. As with network

providers, it is safe to say that the MHA has historically been closer to the ultimate

customer of the public mental health system, the consumer of services. As a provider

and a systems manager, the MHA has had more direct experience meeting the needs of

its clients than has Medicaid, the insurance organization. The nascent consumer empow-

erment movement has been consistently supported by MHA directors across the country,

many of whom have established offices of consumer affairs within the office of the director.

PARTNERS OR ANTAGONISTS IW

In recent years, the concept of involving consumers, not only in their own treatment

| planning and delivery, but also in systems design and governance, has gained wider accep-

| tance. Even where Medicaid and MHA relations have been strained, Medicaid has accepted

| the wisdom of emphasizing consumer rights, grievance and appeals processes, and

| consumer participation in policy development as part of its procurement specifications.

Medicaid’s approach to quality management, consistent with trends in the managed

| care industry, has been to establish systems for measuring and monitoring plan perfor-

| mance. Medicaid directors have displayed leadership at the national level through their

_ work with NCQA to adapt HEDIS (Health Plan Employer Data and Information Set)

for their covered populations. MHA directors have also been eager to support the emphasis

| on creating meaningful, manageable, data-driven performance indicators, working with

| the Federal government in the creation of the Mental Health Statistics Improvement

Program’s (MHSIP) Consumer-Oriented Report Card. Both agencies share a common

desire to institute provider profiling on a regular basis, although neither has yet demon-

| strated the technical capacity to implement such systems. Medicaid was the first to point

out the advantages of procuring private sector technological capabilities in the service

_ of quality management; the MHAs, although at times skeptical as to the merit of marketing

claims by managed care organizations regarding their capabilities, have largely agreed.

Other Considerations: Structure and ‘Turf’

| There are several other factors unrelated to history, mission or operating style that

appear to have an impact on interagency relations. These include the place of each agency

within the governmental structure; the history of working relationships between

agencies; and the ambitions, credibility, and public management skills of the agency head.

Surprisingly, it is difficult to discern any trends with respect to where each agency is

housed in the administration. For example, in some states, the two agencies have histor-

ically been in different cabinet level Departments. Such separation may create a distance

that makes interagency dialogue more difficult, and interferes with coordinated policy

making. By the same token, considerable tension can occur in managed mental health

Care initiatives, even when both organizations are housed within the same Secretariat.

Yet, a history of solid interagency working relationships does not, as one might suppose,

automatically lead to collaboration on specific managed care initiatives. In some states,

good long-term relations coupled with the intimacy of a small state government, have

facilitated that state’s blended funds approach; in others, however, good working

| relationships at the staff level ultimately proved powerless against strong differences in

ep ru a

vision and style between agency heads.

The permutations associated with locally-based MHAs, specifically the balance of

power and responsibility between the state and local- and county-level MHAs, is yet

another complicating factor in terms of designing and implementing a managed care

80 PARTNERS OR ANTAGONISTS

initiative. From the Medicaid perspective, it is logistically easier to deal with a single _

agency than with multiple governmental organizations, particularly when the task is one }

of clarifying complex management and financing roles and responsibilities. In states with |

a strong tradition of county government, the local MHA is a major funding source, and _|

thus a key player in the administration of the public mental health system. In one state, |

tensions between the state and county MHAs led to a scaling back from the original, |

ambitious plan to expand coverage and blend all funding streams on a regional level |

through competitively procured, at-risk managed behavioral health care organizations, |

to a more modest proposal to hire a single organization to manage the acute Medicaid |

benefit on an administrative services only basis. The state’s Medicaid agency was relieved |

to be able to delegate governance responsibility to the state MHA. Medicaid concerns |

regarding MHA systems management capabilities are also exacerbated when dealing |

with an array of county administrations that vary in size, population density, culture and —

systems capacity. Economies of scale for supporting a managed care infrastructure are |

an issue, particularly for smaller counties: multi-million dollar investments in manage-

ment information systems development and staff training, for example, are less attrac-

tive when they spread over revenues generated by smaller risk pools. Finally, there are

legitimate questions as to whether counties can or should bear financial/insurance risk,

and thus a number of states have encouraged (or insisted upon) partnerships with private

for-profit or not-for-profit managed behavioral health care organizations.

History and structure may determine the context in which individual public sector

managers operate, but the agendas and leadership skills which they bring to bear seem

to be the most important factors in determining interagency dynamics, that is, whether

Medicaid or the MHA will assume a dominant role, or whether they will act as equal

partners. During the initial planning process for the carve-out initiative, one state’s MHA

offered to serve as the managed care entity itself, and expressed an interest in assuming

financial risk for the Medicaid premium. The Medicaid agency declined the offer because:

(a) they believed that a private company would be less subject to political pressures in

the course of system reform and network reduction, and (b) they did not have confi-

dence in the MHA’s administrative systems. In the face of a budget crisis, the Medicaid

director was able effectively to enlist support for the Medicaid proposal from both polit-

ical parties, as well as from the community-based providers. The Medicaid agency thus

assumed control of the managed care planning and implementation process. Since then,

both agencies have recognized the value of partnership, and staff from both have made

great efforts at collaboration, significantly improving interagency dynamics. In the second

generation of the program, the MHA has contributed financially to the program, and

has (re)gained an expanded policy role.

In another state, which has enjoyed a history of good working relationships at the

senior staff level, a planning process for joint, cooperative purchase of managed care

services under a carve-out model was replaced in favor of the current carve-in plan. This

PARTNERS OR ANTAGONISTS 81

change was implemented by a new Department Secretary responsible for administra-

| tion of the Medicaid program. A former HMO executive and a forceful proponent of

integrating primary and mental health care, he was successful in winning the confidence

of the key decision maker — the popular Republican Governor. A swift, well executed

‘campaign carried the new design over the belated protests of providers and the

Democratic legislature, while the MHA was caught in the middle.

A skilled and credible public sector manager can have a significant impact on the

| relationship between the MHA and the Medicaid agency. In one case, the MHA director

| mobilized key constituents to support the MHA in its efforts to retain control of an admin-

| istrative services only carve-out design. The design debate covered the usual advantages

| of integration versus specialty care, with Medicaid urging coordination of primary and

| mental health care and the MHA emphasizing the unique skills and experience of the

| existing community-based system. Ultimately, the Governor was convinced that the MHA

had the vision and competence to successfully administer the program. In the ensuing

| carve-out, Medicaid funds are run through the MHA, which administers an adminis-

trative services only contract with the managed behavioral health care organization.

| Considerations for Public Managers

| Whether they like it or not, Medicaid and the MHA are partners; together they share

responsibility for the well being of vulnerable populations. As states look to managed care

| programs to improve their public mental health care systems, the challenge facing both

, Medicaid and the MHA is to find ways to overcome historic differences and develop new

_ methods of collaborative governance and systems administration. These agencies have made

significant investments of both financial and intellectual capital in the public mental health

system. Despite differences in emphasis and operating styles, they ultimately share a common

mission. They both seek to create systems of care that are less reliant on inpatient services

and place greater emphasis on primary and preventive services. They both seek to create

rational management structures supported by a solid informational infrastructure. Finally,

| they both seek to make the best use of limited public resources. To achieve these mutual

goals, public managers may consider the following steps:

Develop structures and processes to support ongoing interagency dialogue.

Regular communication is an obvious and critical element for effective collaboration.

-Managers must determine the formal agendas and frequency of interagency meetings

at both senior and middle management levels.

Identify priority areas for systems improvement. A collaborative, systematic

review of all functional areas should probably be the first agenda item for interagency

discussion. Managers will want to assess current eligibility criteria and member services;

covered benefits; the status of the provider network and network management procedures,

including gaps and areas of duplication; utilization review and management procedures;

—

82 PARTNERS OR ANTAGONISTS

quality management processes; management information systems and reporting capabil-

ities; and system financing. Such a review should be comprehensive and should incor-

porate the activities of both agencies.

Identify strengths, weaknesses, and areas of competence, for each agency. In

addition to identifying the highest priority goals for systems-level reform and improve-

ment, the interagency review should also explore the core competencies of each agency.

The goal is to work as a team, building upon current capacity and taking advantage of

complimentary strengths.

Develop an interagency action plan. The end product of interagency review activ-

ities should be a jointly published vision for system reform, including priority goals and

the steps necessary to achieve them. It is important to clarify the roles and responsibil-

ities to be assumed by each agency, particularly the manner in which they are to manage

and facilitate the participation of key stakeholders.

Develop meaningful, manageable measures of systems-level performance. Any

plan of action that results from an in-depth interagency systems review must include

systems-level (as opposed to individual client- or provider-level) performance indica-

tors. A major challenge for the agencies will be to come to agreement on how to measure

success.

The use of public funds to purchase managed care programs for consumers of mental

health services is a relatively new phenomenon. Responding to varying histories and

arrangements regarding Medicaid and MHA funding and functioning, different states

have launched a series of unique experiments. A number of important issues are still

being actively debated: which populations can or should be managed under the same

plan; whether use of a specialty mental health benefits management (carve-out) organi-

zation is preferable to an integrated approach; what is the legitimate role of the profit

motive in the management and delivery of services. In an environment that has height-

ened expectations for accountability and cost control, state policy makers are particu-

larly challenged to coordinate and optimize the use of limited resources. Although we

currently lack empirical evidence, we suspect that interagency antagonism results in less

than optimal service system quality and efficiency and that interagency collaboration is

critical to successful system reform.

References

Oss, M. (1995). Trends in mental health financing. Open Minds - April 1995. Gettysburg PA: Behavioral Health

Industry News, Inc.

' Journal of the Washington Academy of Sciences,

Volume 85, Number 1, 83-99, December 1998

Public Sector Purchasing of Managed

Behavioral Health Care

Colette Croze, John Allen, Tom Barrett, Ron Copeland, Robert Egnew,

Marilyn J. Henderson, Ronald W. Manderscheid, Candace Nardini,

Eleanor Owen, Darby Penney, Laura Van Tosh, Ivan Walks

The Current Governmental Environment

As is true for all governmental functions, publicly-sponsored mental health services

| are experiencing transition and transformation as state and local public officials re-examine

_ the role of government and its responsibility for vulnerable populations and human

services. Additionally, as government continuously attempts to balance its priorities across

_ health care, education, corrections and tax relief, cost control and containment take center

stage as considerations underlying policy decisions. In the absence of Congressional action

- on national health care, both the commercial sector and public payers are demanding

significant changes in providers’ attention to quality and cost. Increasingly, public payers

are adopting commercial strategies for managing limited resources in health and human

service systems care and sharing financial risk' with private enterprise.

Whether in response to Medicaid reform, or as a continuation of service improve-

ment efforts, a growing number of public mental health systems have been dramatically

affected by states’ initiation of managed care, particularly where the single state

Medicaid agency played a major role. Funding methods, eligibility requirements,

benefit packages, and management structures have frequently all been modified as

Medicaid agencies moved to purchase coverage for beneficiaries through managed care

plans. Public systems have also been re-shaped as previously-funded not-for-profit

providers either assumed significantly expanded or reduced public sector roles or devel-

oped new forms of public/private partnerships to gain competitive advantage in changing

public markets.

Even more significant than the incorporation of managed care strategies into public

mental health systems is the use of risk sharing arrangements between government and

private organizations which allow government to transfer to or share financial risk with

' While there are various forms of risk contracts, they share the characteristic that contractors under these

arrangements receive predetermined, advance payments that cover either a specific benefit package for a

group of beneficiaries or a negotiated set of management functions.

84 PUBLIC SECTOR PURCHASING

managed care organizations. While early forms of care management were overlaid on

reimbursement-based (fee-for-service) financing systems, current strategies for managing

care and costs attempt simultaneously to rationalize clinical practice and create finan-

cial incentives for care managers and providers to offer only the services that are neces-

sary to restore or improve health status.

Pressures for Public System Action

The current wave of public sector managed mental health care initiatives follows

on the heels of both state- based health care reform and Medicaid cost containment.

Many states are still enacting legislation making broad-based changes in both public

and private health insurance systems; the public mental health system is often swept

along with the reform tide towards risk-based managed care. Several Governors have

been forced to make wide-sweeping and precipitous changes in their public health and

mental health systems in response to serious and sometimes sudden funding problems.

Medicaid has aggressively embraced commercial models of risk and care management

for its beneficiaries and gives every indication of continuing this trend. Through these

arrangements, Medicaid can predict and control its future financial liability by sharing

or transferring financial risk to health plans. Numerous state mental health agencies

(MHAs) have had to consider risk-based managed care in order to follow Medicaid’s

lead in adopting more insurance-like purchasing strategies. When one strong state-based

purchaser is so clear about future directions, other components of state government must

often follow along. Like Medicaid, the state MHA has experienced fiscal pressures that

have driven it to new financing methods and risk arrangements; and, in response to actions

by their state’s Medicaid agency, several state MHAs have been forced to move to risk-

based contracting to slow the rate of growth in Medicaid spending for mental health

services or to counteract the effect of other policy decisions, such as deregulation of

hospital-based services. There are other reasons for change: some states, like Ohio, have

developed their managed behavioral health plans as system improvement initiatives and

public stakeholders have often pushed for system reform through managed care efforts.

There is also renewed interest in privatization of government functions. With public

opinion solidly in support of less, not more, government, many states and counties are

feverishly streamlining through reorganization and “right-sizing.”’ Often these efforts

result in downsizing and shifting of government responsibilities to private sector

auspices. Moving to risk-based managed care offers government one more opportunity

to transfer responsibilities to the private sector. The public mental health system’s conver-

sion is often just a small piece of states’ and counties’ larger efforts to divest themselves

of various health care and human services functions. Privatization of child welfare

services, privately-operated correctional facilities and provision of prison mental health

PUBLIC SECTOR PURCHASING 85

| services by managed behavioral health care organizations — all are examples of govern-

| ment’s efforts to outsource functions that were previously governmental responsibili-

| ties. In current outsourcing efforts, today’s government contractor is as likely to be for-

| profit as tax-exempt.

The final external source of pressure for risk-based managed mental health care comes

from the managed behavioral health care organizations themselves. With more than one

| hundred sixty million insured Americans enrolled, understanding that they have

saturated the commercial market, these firms are aggressively pursuing public sector

| business. Managed care organizations and other for-profit industries (for example, enter-

| prises like Lockheed that once thrived on defense contracts) are now very interested in

| the public sector and often create political pressure to promote further privatization.

There are also fiscal and programmatic reasons internal to public mental health

systems that make prepaid, risk-based financing an attractive alternative to current

‘methods. When the public mental health system itself has advocated for the move to

managed care, the primary reason has been the desire for more flexible funding in support

_of community-based, recovery-oriented services and supports. Prepaid arrangements

allow the payer to control its financial risk and reinforce accountability while it offers

the purchaser/care manager broad clinical flexibility. With financial liabilities controlled

and with attention paid to performance standards and outcomes, public payers can transi-

tion from fee-for-service Medicaid with its often rigid categories of services and

| reimbursement methods. Paying for coverage of beneficiaries through mental health plans

| also provides the MHA the opportunity to finance systems of care, rather than individual

| providers or services. If risk arrangements are structured correctly and, if the public

| | payer shifts from “monitoring” to rewarding and sanctioning performance, prepaid

| managed mental health plans can create incentives for outcome-producing, consumer-

sensitive services. With capitated plans and with at least intermediate-length contracts,

the MHA can proactively arrange the interventions and systems of care for plan members;

| | it can begin to turn providers’ attention to relapse prevention, recovery and well-being

as outcomes for public consumers.

A thoughtful assessment of risks and opportunities should occur before the MHA

embraces or rejects managed care. This does not refer to the financial risk analysis

conducted by actuaries, but rather, the risk associated with either changing the public

system or supporting the status quo. Although the status quo may seem comfortable,

_ there are almost always improvements to be made in public systems, and risk-based

' managed care can facilitate some or many of those changes. Grant-based or fee-for-

_ service reimbursement does not establish responsibility for a population of enrollees,

nor facilitate either the development of systems of care or prevention-oriented inter-

ventions. Absent clear accountability for an identified group of beneficiaries, systems

can neither manage care nor produce long-term positive results. Public MHAs may be

/ seen as being captives of their constituencies and shirking their public stewardship respon-

86 PUBLIC SECTOR PURCHASING

sibilities if they refuse to move assertively into the future. Credibility could be lost by

the public mental health system if it is seen as resisting system re-engineering in the face

of needed revisions.

On the other hand, all the current rules of the game change with the initiation of

managed mental health care. Risk transfer signals problems for not-for-profit public

community MHAs who have operated in government-regulated environments with signif-

icant financial and programmatic constraints not felt by for-profit organizations.

Providers will often resist the move to risk-based managed care because of the finan-

cial pressures it places on their organizations (e.g., solvency requirements, risk reserves,

etc.) and the increased management demands it creates. Other stakeholders are often

wary of the value of abandoning a known public mental health system for the potential,

but uncertain, benefits of new financing arrangements that will most certainly change

clinical practice. Public MHAs are often ambivalent about large-scale system change

and may feel that they do not need to fix something that is not broken. In either case,

the MHA must carefully consider the choices and consequences of either reinventing

or reinforcing its existing public system of care.

Considerations for Public Sector Decision Makers

As public systems consider a move to risk-based managed behavioral health care,

they would be wise to formally assess the risks and opportunities presented by such a

venture. The following questions could guide such an assessment:

How does this state or local government define the “public interest” ? What is govern-

ment’s role within its definition of the public interest?

Each state and local governmental must define for itself the public interest as it relates

to behavioral health services, government’s provision of those services, and the roles of

the public and private sector in the delivery of care. A public mental health payer devel-

oping its blueprint for managed care should use its system’s definition of the public interest

to frame its policy choices. These policy choices should guide decisions about what roles

and responsibilities government retains, what functions it privatizes, and how it struc-

tures the relationship between governance, management, and service delivery.

What is the political climate of the state or local government? Are elected officials

for or against changes in governmental operations? Is there positive or negative

sentiment towards government “right-sizing” or “downsizing”? Are other parts

of state or local government considering, planning or implementing risk-based

managed care contracting ?

In public mental health systems where elected officials believe that government's

presence in direct operations should decrease, the MHA may need to consider a struc-

tural model in which some or most managed care functions are privatized. Conversely,

PUBLIC SECTOR PURCHASING 87

if public sentiment supports more government, the MHA might retain a stronger role,

especially if it positively assesses its ability to carry out those roles competently. Likewise,

when other parts of state or local government have set some precedents for adoption of

managed care technologies, the MHA may need to adjust its approaches so that they

_are compatible with those public payers’ techniques.

What is the current assessment of the “state of affairs” in the public mental health

system? Good, bad or something in between? Is there need for system change and/or

improvement in the system and its services?

| Public mental health systems should conduct an honest evaluation of their system’s

| functioning and capacities as they consider a move to managed care. At this stage in

system assessment, recipients’ input is critically important. With accurate information

| on system performance, MHAs can maximize the potential positive results of risk-based

| managed care by incorporating specific quality improvement goals into their managed

| care plans and by operationalizing those goals through the functional and structural design

| choices they make.

i What is the basis for the problems in the public system? How might they be addressed

through at-risk managed care? What are the system’s existing strengths? How can

they be enhanced? Can risk-based managed care reinforce the good points (and

accelerate their system-wide adoption) while it addresses sometimes long-standing

and intractable problems?

Having identified the nature and scope of the problems in its system, the MHA should

| tailor its structural design, assignment of functions, and purchasing specifications to

|) address these problems. For example, an MHA that determined that hospitalization was

| being over-utilized could structure its risk sharing arrangements to incentivize commu-

|) nity alternatives. Similarly, an MHA that assessed its existing contractors (either

|| governmental or not-for-profit) as being unable to assume a robust level of risk transfer,

| might phase in risk sharing over time by moving from performance risk to underwriting

) tisk? Alternatively, the MHA might encourage partnerships between its provider commu-

nity and “managed care competent” managed behavioral health care organizations.

What are the advantages of moving to risk-based managed care contracting? What

are the disadvantages?

| Incorporation of entirely new financial and clinical risk management approaches

\ will necessarily create significant movement in a public mental health system; this

| movement may be required in order to develop recipient-responsive, outcome-oriented

| services. The MHA must balance the need for change against the potential impacts of

| that change as it develops a managed mental health care plan.

? Contracts that transfer underwriting risk require the vendor to insure the beneficiaries whose care it

| manages by covering the costs for all medically necessary services, performance risk contracts hold the

| vendor financially liable for its performance, but not for all costs of services.

88 PUBLIC SECTOR PURCHASING

What relationship will be structured among various funding streams? How will

public insurance programs (1.e., Medicaid) interact with safety net services?

Although most public payers do not develop a seamless plan for Medicaid and “non-

Medicaid” funding, some attention should be given to the interaction among Medicaid, |

state general revenue and local funding since they purchase different components of

the public mental health system. Because service recipients’ Medicaid eligibility

changes over time and non-Medicaid funds pays for services for Medicaid recipients,

a coordinated plan for the use of public behavioral health funds could facilitate conti-

nuity of care and improved outcomes for service recipients.

What are the risks associated with moving in this direction? Will providers revolt?

Will consumers and families be apprehensive? What are the risks associated with

no movement? Will Medicaid make the decisions ? Will the public MHA lose credi-

bility with inaction?

The risks accompanying either action or inaction must be strategically evaluated.

While the MHA may lose significant political support, for example, by implementing

managed care against its providers’ wishes, it may also risk diminished power within

government if it resists an inevitable move toward privatization through managed care.

There are more than a few states in which inaction on the State MHA’s part provided

the State Medicaid agency with the opportunity to assume control of mental health policy

decisions.

Does the public MHA have the authority, responsibility and skills to undertake this

level of system change? If it does not, how can it acquire them?

Development and implementation of a public sector managed behavioral health care

plan is more than a notion; it requires both strong technical skills and knowledge as

well as a savvy political strategy and a targeted approach to issues management.

Construction of the benefit package, articulation of quality management requirements,

selection of risk sharing arrangements that support specific clinical and financial objec-

tives, competitive procurement and negotiation of multi-million dollar contracts—these

are new activities for MHAs. The challenge of competently performing these functions

should not be taken lightly. Public MHAs need to assure that staff who are asked to

assume these challenges have the ability and technical support to become “smart buyers”

of public sector “goods and services.”

What is the lay of the land/division of labor between either the state and counties

or the state and not-for-profit providers? How politically powerful are the not-for-

profit community MHAs? What political strategies will facilitate systems change?

Public MHAs should never underestimate the system’s resistance to change as it

attempts to maintain the best components of its old public system and provide new oppor-

tunities for incorporation of more effective clinical care and financial management. The

MHA must conduct an environmental scan of the political forces as it simultaneously

PUBLIC SECTOR PURCHASING 89

crafts productive, successful roles for its traditional providers and systems managers.

Implementation of public sector managed care must be treated as both a quality

_ improvement effort and a political campaign.

|. Participants in Policy Deliberations and Decision Making

Public mental health systems have an increasingly strong history of offering stake-

_ holders broad opportunities to comment on and influence policy and budgetary direc-

| tions. As public systems define them, stakeholders include service recipients, families,

| advocates and providers as well. Less frequently do MHAs actively incorporate

|| taxpayers, governmental colleagues and “non-mental health” community institutions in

| their planning. Nevertheless, broad-based input has been the norm rather than the excep-

| tion in public mental health for the last ten years.

When public bodies like state and local MHAs make policy and budget decisions,

stakeholders expect to play an active part and to be integrally involved in all aspects of

_ benefit and structural design. While broad-based input is critically important, a distinc-

| tion must be made between participating in policy deliberations and participating in the

_ decision-making process itself. The two are not interchangeable, although each is often

_ mistaken for the other in public mental health policy development. Public MHAs need

— to solicit opinion on managed mental health care design broadly and widely, with over-

| representation of consumers and families of minor children, but then they may need to

_ work within an entirely different policy environment in negotiating the design decisions.

In the development of managed mental health programs, the MHA does not always

control the process or the decision-making. For example, while the MHA may have lead

design responsibility, it may not have final decision-making authority; the designers, then

may not be the decision-makers. To be fair to stakeholders, the MHA needs to make

this clear so that everyone understands that the MHA may be required to move between

a very open “design process” and a more narrowly constrained “‘decision-making process”

in which it negotiates, not makes, the final decisions. It may be that the state Medicaid

agency, the Governor’s Office or a legislative appropriations committee has final

decision-making authority. A delicate balance must be struck between encouraging broad

Stakeholder input and making that input meaningful. The MHA must inform its

constituencies about which issues it is managing and which decisions will be made in

another part of the executive or legislative branch of government so that stakeholder input

_ can also occur there.

To date, one of the major areas of contention in managed mental health care devel-

|| opment has been the division of labor and power between the State Medicaid agency

| and the State MHA. In numerous states, the Medicaid agency has chosen the mental

health benefit design, sometimes without any input from the MHA. In a few states, the

90 PUBLIC SECTOR PURCHASING

MHA has taken the lead on benefit design and in a few more states there has been collab-

orative development of the managed mental health care initiative. Oftentimes, the degree

of unanimity or dissension within the mental health community has determined whether

the State MHA or the Medicaid agency was the final arbiter of public policy on managed

mental health care design.

Impact of the Decision to Initiate Risk-Based Managed Care

In states where either the Medicaid agency or the State MHA has decided to embark

on the path to managed mental health care, a series of activities surround this decision.

First, a political strategy must be chosen to complement the technical plan for managed |

care; something akin to a political campaign is often required to move an agenda of system |

change forward. Assuming that the public payer has settled on its benefit design (including |

a quantifiable description of beneficiaries, definition of the benefit package or service array,

and identification of funds to support both), it must also make choices on structural design: |

who will perform which functions in a managed mental health care system? Choices on

structural design are typically based on the public mental health system’s specific managed |

care objectives as well as on its identification of the required care management capacities |

and an evaluation as to where the MHA can find those capacities.

There are three fundamental roles within health care benefits administration and

management: the payer or sponsor who administers a mental health benefit and pays

someone to manage that benefit; the purchaser or care manager who manages care and

purchases individual, discrete services on behalf of beneficiaries; and providers who deliver

the clinical care. After deciding who the beneficiaries are and what the benefit package

will be, the MHA must then decide which types of organizations will perform each of |

the three fundamental roles. The MHA is always the payer or sponsor and public providers |

will almost always form the clinical core of any managed system of care. The role which

is most hotly contested in public mental health care is that of the purchaser or care manager. |

Although State Medicaid agencies typically use commercial models for care |

management and contract with HMOs or integrated delivery systems, MHAs usually

spend considerable time choosing the “structural” model for their managed systems of é

care. This is not surprising, given the public system’s history of creating and nurturing |

mental health-specific infrastructures, usually by delegating authority to local govern- |

ment or by granting operating franchises to not-for-profit community mental health |

agencies. Deciding which types of organizations will be eligible to act as the care manage- |

ment entity sets the future course for many components of the public mental health system

and dramatically changes the roles of the MHA and its traditional providers.

Most states have invested considerable resources in either county- or not-for-profit-

based administrative systems and most MHAs begin their managed care planning by |

——

—

PUBLIC SECTOR PURCHASING 91

assessing the possibility of using these structures as care management entities.’ States

also carefully consider the possible conflict of interest between care management and

service provision and have sometimes prohibited organizations that provide treatment

from also assuming the care manager role. While this decision may provide some level

of consumer protection and increase consumer choices, it also means that traditional

community mental health providers will not be able to perform care management roles.

This is an important decision since MHAs are particularly concerned about the future

role of their not-for-profit community mental health partners in an at-risk environment.

Most states still fund community providers through deficit-financing or grant-based

‘contracts. Even when “performance contracts” are used, performance is rarely tied to

financial rewards or penalties. Traditional public providers, then, have had no experi-

ence in managing financial risk and have generally been able to manage clinical risk

through waiting lists, ceasing services when grant funds have been exhausted, and

appealing to the state or county for additional funding. With the marriage of managed

care and risk-based contracting, financial and clinical objectives are aligned as the care

manager is placed at risk for the delivery of “the right treatment to the right person at

the right time.” In a capitated arrangement, the vendor receives a prepaid premium for

every person who is enrolled in its plan, regardless of that person’s need for or receipt

of service. With prepayment and responsibility to provide a medically necessary benefit

for an identified group of “covered lives,” the care management entity holds clinical and

financial risk for the delivery of services. While many public system providers believe

ithey have been managing care for quite some time, in reality they have been managing

global budgets, rarely managing costs, and almost never managing care consistent with

industry standards for mental health. These providers must re-engineer their operations

| in order to assume risk in managed systems of care.

| Choosing an Internal or External Agent for Risk-based Care Management

| Once the MHA has identified the functions to be performed by the purchaser or care

/ manager, it must decide where to locate these functions. There are two basic choices:

fe assume the care management role itself or to outsource the functions through either

| sole source arrangements or competitive procurement.* Sole source contracts could be

| *Many MHAs have used the term “care management entity” or “managed care entity” to convey a possibly

» broader definition of these organizations than that implied by the use of the term “managed care organi-

Zation” which is usually associated with the traditional staff model HMO or a managed behavioral health

Care organization.

*TIn sole source arrangements, the MHA identifies the specific organization with which it wishes to contract

without accepting competing applications or bids for award. Competitive procurements are structured to

allow “open and fair competition” from a variety of applicants or bidders.

92 PUBLIC SECTOR PURCHASING

entered into with either existing players or with newly-created organizations whose sole

purpose is often public sector mental health care management. Competitive procure-

ments can be structured to allow all types of qualified organizations to bid, or can restrict

eligibility to only certain types of organizations, e.g., not-for-profit entities. |

There are also several methods for managing risk and for performing care manage-

ment functions. Public payers can transfer all insurance (or underwriting) risk to managed |

care entities through fully capitated arrangements; or they can share underwriting risk |

through either less than full capitation or the use of stop/loss and reinsurance mecha- |

nisms.’ State or local government can contract for administrative services only (ASO) |

through contracts that share performance risk, but not insurance risk. Under these arrange- |

ments, a managed behavioral health care organization would typically process and pay |

claims, authorize care, credential providers, and provide data on system performance, :

but would not bear insurance risk for the enrolled population. Public MHAs can also |

“unbundle” the care management functions, contract for only a portion of them, and |

perform others themselves; these contracts are typically more like “pre-managed care” |

management contracts than managed care organization contracts.

The basic distinction in procurement methods appears to relate to the pre-managed |

care division of labor between the state and either local government or not-for-profit |

mental health organizations. Most often this choice is influenced by the statutory |

mandates governing public mental health administration, the payer’s satisfaction with |

the status quo and the preferences expressed by the state Medicaid agency as the other

public mental health plan administrator. In states where local government has a |

specific and mandated role in system administration, counties and municipalities are |

most often given preferential treatment in managed mental health care procurements. |

When a state has relied on local government as its administrative agent, it typically |

grants those agents either the “right of first opportunity” to compete for the contract,

the “right of first refusal” to accept the care management role, or affords those agents

special status in the application or bidding process. In procurements where counties |

have been afforded the “right of first opportunity,” they are required to submit appli- |

cations to demonstrate their ability to perform the managed care functions (commonly

called “show qualifications”). When states use the “right of first refusal” approach, the

county needs only notify the state that it is ready to assume the care management respon- |

sibilities; once the county expresses readiness, no other bidders are considered. |

Likewise, when not-for-profit community mental health agencies have statutorily- |

mandated status as preferred providers, they may expect to enjoy special considera-

tion in a state’s managed care design. However, with one exception, all states who consider |

° Stop/loss and reinsurance are two methods for limiting the managed behavioral health care organiza- 4

tion’s risk. In the first, there is a dollar limit established for the organization’s financial liability at either |

the individual consumer or aggregate level. In the second method, an organization would purchase insur- |

ance to “reinsure” itself against catastrophic care and service expenditures. |

PUBLIC SECTOR PURCHASING 93

community mental health organizations their local agents have used a competitive process

for choosing the care management entity.

In choosing the preferred organizational type to perform the care management

function, states have generally taken one of two approaches: either they have built on

_ the public system’s pre-existing infrastructure or they have departed radically from the

past and contracted with entirely new organizations. Of the programs currently opera-

tional, seven states have used the first method, five have proceeded with new organi-

zations, and two are using either a combination of new and old organizations or new

types of organizations that are hybrids of managed behavioral health care organizations

and community mental health agencies. Public MHAs also have a policy decision to

make in specifying which types of non-governmental organizations are and are not eligible

_ bidders in these procurements. They can “privatize’’ care management through for-profit

managed behavioral health care organizations or they can require or allow not-for-profit

| mental health agencies to perform these functions; to date, only Arizona has excluded

} for-profit organizations from applying for regional mental health care authority

contracts. Although early managed mental health care contracts were predominately

| awarded to for-profit organizations, more recently, states have begun to incorporate

' managed care practices into the not-for-profit environment, either in programs that are

operational (Colorado) or programs moving towards implementation (Kentucky).

| In states that have purchased care management through an open competitive

_ process, the decision appears to be influenced by a number of factors, each of which

| alone and in combination makes it much more likely that the state will contract with a

large, for-profit managed behavioral health care organization.

Statewide design. The use of a single, statewide contract is attractive since it elimi-

nates the need to adjust the capitation payments to account for differential risk among

enrollees. The use of statewide capitation rates also allows the MHA to ignore any sub-

state differences in historical Medicaid spending that were most likely driven by provider

location and billing practices, not by consumer residence or need. Selection of a for-

profit managed behavioral health care organization, then, allows a new, external agent

_ to make the politically unpopular decisions to re-direct utilization, and therefore

funding, in support of consumer need. The use of a single, statewide contractor is also

likely to lower administrative costs as a percentage of total spending and increases the

| consistency of care management decisions and quality improvement approaches. The

| large scope of work and the requirement for substantial financial reserves makes for-

| profit managed behavioral health care organizations more competitive for these

| contracts and also decreases the likelihood that not-for-profit community mental health

| agencies will be able to bid.

Financial risk. If the MHA intends to fully or substantially transfer its financial

risk to a managed care organization, the state may be more likely to construct its program

design and structure its procurement process to allow for-profit organizations to

94 PUBLIC SECTOR PURCHASING

successfully compete. This is particularly true in states that strictly regulate both risk

bearing organizations and the capacities these organizations must possess in order to

legally bear risk.

Speed and scope of change. Finally, states that want speedy and/or dramatic change

are likely to contract with an organization that has not been part of its traditional provider

group and that, therefore, will likely provide a more objective view of the public system’s

strengths and weaknesses. This is particularly true in states where stakeholders view

traditional providers as one of the problematic components of the system. An organi-

zation entering the public arena for the first time may be presumed to possess abilities

and willingness to effect system change in ways that long-term public sector partici-

pants do not. The MHA may believe that it can accelerate the speed and scope of change

only if it relies on a “foreign body” to be the agent of that change.

The Role of the Public Mental Health Agency

While there are compelling reasons for public mental health systems to move to

managed care arrangements, such moves also present serious challenges, depending on

which of the three primary roles the MHA performs (payer, purchaser or provider).

Almost all MHAs have continued in the service provider role and experience the

typical historical struggles to maintain and improve quality care in government institu-

tions. Since they have most often protected these institutions from participating in the

managed system of care, it is difficult to assess the real impact of risk-based care manage-

ment on state and county hospitals or community services. Although almost all MHAs

have chosen to transfer risk to local government or outsource benefits management to

private corporations, one state has accepted risk from Medicaid and contracted with an

Administrative Services Organization on a performance risk-basis to manage care on

its behalf (Maryland). Several other states (Vermont, for example) are developing plans

in which they will perform the care management functions.

Counties present quite a different picture from states. In contrast with states, many

counties are attempting to retain risk and become proficient care managers. In California,

for instance, only a handful of counties have contracted with managed behavioral health

care organizations, and, then, only through ASOs or “unbundled” arrangements.

Similarly, in Washington State, only two county-based systems have taken the same

approach. (It should be noted, however, that neither of these states has fully capitated contracts

with counties.) On the other hand, in Pennsylvania, where all risk for Medicaid mental

health services has been transferred to five counties,° four of the five counties have trans-

° Pennsylvania is phasing in its HealthChoices behavioral health carve out program on a regional basis;

only the Philadelphia region is operational at this time.

PUBLIC SECTOR PURCHASING 95

ferred risk to for-profit managed behavioral health care organizations. Only Philadelphia

has chosen not to contract with a managed care organization; instead, it has created a not-

for-profit organization to perform care management functions on its behalf.

When MHAs attempt to function as the at-risk care manager, the challenges are

great. For an MHA to meet or exceed private sector’s standards, it needs several critical

capacities. The first one described here often presents insurmountable problems for public

organizations that wish to become at-risk care managers: on line, real time informa-

tion systems and information analysts who can convert data to information. The infor-

mation system must support utilization management, claims payment, and encounter

reporting. The MHA must also have multi-year budgeting authority to carry funds over

from year to year; and it must have the ability to retain all earned revenues. The public

care manager needs the personnel management flexibility to quickly hire, redeploy, and

terminate staff in response to changing administrative and clinical demands.

Public MHAs have difficulty functioning as the at-risk care manager, not because

there are not just as many talented people in government as in private operations, but

because government has structured itself in ways that inhibit or prohibit creative, flexible,

fast-paced operations. Government’s appropriations, personnel and procurement

processes are meant to restrict, rather than facilitate, administrators’ degrees of freedom.

Public MHAs are rarely able to acquire adequate resources for major information system

overhauls — let alone to continue to put money into maintaining those systems once

they have created them. If they do manage to find additional funds for critical human

resources, position classifications, salaries, and hiring processes make it very difficult,

if not impossible, to recruit and retain highly qualified information services, clinical,

and administrative staff.

When MHAs choose to outsource care management functions, they must transi-

tion to the role of “smart buyer.” This shift in government’s role from a fiscal agent who

pays fee-for-service claims (or a philanthropic organization who provides grants for

deserving public agencies) to a sponsor who buys health insurance for its members,

requires attention to benefit design, quality improvement, and strategic procurement.

Buying clinical services and supports is very different than buying utilization manage-

ment, quality improvement, and information analysis. Many MHAs have had to adopt

new methods of contract management and performance measurement as they have entered

into risk-sharing arrangements with care management entities.

Outsourcing Benefits Management

While MHAs are generally reluctant to turn their systems over to entirely new organi-

zations, there are some factors that seem to increase the likelihood that outsourcing will

be considered. Obviously, these forces are powerful since all states who are currently

96 PUBLIC SECTOR PURCHASING

administering carveouts have either entered into ASO contracts or fully outsourced

care Management.

If a public payer is seeking a high degree of system change, with broad scope and

speedy implementation, it will most likely choose to outsource the care management

function. The technologies, experience, and “deep pockets” required by initiatives with

these characteristics make it unlikely that either public or not-for-profit organizations

will be able to manage these types of programs. If the MHA wants to share or transfer

risk; and, if the program’s scope is large (1.e., statewide), these decisions will also drive

the MHA in the direction of allowing for-profit managed behavioral health care organi-

zations to compete for public sector business, even though few of these organizations

have public sector clinical experience. Since Medicaid almost always wants to transfer

risk to another entity, the MHA will need to find a risk-bearing partner (either for perfor-

mance or for underwriting risk) to assist in meeting Medicaid’s objective if the MHA

is either unwilling or unable to accept risk. Similarly, public payers’ desire to capitate

to create incentives for efficiency, early intervention, flexibility, and outcomes leads

to outsourcing since risk transfer requires vendors who can bear and manage risk.

Currently, it appears that all MHAs will seek outside assistance in developing and

maintaining managed care competent information systems. Even MHAs who intend

to perform some or all of the care management functions have contracted for a substan-

tial degree of information system support.

Government is also likely to outsource if it has a longer range vision of more aggres-

sive human service consolidation, even if it only begins with contracting for manage-

ment functions through administrative services organizations arrangements. Similarly,

government may be more able to integrate services (whether this is health/behavioral

health or various components of human services) through an organization that is external

to governmental operations and that can mitigate the effects of “territorialism” within

government. Government may need a fiscal intermediary to integrate funds from various

parts of government, so that individual program focus can be maintained while efficient

and coordinated service provision is encouraged.

The decision to outsource, however, does not require that the MHA contract

with a for-profit managed behavioral health care organization. If the state or county can

share risk with its care management entity, a not-for-profit community mental health

organizations could serve as the managed care organization. In this way, the public sector

could adopt strategies and techniques that were previously performed exclusively by

the for-profit mental health care industry. Several recent public managed behavioral health

care initiatives have allowed or encouraged partnerships between not-for-profit commu-

nity providers and for-profit behavioral health care organizations (e.g., Arkansas,

Kentucky).

PUBLIC SECTOR PURCHASING 97

Risk onl Profits in Public Markets

Both government and not-for-profit organizations are more able to participate in a

| managed care design when the public payer chooses a regional or sub-state framework

for system management. When either government or not-for-profit organizations are

accepting risk, the MHA needs to make sure the care manager can manage the risk it

accepts; several states have experienced serious problems in transferring risk to organi-

zations who were not capable of assuming it. States who are relying on government as

risk-bearing care managers have generally implemented managed mental health care

at a much slower pace. County commissioners often engage in protracted deliberations

_on the merits and downsides of accepting risk from state governments. Because they

are often the final link in the safety net, counties understand the need for their behay-

ioral health services to assist them in managing their human services risk. The fear of

| assuming risk is most often overshadowed by the greater fear of losing control of this

critical system. Similarly, MHAs who are assigning the risk management role to not-

| for-profit organizations must realize that the conditions which signaled success in grant-

| funded systems are not the same as the capabilities demanded by risk contracts. Not-

| for-profit providers may not be able or willing to undergo the reengineering required

| to combine state-of-the-art business practices with their clear commitment to a social

| mission. Quality service providers may want to continue to specialize in highly effec-

tive clinical care and not to develop a new care management product line.

On the other hand, when MHAs contract with for-profit organizations, there is concern

about unnecessary profit decreasing resources for services and supports. With the signif-

icant entry of for-profit managed behavioral health care organizations into public sector

mental health care, questions have been raised about the place of profits in public business.

The National Community Mental Health Care Council, for example, has asked whether

there can be “profits with honor” in the public sector. There are those who believe that

the not-for-profit providers who have managed the public sector’s history should inherit

its future. There are also those who see the advantage of equal competition between

| not-for-profit and for-profit organizations in the interest of quality, cost, and outcomes.

In many public markets, consumers and advocates are welcoming the move to managed

care, believing that it presents an opportunity and provides some incentives for

improving public systems’ clinical practices and increasing their consumer focus. There

is also a school of thought that advances the position that for-profit managed behav-

) ioral health care organizations can often do what government or not-for-profit organi-

| zations can’t or won’t: challenge the status quo, provide a third-party view of the public

| system’s performance and re-orient providers’ practices toward efficiency and effec-

tiveness.

In states that have created an even playing field between not-for-profit and for-profit

organizations in managed mental health care procurements, the MHA has generally paid

98 PUBLIC SECTOR PURCHASING

close attention to issues of excess profit in relationship to public sector funding. States

have either established an administrative/profit cap or have specified the minimum

“medical loss ratio” that is acceptable; more recently, they have linked performance

to the level of profit allowed.

Impact of Competitive Outsourcing

As states develop their blueprint for managed behavioral health care, they must

project a future view of the role and function of the not-for-profit community mental

health industry. Options range from total protection for “essential community providers” —

where managed care entities are required to do business with a specific list of commu-

nity providers, to full competition for inclusion in provider panels where “tradition-

ally public” providers participate on an even playing field with other organizations and _ |

practitioners. In choosing an approach, states generally attempt to balance the need for |

providers experienced in public sector services with the potentially positive effects of |

competition on quality, cost and consumer choice.

While almost every state has grappled with this question, no state has guaranteed

future Medicaid revenues to community mental health agencies. Most states have

attempted to soften the impact of competitive procurements on public providers by |

restricting the managed behavioral health care organization’s degree of freedom in |

choosing providers for its panel or network — at least in the early stages. All states

with carve out programs’ have specified the qualifications of providers with whom the

managed care organization can contract and have also required that the “post managed _

care” provider availability be as good or better than that which existed “pre managed |

care.” Some states have required these providers to already have contracts with the State

MHA; a few states must actually approve the providers with whom the managed care

organization contracts. One state, while not protecting individual providers, requires

that half of all beneficiaries referred for specialty treatment be referred to public providers.

Public MHAs’ decisions on roles and opportunities for public sector providers are

important for many reasons, not the least of which is that community mental health

agencies have had fairly serious reactions to states’ competitive procurements and, in

several jurisdictions, have delayed implementation through appeals. Public mental health

systems do not have a tradition of competitively purchasing goods and services; the

incorporation of this approach often sends shock waves throughout its provider

community.

’ “Medical loss ratio” is a measure frequently used to evaluate commercial health plans and describes

the percent of revenue/premium payments the plan spends on medical care.

* Carve out programs are those in which mental health services are included in the benefit package and

then carved out from health services for specialty care management and separate financing.

PUBLIC SECTOR PURCHASING 99

While some community mental health agencies have attempted to obstruct the

movement to at-risk managed care, others have taken more proactive approaches. There

are growing numbers of community mental health agencies who are considering, and

developing, organizational alliances or affiliations as a means of increasing their leverage

and attractiveness to payers and in order to gain the capital and competence required

by risk-based managed care. Community mental health agencies are partnering with

each other in horizontally integrated structures, creating joint ventures with managed

behavioral health care organizations, and joining with diverse sets of health care providers

in vertically integrated networks.

Whatever role they assign to not-for-profit community mental health providers,

MHAs should not underestimate the public sector’s resistance to change. They must

also realize that intergovernmental squabbles of the past will continue to haunt the future

and can be exacerbated by significant systems change. While the installation of

managed care systems can create opportunities for program improvements, its initia-

tion will also create the need to attend to the often overwhelming political forces active

within governmental operations.

Future Public Purchasing Decisions

Future public sector managed care activity will occur within the context of its govern-

mental environment, just as previous activity has. Consequently, it is difficult to predict

its direction because of counter-balancing pressures. In contrast to a period five years

ago when budgetary problems were the backdrop for Medicaid’s early managed care

efforts, most states’ finances are currently in good shape. There may be little impetus,

therefore, for taking on the tough work of systems change since governments will not

be able to “blame” change on budget deficits. We may, therefore, see fewer public mental

health systems that are willing to spend increasingly limited political capital on system

re-structuring. On the other hand, MHAs may not be major players in making these

decisions, as their presence recedes within large-scale state government reorganizations

and there is still pressure for government downsizing and human services re-engineering.

With these countervailing forces, it is still likely that government will continue to

adopt private approaches to human service management; mental health systems will

be no exception. Managed mental health care contracts may become more regional-

ized but MHAs will continue to seek innovative public/private partners when a system

needs significant restructuring. The use of ASO arrangements may increase in popularity

since they allow public providers to retain a greater level of control while still allowing

government to capitalize on managed care organizations’ technological capabilities.

Pressure for consolidation may drive mental health, addictions and child welfare agencies

collaboratively to purchase compatible benefit packages from a single point of manage-

100 PUBLIC SECTOR PURCHASING

ment that integrates, but does not blend, funding streams. Government will continue

to rely on private enterprise to perform functions it will not perform itself. Within this

environment, MHAs will continue to experience pressure to make smart purchasing

decisions about services and systems of care.

Journal of the Washington Academy of Sciences,

_. Volume 85, Number 1, 101-113, December 1998

Issues Affecting Clinical Practice in an Era

of Managed Behavioral Health Care

James T. Winarski, Martin Cohen, Saul Feldman, Marilyn J. Henderson,

Vivian Jackson, Harriet Lefley, Ronald W. Manderscheid, Peter Panzarino,

Ian Shaffer, Joel Slack, Cynthia Zubritsky

Introduction and Background

This paper summarizes the most pressing issues affecting clinical practice within

emerging systems of managed behavioral health care. It also describes some of the major

changes in clinical practice that have been brought about by managed care and analyzes

the implications of these changes. It is important to note that many of the challenges

described in this paper existed long before the emergence of managed care. However,

_ managed care has provided a new organizational context that has required special

a er a

responses from clinicians as part of providing effective clinical practice. The specific

issues that are addressed include:

e adapting to managed care;

e loss of autonomy and changes in role;

e challenges to providing quality care;

¢ ethnical standards;

e addressing cultural diversity; and

¢ developing new competencies.

The behavioral health care field, focusing on the prevention and treatment of mental

health and substance abuse problems, has experienced extraordinary change during the

last decade. New treatment technologies, the advent of new management systems, the

influx of market forces, and shifts in economic and political priorities have had a signif-

icant impact on every aspect of service delivery. In spite of all of the rapid changes,

there is an emerging consensus among purchasers, providers, and consumers of behav-

ioral health services in both the public and private sector: they share the goal of devel-

oping an accessible system that provides quality care at an affordable cost to all people

who need it.

Developing and implementing such a system, however, has presented formidable

challenges. Medical ethicists have described the fundamental issue as centering around

the need to make decisions about how to equitably distribute finite health care resources.

102 ISSUES AFFECTING CLINICAL PRACTICE

(Boyle and Callahan, 1993) Providing mental health and substance abuse services is

especially challenging because of the inherent nature of psychiatric and addictive disor-

ders. Consumers require treatment for problems that are often long in duration, and

complicated by complex psychosocial needs related to housing, income, family, and

related issues. Acute symptom exacerbations and recurrent crises that are difficult to

predict are often part of the course of these disorders.

Managed care has responded with a set of principles and technologies designed with

the stated goal of setting limits on spending while still ensuring quality care. The inten-

tion is to reduce cost by improving efficiency and carefully monitoring treatment processes _ |

and outcomes. Specific cost saving strategies include using less expensive providers, |

providing care in less expensive settings (i.e., outpatient rather than inpatient), empha- |

sizing short-term treatment methods, creating frameworks for capitated rates, and |

managing the utilization of services. For many clinicians, experiences of managed care !

have been difficult and wrought with challenges. The language and technologies of the

business world, and the forces of the marketplace, have now entered the clinical process

— with profound implications for how clinicians provide care.

The relationship between the clinician and consumer is the focal point of the behav- |

ioral health care system. Clinicians routinely deal with issues that are reserved for our

most intimate relations. Therefore, it is not surprising that the clinician/consumer relation- |

ship has special properties. Managed care has imposed another person, a care manager, |

onto this dyad. Though insurers have always had a significant influence on the parame- |

ters of clinical practice, the input of care managers brings a heightened focus on account- |

ability. Within the resultant triad, the relationship that once focused primarily on issues

of individual treatment needs now must also be concerned with controlling costs through

improved efficiency and coordination, reducing unnecessary or inappropriate service |

utilization, and demonstrating quality through measurable outcomes. Though financial

considerations were part of managing clinical practices long before the era of managed |

care, the demands for accountability and standardization and the direct influence of third |

party payers represent significant change. For clinicians, this has been a difficult transi-

tion, one that has become a source of tension in the delivery of managed behavioral

health care. |

To consider managed care as it relates to clinicians is to address a broad and diverse }

range of arrangements and relationships. Managed care is not a uniform set of program |

structures and processes, but a series of technologies with differential applications. |

Clinicians may work directly for a managed care organization, as in staff model health

maintenance organizations (HMOs); contract privately with one or more managed care |

organizations, as in preferred provider organizations (PPOs); work for a provider that }

contracts with a managed cared organization; or any combination of the above. Two |

key elements are common to all these relationships and organizational arrangements: |

(1) the relationship between the clinician and the consumer is a primary determinant

ISSUES AFFECTING CLINICAL PRACTICE 103

of quality and, (2) the tension introduced by managed care as a third party in the clini-

cian/consumer relationship holds the potential for both positive and negative impacts

on the quality of care. (Feldman, 1992) Understanding the experience of clinicians in

managed care environments and the effect of managed care on clinical practice is critical

to developing effective managed behavioral health care policy and, ultimately, to providing

high quality, cost-effective care.

Current Issues

Adapting to Managed Care

Managed care has created a fundamentally new system for organizing and deliv-

ering behavioral health services, and is rapidly becoming the standard for health systems

management. Clinicians who were accustomed to providing care through a fee-for-service

or publicly funded system and who now work under the auspices of a managed behav-

ioral health care organization must make adjustments in practice and attitude, as well

as acquire new knowledge and skills. As the number of people served under managed

| care organizations has increased, the number of clinicians who provide services under

agreement with them has also risen. Most clinicians now have experience with providing

_ service in managed care environments and are engaged in a process of adjusting to this

a __

new system. Though reactions vary greatly among clinicians, several themes are

| apparent:

Economic necessity has been a driving force behind change. The shift from

providing care to also managing cost represents one of the most significant points of

tension for clinicians in managed behavioral health care. Clinicians are generally

motivated by the desire to provide high quality care as part of a plan for treatment that

combines their best clinical judgement and the preferences of the consumer. The new

focus on standardization and cost containment is in conflict with traditional clinical

training and provider attitudes. For many clinicians, the transition to managed care is

driven by economic necessity and not a belief in its intrinsic value as a method for

organizing and providing behavioral health services.

Most clinicians have decided to participate in managed care systems and have adapted

their practices in order to remain fiscally viable. Most clinicians also recognize the need

to reform the inefficiencies of the traditional fee-for-service system, but would not enthu-

siastically endorse managed care as a preferred approach. Though economic considera-

_ tions have always been a part of managing a clinical practice, clinicians were rarely required

to play a central role in setting limits on care because of cost. Managed care’s mecha-

‘nisms for controlling costs and placing limits on care creates a conflict of values for many

clinicians who only reluctantly participate because of the need to remain employed.

104 ISSUES AFFECTING CLINICAL PRACTICE

Though contractual parameters for providing treatment also existed in fee for service

systems, the pressure to control costs has been greater with managed care benefit packages

due to greater levels of oversight and, in some cases, reduced funding and benefits. Clinicians

experience tension when they are providing services within the parameters of contracts

that do not, in their estimation, provide the resources needed for sound clinical practice.

Clinicians in the public sector face special challenges. For clinicians in publicly

financed hospitals and clinics, and those serving publicly insured consumers, managed

behavioral health care is a relatively new phenomena. They serve people who have tradi-

tionally relied for services upon government-sponsored programs and not-for-profit

agencies, and have not experienced the level of oversight and demand for accountability

that is common in managed care systems. Managed care organizations now have

contracts to provide services to these individuals within a fixed budget that may include

some margin of profit. Mechanisms for controlling cost and managing service utiliza-

tion represents a significant departure from traditional public sector management policies

and procedures.

Many publicly funded organizations have not, or have only recently adopted managed

care systems. Consequently, public sector clinicians have been required to make signif-

icant changes in practice within short periods of time. They expressed concern that managed

care cannot adequately serve the large number of low income consumers who have severe

and long-term disorders and require a broad range of psychosocial services and supports.

Public sector clients, they point out, are also more likely to experience problems that are

not reimbursable under current criteria for defining medical necessity.

Clinicians wish to ensure that profits are not realized by compromising the quality

of care. In principle, managed behavioral health care controls cost by managing a fixed

set of resources that should be distributed equitably over the entire population covered

for care. Clinicians have been troubled by the way in which profit motives have affected

the distribution of resources in practice. They are particularly concerned about profits

being realized at the expense of quality. Cuts in important services, premature discharges,

and “revolving door syndromes” have always been a problem, but clinicians now cite

an increase in their prevalence as evidence of managed care’s tendency to reduce expen-

ditures rather than improve patterns of care.

Strong partnerships between managed care organizations and clinicians are critical

to making an effective transition to managed care. The process through which the transi-

tion to a managed behavioral health care approach occurs has a significant impact on

the clinician’s perception of managed care. When managed care organizations include

clinicians in decision-making and develop policies that support staff adjustment to admin-

istrative change, clinicians are more likely to have a higher regard for managed care.

Clinicians who have had managed care imposed on their practice and who do not have

a mechanism for participating in the process of change often feel resentful, burdened,

uninformed, and unprepared to deal with the transition.

ISSUES AFFECTING CLINICAL PRACTICE 105

The transition to managed care, like all organizational change, is an evolutionary

process. Purchasers, managed care organizations, provider programs, clinicians, and

consumers are all becoming increasingly more sophisticated in understanding the

theory and practice of managed care models. As sophistication grows, so does the capacity

to move beyond simply reacting to change. Key stakeholders should participate in the

development of strategies to shape a behavioral health care system that will be respon-

sive to both cost concerns and the complex health care needs of our communities. As

direct care givers, the input and leadership of clinicians in shaping future change will

be crucial to advancing the evolution of managed care.

Loss of Autonomy/Changes in Role

Professional autonomy is highly valued by clinicians and has traditionally been a

_ significant source of job satisfaction. In the past, clinicians have enjoyed a great deal of

latitude in using their clinical judgments to determine treatment activities. The realities

of health care financing and the need to manage cost has diminished some of that autonomy

and impacted the role of the clinician in several significant ways.

Clinicians have assumed new roles as negotiators and advocates. Although clini-

cians in managed behavioral health care systems establish plans for treatment, managed

care organizations and purchasers hold the ultimate decision-making authority, based

in benefits packages, practice guidelines, and/or utilization review. Care managers are

now routinely involved in decisions regarding the type and amount of care that will be

approved and reimbursed. Though protocols and standards have been established to facil-

itate a care approval process that is efficient and responsive to consumer need, the role

of the clinician has shifted from being the prime decision-maker to the prime advocate.

As decision-making authority has diminished, clinicians have been required to take on

new roles as negotiators, balancing the need to control cost and provide quality care,

while also balancing the interests of the managed care organization and the consumer.

In addition to providing treatment within the parameters of a benefit package, clinicians

are often required to demonstrate the needs of the consumer to managed care organi-

zation staff, as well as translate the rules of the organization to the consumer. Clinicians

also may advocate for consumers through an appeals process, established by managed

care organizations to deal with differences of opinion that cannot be reconciled through

standard procedures for approving services.

Each of the professional disciplines has experienced some change in roles and

responsibilities. Managed care organizations generally pay for clinicians who can provide

services at the lowest cost under current standards for practice. Treatment activities are

more often organized in relation to function rather than professional discipline. The tradi-

tional discipline-based lines of authority and responsibility have been redefined in managed

care environments. Psychiatry, psychology, psychiatric nursing, and social work have

106 ISSUES AFFECTING CLINICAL PRACTICE

all experienced some change in the types of clinical activities performed. For example,

medication management has become a predominant activity for psychiatrists, while

diagnostic assessments and psychotherapy are now often performed by less expensive

mental health clinicians or primary care physicians. Treatment plans typically include

a series of activities that require clinicians to assume a range of roles and functions that

are coordinated by a care manager. Clinicians from nursing and social work have also

taken on a greater role in providing triage and case management functions. Traditional

discipline-based compensation is also being modified, with some companies paying for

“therapy” at the same rate regardless of the discipline of the provider. There is gener-

ally greater emphasis on flexibility and teamwork among the professional disciplines.

Strategies for managing service utilization have impacted the length and locus

of care. A significant mechanism for controlling cost in managed care involves

managing service utilization. Managed care organizations seek to reduce unnecessary

visits and provide care in the least expensive settings. They emphasize outpatient, time

limited, episode-based segments of treatment with goal-oriented objectives. Behavioral

and cognitive therapies have replaced long term, insight-oriented psychotherapies.

Clinicians in solo private practice have responded to managed care’s cost control require-

ments by discounting fees, consolidating provider groups, and emphasizing short term

treatment approaches in outpatient settings.

New roles and changes in professional identity require that managed care organt-

zations and clinicians develop new partnerships. Clinicians without a background in

the business or managerial aspects of behavioral health services may not be adequately

equipped to be successful in managed care environments. Some clinicians have

complained that new management systems have been imposed without sufficient clini-

cian input and without allocating the time and resources required for effective “retooling.”

The purchasers, providers, and consumers of services will all benefit from clinicians

working in partnership with managed care organizations on cost and quality manage-

ment strategies; and the organizations themselves could advance this partnership by

involving clinicians in all phases of planning and implementation.

Challenges to Providing Quality Care

The initial force behind managed behavioral health care was the need to control

escalating costs. However, purchasers of care are now beginning to demand documen-

tation that services are effective. Providing quality care is no longer just a guiding principle

but an economic imperative.

Although there is universal agreement on the need to provide quality care, regard-

less of the system used to manage and finance that care, defining, measuring, and managing

quality in the behavioral health care field has been especially challenging. What is quality

care? What processes are used to measure quality? What kinds of and how much service

ISSUES AFFECTING CLINICAL PRACTICE 107

does a consumer really need? How do managed care organizations, clinicians, and

consumers know if a service has been successful? Many believe there is rarely a clear

cut relationship between diagnosis and treatment needs; between process and outcome.

Clinicians have traditionally had a wide range of discretion in determining the choice

and course of treatment activities, without clear criteria for determining success.

Managed care’s emphasis on accountability has challenged the behavioral health care

field to define quality in terms of quantifiable outcomes. The cost management issues

discussed below have significantly impacted clinician practice.

Clinicians need to be active in developing outcome data that accurately define

quality care. The process of treatment planning requires that clinicians and care

managers routinely predict the likelihood of a particular intervention being successful.

Consequently, it is critical to have a reliable base of evidence about the relative effec-

tiveness of various treatment modalities. In spite of efforts by clinicians and researchers

to document “best practices,” there is not always consensus about what is considered

- asuccessful intervention. Though there has been substantial progress in developing empir-

ically based outcome indicators, clinicians and care managers routinely determine courses

_ of treatment based on “best guesses.” Systems of care mapping and critical pathways

have been designed to assist clinicians with selecting appropriate interventions. These

methods are helpful, but only as good as the outcome data that support them.

Treatment planning for behavioral health care is a complex process in large part

_ because the course of illnesses and addictions, and the stages of recovery, can vary greatly

among individuals. In addition, it is important to distinguish between short and long

term goais for treatment and to understand the complex relationships between treatment

interventions and outcomes. Determining who should be involved in specifying the

outcomes that define treatment provision and reimbursement can be especially compli-

cated in the behavioral health care field because of community concern about these

problems, and the broad range of stakeholders who have a legitimate interest: consumers

and family members, treatment programs, payers, managed care organizations, regula-

tory agencies and monitors, criminal justice and social service systems, employers, and

the general public. (Edmunds et al., 1997) Given these complexities, it is not surprising

that there is no standard set of outcomes and outcome measures, and that preferred

measures vary widely across stakeholders. Unfortunately, clinicians are responsible for

assuming the burden that comes with increased demands for quality without accepted

definitions or adequate methods and tools for measuring it. Much needs to done to develop

appropriate vehicles to define and measure outcomes, to provide adequate guidelines

for clinicians, and to ensure that care is judged on the basis of its quality rather than

solely on its cost. (Manderscheid and Henderson, 1996)

Clinical guidelines need to be accurate, reliable, and flexible. Capitation is an import-

tant method for managing costs and controlling financial risk. Accurate capitation rate

estimates require an analysis of expected performance, desired outcomes, utilization

108 ISSUES AFFECTING CLINICAL PRACTICE

data, and characteristics of the covered population, all of which needs to be linked to |

clinical guidelines that provide clear standards for treatment. Guidelines should also :

be flexible, evidence-based, and able to accommodate the sometimes unpredictable course

of behavioral health disorders.

Outcome measures and clinical guidelines need to reflect the range of differences

in the types and severity of problems treated, the various stages of illness and recovery,

cultural/environmental factors, and individual consumer preferences. Translating

outcome data into useful clinical guidelines presents special challenges for both the

managed care organizations responsible for developing them and the clinicians who have

had difficulty adjusting to this standardized approach to care. Mental health and

substance abuse clinicians have traditionally viewed recovery as a process that varies

among individuals, is influenced significantly by non-medical environmental factors,

and is extremely difficult to predict. Consequently, they typically perceive behavioral

health care as being an art as well as a science. Nevertheless, the demand for account-

ability remains.

Using outcomes as incentives will require some adjustment for economic risk.

Clinicians have significant reservations about linking financial rewards to clinical

outcomes. They contend that doing so puts them at great economic risk because of the

lack of guidelines that accurately reflect the relationships among diagnoses, treatment

activities, and outcomes. Linking financial rewards to clinical outcomes first requires

development of standard criteria to predict accurately the various levels of financial risk

that different consumers bring to a clinician’s caseload; rewards and incentives can then

be adjusted accordingly. Because it is difficult to predict both the course of behavioral

health disorders and the outcomes for different treatment modalities, positive and/or

negative consumer outcomes may not be the most accurate gauge of clinician compe-

tence or effort. Clinicians are concerned about being judged by measures that are not

fully valid or reliable. It is also not clear how both long- and short-term outcomes should

be applied as measures of success, especially when clinical guidelines emphasize short

term treatment approaches.

Clinicians, consumers, families, payers, regulatory agencies, and other key stake-

holders often have dramatically different interpretations of what constitutes an accept-

able outcome. In addition, the great variability among individuals in responding to treat-

ment, the chronic nature of many behavioral health disorders, and the need to provide

long-term care are also of great concern to clinicians. Indeed, the complex biological,

psychological, and social factors that contribute to recovery, including consumer readi-

ness and motivation to engage in treatment, are often beyond the control of clinician

influence. The potential for creating disincentives for treating consumers with difficult

problems through capitation and case rates also introduces ethical dilemmas. Individuals

with the greatest need for care are often the least likely to demonstrate immediate discern-

able improvement. Requiring clinicians to assume personal economic risk in caring for

ISSUES AFFECTING CLINICAL PRACTICE 109

these individuals would be unfair to both the consumer and the clinician until adjust-

ments for risk can be agreed upon.

Credentialing programs need to be coordinated and simplified. Managed care organi-

zations and the professional disciplines rely on the process of credentialing as an impor-

tant mechanism to ensure the provision of quality services. The credentialing process

usually includes setting a standard for clinician competence, establishing a mechanism

for on-going review, and restricting the practice of clinicians who violate practice

standards. Credentials also provide a basis for determining rates for clinician reimburse-

ment. Though most clinicians support the need for credentialing in managed behavioral

health care, the current system of multiple and complex programs for credentialing is

confusing and costly to administer. State regulatory boards credential through licen-

sure. Managed care organizations credential through an application process in which

education, experience, supervision, malpractice experience and coverage, licensure, and

documented expertise are evaluated and reviewed managed care organizations. Managed

care organizations also “privilege” clinicians to perform certain designated tasks such

as family therapy or crisis intervention. Professional disciplines credential through special

certification boards that evaluate levels of knowledge and performance. Integrating creden-

tialing programs as part of a coordinated system would simplify procedures, reduce cost,

and enhance the utility of this important quality assurance mechanism.

Consumers and paraprofessionals often provide behavioral health care services, but,

because they are not credentialed, there have been problems with creating mechanisms

for reimbursement and quality management under managed care. Some benefit plans

and managed care organizations expect that each individual having a therapeutic role

in a clinical setting be licensed by the state; they do not always recognize the quality

assurance functions and liability for malpractice that already existed within the organi-

zation. There is a consensus on the importance of including consumers and parapro-

fessionals in providing care and on the need for fair reimbursement, but there is little

agreement as to how this should be accomplished. Future discussions clearly require

major input from consumers and paraprofessionals.

Advances in technology and automation have been hindered by the lack of a

standardized data system. The capacity to compile, track, and analyze information is

critical to quality improvement in managed behavioral health care. Managed care organi-

zations have been at the forefront of developing new technologies and management infor-

mation systems. These systems have the capacity to track indicators on quality, access

and cost, and contribute to effective decision making in all phases of care. Clinicians

can use these systems to manage more efficiently multiple levels of care for popula-

tions with diverse needs. However, the current lack of standardized data and integrated

information systems significantly limits the utility of this technology. Similarly, the

absence of dialogue between clinicians and information technology personnel in the

design, implementation, evaluation, and improvement of these systems further constricts

110 ISSUES AFFECTING CLINICAL PRACTICE

their value. There is a need for the behavioral health care industry as a whole to come

to an agreement on standard data collection processes.

Measurement tools built with input from a wide range of stakeholders now exist, and

need to be used more extensively. Supported by the Center for Mental Health Services,

the Mental Health Statistics Improvement Program (MHSIP) has developed a consumer-

oriented report card that assesses mental health and substance abuse services across the

critical domains of access, appropriateness, outcomes, consumer satisfaction, and

prevention (MHSIP, 1996) and a minimum data set for enrollment and encounter data.

In addition, the Center for Mental Health Services is conducting an on-going Human

Resource Workgroup that has drafted a minimum data set for human resources data.

Such data would allow corporate purchasers, state agencies, and consumers to compare

the performance of different health plans.

Ethical Standards

Clinicians have been required to deal with ethical problems well before the advent

of managed care and many of the current ethical issues are part of profound cultural

changes that extend beyond the health care field. Responding to ethical dilemmas has

long been a part of clinical training programs, professional codes of conduct, clinical

supervision protocols, and program policy development. However, managed care has

introduced some new ethical challenges that require the development of new ethical

standards. Clinicians have been most affected by issues related to privacy, confiden-

tiality, and the need to balance quality and cost effectiveness.

Clinicians need to ensure trust and confidence in the clinician/consumer relation-

ship. Trust and confidence in the clinician-consumer relationship is an integral compo-

nent of delivering quality health care. Privacy is especially important to consumers of

behavioral health care services because of the stigma attached to mental illness and

substance abuse. However, managed care organizations argue that they need to know

about an individual’s diagnosis, life situation, functioning, and treatment in order to make

accurate determinations about the necessity for and level of care that should be

provided. Clinicians are often required to share consumer information not only with

the payer for services but also a case manager. As group treatment becomes a more preva-

lent treatment modality, consumers share private information with increasing numbers

of individuals other than their clinicians. Specific policies and procedures need to be

developed for dealing with issues of disclosure and privacy for all these circumstances.

The advent of consolidated data systems also increases the potential for violating

consumer privacy and highlights the need for safeguards.

The demand for quality care and cost control can create conflicting interests. The

conflicts that occur as a consequence of employees representing the interests of both

ISSUES AFFECTING CLINICAL PRACTICE 111

an organization and a consumer are certainly not unique to health care or managed care.

Clinicians have always had to address the needs of the consumer within the parame-

ters of institutional structures. However, they balanced consumer and institutional

concerns from within an autonomous clinician/consumer relationship. By directly intro-

ducing a third party into this relationship and instituting a process of quality and cost

control, the need for clinicians to balance a variety of conflicting interests has become

a routine part of clinical practice. Whether the tensions inherent in balancing cost and

quality have a positive or negative impact on consumer care is dependent upon both the

managed care organization’s standards and practices and the conduct of the clinician.

The following ethical questions are common to clinicians working in managed behav-

ioral health care settings:

e When differences of opinion with care managers about the need for clinical service

cannot be resolved, and the clinician is convinced that deleterious consequences

will result from withholding services, what course of action should he or she

take?

e When networks create financial incentives for reducing service utilization, how

can clinicians make clinical decisions that are truly in the best interest of the

consumer?

e When clinicians can be dropped from managed care networks because of differ-

ences in interpretation of criteria for providing care, how can they make clinical

decisions that are truly in the best interest of the consumer?

Ethical issues related to privacy, confidentiality, and managing cost and quality in

managed care environments are of critical importance to clinicians, managed care organi-

zations, and consumers; existing codes of professional ethics and organizational proce-

dures for approving care are two primary areas that need to evolve.

Addressing Cultural Diversity

The great cultural, ethnic, and racial diversity of the United States and cultural differ-

ences among consumers and clinicians has important implications for the delivery of

managed behavioral health care. The field is developing a greater appreciation for how

an individual’s cultural background influences perception, beliefs, and behaviors

related to the experience of health, illness, treatment, and recovery and how these factors

affect the quality and outcomes of care. Clinicians can demonstrate cultural competence

by accounting for cultural factors in history-taking and assessments, by making multi-

lingual staff or interpreters available, and by adapting patterns of communication and

treatment interventions that are sensitive to the beliefs and practices of an individual’s

culture.

112 ISSUES AFFECTING CLINICAL PRACTICE

There is a general consensus that clinicians need to be culturally competent, adjusting

practice styles to accommodate the needs of different cultural groups. To advance cultural

competence, managed behavioral health care organizations should recruit and retain

culturally competent staff and establish policies, procedures, and practices that accom-

modate diversity and encourage culturally sensitive interventions. Purchasers should

require managed care organizations and networks to have culturally diverse clinicians

and management staff. Federal and state governments should take a leadership role in

ensuring that culture is not a barrier to receiving quality health care in both the public

and private sector.

Developing New Competencies

The changes brought about by managed behavioral health care have influenced the

core set of competencies required to maintain a successful practice. Clinicians now need

to develop greater expertise in the areas of brief treatment, group work, and care manage-

ment; in addition, they need management, computer, and outcome/evaluation skills.

Providers have needed to acquire new staff and develop the knowledge and skill levels

of their current staff to function effectively in managed care systems. Managed care organi-

zations, service provider agencies, and clinicians themselves indicate that training

programs have not adequately prepared clinicians to work in managed care environments.

A prime problem has been the lack of resources designated for training in academic

settings and after graduation. For example, since managed care organizations do not

reimburse interns for providing treatment in clinical training programs, options for training

sites have diminished. Experienced clinicians who completed their formal education prior

to the advent of managed care, need continuing education about managed care technolo-

gies. There is general agreement that both public and private payers need to share respon-

sibility, and that states, counties, managed care organizations, and provider organiza-

tions all need to support the training of the next generation of clinicians as well as the

continuing education of the current generation.

Conclusion

As the next generation of managed behavioral health care moves from a focus on

cost toward an investment in quality, clinicians will be required to play a larger role in

shaping the process and outcomes of service delivery. Organizational change is never

accomplished without growing pains, but the rapid and sometimes radical changes brought

about by managed care have caused reverberations across our entire culture. Clinicians

represent the point at which theories and systems of management translate into the actual

care of consumers. For managed behavioral health care to achieve its goal of providing

ISSUES AFFECTING CLINICAL PRACTICE 113

quality care at an affordable cost, the adjustments required in clinical practice need to

be recognized as one of the primary determinants of quality. As the field continues to

evolve, it is critical that individuals in clinical practice evolve as well. Advances in manage-

ment technologies, evaluation, and services research need to be applied under real world

conditions where problems are complex, the pace is fast, and the forces of the market-

piace are powerful. Success in clinical settings requires the continued development of

partnerships among all key stakeholders, including clinicians, consumers, providers,

payers, government agencies, and managed care organizations.

References

Boyle, P., & Callahan, D. (1993). Minds and hearts: Priorities in mental health services. Hastings Center Report

Special Supplement. September/October: S3-23.

MHSIP. (1996). Task force on a consumer-oriented mental health report card. Final Report. April.

Edmunds, M., Frank, R., Hogan, M., McCarty, D., Robinson-Beale, R., & Weisner, C. (Eds.). (1997). Managing

_ managed care: Quality improvement in mental health. Institute of Medicine. National Academy Press.

Washington, D.C.

Feldman, S. (1992). Managed mental health services: Ideas and issues. In Feldman S. (Ed). Managed Mental

Health Services. Springfield; IL: Charles C. Thomas Publishers.

Manderscheid R. W., & Henderson M. J. (1996). The growth and direction of managed care. In Manderscheid

R. W. and Sonnenschein M. A. (Eds.). Mental Health, United States, 1996. Rockville, MD: U.S. Department

of Health and Human Services.

Journal of the Washington Academy of Sciences,

Volume 85, Number 1, 114-124, December 1998

Clinical Practice Guidelines

Denise Noonan, Robert Coursey, Janice Berry Edwards, Allen Frances,

Tom Fritz, Marilyn J. Henderson, Anne Krauss, Tom Leibfried,

Ronald W. Manderscheid, Sarah Minden, Kirk Strosahl

Introduction and Background

Containing health care costs while maintaining quality is a challenge that has inspired

a number of innovations in health care, including clinical practice guidelines. This paper

summarizes the critical issues relating to the development and use of guidelines and

suggests directions for advancement of the field. The issues discussed include:

e the process of developing clinical practice guidelines and standards for guide-

lines:

¢ the implementation of clinical practice guidelines;

e the role of guidelines in quality improvement; and

e the future of clinical practice guidelines.

The treatment of people with serious mental illness has changed dramatically over

the past 30 years. Improved psychotropic medications, deinstitutionalization, and

restructuring of the financing of health care are among the factors that have contributed

to such a transformation. Increasingly, this population receives services in managed behav-

ioral health care settings, whether in the public or private sector. Governments at the

local, state and Federal levels now routinely contract with private for-profit managed

care organizations to provide services for their most vulnerable citizens.

The shift from a fee-for-service system to population-based flat fees or capitation

arrangements has created incentives to control costs, primarily by negotiating discount

rates for providers and by restricting services to those deemed “medically necessary.”

Medical necessity might be narrowly defined as the clinical services needed to diagnose

and treat particular conditions, or, it might be more broadly defined to include whatever

services (psychosocial or vocational rehabilitation, housing, case management) are neces-

sary to ensure an optimum level of functioning and quality of life (Bazelon Center, 1997).

There is significant concern that inadequate or inappropriate care may result from attempts

to save money by restricting or denying access to needed treatments or services. It is

vitally important that consumers, providers, and purchasers of these services have tools

to help them evaluate their quality. Clinical practice guidelines are one such tool.

Clinical practice guidelines are defined as “systematically developed statements to assist

CLINICAL PRACTICE GUIDELINES 115

practitioner and patient decisions about appropriate health care for specific clinical circum-

stances.” (IOM, 1990) While their primary purpose is to guide clinical decision-making,

they can be used to:

¢ improve quality, appropriateness and effectiveness of care by specifying processes

of care known to be associated with good outcomes;

¢ decrease costs by reducing ineffective or unnecessary services and enhancing

coordination of care;

¢ help consumers make informed choices;

° assist consumers and their families in advocacy efforts;

e assist payers in establishing rates of reimbursement;

¢ encourage standardization of clinical data for purposes of outcome research; and

e improve clinical training.

Practice guidelines were first envisioned as a strategy for reducing variation in

practices such that consumer outcomes would be more predictable and favorable.

Unnecessary and inappropriate treatment of medical conditions would be reduced,

resulting in lower costs. Two types of guidelines emerged, the first to guide decision-

making about level of care (e.g., inpatient, intermediate, ambulatory) and the second to

guide the types and processes of care. This paper will focus primarily on the latter type

of guidelines. Over the years, hundreds of practice guidelines have been written and their

uses, merits, and risks have been debated. Many concerns were raised: guidelines might

be used to restrict or deny access to services in order to save money; might not include

treatments of known benefit due to the bias of their authors; could discourage indepen-

dent or innovative thinking by clinicians; might increase malpractice litigation; and might

be used punitively to evaluate and sanction clinicians.

Over time there has been increasing acceptance of guidelines, especially by providers

who see them as a welcome support when treating complicated conditions (Shye, 1995).

Today it is clear that guidelines are here to stay. Discussion now centers on questions

such as who should develop guidelines, what makes a good guideline, what are appro-

priate uses for guidelines, and how guidelines should be adapted to the needs of the setting

and the individual consumer.

The Process of Developing Clinical Practice Guidelines and Guideline Standards

Guideline development in behavioral health care is especially challenging because of

the variety of perspectives that different stakeholders bring to the task. Provider guilds

have varying theoretical models of treatment and compete for the opportunity to deliver

116 CLINICAL PRACTICE GUIDELINES

services. Managed care organizations view behavioral health care as an area in which

restriction of services can potentially increase profits. Knowledgeable, well-organized

consumer and family advocacy groups expect an opportunity for input and choice. Not

surprisingly, the current status of practice guidelines in behavioral health care is a reflec-

tion of the field, with all of its complexity, ambiguity, and competing agendas.

Guidelines for guidelines. The behavioral health care field now has a decade’s worth

of clinical guidelines to examine and compare along a number of different dimensions.

The Institute of Medicine (LOM), which has assisted the Agency for Health Care Policy

and Research (AHCPR) in developing strategies for creating and implementing guide-

lines, specified eight criteria by which guidelines should be evaluated. (IOM, 1990)

e Validity — Faithful adherence to a valid guideline will lead to the expected health

and cost outcomes.

¢ Reliability/reproducibility — Groups of experts would independently arrive at the

same recommendations given the same scientific information; different practi-

tioners would consistently apply and interpret the guidelines in similar clinical

situations.

e Clinical applicability — Guidelines should specify the populations to which they

apply and be as broadly applicable as possible based on current scientific and

clinical information.

e Clinical flexibility — Guidelines should specify any known exceptions to their

recommendations.

e Clarity — Guidelines should be written in clear, precise language and presented

in user- friendly formats.

e Miultidisciplinary development process — Groups who will be affected by the guide-

line should have a role in their development.

e Scheduled review — Guidelines should specify when a review is recommended.

¢ Documentation of the process — The entire process of guideline development

(methods, participants, scientific evidence, etc.) should be documented.

Guideline limitations. Experts in the field of practice guidelines find that a number

of the available guidelines fall short of these standards. Many guidelines are proprietary;

especially those developed by managed care organizations. Closed to public scrutiny,

there is a danger that such guidelines may inappropriately serve certain needs of the organi-

zation at the expense of the consumer. Moreover, guidelines are often developed

without consumer input. Consumers emphasize that without their input there may be

insufficient attention paid to such issues as choice, collaboration in treatment planning,

and inclusion of services such as psychosocial rehabilitation, case management, and

housing. Consumers want to be included from the beginning of the development

CLINICAL PRACTICE GUIDELINES 117

process where they believe they can make suggestions that will enhance the likelihood

of a collaborative consumer-provider relationship.

Many guidelines are too long and too complicated; implementation of overly

complicated guidelines is unlikely. Guidelines are not specifically targeted to the type of

_ practitioner who will use them. The practitioner may have a different background or level

of expertise than assumed by the guideline. Educational materials that would promote better

understanding of the guideline by consumers and practitioners are generally inadequate.

Improving guidelines. Growing awareness of the limitations of available guidelines

has led to efforts to improve their quality. A number of organizations have been

involved in this endeavor including: the Agency for Health Care Policy and Research

which established standards for guidelines (Woolf, 1991) and the Institute of Medicine

_ developed a “provisional instrument” for evaluating clinical practice guidelines IOM,

1992). The American Psychological Association produced a “Template for Psychological

Intervention Guidelines” which is being used to evaluate the scientific validity and clinical

effectiveness of existing guidelines, including those of managed care organizations

- (Abrahamson, 1997). Finally, the Practice Guideline Coalition was founded to bring

together all of the parties with an interest in guidelines to develop, distribute and imple-

ment “non-proprietary, user-friendly, scientifically-based clinical practice guidelines”

(Practice Guideline Coalition, 1998).

Consensus-based guidelines. Another noteworthy trend in the development of clinical

practice guidelines has been a diminishing reliance on the results of randomized

controlled treatment trials. While this is the recognized standard for clinical research,

itis difficult to design feasible studies that reflect the complexities of the “real world”

in which people with mental illness have coexisting substance abuse and medical condi-

tions and receive multiple therapies. The limitations resulting from adherence to true

experimental designs have led some guideline developers to rely more heavily on the

- consensus of experienced clinicians regarding key clinical decision points. The Expert

Consensus Series of guidelines is representative of this approach (Frances, Docherty &

- Kahn, 1996). The Practice Guideline Coalition also uses a consensus approach, but goes

_ beyond clinicians to include consumers, family members, representatives of managed

- care organizations, and other stakeholders in the process of guideline development. While

a consensus approach offers some practical advantages, it is important that experts’

opinions be grounded in knowledge based on the most current and reliable data derived

_ from rigorous research. It is also incumbent upon researchers to attempt to design studies

_ that more closely approximate “real world” settings.

Data-based guidelines. Yet another approach to guideline development is to base

recommendations on information culled from large databases. Information obtained

at intake, during treatment, and at follow-up is analyzed for use in shaping treatment

protocols (Faulkner & Gray, 1992; Pigott, 1995). As information systems become more

sophisticated, it is possible to continually feed outcome data back into the loop and revise

118 CLINICAL PRACTICE GUIDELINES

guidelines as necessary. This process has the advantage of producing guidelines that are

tailored to the needs of a particular clinical setting and that can be frequently updated.

Implementation of Clinical Practice Guidelines

Too often, guidelines sit unused on shelves in clinicians’ offices. The documents

may be too long, too complicated, presented in a confusing format, geared to a different

audience, or better suited to another clinical population or setting (Lomas, 1989, 1991).

Even a “good” guideline can languish in obscurity if proper attention is not paid to the

implementation process.

Strategies for Enhancing Use of Guidelines

“Translating” guidelines. Guidelines are commonly modified for local use. This

process is sometimes referred to as “translating” a guideline, and can be beneficial in a

number of ways. It can create a more user friendly format and a better fit can be tailored

to the unique characteristics of the local organization and its community. Consumer prefer-

ences as well as the opinions of providers can be incorporated. Credibility of the guide-

line can be enhanced if the translation is done by respected colleagues. During this process,

suspected barriers to implementation can be identified and steps can be taken to reduce

or eliminate them.

The challenge of guideline translation is to preserve the overall message while

increasing the likelihood that the guidelines will be used. There are some strategies for

guideline modification, however, that run the risk of disconnecting the guideline from

its scientific base, thereby introducing bias or inaccuracy. “Academic detailing,’ for

example, is a technique that selects a limited number of clinical behaviors from a guide-

line and implements only those. (Soumerai and Avorn, 1990) While this strategy can be

a useful approach to addressing local problems, care must be take to maintain the integrity

of the guideline. Clinical quality improvement efforts that selectively implement

segments of a guideline may also undermine its validity. (Brown et al., 1995) However,

without efforts to modify guidelines, they are far less likely to have widespread use.

(Brown, Shye & McFarland, 1995)

Incentives and penalties. Other strategies, some controversial, have been proposed

to encourage implementation of guidelines. These include legislation to protect

providers who follow guidelines from malpractice litigation (Barlow & Barlow, 1995),

financial incentives for providers who practice according to established protocols, and

sanctions against those who fail to adhere to guidelines. Many experts in the field believe

that such proposals are ill advised. Ultimately, treatment decisions must be made

in the context of a collaborative relationship between clinician and consumer.

The decision-making should be informed by the guideline, not ruled by it.

CLINICAL PRACTICE GUIDELINES Ms

Format. Experience with guidelines in managed behavioral health care settings has

shown that there are a number of tools that can be derived from guidelines that enhance

their usefulness. (Gottleib, 1993) Guidelines presented in algorithmic formats tend to

be brief and easily followed. Guidelines on discs can be used on desktop computers and

durable laminated cards containing only the key clinical decision-making points can be

carried by clinicians; such formats are also suited to preferred drug lists based on first,

second and third line treatments for conditions covered by guidelines. Clinical reminder

systems based on guidelines include automated laboratory and medical record systems

that generate notices to clinicians if there is an unusual finding or follow-up is recom-

mended at certain intervals. CD-ROMs published by guideline developers could provide

detailed information about the scientific basis for the guideline and synopses of key reports

in the literature.

Education. Experts in the field advocate strongly for a variety of educational programs

‘to accompany clinical practice guidelines. These programs should be targeted at

consumers, families of consumers, practicing providers, and providers in training. For

consumers, materials can be presented in a discussion or document format to promote

understanding of a condition and options for treatment. Consumers want tools to help

them engage actively in treatment planning. They want to know about the risks and benefits

of standard and alternative treatments.

Educational programs can familiarize established clinicians with the scientific basis

for a guideline and review skills required for providing the recommended treatments.

| Trainees in all behavioral health care disciplines should understand the process of guide-

line development, be able to distinguish good from flawed guidelines, and be familiar

| with the quality guidelines for the conditions they are likely to encounter in their profes-

sional work.

Challenges to Implementation in the Public Sector

| Implementation of practice guidelines in public sector behavioral health settings

presents special challenges. A number of Federal and state funded programs are

working towards implementation, some with the assistance of guideline developers, and

| trying to address a variety of complicating factors. For example, coexisting major mental

illness and substance abuse is extremely common in the population served by the public

‘sector; most guidelines, however, address only a single diagnosis. Furthermore, the public

sector population includes many people who do not respond, or only partially respond,

‘to psychopharmacological treatment. Most guidelines do not give clear indications about

how to proceed in difficult to treat cases. People with serious mental illness often use

case management and a variety of social services such as housing, vocational rehabili-

tation, and social skills building programs; most guidelines do not adequately address

these psychosocial interventions.

120 CLINICAL PRACTICE GUIDELINES

Many people who are treated in public mental health systems receive their care across

a mixture of public and private facilities. Public and private settings may not use the

same guidelines, creating potential inconsistencies in care. For example, guidelines that

recommend expensive first line treatments for serious illnesses may make it difficult

for publicly funded programs to comply due to budgetary constraints. Many would argue,

however, that in the long run expensive treatments are cost-effective if they prevent treat-

ment failures and optimize functionality and quality of life.

Clinicians and administrators in the public sector appreciate the value of guidelines

and are beginning to develop tools that are better suited to their needs. As public mental

health authorities and Medicaid agencies contract for services with managed behavioral

health care organizations, they can include adherence to specific guidelines in their

contracts. Government officials need guidelines that lay out the current understanding

of the most effective interventions for treating people with serious disorders. These recom-

mendations should be derived from the best scientific and clinical information avail-

able, without regard to cost. Only then can there be a meaningful consideration of costs

— not only the direct costs of providing high quality care but also the indirect costs

(e.g., poor quality of life, repeated hospitalization) of providing inferior care.

The Role of Guidelines in Quality Improvement

Clinical practice guidelines have proven to be useful components of quality

management programs (Gottleib, 1990, Pigott, 1995). They provide a framework for

discussions about clinical decision-making, standards of care, and cost of care. They

may also soon become required components of quality management. In April 1997, the

National Committee on Quality Assurance (NCQA) published new Standards for

Accreditation of Managed Behavioral Healthcare Organizations. They require that organi-

zations select clinical practice guidelines and make them available to their providers.

In addition, each year the organizations must measure provider adherence to a minimum

of two of the guidelines.

Adherence to guidelines is of no benefit unless the outcome for the consumer is of |

acceptable quality. Efforts are underway to link practice guidelines to outcomes

analysis so that the effectiveness of particular processes of care can be examined. AHCPR

(1995) has been working on a methodology for using practice guidelines to evaluate

quality of care. Guidelines form the basis for both medical review criteria, which are

used to assess specific decisions, services and outcomes, and for performance measures,

which monitor the extent to which a provider’s service conforms to a guideline. The

measurements derived from these evaluation tools can be compared to standards of quality

to determine whether the care delivered is at an acceptable level. The quality manage-

ment cycle is complete when data from this process is used to update a guideline.

CLINICAL PRACTICE GUIDELINES 121

The proprietary nature of most managed care organization guidelines raises strong

concerns that quality of care may not be properly balanced against cost considerations.

While it is true that practice guidelines were envisioned as a tool for cost containment,

the goal was to create savings by reducing unnecessary or inappropriate care. A good

practice guideline should allow clinicians, consumers, and others to see clearly the inter-

ventions and services that are associated with the best outcomes. Interventions that are

equally effective, but of lower cost, should be highlighted. Decisions about the costs

of delivering care to individuals or populations may belong more properly to discus-

sions of standards of quality or to contract negotiations than to clinical practice guide-

lines.

Understanding the complex interrelationships among structure, process, and

outcomes in behavioral health care is clearly important. Consumers and clinicians need

information about outcomes for large groups of consumers to guide them in making

the best decisions for each individual. Clinicians and managed care organizations need

information about individual providers and how their performance compares with other

providers to assess and improve care. And payers and purchasers of health care need

information to help them decide what they should pay for and to determine if quality

care was delivered. Outcome studies will enable the identification of systems or sites

_ that successfully implement guidelines.

Experts in the area of clinical practice guidelines point out, however, that linking

- guidelines to outcomes should proceed with caution. In the first place, experience with

the development and implementation of guidelines is relatively limited and, in the second

place, outcome research is a complicated and expensive endeavor in the behavioral health

sciences. Outcomes can be defined in many different ways: short or long term, broadly

related to mental health and substance abuse conditions, or specific to a diagnosis or

individual. Furthermore, it is challenging to define “good” outcomes for behavioral health

problems because of lack of consensus among interested parties. This is an area that

will benefit substantially from a collaborative effort by researchers, consumers and

families, clinicians and health care administrators.

The Future of Clinical Practice Guidelines

The behavioral health care field has not yet achieved the level of acceptance afforded

other areas of health care. There is skepticism about the kinds of treatment that are deliv-

ered in clinicians’ offices and how those treatments impact the well being of consumers.

The field has been slow to convincingly demonstrate that it can provide effective treat-

ment at an affordable cost. This has contributed to a reluctance to pay for these services

on the part of insurers, employers, and managed care organizations. Practice guidelines

are beneficial to the field in that they give consumers, purchasers, administrators, and

122 CLINICAL PRACTICE GUIDELINES

practitioners a window into the consulting room. They can see “best practices” and

compare promised or delivered services to these standards.

Clinical practice guidelines will not and should not eliminate controversy in the field.

There will continue to be disputes about who should deliver care, what treatments work

best, and how to pay for services. Such disputes derive from the diversity of interests

in the field and can, at best, stimulate creative problem solving. Development of guide-

lines offers the mental health care field an opportunity to bring diverse groups together

to try to reach consensus on major points of disagreement. Of course, some justifiable

and sincere differences of opinion will remain.

There is strong consensus among experts in the area of clinical practice guidelines

that they are potentially valuable tools when developed, modified, and implemented in

a collaborative, scientifically valid and pragmatic manner. Experts make a number of |

suggestions towards that end:

Stakeholder involvement. Guidelines should be developed through a systematic

process involving all interested parties: consumers and families, advocacy groups,

providers, researchers, educators, purchasers, government officials, and health care

delivery system administrators. Representation of diverse interest ensures that issues such

as theoretical perspective, consumer choice, cost and health care policy will be consid-

ered. In this way, the needs of all those affected can be addressed.

Standardization. Guidelines should meet high standards for quality. The mental health |

care field should adopt some universal standards that would assist those who are devel-

oping guidelines as well as those who need to evaluate their quality. Standards need not

dictate a single method for developing a guideline, but instead would define the basic

parameters for a guideline such as validity, reliability, and clarity.

Evidence- and consensus-based. There is a public need for guidelines that have been |

developed with the sole purpose of identifying the interventions that research and clinical |

experience suggest are associated with optimal quality of life for people suffering from |

serious disorders. These can help decision-makers balance quality and cost considera-

tions. |

Open to scrutiny. Guidelines should be nonproprietary. Managed care organizations ]

should be free to adapt and implement guidelines according to their needs, but these

documents should be available for review by consumers, purchasers, and accrediting

bodies. Interested parties have a right to know that the treatments recommended are associ-

ated with the best possible outcomes according to the latest scientific information. |

Easily used, culturally competent, and flexible. Guidelines should be brief, concise

documents that are easy to follow. Educational materials for consumers, family members _ |

and providers should support them. Guidelines should be sensitive to ethnic, religious |

or cultural factors that may bear upon consumers’ acceptance or rejection of a recom-

mendation for intervention. Guidelines should be updated on a regular basis to reflect

new treatments, problems with existing strategies, and results of outcome studies.

CLINICAL PRACTICE GUIDELINES 123

Useful to primary care. Guidelines should be applicable to both primary and specialty

care settings. As many as 50 percent of all mental health and substance abuse treatment

episodes occur in a primary care setting. In order to improve recognition and treatment

of behavioral health problems, primary care providers must have access to clear,

practical guidelines.

Training. Clinicians in training should be introduced to guidelines that are relevant

to their areas of expertise. They should understand the characteristics of a good guide-

line and the role of guidelines in clinical quality improvement.

Expand development. Guidelines are currently available for only a limited number

_ of conditions. Priority should be given to the development of guidelines for high-risk

conditions such as dual diagnosis. Guidelines for disorders of childhood and adolescence

are largely unavailable and need attention. Guidelines should consider the need for coordi-

nation of treatment for populations across a variety of settings.

Conclusion

There is much to learn about clinical practice guidelines. Empirical studies have yet

to determine whether guidelines contribute to improved outcomes for consumers, limit

unnecessary or inappropriate care or reduce costs. At the very least, the concept of guide-

lines has captured the interest of groups with diverse and sometimes competing agendas

and has fostered communication about issues of quality, cost, and accountability.

Further experience with implementation of guidelines and assessment of their useful-

ness will clarify their future potential.

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AHCPR Pub. No. 91-0018.

- Journal of the Washington Academy of Sciences,

Volume 85, Number 1, 125-143, December 1998

Measuring Outcomes of Mental Health

Care Services

Sarah Minden, Jean Campbell, Jeanne Dumont, Bill Fisher,

Laurie Flynn, Marilyn J. Henderson, J. Rock Johnson,

Teresa Kramer, Ronald W. Manderscheid, Deborah Nelson,

| Peter Panzarino, Paul Weaver, Gayle Zieman

‘Introduction

Consumers of mental health services want to determine the quality of the care they

receive. Purchasers of services want to know that what they pay for is of value. Both

constituencies increasingly demand that quality be demonstrated in an objective and clear

manner. It is no longer enough for providers, insurers, and managed care organizations

simply to claim that care is “good”: they must prove it. These new expectations have

_led to important advances in our ability to measure the quality of care.

| From the consumer’s perspective, one of the most important ways of judging the

quality of care is by its outcome. A consumer might ask: “What were the effects of the

services I received? What impact did they have on my life? Were things better or worse

_as aresult of my receiving the services? Did they help me achieve my goals?” The answers

| to these questions can help the consumer decide whether to continue using the services,

how to change them, and what to look for in accessing mental health services.

: For providers — whether clinicians working with individual consumers, state or

| county mental health authorities providing services for a community, or managed behav-

| ioral health care organizations delivering care to an eligible population — information

‘about the outcome of care is essential for improving its quality. Providers might ask:

| “What were the results of the services provided? Were things better or worse as a result

| of the services? If not, what changes should we make?” Whether these questions refer

-to the treatment of one individual or to a wide range of services for a whole group of

| people, the answers can effectively guide decisions for enhancing the quality of care in

‘the future.

| Purchasers of services, whether employers or government agencies, use data on

outcomes to choose wisely among health care plans. Purchasers might ask: “How do

the outcomes achieved by different organizations compare to each other? Which organi-

zation has demonstrated the kinds of outcomes we would like to see for the money we

spend? What is the most cost-effective plan that provides the outcomes we want?” When

payers can systematically compare outcomes for particular services across organizations,

126 MEASURING OUTCOMES OF MENTAL HEALTH CARE SERVICES

they can select plans that best meet the care needs of their constituents and their own

needs to purchase cost-effective services.

In this paper we summarize the issues involved in measuring outcomes of mental

health services and in developing outcome measurement systems for the purpose of

improving quality of care. We discuss the value and purpose of such measurement for

individual consumers of services and for service delivery systems. We also describe current

efforts to measure outcomes rigorously and systematically and highlight areas where

work is needed in the future. We put before the experts a number of questions that form

the framework for this analysis:

e Why should we measure outcomes?

¢ What are the key issues in developing an outcome measurement system?

¢ What are the key issues in implementing an outcome measurement system?

¢ What activities are currently underway in outcome measurement?

e Where should we direct our future efforts and resources?

Why should we measure outcomes?

“Some of the intended purposes of outcome measurement are to provide informa-

tion for consumer choice among health plans, health care providers, or treatment

alternatives; to design financial incentives to accomplish various cost containment,

access, or quality-of-care goals; to identify areas in which quality of care should

be improved; and to monitor and evaluate changes in policy or new treatments.”

(McGlynn, 1996)

In the context of mental health care, an outcome is the result of a medical, social,

or psychological intervention. Although outcomes typically are discussed in regards to

the quality of care, decreased cost or increased access are also desirable effects of an

intervention. A positive outcome implies that an objective was achieved as the result of

an intervention; a negative outcome implies that it was not. For individuals receiving

mental health services, a positive outcome might mean improvement in the condition

of those who received the services; a negative outcome, a worsening of their situation.

For purchasers of services, positive outcomes might be that services cost less or that

access to services increased. In short, we measure outcomes to determine whether our

interventions produced a change and whether that change was in the direction we wanted.

Outcomes can be measured on two levels. On the consumer level, we measure the

outcome of treatment for a particular individual to determine whether the intervention

was effective for that individual. On the system level, we measure outcomes for entire

populations to determine whether the services provided by a public mental health authority

or a managed behavioral health care organization were beneficial to the community. In

both cases, we are judging the quality of care by examining its tangible effects on the

MEASURING OUTCOMES OF MENTAL HEALTH CARE SERVICES — 127

actual recipients of care. We are not hypothesizing about what ought to work—we are

actually measuring whether it does, in fact, work.

The shift to a public health model — to looking at the impact of care on a popula-

‘tion — marks a major transformation in outcomes research. While the care of individ-

uals remains important, other questions are equally important: Where do we stand with

| prevention? What happens to people who do not have access to services? What are the

outcomes for people who receive no treatment?

By routinely monitoring outcomes, whether of the treatment given to an individual

or of the way services are organized and financed, and by feeding back this information

‘to the treatment providers and to the service delivery systems, both can evaluate their

performance on a continuous basis and make improvements in the quality of care they

provide. Outcome measurement establishes the value of what we do — and points to

how we can do it better. (Burnam, 1996) “It is the degree to which that information is

incorporated in the organization’s decision processes that reflects the utility and impact

‘of outcome information.’ The central purpose of outcome data is “to improve service

planning and direct service delivery.” (Hernandez and Hodges, 1996; Hernandez et al.,

1996) |

By standardizing the measurement of outcomes, we can compare interventions and

‘make choices among them—again, on both the consumer and system levels. If, for

example, we compare the outcomes of treatment with medication alone or medication

in combination with psychotherapy for a single consumer over time, both provider and

‘consumer have the data they need to make informed decisions between treatment alter-

natives. Comparing outcomes of different interventions among consumers with the same

disorder—and determining which interventions are associated with superior outcomes—

‘enhances provider and consumer decision-making. It also allows public mental health

authorities and other service delivery systems to wisely allocate their resources.

‘Consumers also want to be able to compare the outcomes achieved by different providers

so that they can effectively make choices among different caregivers. (Feldman, 1996)

Stakeholder groups have different reasons for wanting standardized outcome

measurement. (Feldman, 1996) Employers and public payers need comparable outcome

data to choose among health plans and make rational purchasing choices. Purchasers

‘increasingly require managed care organizations to measure outcomes and use them to

set performance standards and goals in their contracts; in negotiating benefit and premium

‘levels, they want to know which services produce better outcomes—which ones are worth

‘paying for, and how much.

| Measuring outcomes ensures accountability. Purchasers and consumers expect

= programs, and systems to monitor specific, measurable outcomes and demon-

strate that they have accomplished what was expected of them. Indeed, “interest in outcome

accountability is leading to discussion about the strategies that must be created in order

to move systems from compliance-oriented data collection to outcome-based measure-

128 MEASURING OUTCOMES OF MENTAL HEALTH CARE SERVICES

ment and from rule-driven decision making to decision making based on practical data.”

(Hernandez and Hodges, 1996)

Measuring outcomes can be as simple as a provider regularly asking consumers to

complete symptom check-lists and determining change compared to previous ratings.

Or, it may involve extensive data collection from all providers and consumers in a service

delivery system, computerized databases, and detailed reports on a variety of outcomes.

A wide array of outcome measurement systems and software purport to meet any outcome

measurement need. Our purpose is not to recommend particular instruments or ways of

measuring outcomes, but rather to highlight the most important issues in developing and

implementing outcome measurement.

What are the key issues in developing an outcome measurement system?

The key issues in outcome measurement include attention to differences among stake-

holder groups; assurance of privacy and confidentiality; appropriate use and interpre-

tation of data; standardization of outcome measurement; and technical considerations

in designing an outcome measurement system.

Differences Among Stakeholder Groups

Consumers, families, providers, purchasers, and managed care organizations differ

in what they consider to be the key areas or domains in which outcomes should be

measured. (Campbell , 1996) Consumers, for example, see quality of life, functional

status, and satisfaction with care as important domains whereas providers may empha-

size symptom reduction, and family members may focus on welfare and safety.

Purchasers and managed care organizations are often most interested in cost outcomes.

While there is a consensus on the value of many domains, there is less agreement

on the indicators that characterize a domain and on the instruments to measure them.

Consumers, for example, might want to see “independent living” as an indicator of quality

of life, whereas purchasers might be more interested in an indicator such as “employ-

ment status.” There is often heated debate over which instruments most reliably measure

any given indicator. Since it is important to limit the amount of outcome data collected

and to standardize procedures, system developers cannot include all domains, indica-

tors, and instruments—they must choose among them.

Consumer advocates argue that consumers are given too little say—not only in what

counts as a desirable domain for measurement, but also in what counts as a successful

outcome. They feel that this results from the erroneous assumption that care recipients

do not know their own best interests. Advocates assert that what the consumer believes

to be the crucial outcome—and whether it is achieved—are the key determinants of both

satisfaction and compliance with treatment. For example, one study compared outcome

MEASURING OUTCOMES OF MENTAL HEALTH CARE SERVICES = 129

preferences of consumers, families, clinicians and administrators, and found that all groups

considered symptom reduction an important outcome but differed on family involve-

ment and safety. (McGuirk et al., 1994) Furthermore, as Campbell points out, the power

of outcome data to affect changes in service delivery systems means that stakeholders

will contend over the choice of domains, indicators, and instruments. She argues for a

shift “toward a multistakeholder model based on collaboration [where] divergent views

can be shared and reconciled ... [to] facilitate individual recipient choice.” (Campbell,

1996) Hernandez urges synthesis of cost and quality outcomes to maximize the quality

of care within available resources. (Hernandez and Hodges, 1996; Hernandez et al., 1996)

The ideal system should meet the needs and interests of all constituencies. The

domains, indicators, and instruments will, inevitably, reflect the values of those involved

in the selection process. Bias will be minimized by including all stakeholders in this

process and by making a conscious effort to be value- neutral. If stakeholders are to find

outcome data relevant and accessible, they need to be actively involved in choosing the

domains and indicators to be studied, selecting the instruments and methods of assess-

ment, and elucidating the meaning of the results. Such involvement promotes culturally

competent decision-making in planning and delivering services.

Campbell finds the multistakeholder approach exemplified in models developed in

industry and marketing. Total Quality Management, with its goal of satisfying the

customer, first finds out what the customer wants through surveys, focus groups,

consumer councils, complaint tracking systems, and test marketing; and then uses

customer feedback in an iterative process of Continuous Quality Improvement. The

Constituency-Oriented Research and Dissemination (CORD) model developed in 1992

by the National Institute of Disability and Rehabilitation Research ( NIDRR) ensures

consumers a role in identifying needs and setting priorities: consumers participate in

writing requests for proposals, preparing applications, peer review, making awards,

conducting projects, disseminating results, and conducting evaluations.

Assurance of privacy and confidentiality

A major challenge facing all stakeholders, but particularly the consumers, families,

and providers who are the “subjects” of outcome measurement, is to assure each person’s

right to privacy and to maintain the confidentiality of all data that are collected. Critics

of outcome measurement argue that the threat to personal privacy that exists when sensi-

tive information is stored on an individual has not yet been outweighed by systematic demon-

stration of the value of collecting and analyzing outcome data. As Gellman and Frawley

(1996) write, “One of the myths of modern medicine is that health records are confiden-

tial and highly privileged. The truth is that legal protections for health records are incom-

plete and inconsistent, that medical ethics are inadequate to address confidentiality in the

modern health delivery system, and that new technology and changing administrative

130 MEASURING OUTCOMES OF MENTAL HEALTH CARE SERVICES

patterns are undermining whatever limited protections exist. Demands for nontreatment

uses of identifiable healthcare information are escalating and weakening the ability of

patients and providers to know how information is being used and disclosed.”

These authors point out that there is no general Federal law that provides for the

confidentiality of health records except for those in facilities operated by Federal agencies

or Federally funded for alcohol or drug treatment programs, and that state laws vary

enormously in scope, quality, and applicability to current practices. Even though all

providers are bound by codes of ethics to protect the confidentiality of a consumer’s

communications, there are no explicit guidelines on what information can and should

be passed on to insurers, researchers, utilization and peer reviewers or—outcome system

managers. Furthermore, these codes of ethics do not extend to personnel who, day-to-

day, typically have access to private information such as secretaries, administrators, claims

and other data processors, and computer system operators, or to individuals to whom

information has been appropriately transferred. (Institute of Medicine, 1994) It is not

only the well-documented cases of fraudulent trafficking in health information that are

of concern, but the simple fact that “computers and networks increase the number of

people who can access the information, the centralization of data, and the risks from

breaches in security.” (Gellman and Frawley, 1996)

Still, proponents of outcome measurement would insist that we should find solutions

to these problems and not simply abandon efforts either to improve the quality of care

by collecting data on consumer outcomes and system performance or to increase our

understanding of mental illness and its treatment by aggregating these data to study popula-

tion trends or services utilization. A comprehensive discussion of issues of privacy and

confidentiality is beyond the scope of this paper, but several key principles should underlie

development and implementation of any outcome measurement system. Above all, those

who collect and store data should be held accountable for ensuring that:

e the existence of an outcome measurement system, or other record-keeping

system, its purposes and use, is public knowledge;

e individuals are able to review, revise, or remove any information about themselves;

e data are collected only with the knowledge and informed consent of the subjects;

e data are accurate, complete, timely, and used only for the purposes and by the

persons approved by the subject; and

e data are secure from loss and from unauthorized access, use, or disclosure.

(Bennett, 1992) |

Designers of computerized outcome measurement systems must develop the technical

procedures and mechanisms to facilitate appropriate use of data (e.g., only ‘need-to-know’

users and 24-hour user support); prevent unauthorized access to data (e.g., unique passwords

or other user identifiers, system locks, ability to recognize inappropriate access, automatic

MEASURING OUTCOMES OF MENTAL HEALTH CARE SERVICES = 131

log-off); maintain data integrity and security (e.g., verification procedures, maintenance

procedures, automatic back-up systems, disaster-recovery procedures); and educate and

continuously monitor users (e.g., user-training programs, enforced policies against

sharing passwords, audit trails, data transfer monitoring). (Gellman and Frawley, 1996)

Appropriate Use and Interpretation of Outcome Data

Just as all stakeholder groups are concerned about the privacy and security issues

involved in data collection, storage, and transfer, they also insist that if valid conclu-

sions are to be drawn from outcome data, the information must conform to the highest

methodological standards and be interpreted with care and sensitivity.

Outcome assessment in clinical settings is naturalistic. Unlike studies that randomize

subjects to treatment groups or use placebo-controlled, double-blind procedures

outcomes, data gathered in clinical settings do not “prove” anything; instead, they suggest

hypotheses that can be tested under more rigorous conditions.

How outcome data are reported affects their usefulness. The information must be

accessible to all types of users in both format and language. Reports should use non-

technical terminology and address issues relevant to different users’ needs. They should

include explicit statements about what the data do and do not mean. For example, reports

should make clear that mental health outcomes are complex phenomena, the result of

a great many events and circumstances, and that there is rarely a simple and direct link

between an intervention and a particular outcome. Too often data are presented in ways

that are misleading and confusing and do not clearly spell out the implications for policy-

and decision-making.

To the extent that outcome data are used as marketing tools, it is critical that we be

aware of the potential for misinterpretation and consider the factors that could bias the

results. For example, when reviewing outcome data, readers should ask themselves these

questions: What are the characteristics of the population under study? How was the sample

selected? What instruments were used and how reliable and valid were they? What rate

of follow-up was achieved? What statistical tests were used? What do the investigators

really mean by a “good” or “successful” outcome? Those who use outcome data must

become informed consumers of this information in order to use it wisely. (Erdlen, 1992)

Standardization of Outcome Measurement

If outcome data are to facilitate comparisons — whether among treatments,

programs, providers or plans — it is necessary to measure the same outcomes in the

same way. For example, it would be meaningless to compare managed behavioral health

care plans in terms of readmission rates if one plan counts admissions that recur within

one month and another counts those that recur within two months of the original hospi-

talization. Similarly, comparisons across programs must adjust for the types of disor-

132 MEASURING OUTCOMES OF MENTAL HEALTH CARE SERVICES

ders and severities of illness in the different populations. Until the field develops “high-

quality normative data that can be used to make comparisons and to benchmark system

outcomes against national or regional norms .... providers, payers, and consumers cannot

determine whether performance of any mental health care system is average, or above

or below average.” (Steinwachs et al., 1996) Such data depend on having standardized

and uniform data collection tools and methods and willingness to use them.

The need for standardization also applies to describing service recipients and

providers, clinical conditions, and therapeutic procedures. Providers and payers use the

terminology and diagnostic criteria in the American Psychiatric Association’s Diagnostic

and Statistical Manual (American Psychiatric Association, 1994). Consumer advocates,

however, note that diagnostic labels overshadow more essential qualities of a person

and correspond to a medical model of illness rather than a model of recovery. We lack

terminology that incorporates both points of view. Similarly, we need uniform descrip-

tors that accurately portray the types and intensity of services and the full range of settings

in which they are delivered (e.g., community mental health clinic, school, prison, home).

Because developers of outcome measurement systems generally select instruments

they know and like, there are no standardized approaches to measuring outcomes in any

domain—even though there are many reliable and valid instruments from which to choose

(see Table 1). We cannot compare an outcome even as seemingly simple as the presence

or absence of depression when we use different instruments to measure it. There are,

literally, hundreds of instruments. Narrowing the options to commonly accepted

psychometrically sound measures such as the examples is a first step toward finding

agreement on a core set of instruments.

Standardization does not preclude using special assessment methods and instruments

for distinctive populations. For example, accurate measurement of outcomes for

children and adolescents requires special interview techniques and instruments that

address relevant issues such as school performance. (Epstein et al, 1996; Outcome

Roundtable for Children and Families, 1998) People with psychotic disorders and cogni-

tive impairment may need help reading and understanding written questionnaires.

Technical Considerations in Designing an Outcome Measurement System

Public mental health authorities, managed behavioral health care organizations,

providers, and consumer groups are forging ahead with developing outcome measure-

ment systems. This is an expensive undertaking, however, and the array of available

computerized systems and assessment instruments is overwhelming. Too often groups

are so eager to begin that they select tools before they develop the conceptual founda-

tion for their systems. It is only after users decide what it is that they want to know, that

they can proceed wisely with technical matters.

Developers must begin with determining why they want to measure outcomes. A

day treatment program, for example, wants to know whether its new psychotherapy group

MEASURING OUTCOMES OF MENTAL HEALTH CARE SERVICES — 133

is effective. A consumer-run social club wonders whether its outreach activities increase

participation. A public mental health authority expects its managed behavioral health

care vendor to show whether it has met its contractual obligation to increase access to

services. Providers in a health maintenance organization want to compare the effectiveness

of two different treatment modalities before endorsing one of them in its clinical guide-

lines. Depending on the objective, developers will need to decide whether to use disorder-

specific outcome measures or generic instruments; measure outcomes in an entire popula-

tion or only a sample; assess a particular condition or all disorders; or use brief assess-

ments or more complex multidimensional ones.

Experts agree that the ideal outcome measurement system uses both generic and

disease-specific measures and collects both quantitative and qualitative data. Sampling

and brief assessments are the least costly approaches. Focusing on particular conditions

reduces the burden of assessment and sharpens the assessment. Indeed, it is often possible

to generalize results from one condition to the entire system of care “since most of the

findings concerning the processes of care and the outcomes of care are system rather

than clinical issues.... For example, if proper prescribing of psychotropic medication is

a problem for physicians who are treating people with anxiety disorders, it is likely to

be problematic in the treatment of mood disorders as well.” (Smith, 1996)

The system should thoroughly and objectively determine the process of care: types

of treatment, frequency of contact, and intensity of involvement. Outcomes should also

be assessed for people who are not treated, i.e., people who leave treatment prematurely

or who do not have access to care at all. The analytic techniques and statistical proce-

dures should address any problems in sample size and bias, and manage the complex

relationships between processes of care and outcomes (Burnam 1996). Finally, inter-

pretation must avoid unsupportable claims that an intervention caused an outcome because

these are not controlled intervention studies. The big question—Which outcome

measurement method is best?—has no answer: “The options surrounding data collec-

tion are numerous, but there are no data to support one method over another.” (Smith,

1996)

What are the Key issues in implementing an outcome measurement system?

Even if the ideal outcome measurement system could be designed, implementing

it in the real world remains a formidable challenge. Experts recommend several steps

in implementation; each one requires thoughtful consideration and careful planning.

(Smith, 1996; Hernandez and Hodges, 1996; Steinwachs et al., 1996; Kramer, 1995;

Kramer and Smith, in press)

Build consensus on accountability. The political climate can make or break an

outcomes system. People and organizations are not willingly or easily held account-

134 MEASURING OUTCOMES OF MENTAL HEALTH CARE SERVICES

able—even when they sincerely believe that accountability is important. There must be

a strong commitment at all levels to develop and maintain an outcome measurement

system, and to use it both for accountability and quality improvement.

Define objectives. A hospitable political climate depends on establishing a common

vision of the purposes of measurement, the outcomes to be assessed, and the roles of

participants. Identify key stakeholders early on and engage their input through surveys

and focus groups. Clarify leadership and responsibilities from the beginning; define the

“customers” of the outcome measurement system and clarify what they want to learn

from outcome measurements.

Spend time planning. The more time spent planning the outcome measurement

system, the more effective it will be. Planning should begin with defining objectives:

will the system be used to improve quality, to meet reporting requirements, or to study

the impact of innovative treatments? (Zieman and Kramer, 1996) Planning should be

realistic and attend to cost, training, and staffing. Experts encourage talking to people

involved in outcome measurement, seeing ““what’s out there,’ and learning from the work

of others. They also recommend starting small and then expanding. Developers should

pilot test their instruments and procedures and make revisions as necessary. The Texas

Children’s Mental Health Plan, for example, was initiated in five sites, then 16, and only

after that was rolled out across the whole state. Implementation should be gradual, benefit-

ting from the knowledge gained at each step along the way.

Gain provider, staff, and consumer cooperation. Unless providers, office staff, and

consumers are committed to outcome measurement, it will not succeed. It is a burden

to complete questionnaires and rating scales, enter data, and track clients. Successful

involvement of key participants can be achieved by engaging them from the beginning,

by enlisting their help in designing, planning, and implementing the system and when

accountability is part of the ethos of an organization. Administrators may need to offer

incentives to complete forms (e.g., payments, bonuses, dissemination of collection rates)

and should ensure that participants understand the value they will receive from the data.

Guarantee the place of consumers. Information regarding the experience of

consumers and families should be collected directly from them, rather than from providers

or administrators. Values and experiences vary widely among consumers and systems

should include the range of domains and indicators important to different individuals.

Data on physical, mental, and social functioning is more meaningful and useful when

it is combined with information on consumer satisfaction.

Select appropriate domains, indicators, and instruments. Experts note that in discus-

sions of outcome measurement they are often asked to recommend particular instru-

ments. While they agree this is an important question, it is premature unless concep-

tual issues are addressed first. The most basic issue is to reflect the needs of those served

by that system in the outcome domains and indicators selected. Hernandez proposes

the following questions to guide selection:

MEASURING OUTCOMES OF MENTAL HEALTH CARE SERVICES — 135

e Is the information useful to administrators, providers, and consumers?

e Do the outcomes create opportunities for corrective action?

¢ Do they support achievement of cultural competence?

e Does the indicator specify the outcome and can it be easily measured?

e Does the instrument provide valid and reliable information about the outcome?

e Can data collection and reporting be sustained?

e Is the level of respondent burden for both consumers and providers acceptable?

Pool data from a variety of sources. Combining data from many sources provides

the most illuminating look at outcomes. Outcome data are best understood in conjunc-

tion with enrollment, encounter, and cost data so that the effects of treatment can be

appreciated in the context of who received services, what the interventions were, and

how much they cost. Other data sources include: administrative data from billing records

to examine patterns of utilization and cost of services; clinical data from medical records

to describe a person’s functional status; surveys of consumers to address quality of life

and satisfaction with care; and surveys of providers to show customary practices, job

_ Satisfaction, adherence to guidelines, and opinions and attitudes.

Establish clear procedures for collecting and analyzing data. Consumers,

providers, and staff are not accustomed to the stringent requirements for accurate and

complete data collection that researchers follow, and may not understand how impor-

tant these are for having confidence in the data. Experts suggest collecting only essen-

tial data to minimize respondent burden and explaining why the information is needed

and how it relates to the goals and purposes of the organization. Data elements should

be well-defined and of obvious value. Participants should be carefully trained in their

specific tasks (e.g., collecting, verifying, correcting, and entering data) and in retrieving

the information they want from the system. Forms should be easy to complete quickly

(e.g., online, touch-screen or scanable data entry) and reviewed immediately so that

missing data can be tracked down. Data collection and reporting processes should be

timely and predictable.

Use outcome data regularly. The value of outcome information will become most

apparent if it is used on a routine basis—if it becomes part of the everyday life of the

program or organization. Therapists, for example, can be trained to use outcome data

in their assessments, treatment planning, and treatment program reviews. (Bergen-Seltzer,

_ 1997) Outcome data can be discussed at clinical staff meetings and reported in newslet-

_ ters to consumers as demonstrated by the LA County Outcomes Initiative.

Ensure that what is measured is what really occurred. What providers think they

_do and what they actually do can be quite different. Similarly, an outcome that a provider

or consumer attributes to an intervention might, in fact, have occurred for another reason.

136 MEASURING OUTCOMES OF MENTAL HEALTH CARE SERVICES

It is not enough simply to ask what services were delivered; rather, we need to deter-

mine the fidelity between what was intended and what actually happened.

Integrate outcome with other kinds of measurement. An important goal of current

research in information systems is to integrate data collection and measurement activ-

ities. Outcome data should be used, for example, to develop practice guidelines, and,

in turn, guidelines “can provide a standard against which current practices can be evalu-

ated in order to improve outcomes.” (McGlynn, 1996). Outcomes measurement systems

should be integrated with other approaches to assessing quality of care such as perfor-

mance indicators and report cards—this will facilitate understanding of the relation-

ship between the process of care and outcomes. Different kinds of data should be stored

in compatible databases, databases that can be exported to a common system, or in virtual

systems. (Manderscheid and Henderson, 1995) The ultimate goal is a fully integrated

information system that combines enrollment, encounter, and cost data, health status,

system performance measures, and consumer and system outcome measures.

Take action to improve services. The reason to measure outcomes is to have infor-

mation to guide improvements in the quality of care. According to the Ecology of

Outcomes model developed by Hernandez and colleagues (1996) “simply having outcome

information does little to improve services if agencies and providers have no way of

understanding outcomes in the context of who the system is serving or what services

are being provided.” The service system and the accountability system must overlap

and work together: “Understanding outcome information contextually is a prerequisite

for the informed use of outcomes in decisions regarding service planning and delivery.”

What activities are currently underway on outcome measurement?

“The science of patient outcomes assessment has become increasingly precise and

reliable in quantifying the elements of mental health and substance abuse treatment.

Outcomes assessment is now being used to link people, both patients and providers,

with various treatment approaches and the outcomes of those treatments in ways that

can improve care and hold those who provide care accountable.” (Smith 1996)

Many mental health care programs and service delivery systems are now using

outcome assessments. Providers, payers, and consumers are increasingly familiar with

measurement tools and procedures and researchers are increasingly proficient in the

science of outcomes. Work is progressing in formulating policies and standards, in devel-

oping and implementing outcome measurement and measurement systems, and in

reporting data to consumers, providers, accrediting agencies and other stakeholders.

Below we summarize some of the major accomplishments to date and the programs

and activities currently in the field.

MEASURING OUTCOMES OF MENTAL HEALTH CARE SERVICES — 137

Formulating Policies and Standards

As discussed earlier, standardizing outcome measurement is important to its

_ success and further development. The more uniformity in data collection practices and

procedures there is across systems, organizations, agencies, and programs, the more the

data can be shared, the less redundancy and overlap there will be, and the more useful

the assessments will become for consumers, providers, and systems. At the same time,

it is recognized that differences among entities in regard to goals, services, populations

served, and resources will mean that outcome systems will also differ as they are tailored

to meet each entity’s particular needs and characteristics. Therefore, public and private

organizations in leadership positions in mental health services have supported efforts

to establish policy and set standards for outcome systems. In this way they hope to guide

_ system development along a uniform path to ensure adherence to sound principles and

compatibility among different systems.

| For example, the National Alliance for the Mentally Ill (NAMI), the Center for Mental

Health Services (CMHS), the National Institute of Mental Health (NIMH), the National

Institute on Alcohol Abuse and Alcoholism (NIAA), and Eli Lilly have jointly sponsored

the Outcomes Roundtable, a multidisciplinary and multistakeholder group whose work

began in late 1994 with a national meeting that set up three task forces: one to formu-

late principles and recommendations for outcome measurement; another to develop

standards for outcome measures that are accurate, affordable, and practical and for

-methods of sampling, follow-up, data collection, and analysis; and a third to dissemi-

nate findings to consumers, families, providers, payers, managed care organizations,

policymakers and the general public. (Shern and Flynn, 1996; NAMI 1996; Smith et

al., 1997) Similarly, in the fall of 1996, CMHS convened the Adult Outcome Measurement

Standards Committee to address methodological standards for outcome measurement

systems. This group has defined key terms, identified salient issues, and suggested

standards for design, quality, and measures. (Adult Outcomes Measurement Standards

Committee, 1997) In the same vein, the American College of Mental Health

Administration (ACMHA), having determined to offer itself “as a neutral forum for devel-

- opment of consensus on challenging issues facing the field of mental health and substance

abuse treatment and prevention,” devoted its first summit meeting in 1997 to outcome

measurement. Representatives of leading national stakeholder organizations drafted value

statements and recommended key indicators and measures for outcome assessment.

(American College of Mental Health Administration, 1997)

| The consumer perspective on policy and standards has been articulated by The

-Consumer/Survivor Mental Health Research and Policy Work Group. This group, with

Support from the National Association of State Mental Health Program Directors

(NASMHPD) and CMHS, convened two consumer focus groups (using concept-

138 MEASURING OUTCOMES OF MENTAL HEALTH CARE SERVICES

mapping technology) to discuss system reform, research, and evaluation. The groups

concluded that “traditional mental health systems pathologize problems in living, hold

low expectations of consumer achievement, are paternalistic, offer a limited range of

options, and are too quick to define anger as symptomatic....researchers fail to ask

questions that capture adverse or negative effects of treatment and care or outcomes

such as recovery, personhood, well-being, and liberty.” (Campbell, 1996; Trochim et

al., 1993) This group also identified important domains in which consumer outcomes

should be measured: “legal issues, consumer impact on service delivery and system devel-

opment, oppression and racism, healing and recovery, coercion and control, personhood,

damaging effects of treatment, alternatives to traditional services, citizenship, quality

of life, employment, and validity of research.” (Campbell, 1996)

Similarly, principles and standards for outcome assessment of children and adoles-

cents has been the focus of the Outcome Roundtable for Child Services since October

1996. (Epstein et al., 1996) While the Roundtable recognized an urgent need to add

outcomes to managed care’s limited concern with cost and length of stay, it also under-

stood the need for a conceptual framework for understanding outcome-based account-

ability: unless outcomes were placed within that framework, “there was a risk that infor-

mation would be obtained solely on the attainment of specific outcomes, and that such

information would be subject to misinterpretation.” (Outcome Roundtable for Children,

1997) Therefore, rather than identify or develop indicators and measures, the Roundtable

began to develop a conceptual model and to “identify research and evaluation based

criteria ... for selecting outcomes ... [and] criteria about other types of information that

should be collected in order to better interpret results and support continuous quality

improvement.” (Epstein et al., 1996) For example, they identified three domains that

had to be described and linked together to provide a framework for data on specific

outcomes: the children and families to be served (the population), the desired outcomes

for them, and the intervention(s) developed to help achieve the outcomes. The group

also recommended that data should be collected by a variety of methods (e.g., self-admin-

istered surveys, focus groups, interviews, standardized questionnaires), from multiple

sources (e.g., children, parents, direct service workers) in multiple systems (e.g.,

health, education, child welfare, juvenile justice), and across many domains for both

the child and the family (e.g., functional status, symptoms, physical health, cultural and

ethnic background, educational achievement, life/work skill development, emotional

functioning, safety, social life, stability/permanence of living arrangements, satisfac-

tion with services, empowerment/decision-making, and quality of life). They also noted

that interpretation of results should include multiple stakeholders and that information

users at all levels should be trained in the use, scope, and limits of outcome data, partic-

ularly for purposes of quality improvement.

At its 1997 Santa Fe Summit the American College of Mental Health Administration

also addressed the unique methodological issues of measuring outcomes for children

MEASURING OUTCOMES OF MENTAL HEALTH CARE SERVICES — 139

and families. A Child Outcomes Work Group drafted a report on basic principles, indica-

tors, and measures.

Developing and Implementing Outcomes Systems and Reporting Outcomes Data

Activities are also underway to identify specific outcome measures, develop and

implement outcome measurement systems, and report and use the information from these

systems. Attention is also being paid to evaluating the effectiveness of these efforts and

learning how to improve the process.

CMHS has sponsored several projects aimed at identifying outcome measures. These

include work on developing measures that are brief and easy to use such as the Medical

Outcomes Study Short Form-36 (SF-36), the Behavior and Symptom Identification Scale

-(BASIS-32), and the Global Assessment of Functioning Scale (GAF) and on an

outcomes tool kit to help providers and programs develop outcomes assessment

systems relevant to their particular needs. (Human Services Research Institute [HSRI])

ACMHA, in its report from the 1997 Summit mentioned earlier, recommended a set of

outcome indicators and measures for both adults and children. The report recognized

the debate in the field about the efficacy of different instruments and chose measures

on the basis of their manageability (relative ease of collecting and analyzing data), measur-

ability (capacity to provide quantifiable and comparable data), and meaningfulness

(relative utility to facilitate decision-making).

Many states now use outcomes measurement to help them decide what services to

provide. Maryland, for example, used outcomes data to help answer questions about

the impact of treatment for schizophrenia, to compare its treatment outcomes with those

of other states, and to compare outcomes across the state. Arkansas compared outcomes

associated with differences in accessibility of community services. (Steinwachs et al.,

1996)

It is also essential to evaluate outcomes and use this information to modify and

improve them. The Outcomes Roundtable task force on standards and data collection,

for example, is studying the capacity of providers to collect outcomes data on a routine

basis, the financial and organizational obstacles to implementation, and the impact of

outcome information on consumer care choices. (Shern and Flynn, 1996) In 1997 the

Roundtable applauded five exemplary outcome measurement projects: the Arkansas

Medicaid Administrative Project (MAP), the Outcomes Management Project (OMP),

the AT&T Employee Assistance Outcomes Management System, the Colorado Health

Networks (CHN), and the McLean Hospital Project. (Silverberg, 1998; Smith, 1998;

_ Jordahl, 1998) The Michigan Outcome Identification Project is also noteworthy for its

measurement of a diverse set of outcomes for children.

Important lessons have been learned from these projects. First, the MAP, for example,

found that unless clinicians believed strongly in the importance of the project, they tended

140 MEASURING OUTCOMES OF MENTAL HEALTH CARE SERVICES

not to refer clients into the outcome measurement system. Second, retaining clients in

the system varied with how attached clients were to the service delivery system.

(Silverberg, 1998) Third, intensive stakeholder involvement (particularly providers) is

a key to success, as shown by the CHN outcomes system. Meeting monthly from the

beginning of the project, a committee of consumers, family members, providers and payers

helped determine what outcomes would be measured and participated closely in inter-

preting and disseminating the data. Providing regular feedback to providers on both an

individual and organizational level and comparing their outcomes to national norms and

to peers’ outcomes also strengthened their participation (Smith, 1998) Minimizing the

burden on providers by incorporating the requirements of the outcome measurement

system into their customary daily activities (as in the AT&T Chemical Dependency

Outcomes Management System) was instrumental in provider satisfaction and compli-

ance. Finally, for all consumers with complex problems, but particularly for children,

outcomes should be measured in a wide variety of settings including schools, juvenile

justice programs, and out-of-home placements and should examine factors other than

treatment per se that could influence outcomes such as poverty, comorbid conditions,

family functioning, social support, and adherence to treatment.

Where should we direct our future efforts and resources?

The panel of experts recommended a general approach to developing and imple-

menting outcome measurement systems and offered specific suggestions.

Demonstrate the value of outcome measurement. From a common sense perspec-

tive, the experts noted, there is reason to believe that measuring outcomes can improve

the quality of care although solid research-based evidence is lacking. Scientific study

of the impact of outcome measurement on the quality of care is essential.

Proceed thoughtfully and systematically. Outcomes measurement is becoming a

big industry: Everyone wants outcome data, has a favorite instrument, and tries to influ-

ence systems to produce data. Providers and consumers are increasingly asked to provide

information without knowing why and without seeing the results. Thoughtful reflection,

careful planning, and open discussion of all issues are needed before investing valuable

resources.

Standardize and integrate from the beginning. Outcomes should be integrated with

other kinds of measurement and data collection efforts: report cards, performance indica-

tors, and enrollment, encounter, and cost data. Outcomes should be used to guide devel-

opment of clinical practice guidelines, evaluate their effectiveness, and inform revisions.

Developers of outcome measurement systems should ensure that their systems are compat-

ible with those of other programs and agencies through collaboration and communica-

tion, sharing resources, and inclusion of all stakeholder groups.

MEASURING OUTCOMES OF MENTAL HEALTH CARE SERVICES 141

Should outcomes measurement be mandated? Can standardization happen if

particular methods and instruments for measuring outcomes are not mandated? If standards

are promulgated, will organizations follow them? How will compliance be monitored?

‘Some experts suggested that governmental authorities should set overall requirements

_and standards; others recommended writing into contracts, on a case-by-case basis and

with clear incentives, the expectation that providers and managed behavioral health care

organizations conduct outcome assessments and use them to improve the quality of care.

Still others argued that it is primarily a matter of educating communities and organiza-

tions to recognize the importance of outcome measurement.

| Include consumers at all levels of planning and implementation. Meaningful discus-

sions among stakeholders can only proceed if all groups are at the table; if language is

non-technical and readily understood by everyone; and if the outcomes studied are relevant

to all constituencies. Outcome data alone are not enough to guide decision-making: there

must also be ongoing conversations among stakeholders to interpret the data, understand

_its implications, and decide how to use the information. An outcome measurement and

‘accountability system cannot operate successfully unless there is ‘buy-in’ from all those

affected.

Ensure scientific rigor. Although outcome systems (as opposed to outcomes

research) are practical, real- world tools for providers, consumers, and administrators

of mental health care services, the experts urged developers to make use of what has

been learned through experimental study. This includes choosing reliable and valid assess-

ment instruments, using appropriate sampling and statistical methods, and adhering to

accepted canons of interpretation. There are dangers in misrepresenting the meaning of

outcome data. Although a variety of domains and indicators are considered relevant to

Outcomes measurement, and although there are many good instruments available,

experts cautioned developers to understand better the real meaning of these domains,

identify overlap and gaps, and determine whether indicators and measures accurately

and completely address the issues.

Use outcome data carefully. Experts highlighted the value of outcomes data for

improving treatment programs. They cautioned, however, that before investing heavily

in program and system changes, stakeholders needed to carefully consider the limita-

tions of the outcome analysis: Were observed changes (e.g., in symptoms and level of

functioning) significant and meaningful? Was the follow-up period long enough? Did

the study adequately describe the process of care, the nature of the services, and the charac-

teristics of service providers and recipients?

Ensure ethical rigor. The field should develop explicit ethical guidelines and standards

for organizations to ensure the integrity of outcomes data and the privacy of the individ-

uals from whom the data were collected. It is essential to include all stakeholder groups

in this process.

142 MEASURING OUTCOMES OF MENTAL HEALTH CARE SERVICES

Expand the focus of outcome measurement. It is time to identify outcome measures

and develop outcomes systems for special groups of consumers, including children,

geriatric, and culturally diverse groups. Special attention is needed to develop measures

for consumers with complex conditions such as combined mental illness and substance

abuse or medical conditions.

Conclusion

Outcome measurement provides important opportunities for improving the quality

of care for people with mental illness and there families—if measurement systems meet

the needs and interests of all stakeholders, if data are collected and analyzed according

to rigorous scientific standards, if information is accurately reported in ways accessible

to all users, if outcome assessments are culturally relevant and ensure the privacy of all

persons on whom data are collected, and if outcomes are integrated with clinical guide-

lines and other measures of clinical and system performance.

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Journal of the Washington Academy of Sciences,

Volume 85, Number 1, 144-153, December 1998

Mental Health Report Cards

Meryl Friedman, Sarah Minden, John Bartlett, Vijay Ganju,

William D. Gettys, Marilyn J. Henderson, Caroline Kaufman,

Ronald W. Manderscheid, Margaret O’ Kane, John Pandiani,

L. Gilberto Romero, E. Clarke Ross, Deborah Teplow

The Role and Value of Report Cards

Report cards are tools for measuring the performance of health care systems and

providers. They allow for the evaluation of specific aspects of performance including,

but not limited to, quality, access to services, consumer satisfaction, cost-effectiveness

and consumer outcomes. Report cards may include performance measures of the

structures of an organization (e.g., the existence of a quality assurance committee), the

processes by which it functions (e.g., its methods to ensure review of, and compliance

with, guidelines for care), and the nature of the outcomes of the care it provides (e.g.,

improvement in a person’s ability to function).

At present, there is no consensus on what constitutes a “good” report card. There

is agreement, however, that report cards have positive value and play an important role

in fostering the public accountability of managed care organizations. Report cards should

address issues that are measurable, specific, and relevant to the needs of consumers and

purchasers of services.

Ideally, report card data should compare the performance of managed care organi-

zations to each other and compare an individual organization’s performance to estab-

lished standards—either those that experts agree are “best practices” or those that research

has shown to be associated with desirable outcomes. Standards should be evidence-based

and unequivocally related to improving patient care.

It is important to distinguish between report cards and performance measurement

data sets. Performance measurement data sets, from which report cards evolve, are broader

in scope and typically used by accreditation agencies to evaluate managed care organi-

zations. They are also used by the organizations themselves to improve their perfor-

mance. Report cards, by contrast, are aimed at consumers and purchasers of care to help

them judge the relative performance of managed care organizations and choose among

them. For example, while the Health Plan Employer Data and Information Set (HEDIS)

developed by the National Committee for Quality Assurance (NCQA) includes a wide

variety of performance measures that evaluate many aspects of a managed care organi-

zation’s performance, it is not published in a format that facilitates comparisons

between organizations, and, therefore, is not a report card. Compared to performance

MENTAL HEALTH REPORT CARDS 145

measurement data sets, report cards contain fewer measures, address issues of partic-

ular relevance and interest to consumers and purchasers, and present data in a more user-

friendly format.

| Report cards, however, may be generated from performance measurement data sets.

Indeed, there have been efforts across the country, such as that by the New England

HEDIS Coalition of health plans and purchasers in New England, to publish data from

performance measurement data sets in report card formats that are easy for non-special-

ists to understand and that allow for comparisons across organizations.

The Current State of Report Cards

In both the public and private sectors, major initiatives are underway to develop

report cards. In collaboration with the Center for Mental Health Services (CMHS), the

) Mental Health Statistics Improvement Program (MHSIP) established a number of task

- forces to address issues of measuring performance. In 1994, the Task Force on the Design

_ of the Mental Health Component of a Health Plan Report Card under National Health

Care Reform (MHSIP, 1993; MHSIP, 1994) developed a comprehensive set of perfor-

mance measures that emphasized consumer-oriented issues; a second task force was

convened in 1995 to further refine the report card. The MHSIP report card addresses

key dimensions or domains of care including access, appropriateness, outcomes,

_ prevention, and consumer expectations; it includes outcome measures, is research-based,

and tries to minimize cost and respondent burden (MHSIP, 1996). MHSIP’s work differs

from other report card efforts in its clearly articulated values and emphasis on concerns

related to serious mental illness. Its orientation toward consumers is unique in report

_card efforts, since most performance measurement systems are designed for managed

care and provider organizations and for purchasers of services.

The American Managed Behavioral Healthcare Association (AMBHA) is a profes-

sional association comprised of leading managed behavioral health care organizations

that collectively provided managed mental health and substance abuse services to more

than 80 million people in the United States in 1995 (AMBHA, 1995). AMBHA devel-

oped a report card to establish an industry-wide database for policy and benchmarking

_ purposes and to facilitate performance evaluation of its member organizations (AMBHA,

1995; Panzarino, 1995). This measurement system, known as PERMS — Performance

- Measures for Managed Behavioral Healthcare Programs — reports on three domains

of care: access, consumer satisfaction, and quality. In addition, AMBHA stated three

key principles for creating report cards: measures have to be meaningful, measurable,

and manageable. AMBHA sees report card development as an active, ongoing work-

in-process rather than a one-time effort.

The National Alliance for the Mentally II] (NAMI) recently published a report card

146 MENTAL HEALTH REPORT CARDS

for managed behavioral health care organizations (Hall et al., 1997). NAMI developed

standards for critical components of a system of care for treating and managing serious ||

mental illness, and surveyed managed care organizations to assess their performance |

in each area: treatment guidelines and practice protocols; intensive case management h

according to the Program for Assertive Community Treatment model; access to the | |

newest, most effective medications; response to suicide attempt; involvement of |

consumers and family members; outcome measures and management; rehabilitation; |

housing. The report card presents the responses of nine managed behavioral health care —

organizations to the survey and concludes that managed care has failed in its promise |

to provide “a truly accountable, comprehensive, community-based system of care.’ (Hall

et al., 1997) The report also expresses concern about the treatment of persons with severe |

brain disorders. The authors of the report acknowledge its limitations noting that there |

were no Site visits, no assessment of consumer outcomes, and that the survey was the |

only source of information.

The work of influential national organizations such as NCQA, and development |

and refinement of performance measurement data sets such as HEDIS, create a culture |

that supports measurement and continuous quality improvement, and thereby facilitates |

report card efforts. In such a culture, limitations and obstacles to high-quality care are |

seen as opportunities for change rather than “mistakes” or “defects.” Large-scale perfor- |

mance measurement efforts ensure development of the infrastructure and technical |

capabilities to conduct both organizational and consumer-oriented measurement activ- |

ities in an efficient and cost-effective manner. Therefore, it is encouraging that NCQA,

originally focused on measuring general health care services, has now begun to |

measure the performance of plans that deliver mental health and substance abuse services _|

and to add mental health and substance abuse indicators to HEDIS. For example, NCQA |

has completed approximately eight mental health reviews. Rather than accreditation :

reviews, these evaluate an organization’s processes in regard to access to and availability

of mental health services and triage. In addition, NCQA has formed a Behavioral

Health/Substance Abuse panel that includes representatives from both the public and

private sectors to address issues in evaluation of access to, appropriateness of, and

outcomes for mental health care. To date, 21 behavioral health/substance abuse indica-

tors have been identified, and six to eight measures for these indicators will be incor-

porated into HEDIS 1999. Specific measures under evaluation include adequacy of |

pharmacotherapy, provision of family and social support services to families with adoles-

cents with mental health or substance abuse problems, and member satisfaction with

mental health services. |

Performance measurement data sets can be a useful starting point for developing

consumer- and purchaser-oriented report cards. For example, the Agency for Health Care

Policy and Research sponsored development of the Consumer Assessment of Health

Plans (CAHPS) which built on NCQA’s annual members survey that was part of HEDIS

MENTAL HEALTH REPORT CARDS 147

3.0. CAHPS is “an easy-to-use kit of survey and report tools that provides reliable and

valid information to help consumers and purchasers assess and choose among health

plans.” (Agency for Health Care Policy and Research, 1997) Although not specific to

_ mental health care, it is an exemplary system that “yields results that are applicable to

all plan types [and] a wide range of respondents”; presents information in “clear and

_ easy-to-understand formats” through reports that “educate consumers about making health

99, 66

plan choices and guide them through the decisionmaking process”’; “can focus on results

_ that are of personal interest’; and includes free technical assistance for users.

Other large groups of providers, employers, managed care organizations, and

researchers have combined efforts to produce performance measures that may affect

development of report cards. These include the Consortium Research on Indicators for

System Performance (CRISP) initiative, the Foundation for Accountability (FACCT),

the Employee Health Care Value Survey (EHCVS), the HMO Quality Assessment

Consortium, and the Medicare HMO/CMP Review Performance Measurement (MHSIP,

1994). Individual health plans have begun disseminating the HEDIS measures or their

own consumer report cards; local coalitions of employers and consumer organizations

_ have developed standards and published guides that compare performance of physicians,

_ managed care organizations, and hospitals (National Health Policy Forum, 1994).

~ Issues Related to Developing Report Cards

The key issues that affect mental health report card development efforts include

standardization, confidentiality, interpretation of data, and consumer choice.

Standardization

Standard data definitions, uniform data collection procedures, and accepted analytic

methods are essential if comparisons across managed care organizations are to be valid.

For example, to compare outpatient follow-up rates after hospitalization, data must be

collected on populations that are similar with respect to demographic and clinical charac-

teristics and be based on a uniform definition of “follow-up” (e.g., the specified length

of time between discharge and first outpatient visit). Similarly, for comparisons of utiliza-

tion, treatment retention, or outcomes, populations at-risk and populations receiving

services must be defined consistently across organizations.

Some expert panelists argued that report cards will not be of much use until there

is a uniform data infrastructure consisting of a minimum set of data elements, standard-

_ ized data collection specifications, and analytic guidelines. Others felt that there is value

in beginning to collect and use data now, before we have comparable measures and

rigorous methods, because, at the very least, we will be moving these complex and diffi-

cult measurement efforts forward. They believe that using some simple measures now

148 MENTAL HEALTH REPORT CARDS

(e.g., estimating access to services by asking consumers whether they were able to obtain

the services they needed) is better than using none at all.

Panelists commented that critics of report cards insist that measuring the quality of

mental health services is more subjective than evaluating the quality of physical health

services and that it is much more complicated to assess the impact of psychotherapy

than it is to determine the outcome of a surgical procedure. They responded that objec-

tive measures for mental health care do, in fact, exist and that new ones are continually

being developed. They pointed to psychiatric hospitalization rates, mortality rates, and

percent of providers who utilize and conform with mental health practice guidelines as

examples of objective measures, and noted that the mental health field leads other areas

of medicine in its standardized symptom rating instruments and diagnostic interview

schedules. Panelists also indicated that there is value in asking a question as elemen-

tary as whether a person felt that he or she functioned better as a result of treatment.

Gelber and Duggar (1995) have sounded a warning: “the uncontrolled prolifera-

tion of report cards and performance standards...threatens to become a torrent that could

drown both the managed care systems themselves and the consumers who are the intended

beneficiaries of the standard-setting initiatives.” Instead, the present situation offers the

opportunity for greater dialogue among stakeholders and consensus-based development

of uniform and standardized approaches.

Confidentiality

Confidentiality is a critical issue for both consumers and providers. Many consumers

are concerned that information they reveal about themselves may at some time be “used

against them” by a managed behavioral health care organization, insurance company

or health care provider. As a result of such concerns, consumers may limit what they

disclose. Even where no breach of privacy is intended, when sample sizes are small,

advocates point out, there is a real possibility for determining a single individual’s identity.

(Ziglin, 1993; Ziglin, 1995)

The need for confidentiality, however, must be balanced with the need for infor-

mation. Without collecting data to measure performance, we cannot hold managed care

organizations and service providers accountable for their practices or determine where

and what kind of improvements are needed. Therefore, although there is some risk to

privacy with any disclosure, many consumers and advocates feel that it is warranted—

if appropriate procedures are established to ensure the confidentiality and security of

the data— given the importance of obtaining data that supports informed choices and

enhances accountability.

Interpretation of Data

Accurate interpretation of report card data requires attention to background infor-

mation on the population and organizations being studied. It also requires technical data

MENTAL HEALTH REPORT CARDS 149

analytic skills, commitment to scientific rigor, and inclusion of the perspective of all

stakeholder groups in the interpretive process. Analysts must clearly inform users of

the strengths and limitations of the data and avoid exaggerated or misleading claims.

_ They must not draw conclusions about aspects of quality that are beyond the scope of

the particular measures used in the report card. Report card data should indicate clearly

which aspects of care are being measured. Experts agree that “bellwether” measures

that support conclusions about quality more generally would be valuable, but such

measures do not currently exist for mental health services.

Report card users, themselves, need to be educated to use this information wisely

— to know what conclusions can be drawn from the data and what cannot. For example,

users should recognize that at the current stage of development of performance indica-

tors, it is impossible to attribute specific consumer outcomes to the delivery of partic-

ular services: many factors can influence an individual’s response to treatment.

Consumer Choice

As use of report cards increases, consumers will become aware of data on managed

care organization options that are not available to them. Consumer representatives have

been frustrated when presented with report card data on organizations that are not offered

by their employers or government purchasers that perform better than available choices.

Needs of Different Constituencies for Report Cards

Several constituencies require report card data: consumers, families, managed behav-

ioral health care organizations, providers, and public and private purchasers of care.

Depending on the constituency, different types of performance indicators and analyses

are needed.

Some experts noted that because constituencies vary in their needs for and use of

data, it is difficult to develop a report card that would be useful to all audiences. Others

felt that all constituencies are concerned with the same issues of quality, cost and

outcomes, and, although the emphasis may depend on the needs of a particular group,

the common concerns could be addressed in a single report card. One solution, they

agreed, however, was to develop a core set of items for all groups that could then be

expanded by adding questions or measures to address particular concerns or issues. It

is important, then, to understand the uses of report card data by different constituen-

cies and to think creatively about how to provide each one with the essential data it needs.

Consumers and Families

For consumers and families, report card data provide information on plans and

providers to allow for informed selection among alternatives. In addition to choice among

150 MENTAL HEALTH REPORT CARDS

plans, report card data can be used by consumer and family advocates to negotiate and

press for improved access to services and quality of care within plans. Report card data

showing outcomes compared to benchmarks, or to outcomes obtained by other plans,

provide consumers, families, and purchasers with the information they need to focus

and support their positions in contract and benefit negotiations and in monitoring perfor-

mance. The data, in turn, guide the plans toward the kinds of changes in access and quality

that consumers and purchasers want.

Routine use of report cards is both supported by and reinforces accountability of

managed care organizations and providers; it encourages quality improvement. Advocates

assert, however, that some report cards are so technical that consumers and families cannot

understand them.

Use of report cards by consumers can be enhanced by involving consumers early

in the development process so that they can participate in developing a user-friendly

product that responds to their needs. Consumers and families should advise on data

elements, interpretation, and format of presentation. The Massachusetts Division of

Medical Assistance, for example, conducted focus groups to hear the opinions of

consumers on different data elements and formats.

Report card developers should attend to cultural issues. Consumer and family repre-

sentatives recommend that report cards be published in the preferred languages of

consumers. They also stress that cultural sensitivity goes beyond language preference

to include a more general responsiveness to cultural beliefs and ways in which culture

affects utilization of services.

Report cards should address consumers’ and families’ specific needs. Report cards

should be designed to address their questions and to do so in ways that are easily under-

stood. They need to take into account the varying levels of linguistic and quantitative

skills in the population.

Purchasers of Care

Performance data from report cards can help those responsible for purchasing health

care coverage make informed decisions on behalf of employees, retirees or beneficia-

ries of government programs. Like consumers, purchasers need data presented in ways

that allow accurate and complete understanding of plan performance. Given the large

number of covered lives and the associated dollars, public purchasers are in an excel-

lent position to demand particular types of performance measurement data from the

marketplace, and therefore can influence development in this area. Once data are

produced, public purchasers can influence enrollment in managed care organizations

and quality improvement activities by distributing report card data within state and Federal

government agencies and to advocates, consumers, and other purchasers of care.

Public purchasers can also have a significant impact by promoting responsible use of

MENTAL HEALTH REPORT CARDS 151

this type of information and by leading efforts to explain the strengths and limitations

of report card information to ensure credible comparisons.

Providers

| In addition to system-level data that elucidates a managed care organization’s overall

performance, report card data allow individual providers to compare their performance

to that of other providers in the organization or to established benchmarks. Recognizing

the importance of studying provider-level data, many managed care organizations have

begun to distribute reports to individual providers displaying the provider’s performance

‘relative to colleagues and other normative data. For example, “Healthy People 2000”

has been cited as a benchmark against which to judge a managed care organization’s

| preventive immunization rates. A report card can compare individual performance to a

standard applicable to all managed care organizations or to an internally-referenced data

point (e.g., the average rate within the upper quartile of performance).

Providers have voiced concern, however, that when managed care organizations

evaluate an individual provider’s performance, they do so against aggregated data from

such a small number of providers that the limited statistical power makes it impossible

to draw valid conclusions regarding the individual provider’s performance. Others

disagree, arguing that such comparisons are an important aspect of continuous quality

improvement within an organization.

Managed Behavioral Health Care Organizations

Through report cards, the performance of managed care organizations is publicly

compared to that of their competitors. To the extent that report cards influence

_ purchasing decisions, they have enormous financial implications in this competitive arena.

Report card data are considered newsworthy by the media whose comments about an

organization’s performance could significantly help or harm its reputation and market

position.

Next Steps in Report Card Development

To make report card data available to the constituencies that most benefit from such

information, several next steps should be considered:

Standardize data collection. Standardized data collection can ensure the availability

of more complete, accurate and comparable data across managed care organizations.

‘Consensus on a minimum data set for report card data would enhance the value of the

information.

| Use existing data sets. Arguing that “the perfect is the enemy of the good,” most

experts endorse maximizing the use of existing data sets. While these may not be perfect,

152 MENTAL HEALTH REPORT CARDS

reporting efforts completed with available data will help move the field forward.

Stakeholders should not wait for the ideal data specifications and analytic methods that

will produce perfectly comparable data.

Identify users. It is necessary to identify potential report card users and better under-

stand their particular needs for data to ensure that all who need performance data will

be able to obtain the right type of information in a usable format.

Establish a forum. An ongoing forum is needed to discuss issues relevant to the

production and dissemination of report card data. Such a forum should begin by

defining the public interest and move to promoting development of increasingly

meaningful performance indicators and report cards for consumers. The forum should

include the range of report card users and facilitate their discussion of key issues.

Educate users. Methods need to be developed to educate users on technical issues

so that they can understand and use report cards in a meaningful way.

Institute a public health approach. Report card efforts have thus far focused exclu-

sively on use of and quality of services. There is now a need to take a public health

approach to mental illness and address the needs of communities and populations. Report

cards should expand their gaze beyond acute care and treatment settings to evaluate the

quality of prevention and early intervention programs. They should broaden their study

of access to care by examining not only the use of services in a community but also the

population’s knowledge of and attitudes toward mental illness and treatment and its aware-

ness of available services.

References

Agency for Health Care Policy and Research. (CAHPS). (1997). Consumer assessment of health plans. AHCPR

Pub. Nos. 97-0001 and 97-RO13.

American Managed Behavioral Healthcare Association (AMBHA). (August 1995). Quality improvement and clinical

services committee. Performance measures for managed behavioral health care programs.

Gelber, S., & Duggar, B. Performance standards: Measurement tools for managed mental health and substance

abuse programs. Special Report. Division of Planning and Policy Implementation. Office for Policy and Program

Coordination. Substance Abuse and Mental Health Services Administration. October 1995.

Hall L. L., Edgar E. R., & Flynn L. M. (1997). Stand and deliver: Action call to a failing industry. The NAMI

managed care report card. Arlington VA: National Alliance for the Mentally Ill.

MHSIP Task Force on the Design of Performance Indicators Derived from the MHSIP Content. Performance indica-

tors for mental health services. Values, accountability, evaluation, and decision support. Final report. June 1993.

MHSIP Task Force on Design of the Mental Health Component of a Health Plan Report Card Under National

Health Care Reform. Progress Report. Draft. May 1994.

MHSIP Mental Health Report Card Phase II Task Force. Progress Report. June 1995.

MHSIP Task Force on a Consumer-Oriented Mental Health Report Card. Final report. April 1996.

Mulkern, V., Leff, H. S., Green, H. S., & Newman, F. (1995). Performance indicators for a consumer-oriented

mental health report card: Literature review and analysis. Draft report. April 1995.

National Health Policy Forum. (1994). Grading the graders: Using ‘report cards’ to enhance the quality of care

under health care reform. Issue Brief No. 642.

Panzarino, P. (1995). Behavioral healthcare report card indicators: AMBHA (American Managed Behavioral

Healthcare Association) begins to define standards for accountability. Behavioral Healthcare Tomorrow, 4:

49-50.

HEADER 153

Ziglin, A. L. (1993). The importance of unique client identifiers in the public sector mental health service delivery

system. Report prepared for the Mental Health Statistics Improvement Program.

Ziglin, A. L. (1995). Confidentiality and the appropriate uses of data. Report prepared for the Nebraska Department

of Public Institutions and the Center for Mental Health Services. May.

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; Ve S17 eec ae pe ss VOLUME 85

< N Le. re: Number 2

Journal of the ; | ss December, 1998

ISSN 0043-0439

Issued Quarterly

at Washington, D.C.

CONTENTS

Articles:

Robert Simon, Padmavathi Mundur, Arun Sood,

“Access Policies for Distributed Video-on-Demand Systems” ................. 155

Susanne Furman, Debarah A. Boehm-Davis, Robert W. Holt,

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Washington Academy of Sctences

Founded in 1898

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President

Cyrus R. Creveling

Secretary

Michael P. Cohen

Treasurer

John G. Honig

Past President

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Clifford Lanham

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Phil Ogilvie

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W. Allen Barwick

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Peg Kay

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Centennial Committee

Eric Rickard

Grover Sherlin

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Academy of Sciences, (202) 326-8975. Periodicals postage paid at Washington, DC and additional

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Special Centennial Issue

of the

Journal of the

Washington Academy of Sciences

This is the second of two special centennial issues of the Journal, published as part

of our 100th year celebratory activities. These were envisioned as special issues in that

the papers in each issue would focus on, or in some way be related to, the centennial

theme: Communications, Past, Present and Future — Within and Among Entities in the

Biological Hierarchy of Life.

: The multidisciplinary origin of the Washington Academy of Sciences has given the

Journal an eclectic image, with a wide variety of subjects and authors appearing over

the years. That diversity is reflected in this issue — a paper by Simon et al. looks at the

emerging technology of Video-on-Demand; and Furman et al. explore communication

-among computer programmers via the programs that they write and modify.

Also, we take much pleasure in recognizing over 100 high school authors who took

the challenge to prepare a paper for our essay contest, and especially the six winners

who were chosen to be included in this issue.

On behalf of all members of the Academy, I thank each of the authors of this issue

for providing us with their view into our centennial theme.

Thomas Bottegal, Ph.D.

Editor

burnal of the Washington Academy of Sciences,

folume 85, Number 2, 155-176, December 1998

Access Policies for Distributed

Video-on-Demand Systems

Robert Simon, Padmavathi Mundur and Arun Sood

Department of Computer Science

George Mason University

| Fairfax, VA 22030

| Abstract

Distributed Video-on-Demand (VoD) systems that deliver digitized video directly to users are expected

to become one of the most important types of communication technology enabled by the next gener-

| ation of computer networks, video servers and distributed multimedia systems. This paper discusses

some of the challenges posed to computer science in VoD design and implementation. In a VoD system,

tight coordination among all subsystems 1s required for real-time performance. We argue that a central

| part of any coordination strategy should be end-to-end threshold-based admission control policies.

End-to-end admission control policies determine if adequate resources are available along the entire

service path of a new video requests so it can be admitted without violating the real-time performance

requirements of the requests already in service. Threshold-based policies provide a way of assigning

higher priority to selected classes of requests based on their relative importance, such as popularity.

This is accomplished by imposing a threshold on other classes, thereby restricting access to system

resources for those lower priority classes. This paper presents an analytical model to evaluate such

threshold-based admission control strategies for distributed VoD systems with multiple classes of video

| programs. We prove the existence of computationally efficient ways of determining blocking proba-

bilities for newly arriving requests. Through numerical analysis we show that threshold-based policies

offer better performance for selected high-priority video classes.

1. Introduction

The rapid evolution of technology and communication protocols for high speed

networks coupled with advances in computer, storage, and display hardware and

software has paved the way for new types of distributed multimedia applications. These

applications allow users great flexibility in deciding what kind of information to obtain

or exchange, and when to obtain or exchange it. This freedom represents a break from

traditional types of mass communication using broadcast medium, such as radio or TV,

where the providers and content distributors decide what to send and when to send it.

The user-centric aspect of distributed multimedia applications represents an entirely new

mode of mass communication.

One of the most important types of emerging multimedia applications are distrib-

uted Video-on-Demand (VoD) systems. A distributed VoD system delivers high quality

digitized video directly to viewers. A fully realized VoD system is extremely powerful

156 SIMON, MUNDUR, SOOD

and flexible because it permits users to decide when, where and what to watch. By unteth-

ering viewers from content distributors, VoD offers a prime illustration of some of the

creative possibilities offered by distributed multimedia.

Designing and implementing a distributed VoD system poses significant challenges

for computer scientists and engineers. This is because, unlike most existing distributed —

computer communication systems, delivering digitized video to users requires tight coordi- |

nation of all subsystem components, from files servers and I/O systems, to computer |

networks, to end-user presentation devices. Such coordination is needed because of the |

stringent real-time performance and synchronization requirements of video applications |

and the enormous amount of data present in video objects. A central part of this coordi- |

nation strategy is the development of an appropriate set of admission control policies. |

There are two levels of VoD system admission control. The first at the subsystem level, .

including admission control policies for a video file server. This type of policy may ensure —

that a request for playing a new video will only be granted if bounds on retrieval latency |

can be guaranteed without violating the performance requirements of other videos already |

in service. The second level of admission control policy is end-to-end. End-to-end admis- |

sion control strategies determine if adequate resources are available throughout the entire |

path of system resources required by the new request so the request can be admitted |

without violating the continuous playback requirements of the requests already in service. |

This paper discusses the design and analysis of a distributed VoD system in the context |

of developing end-to-end admission control policies. The successful deployment of a

widely available VoD system is to a large extent contingent upon the successful

development of end-to-end admission control policies and methods. Our focus is on the |

development of an analytical framework to evaluate various priority or threshold based |

admission control policies. Using this framework we identify appropriate performance

measures, such as system throughput under a variety of demand levels, for evaluating

the effectiveness of different policies. The results of our analysis provide the necessary

techniques with which to perform capacity planning, match user needs to equipment

investment, and guide policy evaluation strategies. We also show the existence of efficient

quantitative techniques to compute these performance measures. These performance |

measures are necessary in order to effectively deploy all large scale distributed systems

(Menasce, Virgilio, Almeida, and Dowdy, 1994). |

To make this work concrete, we use the design and implementation of a VoD system |

on the scale of a hypothetical county-wide school system. While the entertainment |

industry represents a huge market for future VoD services, we believe that VoD systems

can have a critical impact on the quality of services provided by many types of organi-

zations, such as educational institutions, business marketing and training, and internal |

corporate communications. VoD deployed at the level of a school system can be used |

to distribute lectures, provide teacher training material and show movies or shorter video |

}

VIDEO-ON-DEMAND SYSTEMS 157

| clips of educational or cultural value. A major attraction of such a system is its flexibility.

| Teachers and students select when, where and what kind of videos to watch.

Videos can be viewed by larger audiences in a classroom or lecture room setting

| via TV sets or video projectors, or individually via desktop and laptop computers. Using

the school system as an example, we present numerical analysis which shows the effect

of threshold-based admission control on system throughput. Our analysis and numer-

| ical results clearly show the need for well designed admission control policies for effec-

tively deploying VoD systems.

The paper proceeds as follows. Section 2 explains how VoD systems could be used

by a typical school system. We also describe current and emerging technologies which

enable VoD, including issues with respect to video server design and networks, along

_ with compression technology. Section 3 develops an analytical model for our school VoD

system. We prove that efficient algorithms exist for calculating these performance

| measures. In Section 4, we present numerical analysis to show that threshold-based policies

result in lower blocking rates for selected classes of requests, as compared to a naive

admission control policy. Section 5 offers some observations and a conclusion.

2. Distributed Video-on-Demand Systems

This section describes system architectures, enabling technologies, and issues in

designing admission control policies for distributed Video-on-Demand systems. These

topics are illustrated in the context of a hypothetical VoD system designed to serve the

needs of a county wide public school system. We call a system of this type School Video-

on-Demand (S-VoD).

System Architecture

Figure | shows the overall S-VoD system architecture. The central repository, or

Archival Server (AS), provides high capacity long term video storage. The server is

connected via a network to school system sites. This network is used to download videos

directly to a high speed video server within each site. The videos are downloaded to a

particular site upon a user request from that site. Figure 2 shows the S-VoD distribution

system inside a typical school system site. Videos are stored locally on a smaller but

faster server, called a Video File Server (VFS). VFSs have network connections to the

central AS. A VES is a high speed file server capable of real-time delivery of multiple

streams of digital video. The VFS transmits to video display stations via set-top boxes

and PCs, over a Local Area Network. VFSs have lower storage capacities than an AS.

A user requests a particular video via system software. Since PCs and set-top boxes

_ do not have sufficient capacity to store entire video clips, the video is transmitted directly

158 SIMON, MUNDUR, SOOD

from the VFS into the display device via the school sites LAN. If the requested video

is not present on the VFS it needs to be obtained from the AS. An overview of S-VoD |

operations follows:

e Video clips are stored in compressed form on VFSs and/or at the archive server. |

¢ An admission control test is performed by the system for each new viewing request. |

The outcome is either to accept the request and retrieve and display the video, |

or to reject the request. |

Elementary

High ie School

School

Video

Network Nodes Archive Communication Links

Server

(AS)

Training

Center Administrative

Offices

Figure |: The architecture for a hypothetical Video-on-Demand system for a county wide school

district. The system stores videos in a central repository called an Archival Server (AS). Videos

are delivered to different locations via a computer communication network.

e If the video is present on the archive server and not on the local VFS, the video

is downloaded to the VES.

¢ Once the video data is on the VFS it is continuously retrieved from the VFS and |

transmitted over the network to the set-top boxes or appropriately-equipped PCs.

e The received video data is decompressed at the set-top boxes and displayed at

the receiving sites.

In the next section, we discuss the technologies that enable our S- VoD system such

as compression, storage and retrieval at the servers, transmission over networks, and

decompression at the set-top boxes.

VIDEO-ON-DEMAND SYSTEMS 159

2.2 Enabling Technologies

2.2.1 Compression

Video data is typically stored and transmitted in compressed form. A compression

method for color video reduces the amount of space required to digitally represent chromi-

nance and luminance values. This space reduction is usually obtained by several

processing steps. Typically, a video frame is divided into square blocks of pixels. This

block then undergoes a frequency domain transform step, a quantization step, and a

Classroom {_ 4th Su

specs 7

See , .

ws \

/ \

| School-wide

Multimedia | Local | Cl

Bae gedit i. oy z peerimieins Sei assroom

is Area

\ Network j

ee» 7

Video File Server (VES)

SA ee

Network Connection

to Archival Server

Figure 2: Individual school system sites store local videos for playback on a Video File Server

(VES).

compression step. Further compression is achieved by removing redundant informa-

tion between frames, e.g., if the background in a scene does not change, there is no need

to store the background for each frame. The primary advantage of compression is there-

fore space savings.

The amount of space savings resulting from compression depends upon the partic-

ular technique employed, and can vary from 2 or 3 to 1 to over 100 to 1. Popular compres-

sion standards include H.261, for video coding over ISDN lines, different Motion Picture

_Expert Group (MPEG) standards, such as MPEG-1, MPEG-2 and MPEG-4, and

H.263, for very low rate video encoding. Compression standards also vary dramatically

160 SIMON, MUNDUR, SOOD

in terms of output quality. For instance, the normal resolution of an MPEG-1 frame is

320 by 240 pixels, while for MPEG-2 the resolution is 720 by 480 (Rao and Hwang, |

1996). For our S-VoD system, the compression technique determines the required level _

of system storage and system throughput. MPEG-1 requires 1.5 Mbps, while data rates _

for MPEG-2 vary anywhere from 3 Mbps to 100 Mbps.

2.2.2 Video File Servers

Continuous media, such as audio and video, has spatial, temporal and performance |

constraints not present in textual data retrieval and transfer. Video file servers must offer |

high storage capacity, low latency retrieval and a high data transfer rate. There are several |

ways to achieve a cost effective solution to these design problems, including architec- |

tural solutions such as faster and larger disks and hierarchical configurations of |

secondary and tertiary devices that distribute the load within and across different levels _

(Brubeck and Rowe, 1996).

Server design research has focused on finding efficient storage techniques that

minimize the overhead related to the retrieval of multimedia data and maximize the number _

of concurrent requests. Since disk transfer rates are significantly higher than single stream |

real-time data rates, it is possible to serve multiple requests simultaneously. This |

requires disk head scheduling policies which guarantee continuous and synchronized |

data retrieval. In particular, it is essential that the disk scheduling policy for data retrieval |

does not starve, even on temporary basis, one video stream in favor of another. A wide

range of disk scheduling algorithms are used to achieve this purpose, including Earliest |

Deadline First, Scan Earliest Deadline First, Grouped Sweeping Scheme (GSS) and |

Round-robin. These algorithms typically require an admission control test before the

video stream goes into service. Once the request is accepted these scheduling algorithms

ensure real-time, continuous and starvation-free retrieval (Gemmell, et al, 1995) (Yu,

Chen and Kandlur, 1992).

The effect of requiring admission control for video server access is to place a limit |

on the number of simultaneous requests that can be handled at the VFS. Different types

of admission control tests are possible. For instance, deterministic admission control strate-

gies are based on worst case assumptions regarding service times, while statistical admis-

sion control strategies typically use a stochastic characterization for service load and perfor-

mance reliability (Chang and Zakhor, 1994) (Vin, Goyal, Goyal, and Goyal, 1994).

In addition to disk scheduling methods, data placement and retrieval techniques are

important, since a multimedia data stream is stored as blocks on a disk. Because of presen-

tation continuity requirements the placement of video data blocks on a disk is critical.

This problem is exacerbated by the presence of multiple video streams. Techniques used

to solve the block placement problem include random, contiguous, and constrained block |

placement (Rangan and Vin, 1993) (Vin and Rangan, 1993). Use of these policies involves

VIDEO-ON-DEMAND SYSTEMS 161

different tradeoffs and considerations. For instance, random block allocation is common

in storage server architectures, but may not guarantee support for continuous retrieval,

because average or worst-case access and latency times of successive block retrieval may

be too large. This forces the use of complex buffer management methods in order to

nullify the variation in retrieval time. Contiguous block allocation guarantees contin-

uous retrieval, but results in disk fragmentation and wasted space. Constrained block

allocation can be used to satisfy the real time playback requirements of multiple video

streams through block placement and interleaving strategies. These policies also result

in simpler buffer management procedures. The drawback is that constrained block alloca-

tion policies require detailed knowledge of characteristics of video data for a particular

clip or movie.

Hierarchical storage consisting of secondary and tertiary storage devices are

essential for meeting large storage requirements of a VoD system. Secondary storage

devices at the VFS may consist of regular hard disks or RAID devices. While it is expen-

sive to maintain all video programs on secondary storage devices, tertiary storage devices

available to each archive server, such as magnetic tapes and optical disks, provide a

cost effective way of storing terabytes of data for a VoD system. These devices are not

suitable for directly servicing concurrent user requests because they typically have low

data transfer rates.

2.2.3 Networks

The network in a VoD system needs to simultaneously serve multiple users. The

networked transfer of data between archive servers and the video file servers requires

the availability of networks with transmission rates on the order of gigabits per second.

These rates are obtainable by high speed, Jntegrated Services Networks (ISNs) such

as Asynchronous Transfer Mode (ATM) or the next generation of the Internet. ISNs

provide reliable and real-time data transfer by reserving and allocating resources for

connections on an end-to-end basis. Connection establishment protocols include the

Resource Reservation Protocol (RSVP) in the Internet, and Q.2931 for ATM (Zhang,

Deenns, et al, 1993).

VFSs are connected to end-user display units (described below) by a Local Area

Network or other type of distribution service. Examples of these distribution networks

include various kinds of Digital Subscriber Line technology using twisted pair wiring

for digital transmission, and computer communication networks such as 100 Mbps

Ethernet and ATM for a LAN environment.

2.2.4 End-user Display Units

The end-user display unit consists of a high resolution workstation or a high-definition

television, an interactive control device, and a network interface. The interactive control

162 SIMON, MUNDUR, SOOD

device could be a set-top box (STB) providing decoding functionality at the user’s |

premises. The video servers are connected to the STBs over a network. They may also |

allow some amount of VCR-like interactive control, such as fast forward and rewind.

A typical architecture of an STB consists of a processing subsystem with an operating

system to manage the STB, a video subsystem to decompress MPEG- 2 type video streams, |

a graphics subsystem for presentation purposes, and an audio subsystem to decode audio |

to synchronize with the video (Furht, Kalra, et al, 1995).

2.3 Threshold-based End-to-End Admission Control

Implementing VoD systems requires the introduction of end-to-end admission control |

policies. End-to-end admission control strategies determine if adequate resources are |

available along the path of the new request so it can be admitted without violating the

continuous playback requirements of the requests already in service. The path includes

both video file servers and communication networks. Threshold-based admission

control policies provide a way of introducing priorities among request classes and distin-

guish between their relative importance. An attractive approach for maintaining certain

performance and throughput levels for more popular classes is enforcing a threshold

on classes that are not as popular. The threshold relates to the maximum number of |

unpopular movies which the system will allow to be supported at one time.

2.4 Video Classification

An S-VoD system will only be used if it can meet viewers demands in a flexible

manner; be reasonably economical; does not require extensive maintenance; and

can accommodate a wide variety of usage patterns. Achieving these goals requires an

accurate viewer model. Our admission control analysis models user habits by classi-

fying types of demands for particular videos. One type of classification is popularity.

In general, VoD systems must support requests for popular videos, 1.e., videos repeat-

edly requested. True VoD systems also must allow access to videos which are relatively

unpopular, and are only occasionally requested. Another classification axis is when the

video is available for playback. For instance, some videos may be produced and

consumed at the same time, similar to broadcast TV. Without loss-of-generality we

identify 3 classes of videos which the S-VoD system must support — archived, first-

time and ad-hoc. These three user classes enable system builders to design the system

to meet anticipated user demand.

Archived videos are videos produced and stored well in advance of their viewing,

are popular, and therefore are used in a semi-predictable way. An example is a 45 minute

video clip demonstrating orbital mechanics which the school system may have

VIDEO-ON-DEMAND SYSTEMS 163

purchased. A high school physics teacher may decide to show this clip at different times

during the semester.

First-time videos are videos stored immediately before their usage. Similar to archive

videos, first-time videos are popular and are requested in a semi-predictable way. An

example of a first time video may arise during a space shuttle mission. NASA may

provide daily status briefings for these missions. Each briefing may last anywhere from

5 to 20 minutes, and can be recorded and distributed digitally to interested school systems

| via satellite, cable TV or computer network. Individual classes could playback the videos

that day during homeroom periods.

Ad-hoc videos are videos whose usage is relatively spontaneous and whose average

usage patterns cannot reasonably be predicted in advance. They may or may not be stored

(or produced) well in advance of their usage. An example of this kind of clip is a high

school English teacher who wants to show an experimental production of a Shakespearian

_ play as an ad-hoc response to a particularly interesting classroom discussion about

alternate staging.

3. S-VoD Analytical Model

| 3.1 Threshold-based Admission Control

| An admission control procedure for all arriving requests is run at the VFS. The proce-

_ dure determines if capacities are available on the VFS and the network to transfer the

| data to the user display devices. If the program needs to be downloaded from the archive

' server, the availability of network capacity for that transfer is checked. In addition to

| the capacity constraints, the VFS assesses further class-based constraints imposed by

the admission control policy.

An admission control policy determines whether an arriving request for a certain

class of videos should be admitted, given the current state of the S-VoD system.

Threshold-based policies provide the means for increasing the number of requested

videos from preferred classes. For example, in our situation we may need to place access

| restrictions on ad-hoc requests (class 3), so we can support more of the semi-predictable

requests (class 1 and class 2). A threshold class-3 policy limits the class 3 requests up

to a specified threshold, and always accepting class 1 and class 2 requests if there is

| available capacity.

| Without loss of generality, suppose there are three classes of requests and the vector

| (721, 2, 73) describes the state of the S-VoD system in terms of the number of class 1

requests, 72], class 2 requests, Ny, and class 3 requests, nN. The state of the S-VoD system

is describable as a state space constrained by capacity. A capacity constraint is defined

by )-;_, m < C where C is the maximum number of simultaneous requests that a

_ VFS can handle. The state space can be further constrained by other restrictions, such

164 SIMON, MUNDUR, SOOD

as when the admission control policy restricts access to one of the classes by enforcing |

a threshold on that class. The state space for a threshold class-3 policy is illustrated in —

Figure 3. The state space is bounded by the three positive co-ordinates and the trian- |

gular plane representing the capacity limitation. The threshold plane on the class 3 dimen-

sion truncates the state space. All the admissible states are within this bounded space. |

The state space, Q2, is defined by |

Q = {(nj1, ne, n3):0< ny < Cand0 < ng < C and0 < nz < ly and: aia Ct

Given the state space of the system based on the admission control policy, we can

identify those states where an arrival is blocked either because of the capacity constraint |

or the threshold. We compute blocking probability using this information. |

| € tlass 2|

[ Max Capracity ]

Figure 3: S-VoD State Space

3.2 Three Class Server Model

Each VFS at a school site has access to a centrally located pool of archive servers.

The video programs will be served only through the VFS. The programs from the archive

servers therefore need to be first downloaded to the VFS. The VFS handles amaximum |

of C’simultaneous requests, primarily determined by the I/O bandwidth of the server.

The VFS acts as C'virtual servers, each of which is serving a request. We assume that

the requests for viewing new videos arrive according to a Poisson distribution and the

service times according to a general distribution. The Poisson assumption for arrival

rates is the standard assumption used in analysis of VoD queueing systems (Li, Wong,

Liao, Qiu, 1996).

The state of the S-VoD system is describable by a Markov chain with a birth-death

process and a state space 2. By using the Markov chain model, the threshold type admis-

sion control policy falls into a class of policies known as coordinate convex (Aein, 1978).

Arrivals or departures are never blocked, except for boundary states, where any further

arrivals are blocked. The advantage of coordinate convex policies is that they give rise

VIDEO-ON-DEMAND SYSTEMS 165

| to product form solutions to the equilibrium state probabilities, from which performance

| measures such as blocking probabilities can be determined.

! There are three classes of requests: class 1 refers to archival programs, class 2 to

) first-time programs and class 3 to ad-hoc programs. Based on this model class 1 and

| class 2 requests are more “important” than class 3, and more of those requests should

| be admitted into the system. We impose a threshold on class 3 requests because we would

| like class 1 and class 2 requests to have access to a larger share of the server resources.

We assume adequate network resources between the VFS and the user display devices,

| as well as to the archive servers. This means that there is no blocking at either the network

| or the archive server level. The VFS is modeled as a single node, multi-server, 3 class

queueing model. The following analytical model evaluates admission control policies

based on different threshold values for class 3 at the video server. Blocking probability

for each class under a certain class 3 threshold value is computed using the approach

below. We first present some model parameters and definitions:

Model Parameters:

dy average arrival rate of request for archival programs (class 1)

A3 average arrival rate of request for ad-hoc programs (class 3)

1/1 | average service time for class 1

1/p12 | average service time for class 2

1/3 | average service time for class 3

| | Cc | maximum number of requests that the VFS can handle simultaneously

ly, threshold for class k, k = 1, 2,3 |

Definitions:

P,, - blocking probability for class | requests

P,, - blocking probability for class 2 requests

P,, - blocking probability for class 3 requests

P(n4,2,n3) - probability of n; class-1 requests and nz class-2 requests

and n3 class-3 requests at the VFS, Spt: ips, ©

(2 - set of admissible states under a given policy for a system with

threshold on all classes,

Q = {(n1, n2, 23): 0 < ny <l,and 0<n2 <I and 0<n3<ls and) -)_ng< C'}

for a threshold class-3 system,

166 SIMON, MUNDUR, SOOD

Q ={(n1,n2, n3):0 < ny < Cand 0< no < Cand0 <7n3 < J3 and pares te Ot

e (), - set of blocking states for class 1 requests

e ()5 - set of blocking states for class 2 requests

e (23 - set of blocking states for class 3 requests

As shown in (Aein, 1978) and (Kaufman, 1981), the equilibrium probability,

i (1, 27, 73), has the following product form:

it 2

P(ny1, n2,n3) = = |] oft /ne!, all (n1, 2,3) € Q (1) |

G k=1 |

where

a= YS Tfatne

(n1,n2,n3)EN kK=1

and

PE= Xr | Lk

The blocking probability, P,,, is given by

Py, = De ¢ P(nyz, n2, 3) — G(Qz)/G (2) |

(n1,N2,N3)EQK

where 62; = { (71, 25, 13)| (M1, No, 13) E 2, (m, M, 1) + oe E Oo} and @; is a vector |

set to (1, 0, 0), (0, 1, 0) or (0, 0, 1), where the 1 is in the 4” position. Q,, Q5, and Q3 |

are the set of blocking states for class 1, class 2, and class 3 requests respectively. |

The cardinality of 62 grows on the order of C k making exhaustive enumeration —

techniques computationally too expensive. Hardware limitations rule out computing G |

for even moderate sized problems. We therefore must develop alternate, computation-

ally efficient methods for computing G. Some previous studies in finding computationally |

tractable solutions for computing G were done in the context of multi-rate circuit switched

networks. For instance, Kaufman (1981) and Roberts (1981) independently developed |

recursive relations to compute the G factor for complete sharing policies. Threshold type —

policies introduce additional blocking states that should be included in the computation

of blocking probabilities. Also, the state space (2 is now truncated according to the threshold

values. Kaufman/Roberts recursion was generalized to compute blocking probability for —

multi-rate tree networks in (Tsang and Ross, 1990). Here we develop a recursion for a |

VIDEO-ON-DEMAND SYSTEMS 167

single node, multi-server, 3 class threshold type system that is similar to the recursion

presented in (Tsang and Ross, 1990) (Mundur, Sood, and Simon, 1998). The recursion

is applicable to one or more classes having a threshold restriction.

The basic idea behind the recursion is summing recursively along disjoint parallel

planes on the diagonal, as shown in Figure 4 for a two-class situation. Since each request

‘requires one server at the VFS, the number of requests present in the system also indicates

the number of server resources being used. From the summing technique,we get a distri-

bution in terms of the total number of servers being used. Denote the total number of

servers used as J = )~;_, ng, and define a state space,

O() = {(n1, n2,n3) ED: ae =p

k=1

The distribution q; indicates the number of servers being used:

Pe Pate, 75), = 0,4, ..8,C (3)

(n1 n2,n3)EO(2)

Aacs i

Figure 4: Planar States for Distribution g;

3 :

») = con) Wet iy i, ==) i . & uO,

Gli) = ,

0 otherwise

‘Multiplying (3) with G and substituting for P (11, 2, Nz) from (1) we get the expres-

sion above for G(z),

168 SIMON, MUNDUR, SOOD

To handle threshold type policies, we define a threshold value which is less than C'to |

limit the number of requests for those classes. Define l, < C’as the threshold for class

k requests. Define for = 1, 2, 3,

Pid daiye=ily)G) hvinly SSC (5) |

JER) |

0 otherwise

B,(1) is the unnormalized probability of being in one of the additional blocking states _

due to the threshold. If no threshold is defined for a particular class, B,(z) for that class |

is 0. The blocking probability P, pi is given by:

Pe (a eae Ol ai ae)

Pee G(C) + ite By,(%) (6) |

| dixo G (i)

To compute blocking probability, we need only calculate the G factor and B,(1), i |

lL,,...,C-1, fork =1, 2, 3. We use the following recursion to accomplish that.

Theorem 1

i 3

G(i) ==) pelG@i — 1) - Be — 1], (=1, 206 7) |

The proof of Theorem | is contained in the Appendix. The result is the computation- |

ally efficient form we have been seeking. |

Based on our classification of viewer needs, it is reasonable to limit class 3 ad-hoc |

requests and allow more of predictable class 1 and class 2 requests to be accepted into |

the system. We therefore must compute B,(z) for a threshold class-3 system. A threshold _

class-3 system allows class 3 requests up to a threshold and always accepts class 1 and

class 2 requests if capacity is available. By definition B, (2) = 0 and Bo(z) = 0. A new

function 7(z) is used to compute 63(z) and to determine the resource distribution of |

class | and class 2 requests. This is defined as

=-lpr(@i-—1)+ per(i-—1)], 1=0,...,C—1-—1; andr(0) =1

r(1)

} |

VIDEO-ON-DEMAND SYSTEMS 169

] r(z) is similar to G(z) and is computed using the same recursion as in Theorem 1, but

| only on class 1 and class 2 state space. Notice that by definition, B3 (2) indicates a resource

| usage of /3 requests for class 3.

(Bl 0) = (02 el aG = fey ey ben' ,C-1 (8)

| Stripping off the recursion in (8), we have

Bs(i) = (02 /is!)[or (GG — b+ py '/G - BY

| which can be proved from equilibrium conditions, the product form expression in (1),

| and the definition of Bs(z).

4. Numerical Results

This section demonstrates the effect of various threshold-based admission control

policies on blocking for each of the classes. We show that using carefully chosen threshold

levels for threshold based admission control policies results in higher acceptance rates

for selected classes. Specifically, the acceptance rates are higher for selected classes for

threshold policies than complete sharing policies, where all classes of requests are admitted

| into the system as long as capacity is available. An admission control policy defines a

threshold for class 3 and admits class 3 requests only up to that threshold. Different

| threshold values result in different levels of blocking for each class. The acceptable

_ blocking level for each class is decided based on the performance goals of the VoD system.

The numerical results test the advantage of having flexible class 3 thresholds and the

ability to set thresholds at various levels to achieve the desired performance for all classes.

Our experimental setup studies the effects of changing arrival rates and threshold

values. The average service times are set to one. The capacity of our hypothetical school

S-VoD system is assumed to be C = 500, allowing up to 500 simultaneous requests.

This could roughly match the number of network connections a county-wide school system

might have. Further, this capacity should be large enough to accommodate requests from

various classes and laboratories in the school for video on demand. We assume a dedicated

VFS for each school. Within the school environment, we assume that there is enough

network bandwidth to all the display stations. We assume no blocking due to the network

or the archive server wherever archival transfers are considered.

For our S-VoD system, we assume three classes of requests, class 1 (archival), class

2 (first-time), and class 3 (ad-hoc) to the VoD system. We assume that class | and class

2 requests are more important than class 3 requests and should receive higher priority

and a larger share of the server resource. For that reason, we impose a threshold

170 SIMON, MUNDUR, SOOD

restriction on class 3, restricting the sharing of server resources. One result of this policy

is that even if there is server capacity available in the S- VoD system, a class 3 request

is blocked by the threshold restriction. Class 1 and class 2 requests are accepted as long

as there is capacity available. Since both class 1 and class 2 are limited by the capacity,

blocking probability will be the same for both.

We use the results of the previous section to compute blocking probability for each

class. The steps involved are:

¢ The recursion r(i) = $[pir(¢ — 1) + por(é — 1)] is used to first compute

all r(z)s.

¢ Equation (8) is used to compute 63(z) next.

¢ Once all B3(z) are determined, Theorem 1 is used to compute G(z).

06 Bik. Prob4

Bk, 05 Blk. Prob2

Prob, 0.4 Bik. Probs

0 &) 9 100110120 190 140 190 160170 140 150 200

Chss3 Threshold

Figure 5: Blocking Probabilities on the y-axis for varying Class 3 Threshold on the x-axis,

P 1 = 300, Pz = 150, P3 =200

e Blocking probability for all three classes are calculated as follows:

salle)

cua Bante ©)

_ eo

gua scayelr oy

G(C) + OS, Bali)

a ee ee (11)

eel)

¢ The throughput is computed using A iP (1 - P, 1) :

A computer program was written to compute blocking probabilities using equations

(9), (10) and (11). The program used standard 15-digit double precision using GNU C

compiler on a Sparc workstation to compute our results. All numerical experiments assume

a maximum capacity of 500 simultaneous requests. The main focus of threshold-based

VIDEO-ON-DEMAND SYSTEMS 171

analysis and these experiments is to set a threshold that results in a tolerable level of

blocking for class 3 with a desirable level of blocking for class | and 2.

The results of the first numerical analysis are shown in Figure 5, demonstrating the

effect of varying the admission threshold for class 3 while 01, 07, and (3 are held constant.

The threshold for class 3 ranges from 80 to 200, (j is set to 300 and pz to 150 and p3

to 200. As the threshold for class 2 approaches the value of the blocking probability for

class 1 increases as a result of increased sharing of resources. The blocking probability

for class 3 decreases because of increased threshold. Eventually the situation becomes

similar to complete sharing policy, where each class has the same blocking probability.

Notice that the blocking probability for both class | and class 2 are the same because

they are both limited by the capacity of the VFS. However, the respective throughput

for class 1 and class 2 will depend on the arrival rate for each class. The throughput using

the same set of experimental parameters is shown in Figure 6.

0 O HO 120 19 170 19

| Clase Threshold

Figure 6: Throughput on the y-axis for varying Class 3 Traffic Intensity on the x-axis,

P 1 = 300, Pp = 150, P3 =200

2 © 7 & © iW iD iW i 1 1H

Class3 Traffic Intensity

Figure 7: Blocking Probabilities on the y-axis for varying Class 3 Traffic Intensity on the

x-axis, 01 = 300, 07 = 150

172 SIMON, MUNDUR, SOOD

1) 12 19 i756 20 25 BO 275 WO 35 XO

Chest Traffic Intensity

Figure 8: Blocking Probabilities on the y-axis for varying Class | Traffic Intensity on the

X-axis. P2 = 50: P3 =100

Figure 7 shows the effect of increasing the arrival rate of class 3 while maintaining |

a fixed threshold at 100. The blocking probability sharply increases for class 3 as the |

arrival rate goes beyond the threshold, while the blocking probability for class 1 and |

class 2 barely varies. |

Figure 8 shows the effect of increasing the arrival rate for class 1, while maintaining |

a fixed arrival rate for class 2 and 3 and a fixed threshold for class 3 at 100. Blocking |

for both classes remains constant until the value of p> approaches capacity, at which |

point, blocking for both classes increases rapidly, as expected. At higher values of class |

1 traffic intensity,all three classes have the same blocking as capacity becomes the |

overriding limiting factor for all three classes and threshold effects become negligible. |

The results shown in Figures 5 — 8 demonstrate the basic relationship between the |

arrival rates of classes, the threshold of class 3, and the resulting blocking probability. |

The advantage of being able to change thresholds on class 3 to achieve the desired blocking |

on class 1 and 2 is illustrated in Figure 9. Lower thresholds on class 3 result in lower |

blocking probability for class 1 generally and in particular, keep blocking to a low level |

in the face of increasing class | arrival rate.

Figure 10 shows that low thresholds again result in stable blocking for class | and |

class 2 as class 3 arrival rates are increased. There is more variability in class 1 and 2 |

blocking with respect to increasing class 3 arrival rate at higher thresholds. This result |

is expected because at higher thresholds, the situation degrades to one of complete sharing. |

The effect of varying class 1 and class 3 arrival rate in lock step on class 3 blocking |

is shown in Figure 11. Low thresholds result in higher blocking for class 3, more so at |

higher traffic intensities and as mentioned before, results in lower blocking and stable |

performance for class | and class 2. |

All of these results demonstrate the advantage of using threshold based end-to-end _

admission control policies in order to manage system throughput for popular videos.

VIDEO-ON-DEMAND SYSTEMS 173

1G 190 175 20 ZS GO 27S N0 3G 300 376 400

Dlasst Traffic Intensity

Figure 9: Class 1 Blocking Probability on the y-axis for varying Class 1 Traffic Intensity at

different Thresholds on the x-axis, P2 = 150, P23 =['50

GD 70 & HX 100 110 120 10 140 190 160 170 1 1%

Cass Tra tensity

Figure 10: Class 1 Blocking Probability on the y-axis for varying Class 3 Traffic Intensity at

different Thresholds on the x-axis, Pi = 300, P2 = 150

100 410 120 180 14 180 160 170 18 190 200

Classi & 3 Traffic Imensity

Figure 11: Blocking Probabilities on the y-axis for varying Class | and 3 Traffic Intensity at

various Thresholds on the x-axis, 07 =150

174 SIMON, MUNDUR, SOOD

5. Conclusion

In this paper, we discussed issues related to the deployment of a distributed VoD

system. We argued that Video-on-Demand systems represent a new type of user-driven

communication technology. We presented a hypothetical Video-on-Demand system for

a county-wide school system, called S-VoD. We described enabling technologies |

required for deploying a S- VoD system. We also provided an analytical model to evaluate |

the performance of such VoD systems under various admission control policies. |

By running a series of numerical experiments we showed that threshold-based analysis |

results in better performance and lower blocking for class | and class 2 requests than if

all three classes had the same access to the server resources at the VFS. Our numerical

results show that threshold based admission control polices are an appropriate and effec-

tive tool for our S-VoD system with multiple classes of requests, each with differing —

importance. The results of this analysis can be used to guide the deployment of a real

Video-on-Demand system on the scale we have described.

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| Appendix: Proof of Theorem 1

Let @ be (1,0,0) or (0,1,0) or (0,0,1), where the 1 is in the k’” position. Under

equilibrium conditions, we have

| Sue ee,

(n1,n2,n3)€O(2)

| Pio — tome, — Jp) (12)

| Consider resources used [ = Sak n, and multiplying (3) with 2 and substituting for 2

and rearranging on the RHS, we have

| qi = yn 3 NP (n1, N2, 3)

' k=1 (n1,n2,n3)€O(2)

Substituting from the balance equation, nz P(n1, n2,n3) = prP((n1, n2, 3) — Ex) we have,

k=1 (nj,n2,n3)€O(2)

: ig =>, >) peP((M, 22,73) — &)

10; = iO Se P((n4, n2, 03) 7 CB)

al (n1,n2,n3)EO(2)

Substituting from (12) for Gee P((ny, n2, 23) — x) we have,

| ig: = J px[PU =1-1) — PUT =i 1m =k)

k=1

176 SIMON, MUNDUR, SOOD

Multiplying with G and using (4) and moving z to RHS we have the recursion in

Theorem 1.

Goes =) palG (i - 1) — Bet - 1) ie ee

and G(z) = 1 for 2 = 0 and 0 for negative 7.

QED

Journal of the Washington Academy of Sciences,

, Volume 85, Number 2, 177-192, December 1998

A Look at Programmers Communicating

through Program Indentation

Susanne Furman, Deborah A. Boehm-Davis, and Robert W. Holt

George Mason University

Fairfax, VA

ABSTRACT

Fundamental to the maintenance of computer programs is software comprehension — the

ability to understand what a program does and how it does it. Software comprehension involves

reconstructing the logic, structure, and goals of the programmer who originally wrote the

program. A number of techniques have been developed to increase the comprehensibility

of software by facilitating the implicit communication between the original programmer and

succeeding programmers.

One such technique is physically structuring the code to communicate program structure.

The most common form of physical structuring is indentation. Although intuition suggests that

using a physical structure to highlight a conceptual structure should be helpful, research has

not always supported the value of using indentation in communicating program structure.

This research examined earlier work on indentation and identified methodological flaws

that may have contributed to the lack of effect of indentation on program comprehensibility.

The data from this research suggest that indentation does communicate certain types of infor-

mation about program structure. Implications of these results for programmers trying to appro-

priately structure their code for future use are described.

A Look at Programmers Communicating Through Program Indentation

Fundamental to the maintenance of computer programs is software comprehension

— the ability to understand what a program does and how it does it. Software compre-

hension involves reconstructing the logic, structure, and goals of the programmer who

originally wrote the program. A number of techniques have been developed to increase

the comprehensibility of software by facilitating the implicit communication between

the original programmer and succeeding programmers.

One such technique is physically structuring the code to communicate program struc-

ture. The most common form of physical structuring is indentation. This approach to

facilitating communication is appealing not only intuitively, but also on the basis of theories

of program comprehension.

Theories of Program Comprehension

Given that a program is a conceptually connected group of statements translated and

executed by a computer, it has been argued that programs are a form of text (Curtis et

al., 1986; Detienne, 1996). They argue that principles of text comprehension can apply

to the study of software comprehension.

178 FURMAN, BOEHM-DAVIS, HOLT

In text comprehension, grammar and composition rules are used to logically

organize and coalesce ideas into unified paragraphs or manageable pieces of informa-

tion. Typographic cues, such as paragraph indentation and white space, signal unified ||

paragraphs. Readers are trained to notice indentation when comprehending a composi-

tion. Indentation has been found to aid written communication and to help readers inter-

pret the meaning of a composition. Research has shown that poor indentation slows the

reader, introduces ambiguity, and hinders interpretation of written communication (Kessler

et al. 1984).

Highlighting information to make program structure more salient should similarly

facilitate program comprehension. Specifically, indentation should improve the saliency

of broad scope information — information about the overall function of the program or

the purpose of each of the modules of the program. Indenting should also aid in identi-

fying detail-level commands.

Other theories of program comprehension support this possibility. Myers (1975)

argued that appropriate structuring of the system, its documentation, the project, its

management and all communications greatly enhances the maintainability of software

and extends the lifetime of large, complex, programming systems.

Brooks (1977) proposed that improved organization of code can reduce the cogni-

tive load involved in understanding a program. His method for achieving this goal

constrained programmers to organize programs hierarchically and modularly in such a

manner that an operation at any one level can be broken down into a small number

of simpler operations. The aim of the process is to reduce the number of units of infor-

mation that are necessary to understand any given piece of program. He suggested a hierar-

chical structure for the code, marked by successive levels of indentation, to obtain these

reductions.

Soloway and Ehrlich (1984) believe that program knowledge contains plans for

specific computations and a particular program language’s statement rules. Programmers

construct program knowledge from these elements. Larger, more complex chunks indicate

higher programmer ability. Using more meaningful chunks and highlighting those chunks

through indentation should increase program comprehension.

Boehm-Davis (1988) proposed a cognitive model of comprehension which synthe-

sizes earlier work on cognitive models and information processing. This model consists

of a knowledge base, an integration process, and a segmentation-hypothesis generation-

verification process, leading to program comprehension. The knowledge base contains

a programmer’s knowledge of programming and a summary of past programming experi-

ences. The integration stage coordinates the generation and testing of hypotheses based

on an interaction between information from the knowledge base and from the current

understanding of the program.

COMMUNICATING THROUGH INDENTATION 179

The segmentation, hypothesis generation, and verification stage is an iterative loop

that predicts solutions from bottom- to top-level commands and forms the basis for this

integration process. Segmentation refers to breaking the code into manageable pieces.

Although the process is thought to be initially guided by the syntactic structure of the

program, it later comes to be driven by schema that develop out of the initial hypotheses,

and segments may cut across the physical structure of the program to form plans.

Hypothesis generation is the formation of guesses as to what each segment of code does.

This step can also guide the re-segmentation of the code.

Verification is the process of examining the code and associated documentation to

determine the consistency of the code with the current hypotheses. The current under-

| standing stage represents the programmer’s current internal representation of the

program. This stage is a holding place for the current set of hypotheses that guide further

attempts at integration. The output of this stage is the final understanding of the program.

‘Understanding occurs once sufficient information in the program has been processed

to allow a satisfactory interpretation of the program.

This model suggests that anything that helps programmers to segment code into appro-

‘priate pieces should improve comprehension. One approach to segmenting code is the

use of program design methodologies, that teach programmers to divide programs into

‘smaller units that are easier to code, verify, and modify. Figure 1 shows the Boehm-

\Davis model.

| Research on this issue (e.g, Boehm-Davis and Ross, 1992; Boehm-Davis, Holt and

‘Schultz, 1992) supports the notion that techniques such as structured programming, which

aid the segmentation process, do improve or facilitate comprehension and modification

) performance. Adding physical indications of structure should further aid the segmen-

| tation and comprehension processes.

Integration Current Program

Knowledge Base : :

Process Understanding Comprehension

rec Segmentation ere en

Hypothesis Verification

Generation

Figure 1. Boehm-Davis model of program comprehension

180 FURMAN, BOEHM-DAVIS, HOLT

Research on indentation

Despite the theoretical advantage for using indented code, behavioral research on |

indentation has demonstrated mixed results (Sheil, 1987). Korson & Vaishnavi (1986), .

Brooks (1983), Norcio (1982), and Miara et al. (1983) all found that performance was

significantly improved when using indented vs. non-indented code. However, Kessler |

et al (1984) and Shneiderman and Mayer (1979) did not.

However, the studies that did not demonstrate a benefit from indentation each

contained some important methodological flaw. For example, Kessler et al (1984) |

used a 10-question test to measure understanding. However, as Kessler mentions this }

10-item test may not have been long enough to ensure reliable results; Kessler does

not report the reliability of the test. A second shortcoming is that several researchers |

chose programs that were short in length (1.e., an average of 54 lines). In general, studies

using larger programs (e.g., 1,000 lines of code) were able to demonstrate statistically

significant differences (Korson & Vaishnavi, 1986) while those with smaller programs |

were not. |

Finally, Shneiderman and Mayer (1979) attributed their non-significant findings }

to the fact that one instructor had not emphasized the importance of using modularity |

in constructing programs. They believe that modular program construction is more diffi-

cult to understand without adequate training and they argued that modularization may

only increase program comprehension for experienced programmers and more complex |}

programs. This suggests that expertise is another factor that must be considered when

examining the effects of indentation. |

Research Goal

The goal of this research was to study the usefulness of indentation while correcting |

the methodological flaws of earlier research, using more and less experienced program- |

mers. Because indentation is often used to indicate program structure, it may provide :

an outline for understanding the program. Indentation of the program was manipulated |

by changing the indentation patterns to highlight or obscure the functional structure of

the program. The three indentation patterns used were: random indentation, no inden- |

tation (1.e., left justified), and normal indentation. |

The role of expertise was also examined by studying novice and more experienced |

programmers. Programmers with more PASCAL programming experience were |

expected to be better able to identify information using the meaningfully indented form |

of the program. PASCAL is a structured language in which indentation is commonly |

used to designate or scoping or blocks of statements.

Random indentation was expected to interfere with this process by obscuring the |

logical structure of the code and misleading the experienced programmers. Programs |

COMMUNICATING THROUGH INDENTATION 181

with no indentation were expected to obscure, but not mislead the more experienced

programmers; thus, we predicted that this structure would lead to intermediate levels

of performance for the more experienced programmers. For the less experienced program-

_mers, we predicted that structure would have little effect.

| Method

Participants

Twenty-four inexperienced and 18 experienced Pascal programmers served as partic-

_ ipants in this study (10 males and 32 females). The participants were drawn from the

| population of undergraduate students, graduate students, and faculty members at

- George Mason University. The majors listed by the participants were: computer science

S| eee ————————— — 8 ————————————— —

related (30), undecided (5), math (2), biology (1), image processing (1), economics (1),

chemical engineering (1), and urban system engineering (1). Assignment to groups was

based on the number of significantly sized programs written in the Pascal language,

the number of years of programming experience, and the number of Pascal classes

completed/taught.

The undergraduates were students in introductory Pascal programming classes and

they participated for extra credit provided by the instructors of those classes. Graduate

students and faculty were recruited through advertisements posted in the computer

science department and on e-mail.

The mean class level of the inexperienced participants was a sophomore with two

semesters of programming experience who had completed two computer science classes.

These individuals averaged less than | year of professional programming experience

and had written less than 1 computer program of at least 300 lines in length in any of

the languages listed in the background questionnaire. On average, they knew two

computer languages and had taken one Pascal class (which was probably the class they

were completing at the time of this research). The average age was 25, with a range

from 18 to 38. Data collection occurred at the end of the semester, at which time all

inexperienced participants had completed course work covering sort programs.

All experienced participants had to have written at least one program 300 lines in

length or longer to qualify for the experienced group. The average class level for this group

was senior and these individuals had completed an average of 8.5 computer science classes.

These programmers ranged in age from 18 to 47 years old, with the mean age being 28.

_ The average number of years of professional programming experience was 2.7, these

_ individuals knew an average of five languages and had completed an average of two Pascal

classes. On average, they had 1.4 years of paid professional programming experience and

_ had written approximately 40 Pascal programs at least 300 lines in length.

182 FURMAN, BOEHM-DAVIS, HOLT

In addition, these programmers had written programs in Basic (mean number of

program written = 5.7), Fortran (mean number of programs written = 7.1), C++ (one

individual wrote over 500 programs and another 50; those two scores are eliminated

from the mean number of programs written = 2.78), and LISP (mean = 1.1). After comple- |

tion of the tasks, experienced participants received $20 for their participation. Actual |

time on task seemed to reflect intrinsic motivation for task completion rather than either _

the class credit or the monetary compensation.

Inexperienced students were B & C grade level students.

Materials

Programs. The three sort programs, obtained from Wirth (1973), consisted of —

approximately 60 lines of Pascal code each. Sort 1 was a Shaker sort, Sort 2 a shell |

sort, and Sort 3 a recursive sort. Each program was presented in each of the three program

forms: left-justification (1.e., no indentation), 2-4 space indentation (1.e., normally

indented), and randomized indentation. The 2-4 space indented programs were selected

from Wirth (1974). To control for any possible indentation bias, an algorithm was

used to randomize the indentation patterns for the randomly-indented sorts. The

program used the normally-indented version of the sort as the basis for the indentation

patterns. It counted the number of spaces before each line of code in the normally indented

version and applied that number of spaces to a randomly selected line in the randomly

indented sort.

Background Questionnaire. The background questionnaire asked for information

about class in school, number of semesters of programming completed, number of

computer science classes taken, number of years of professional programming experi-

ence, number of Pascal classes taken, number of programs written with more than 300

lines of code for several languages (Pascal, Basic, Fortran, C++, ADA, LISP, or other),

number of programming languages known, age, whether they were currently a paid

professional, major, and gender. SAT or GRE scores were requested, however, only a

few of the participants completed these items, so those questions were not included in

the analyses.

Performance Measures

The objective performance measures for this study included: accuracy (number of

correct answers) for three sets of multiple choice questions (8 questions/program); the

average look time (i.e., the average time that the programmer spent looking at each line

of code); the average search time (i.e., the average time that each programmer took to

choose the next line of code to view); and the total number of lines revealed in compre-

hending the sort program. The subjective measures analyzed included ratings of: how

COMMUNICATING THROUGH INDENTATION 183

fatigued the participants were after comprehending each of the forms, how much they

liked/disliked each form of indentation, and how difficult they thought each indenta-

tion pattern was to comprehend.

Content Questions. Multiple choice questions designed to measure knowledge of

program content were developed for each of the three sort programs. These questions

consisted of six detailed questions and two global questions for each sort. The relia-

bility of the questions used in this effort was calculated and resulted in a Cronbach’s

coefficient alpha of 0.77.

Subjective Rating Questionnaire. This questionnaire included a sample and

explanation for each form of indentation to refresh the participants’ memory. The

questionnaire asked participants to provide Likert-scale subjective ratings to questions

including: subjective difficulty of performing the task using each form, how much the

programmer liked or disliked each form, and level of fatigue after comprehending each

form of the sort.

Design

This study used a 3 X 3 X 2 partially confounded mixed Latin Square design.

Program form (i.e., indented, non-indented, and randomly indented lines of code) and

program version (i.e., Shaker sort, shell sort, and recursive sort) were within subject

| and level of experience (i.e., language-experienced vs. language-inexperienced) was

the between-subjects variable.

Procedure

The DISCOVERY task used in this study was developed by Boehm-Davis and

| programmed by Holt; the task was inspired by the cloze (Taylor, 1953) procedure. The

goal of the DISCOVERY task is to answer questions about the contents and/or execu-

tion of the program based on an examination of individual lines of code.

In this task, the entire Pascal program appeared as lines of Xs. The pattern of Xs

is created by presenting an “X” in place of any non-blank character (see Figure 1). The

task required the participants to select a line of code by depressing the enter key. Once

selected, the actual line of code became visible, allowing the participant to view the

| line of Pascal code hidden under the Xs. The participant could view the line of code

as long as the “enter” key was depressed. When the key was released, the line reverted

back to the line of Xs.

184 FURMAN, BOEHM-DAVIS, HOLT

Program Code |

procedure shuffle (var a:arrangetype;

n: integer);

var I, j, k: integer;

b: boolean;

begin

for I= 2 ton do begin

ks" file

Siesdstis

b= false:

while G>=1) and (not be) do

begin

As Presented in This Experiment — DISCOVERY Format |

XXXXXXKXXX XXXXXXK XXKX XXXXXKXXXXKXKK

XX XXXXXXKXX

XXX XX XX XX XXXXXKXKK

XX XXXXXKKX

XXXXX

XXX X X KX XX K XK XKXKXX

XX X X XXXX

XX X X K KX

XX X XXXXKX

XXXXK XXXKXK XXX XXKK XXX XX

XXXXX

Figure 1: Pascal program code and its DISCOVERY format representation.

Each participant received a pre-labeled packet that included an informed consent |

form, a background questionnaire, a set of questions for each of the three sorts, and |

the subjective measures. After signing the informed consent form, the participants |

completed the background questionnaire. |

Each participant received instructions including the nature of the DISCOVERY |

screen, how to choose a line of code at which to look, and how to move around to different |

COMMUNICATING THROUGH INDENTATION 185

Accuracy Search Time! Time! Difficulty? | Like/Dislike?

Sa AE

[or [om | oe [on [ow | we [on

Paw [ws | oe [oun [uo | om [om

Se eee

1. Time in seconds 3. Like/Dislike: 1 = Dislike

2 = Neutral

2. Difficulty: 1 = Very Difficult 3) SIL

2 = Difficult

3 = Neutral 4. Fatigue: | = Extremely

4 = Easy 2 = Moderate

5 = Very Easy 3 = Not at all

Table 1: Means and Standard Deviations as a Function of Three Forms of Identation

parts of the program. Participants selected a line of code they wished to look at, typed in

the number of that line, and held down the enter key. The line stayed revealed as long as

the participant held down the enter key. Once finished looking at that line, the partici-

pant released the key and that line reverted to the “Xed” out pattern. The participant

continued the process, looking at the selected lines as long as they liked, as many times

as they liked, and in any order they chose.

After the programmers felt they understood the sort program, they answered the

questions. If any participant was unsure of the purpose of the program, they could re-

access the code after they started answering questions to determine its meaning. After

they completed the questions for that version of the sort program, they exited out of

the program. The primary dependent variables measured were: the average time the

programmer took to study each individual line of code (1.e., look time), the average

search time taken to select the next line of code to be examined (i.e., search time), the

number of revealed lines required to comprehend each sort form, the number of correct

answers for the multiple choice questions, the affective response of how much the

186 FURMAN, BOEHM-DAVIS, HOLT

programmer liked or disliked the form, subjective difficulty of each form, and the subjec-

tive fatigue resulting from each form. Participants repeated this sequence until they

completed all three sorts. Finally, a sample of the three indentation forms was presented

so that participants could complete the subjective questions about those forms.

Results

Objective Measures

The means for the objective variables of average search time, average look time,

and lines chosen as a function of type of indentation were in the expected order (see

Table 1). However, large within-group standard deviations made it difficult to confirm

a significant difference. To reduce the effect of extreme scores on the variance, these

objective variables were transformed to the log (base 10) of each participant’s times and

number of lines chosen.

Accuracy. Programmers were expected to score higher on accuracy (i.e., answer

more multiple choice questions correctly) for the normally indented programs than either

the left-justified or randomly indented versions. Results did not confirm the a priori predic-

tions. Although the means appear in the expected order, there was no significant differ-

ence in performance across the three indentation patterns, (F (2,72)= 0.32, p > .05).

However, an analysis of variance did confirm the predicted difference in accuracy

as a function of experience, (F (1,36) = 4.81, p <.05). The experienced participants

answered more questions correctly (mean = 6.06) across sorts and forms of indentation

than their inexperienced counterparts (mean = 3.90). An analysis of variance did not

confirm a significant form by experience interaction, (F (2,72)= 0.11, p > .05) and none

of the a priori predictions were significant.

Search Time. Search time was the average time that each programmer spent searching

for the next line of code to be revealed. Analyses of variance failed to confirm any signif-

icant differences in average search times as a function of type of indentation for either the

original (F (1,72) = 0.62, p > .05) or for the transformed data, (F (2,72) = 1.15, p > .05).

Experience also played no significant role in performance, (F (1,36) = 0.47, p > .05).

Look Time. Look time was the average time spent studying the lines of code revealed.

An analysis of variance of the transformed data confirmed a significant difference for

average look time as a function of type of indentation, (F (2,72) = 4.40, p < .05). Single

df comparisons supported a priori predictions. Participants also had significantly lower

average look times when comprehending programs for the normal (log look time mean

= 1.60) vs. random (log look time mean = 1.53) forms of indentation, (F (1,72) = 11.00,

p < .05). Participants had significantly lower average look time means when compre-

hending the left justified (log look time mean = 1.60) vs. randomly indented (log look

COMMUNICATING THROUGH INDENTATION 187

time mean = 1.53) versions (F (1,72) = 11.00, p > .05). Experience did not influence

the amount of look time (F (1,36), 0.06, p > .05).

Lines Revealed. The number of lines revealed was defined as the total number of

lines that each programmer selected while comprehending the program. An analysis of

variance confirmed a significant main effect of form of indentation for the log trans-

forms of lines chosen (F (2,72) = 3.40, p < .05). Single df comparisons supported the

prediction that normal indentation would produce a lower number of lines revealed for

the normal (log look time mean = 1.76) vs. randomly indented (log lines chosen mean

= 1.85) forms, (F (2,72) = 6.80, p < .05). Single df comparisons did not support a priori

predictions that normally indented versions would produce lower number of lines revealed

than left-justified (log lines chosen mean = 1.82) forms, (F (1,72) = 3.0, p > .05). The

comparison of number of lines revealed for the left-justified vs. randomly indented forms

was not significant, (F (1,72) = 0.76, p > .05). Further, the number of lines revealed was

not influenced by experience, (F (1,36) = 0.06, p > .05).

Subjective Measures

In addition to the objective measures of performance, a number of subjective reactions

to the various forms of code were collected. Analyses of variance confirmed significant

differences in some of these measures across the two groups of programmers. However,

none of the subjective variables differed as a function of experience. Subjective diffi-

culty (F (1,36) = 0.52, p > 0.5), like/dislike (F (1,36)= 0.02, p > .05), and reported fatigue

(F(1,36) = 0.05, p > .05) were not significantly affected by experience.

Subjective Difficulty. An analysis of variance confirmed a significant difference in

perceived subjective difficulty as a function of indentation form, (F (2,72) = 12.97, p >

.05). Single df comparisons supported two of the a priori predictions. The randomly

indented version (mean = 2.12) was reported to be significantly more difficult to compre-

hend than the normally indented (mean = 3.95) version, (F (1,72) = 15.09, p < .05). The

left-justified versions (mean = 2.69) were perceived as significantly more difficult to

comprehend than the normally indented version, (F (1,72) = 7.15, p < .05). There was

no significant difference between the left-justified and randomly indented versions, (F

G2) 0 Saltip >).05).

Subjective Like/Dislike. An analysis of variance confirmed a significant main effect

of indentation for the like/dislike measure, (F (2,72) = 37.98, p< .05). Normally indented

programs (mean = 2.57) were liked significantly more than the left justified (mean=1.69)

programs, (F (1,72)= 37.5, p < .05). Similarly, participants liked the normally indented

(mean =2.57) programs significantly more than the randomly indented (mean =1.36)

ones, (F (1,72) = 19.83, p < .05). Participants did not rate the left-justified versions

significantly differently for like/dislike than the randomly indented versions, (F (1,72)=

2 Dip. 05).

188 FURMAN, BOEHM-DAVIS, HOLT

Subjective Fatigue. The analysis of variance for fatigue confirmed a significant main

effect for indentation form, (F (2,72) = 4.5, p< .05). Single df comparisons also supported

a priori predictions for fatigue when comparing normally indented vs. left-justified and

normally indented vs. randomly indented programs. Participants reported being signif-

icantly less fatigued when comprehending the normally indented (mean = 2.62) versions

as compared to the randomly indented (mean = 1.98) versions, (F (1,72) = 4.30, p <

.05). They did not report being significantly less fatigued when comparing comprehension

for either the normally indented vs. left-justified versions (F (1,72)= 2.30, p > .05) or

the randomly indented vs. left-justified (mean = 2.17) versions (F (1,72) =0.51, p> .05).

Summary

The form of indentation did not significantly affect accuracy; however, it did signif-

icantly affect the number of lines revealed and the average look times. Overall, normally

indented and left-justified versions of the code produced equivalent results. Generally,

these two forms of code produced significantly lower average look times and number

of lines revealed than the randomly indented versions. The difference between random

and either normal or left-indented can be interpreted as due to a facilitation of normal

form of indenting or due to an inhibitory effect of misleading indentation.

The subjective measures tend to support the supremacy of normal indentation. The

three measures all indicated that normally indented programs were superior to either

the randomly indented or left-justified versions. Participants rated the normally indented

programs significantly less difficult and less fatiguing to comprehend than the randomly

indented versions. In addition, participants liked the normally indented versions signif-

icantly more than the two abnormally indented versions.

Experience also played a small role in influencing performance. The experienced

participants were significantly more accurate answering the multiple choice questions

than the inexperienced participants. However, average search time, lines chosen, average

look time, and the subjective variables did not differ as a function of experience.

Effects of a Speed/Accuracy Tradeoff with Levels of Expertise

There was some concern that the task may have frustrated the inexperienced partic-

ipants such that they may have terminated the program without fully comprehending

what the programs did. To test this, correlations were computed for average total time

and average accuracy scores for the three sort programs. A significant correlation resulted

for average total time and average accuracy score (r (42) = .431, p< .01) when computed

across both experienced and inexperienced participants. However, the correlation was

different when the two groups were examined alone. A large significant correlation

between average total time and total scores was found for the inexperienced participants,

————

COMMUNICATING THROUGH INDENTATION 189

r (24) = .543, p < .01. However, for the experienced participants, total time and scores

were not correlated, r (18) = .04, p > .05.

Experienced participants were expected to take less time searching for the next line

of code (i.e., average search time), take less time looking at the next lines of code revealed

(i.e., average look time), and choose fewer lines of code to look at (.e., lines revealed)

than the inexperienced participants. However, inexperienced participants had lower

average look times and chose fewer lines of code to comprehend the programs, but also

comprehended significantly less.

Correlations for time and accuracy may have indicated a reason for this reversal of

predicted results. Total time was significantly correlated with accuracy for the inexpe-

rienced participants, but not for the experienced participants. The shorter times may have

resulted in lower accuracy for the inexperienced participants. It appears that inexperi-

enced participants may have been frustrated and may have terminated the task before

fully comprehending the programs.

Discussion

Highlighting program structure by indenting code should facilitate software compre-

hension. Readers have been trained from an early age that in text comprehension,

typographic cues, such as indentation and white space, signal unified paragraphs.

Programming is in one respect a form of text; therefore, this same logic should hold

true in this domain. Appropriate indentation signals the unified logic structure in the

program code, thereby aiding in reducing the cognitive load involved in understanding

a program.

Despite the theoretical advantage of using indented code, previous research has not

been consistently able to demonstrate the superiority of indenting code. Unfortunately,

a variety of factors leading to a lack of statistical power have made it difficult to show

effects on performance.

For example, in this domain, researchers have typically presented participants with

programs that are short (i.e., 20-40 lines of code). Further, comprehension has been

measured with one or two of the following measurement tools that may have been unreli-

able or too insensitive. Variability among programmers for comprehension and debug-

ging times is another problem; this variability has been documented to be as high as a

22:1 ratio (Korson & Vaishnavi, 1986).

To increase the likelihood of demonstrating the superiority of appropriately indented

program code this research effort used a new technique (the DISCOVERY technique)

and more sensitive measurement tools.

The objective measures included recording the look time, search time, and number

of lines chosen. In addition, subjective ratings were collected for fatigue and difficulty

190 FURMAN, BOEHM-DAVIS, HOLT

while comprehending the different forms of indentation, and for whether the partici-

pants liked/disliked each of the three forms. To help increase the sensitivity of the measure-

ment tools we also used a new technique, which was named the DISCOVERY technique.

Previous researchers included only 10 multiple-choice questions to measure compre-

hension. To increase the sensitivity of measuring comprehension with multiple choice

questions, we used 24 questions and these sets of questions were found to be reliable.

Even though the programs used were not as large as some researchers have

suggested in previous research (Korson & Vaishnavi, 1986), they were longer than most

of the programs used in the past. We were concerned that longer programs may have

made it impossible for the inexperienced participants to complete the task.

Finally, we used a within-subject design to reduce the effects of programmer

variability. The design did help to reduce the variability to a ratio of 8.5:1, which is lower

than the well-documented 22:1 ratio reported in earlier studies. However, these large

individual differences still contributed to an inability to demonstrate significant differ-

ences for the objective variables without using log transforms.

Although this effort was not perfect, the methodological adjustments did allow us

to show that appropriate indentation was significantly superior for some variables and

did show a consistent pattern where normal indentation lead to better performance on

almost all measures. Specifically, the objective measures showed a superiority for the

normally indented and left-justified versions of the code. However, for the more experi-

enced programmers, only the normally-indented code was shown to be superior. Further,

the subjective measures clearly identified the normally-indented code as superior from

the programmers’ point of view.

Overall, indentation offers a sign post for structure. Programmers use indentation

to understand where more important lines of code are located and these sections have

a certain meaning and function. Indentation aids in signaling this meaning and there-

fore affects the way in which programmers search for code. This study used relatively

short programs, which may only begin to push programmers’ short-term memory require-

ments. Although programmers may be able to compensate for these memory limitations

when the programs are short, this is unlikely to be the case for longer programs.

Although future research on indentation is clearly needed, the data from this study,

taken together with previous work, suggests that physical structuring of the code is impor-

tant in communicating information to programmers about the structure of the code. This

is particularly important as other forms of communicating to succeeding programmers,

such as documentation, are rarely maintained and easily separated from the original code.

Thus, taking a cue from our experiences in reading text may be the key to improving

communication from programmer to programmer. |

Typographic cueing refers to the use of variations in the appearance of text. It has

been used since the beginning of printing, for example, for particular emphasis and to

COMMUNICATING THROUGH INDENTATION 191

isolate headings. Foster and Coles (1977) were able to demonstrate that forms of cueing

which can be readily incorporated into printed text have beneficial effects on the perfor-

mance of readers, and that the particular style of cueing (capitals or bold print) is an

important moderating variable.

The notion of signaling also comes from text comprehension (Meyer, 1975) and refers

to the addition of non-content information to a text in order to emphasize certain ideas

and/or clarify the organization. The use of both typographic cueing and signaling may

also aid in program comprehension.

References

Boehm-Davis, D. A. (1988). Software comprehension. In M. Helander (Ed), Handbook of human-computer inter-

action. Elsevier Science Publisher B.V.: North-Holland.

Boehm-Davis, D. A., Holt, R. W., & Schultz, A. C. (1992). The role of program structure in software mainte-

nance. International Journal of Man-Machine Studies, 36, 21-63.

_ Boehm-Davis, D. A., & Ross, L. (1992). Program design methodologies and the software development process.

International Journal of Man-Machine Studies, 36, 1-19.

Brooks, R. (1977). Towards a theory of the cognitive processes in computer programming. International Journal

of Man-Machine Studies, 9, 737-751.

Brooks, R. (1983). Toward a theory of the comprehension of computer programs. /nternational Journal of Man-

Machine Studies, 18, 543-554.

Curtis, B., Soloway, E., Brooks, R. E., Block, J. B., Erhlich, K., & Ramsey, H. R. (1986). Software

psychology: The need for an interdisciplinary program. In Ronald M., Baecker & William, A.S. Buxton (Eds.).

Reading in Human-Computer Interaction. San Mateo, CA: Morgan Kaufman Publishers, Inc.

Detienne, F. (1996). What model(s) for program understanding ? In Proceedings of UCIS ’96, Poitiers, France,

September 4-6.

Foster, J., & Coles, P. (1977). An experimental study of typographic cueing in printed text. Egonomics, 20, 57-66.

Korson, T. D., & Vaishnavi, V. K. (1986). An empirical study of the effects of modularity on program modifia-

bility. In E. Soloway and S. Iyengar (Eds.), Empirical Studies of Programmers. Norwood, NJ: Ablex Publishing

Corp.

Kessler, T. E., Uram, R. B., Magareh-Abed, F., Fritzsche, A., Amport, C., & Dunsmore, H. E. (1984). The

effect of indentation on program comprehension. /nternational Journal of Man-Machine Studies, 21, 415-428.

Meyer, B. J. F. (1975). The organization of prose and its effects on memory. North-Holland, Amsterdam.

Miara, R. J., Musselman, J. A., Navarro, J.A., & Shneiderman, B. (1983). Program indentation and compre-

hensibility. Communication of the ACM, 26, 861-867.

Myers, G. J. (1975). Reliable software through composite design. NY: Van Nostrand Reinhold Company.

Norcio, A. F. (1982). Indentation, documentation and programmer comprehension. Proceedings of Human Factors

in Computer Systems, 118-119.

Sheil, B. A. (1987). The psychological study of porgramming. In Ronald M. Baecker & William A.S. Buxton

(Eds.), Readings in human-computer interaction. San Mateo, CA: Morgan Kaufman Publishers Inc.

Shneiderman, B. & Mayer, R. (1979). Syntactic/semantic interactions in programmer behavior: A model and

experimental results. International Journal of Computer and Information Science, 8, 219-238.

Soloway, E. & Ehrlich, K. (1984). Empirical studies of programmer knowledge. IEEE Transactions in Software

Engineering, SE-10, 595-609.

_ Taylor, W. L. (1953). Cloze procedure: A new tool for measuring readability. Journalism Quarterly, 30, 415-433.

Wirth, N. (1974). Systematic programming: An introduction. Englewood Cliffs, NJ: Prentice-Hall.

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Washington Academy of Sciences

Junior Academy of Sciences

High School Essay Contest

in Celebration of the

Washington Academy of Sciences Centennial

Preface for Student Essays

Students in the greater Washington, D.C., metropolitan area high schools, grades 9

through 12, were asked to write a paper of 1,000 words maximum on any topic concerning

_ the theme Communications Within and Between All Levels of the Biological Hierarchy.

_ The Washington Academy of Sciences offered the following prizes:

| |

| 15! Prize $1000

| 2nd Prize 700

| 314 Prize 300

Honorable Mention 100

Examples of essay communication topics suggesting the wide range of possible

, Subjects were:

e Any kind of communication between individuals

| © Cell tocell

: e Organism to environment

| ¢ Whales singing in the sea

| e Intergalactic or extragalactic communication

: ¢ Communication with or between animals such as apes or porpoises

¢ Color communication: red is anger or emotion; blue is happy or the color

of the sky. What do you get when you put red and blue together? This commu-

nication needs an interpreter to know what these things mean.

e String-can telephone

¢ Individual and computer, or individual or non-living.

Over 100 papers were received from twelve schools. The criteria used by the panel

of judges to rank the papers were as follows:

194

e Uniqueness/Originality

e Reflection beyond facts — added value

e Exposition — style

e Accuracy

e Expressed insight into some aspects of communications.

The panel of judges consisted of:

Mr. Norman Doctor

Fellow, Board of Managers, Washington Academy of |

Sciences

Mr. Rex Klopfenstein Fellow, President-Elect, Washington Academy of Sciences;

Dr. Cyrus Creveling

Dr. Thomas Bottegal

Dr. Allen Barwick

Dr. John H. Proctor

The Mitre Corporation

Fellow, President, Washington Academy of Sciences;

Scientist Emeritus, National Institutes of Health

Fellow, Editor, Journal of the Washington Academy of |

Sciences; Consultant, Arthur D. Little, Inc.

Fellow, Vice President, Junior Academy of Sciences;

Washington Academy of Sciences; Co-Chair, Essay Contest;

High School Physics Teacher; named Teacher of the Century

by the National Science Foundation

Life Fellow, Past President, Washington Academy of

Sciences; Centennial Chairman; Co-Chair, Essay Contest

In May 1998, President Cyrus R. Creveling wrote a letter of congratulations to

each of the winners with a concurrent announcement on the academy’s Website

http://www.inform.umd.edu/WAS/. The winners were:

1 Prize

2nd Prize

3rd Prize

Elizabeth Barnwell, Richard Montgomery High School

The Bridge: Human Communication with Chimpanzees

and Gorillas

Teacher: Ms. Beverly Stross

Lily Simonson, Richard Montgomery High School

‘Equus’ The Language of Horses

Teacher: Ms. Beverly Stross

Anna Burrows, Wheaton High School

Non-Verbal Communications

Teacher: Mr. J. Dewey Brown

195

Honorable Mention Lacey Irby, McLean High School

You’ve Got a Friend in Me: The Therapy of Listening Cures

Cases of Suicidal Feelings

Teacher: Mrs. Demby Banbury

Emily McDonald, Woodrow Wilson High School

“Dear Ian”

Teacher: Mr. Jay Fellows

Daniel Smolyar, Wheaton High School

Communicating with Extraterrestrials

Teacher: Mr. J. Dewey Brown

These winners received their prizes during a Washington Academy reception at the

National Press Club, Washington, D.C., on November 9, 1998. Winners of the 15*, ond

and 3d prizes also read their essays. We wish to thank all those authors who responded

to our invitation to prepare an essay.

The Fellows, Members and Officers of the Washington Academy of Sciences are

pleased to present these essays in this Centennial Issue of our Journal.

Wiebe.

John H. Proctor, Ph.D.

Centennial Celebration Chairman

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Journal of the Washington Academy of Sciences,

Volume 85, Number 2, 197-199, December 1998

The Bridge:

Human Communication with

Chimpanzees and Gorillas

Elizabeth Barnwell

Richard Montgomery High School

Rockville, Maryland

With a tremendous thirst for knowledge and understanding, humans have embarked

on many voyages into the unknown, crossing seemingly indestructible barriers, and finding

new truths about ourselves. One such voyage is the development in interspecies commu-

nication between humans and other species in the biological hierarchy.

Four initial attempts at developing interspecies communication focused on inter-

species communication between chimpanzees and humans. One of the barriers in the

development of interspecies communication is that animals have been considered

inferior to human beings. People were skeptical as to whether or not other species had

the capability to communicate in complex languages. Chimpanzees were chosen as the

preferred species because they are similar to primitive humans. First, there are physical

similarities, such as a larger upper torso than lower limbs, and long fingers with a shorter

thumb. More importantly, however, is that chimpanzees, like humans, use tools. For

chimpanzees, crumpled leaves act as sponges, and stems are used to get termites out of

termite mounds. In addition, chimpanzees are like humans in that they teach their young

to use these tools as well as other necessary lessons. Because chimpanzees resemble

primitive humans, scientists believe they would be the most capable in learning to commu-

nicate with humans.

Regardless of how similar chimpanzees are to humans, success was not immediate

in trying to have a two-way communication with chimpanzees. The first attempt at commu-

nication with chimpanzees was done by Keith and Catherine Hayes. The Hayes’s attempted

to teach their chimpanzee, Viki, to speak English. Unfortunately, Viki never could say

more than five or six words. In addition, the words she did say, she had great difficulty

saying. The fear that chimpanzees really were extremely mentally inferior seemed very

real. Fortunately for the future of interspecies communication, there were two scientists

who identified the problem as something other than mental inferiority.

After the Hayes’s failure, R. Allen and Beatrice Gardner decided to try their theory.

These two scientists had read the result of the Hayes’ s attempt and decided that Viki’s

difficulty with speaking the words seemed to be more of a physical problem than a lack

of intelligence. To test this hypothesis, the Gardners taught their chimpanzee American

Sign Language. This language would only require the use of the chimpanzee’s already

198 BARNWELL

nimble fingers, hands and arms, but still be an intricate language that, if mastered, would

show that chimpanzees have a strong level of intelligence. Washoe, the Gardners’

chimpanzee, learned 34 signs in 22 months and 132 signs in 4 years of studying American

Sign Language. Since this amount of signing is similar to a human child in the first stages

of learning, this new technique was considered a complete success.

Also successful were the third and fourth attempts at two-way communication with

chimpanzees. Requiring only the use of the chimpanzee’s hands and brain, Ann and David

Premack taught their chimpanzee, Sarah, to use plastic symbols in order to speak and

be spoken to. Duane Rumbaugh taught his chimpanzee, Lana, to communicate by using

a computer. Lana was required to type out sentences that not only had to be complete

thoughts, but also had to be grammatically correct. All of the scientists who worked with

chimpanzees in order to establish interspecies communication inspired Dr. Francine

Patterson to try to establish interspecies communication with a new species, gorillas.

Dr. Patterson began teaching American Sign Language to Koko, a female lowland

gorilla, at age one. Although many people had been skeptical of whether gorillas were

as intelligent as chimpanzees, over the years Koko, and later a younger lowland gorilla

named Michael, proved that gorillas were at least as smart as chimpanzees. After only

36 months, Koko was using 184 signs; by age four and a half she was using 222 signs;

and by age six and a half, she was using 645 signs. Koko’s score on the Stanford-Binet

Intelligence Scale at four years old was 95, only slightly lower than the average for a

human child. At 27, Koko has a working vocabulary of over 500 signs, has signed at

least 400 more, and can understand about 2,000 words spoken in English.

Perhaps more important then the number of signs she knows, however, is that Koko

shows that gorillas have the ability to process and use language. Koko often initiates

conversations, describes her feelings and tells why she feels a certain way, and combines

signs to give more meaning to a particular sign. In addition, Koko not only taught Michael

many signs when they were young, but also made up signs that only Michael and Koko

used with each other. It is these points that are the true successes, as these allow for the

greater understanding of gorillas. Examples of her creativity such as these reveal the

depth of gorillas. Koko’s responses and ideas give humans insight into her perspective

of the world.

In conclusion, there are two main reasons why interspecies communication is an

important goal to pursue. First, by being able to hear what the animal feels, humans can

better understand the needs of the species. Understanding the needs of the species allows

for the proper protection of that species. Second, the more that is learned about the many

species of the world, the more humans learn about themselves and their place in the world.

As in this case, humans look outward as our curiosity compelled us to try to commu-

nicate with a species other than our own. The resulting communication led to the realiza-

tion that humans are not the only beings that can communicate through complex languages.

In looking to the future, this realization leads to the ideas that although humans

THE BRIDGE 199

have technology that allows us to communicate with other humans in faster and fancier

ways, humans are not considerably advanced in our communication ability. Communication

between all levels of the biological hierarchy is still a frontier waiting to be explored.

-Humans have discovered their ability to communicate with gorillas and chimpanzees:

——— ee

‘the question is, to which part of the biological hierarchy will humans venture next?

Journal of the Washington Academy of Sciences,

Volume 85, Number 2, 200-202, December 1998

‘Equus’

The Language of Horses

Lily Simonson

Richard Montgomery High School

Rockville, Maryland

Horses have an extremely complex but clear system of communication. Although

horses are often very vocal, using snorts or other noises to express themselves, the primary

communication lies in body language. Horses position their bodies, move parts of

their bodies, and use their faces to convey specific messages or emotions. When these

motions are learned by humans, they can be applied to training or developing relation-

ships with horses.

Conventional methods for a human training a horse have almost always involved

violence and physical harm to accomplish “breaking” the animal. However, the wild

mare has discovered a far superior way to train young horses. If a colt has been bothering

or attacking other foals or mares, he will be punished by being isolated from the herd.

This punishment is signaled by the matriarch of the herd squaring her body up to the

young horse, with her eyes on his, her spine completely rigid, and her head pointed straight

at the colt. The unruly colt immediately knows that he is to be punished and moves away

from the herd. He may come no closer to the group than roughly three hundred feet until

the matriarch again signals with her body that he may return. If his punishment is not

complete, the mare turns to face nim again, telling him not to return.

The possibility of its punishment ending is signaled by the mare turning her body

sideways to the colt. However, she only performs this action in response to what the

youngster communicates to her. It must show remorse and ask for forgiveness by more

body language. This “apology” may be signaled by the foal putting its head and neck

down symbolizing submission. Also, a foal will often curl its lips, exposing the teeth,

and begins to open and shut its jaws. This action is dubbed snapping and says, “I am

only a little foal, please do hot hurt me, you are my leader.’ This action is also performed.

toward a strange, larger horse that comes near the foal.

Body language does not always serve the purpose of discipline, but may simply convey

the horse’s mood or emotions. As a horse becomes more excited and aroused, its posture

becomes more elevated and the entire body seems to get taller. The horse holds its head

high, its neck rigid, and its tail up. When it becomes less excited, however, the horse’s

head and tail slump and its body droops, making it seem smaller. These signals of stimu-

lation and eagerness or drowsiness, boredom, and submission are clearly understood by

‘EQUUS’ THE LANGUAGE OF HORSES 201

other horses, which react accordingly. The main body signals are called the body check,

the rump presentation, and the shoulder barge.

A dominant horse who wishes to thwart the movement of a rival often employs the

_ body check. The horse will swing its body around directly in front of its rival, physi-

cally blocking the advancement of the second horse. The second horse must then react

by challenging the intimidator, or retreating and signaling submission and recognizing

the other as superior. The rump presentation is a defensive response to the body check.

The horse being checked swings its body, offering its rear to the original intimidator.

This is essentially the threat of a kick, known as an “intention movement.” The other

horse reads this preparatory stage of action and may or may not respond by continuing

| the fight. The shoulder barge is a more aggressive form of the body check that involves

actual physical contact. The threatening horse actually pushes into the other, and if the

other horse is not intimidated, the encounter may escalate to a real fight.

In addition to using their entire bodies, horses may use specific parts of their bodies

_ to express certain attitudes or emotions. A horse’s tail signals the animal’s level of excite-

ment. If a horse holds its tail high and pushes it out from its body, it signifies exuber-

ance, excitement, activity, and alertness. A young horse may show another its desire and

readiness for play by flicking its tail up very high, even so that it curls over its back,

towards its head. This is immediately perceived by the other horse as an invitation, and

they begin to play. Horses also raise their tails up during sexual encounters due to excite-

ment. The mare often raises her tail up and to the side as an invitation for sexual inter-

course. When a horse droops its tail low, keeping it very close to its rear and hind legs,

he is indicating fatigue, sleeplessness, submission, physical pain, or extreme fear. A horse

shows irritation, confusion, anxiousness, or frustration by flicking its tail sideways, then

vertically, and finally in an arc. If a horse becomes extremely angry, the power of the

tail movements increases. This extreme force usually signals the onslaught of a violent

kick, intended to harm.

Horses also use their legs to indicate changing moods. Pawing the ground is an action

in which the horse pounds its leg down, scrapes its hoof backward on the ground, then

lifts it up again and repeats the action. It often is used by frustrated horses to show their

strong urge to move forward, but is in some way hampered from doing so. A horse may

threaten another by striking outward with their front leg in what is knows as a front leg

lift. If a horse executes a back leg lift, it is defensively signaling that it plans to kick a

horse that may be provoking it.

Horses also use their face to convey many more moods and emotions. Horses that

are threatening to bite hold their jaws tensely open with their teeth fully exposed. This

stiff mouth, which also accompanies anxiety, fear, and pain, contrasts with the sagging

lower lip of a relaxed, peaceful, or sleepy horse.

These facial expressions, body movements, leg lifts, and tail movements are all part of

the complex body language of horses. All of these signals are universally understood by horses.

202 SIMONSON

References

Morris, D. (1988). Horsewatching. New York: Crown Publishers, Inc.

Roberts, M. (1997). The man who listens to horses. New York: Random House.

Journal of the Washington Academy of Sciences,

Volume 85, Number 2, 203-205, December 1998

Nonverbal Communications

Anna Burrows

Wheaton High School

Wheaton, Maryland

Human beings can communicate through a variety of ways. The most common way

is verbal communication. However, many of us don’t realize how often we use nonverbal

communication to express our emotions to others. Only now are we beginning to discover

and understand how frequently we use nonverbal communication and what a powerful

method it is.

The first area of nonverbal communication involves facial expressions. Due to the

_ fact that there are so many muscles in our face, our face can be the most expressive part

of our body. Most of the expressions we use are instinctive. The naturally occurring expres-

sion of infants is practically identical to those of adults. Babies smile when they are happy,

frown when they are sad, and have wide eyes and a gaping mouth when they are surprised.

Scientists thought that people might have the same basic expressions because we all are

affected by the same influences, such as television. To test this idea, scientists went to

the remote island of New Guinea. They filmed the people showing their own facial expres-

sions. They found that their expressions were easily recognizable by Americans.

Each part of the face is useful to convey many different messages. The eyes and

eyebrows can be very useful. By staring, one sends the message that they are aggres-

sive. By giving only a little eye contact, the person seems as though they have something

to hide. By lifting one eyebrow, one expresses disbelief. With winking an eye, one

expresses intimacy. Also, using other parts of the body we can communicate. By leaning

towards a speaker, we show interest. By leaning away, we show disinterest. We also

communicate with our posture. If we are slumped over, we seem to be in low spirits.

However, if we stand erect we seem energetic and confident. We may cross our arms to

isolate ourselves from others, but if they are uncrossed we seem to be interested in the

conversation. Also, the legs can be used to communicate. A couple sitting next to each

other usually crosses their legs towards each other, as a way to exclude any third person

from the conversation.

Hand gestures are also an obvious way to communicate. The meaning of the gesture

is never mistaken. Almost unconsciously, we rub our nose for puzzlement, tap our fingers

for impatience and slap our forehead for forgetfulness. We also give a “thumbs up” for

satisfaction or agreement, shake our heads sideways for no and up and down for yes, as

well as waving in greeting or farewell. Also, rapidly nodding shows impatience, while

204 BURROWS

slowly nodding expresses interest and validates what the speaker is saying. These gestures

may vary from country to country, meaning one thing in one place and something totally

opposite in another. The “thumbs up” sign, a sign of approval in American, may mean

something crude in another country.

Another area of nonverbal communication is called proxemics. This is a relatively

new concept having to do with the space between people, how they handle it, and what

it says about them. One can tell by the distance between two conversing people, what

their relationship 1s. There are four distance zones: intimate, personal, social and public.

The first, intimate, is from one to eighteen inches. This area is reserved for an intimate

man and woman, family members, or very close friends. Men and women who are not

intimate, if put in this zone, will become embarrassed. The awkwardness is even greater

when it is a man and a man.

The second area, personal, is defined as one and a half to four feet. This area is desig-

nated for most friendly interactions. This is the distance that people who are meeting

on the street usually stop at to talk. At social evenings, most people converse somewhere

within this distance, usually close to two feet. The third zone, the social zone, is from

four to twelve feet. The closer part of this zone is where most business takes place. A

boss addressing his worker will stand over the person at this distance as well as when

someone meets a new co-worker. The farther part of this area is for formal interactions.

The people can sit at this distance and be close enough to talk, but far enough away to

work quietly without being rude. Two family members may sit at this distance across

the living room in the evenings. They are close enough to talk if necessary, but far enough

away to do an individual activity.

The farthest distance of interaction is from twelve to over twenty-five feet. This is

the distance from which politicians and speakers address their audience and actors perform.

Actors know that it is easier to deceive an audience with stunts far away than at an intimate

distance. This space is also used for informal meetings and classrooms. A person of authority

can easily address a crowd at this distance. Interestingly enough, many animals will move

away once a human enters this distance for their own security.

In some countries, however, people treat space a little differently. In Japan, being

crowded together is a sign of intimacy and friendship. In Middle Eastern countries, people

also require far less person space than Americans. It is not uncommon to see two men

holding hands, but in our country that is unheard of. In Arab countries, men like to look

deep into the eyes of the person they are talking with. If in a crowded situation, they are

not bothered by personal contact with strangers. In our country, such looks are consid-

ered offensive. Americans, if put into a crowded situation, hold themselves rigidly, avoiding

any contact with their neighbor. If such contact occurs, they immediately pull away

and apologize. While to Americans personal space is essential, people in other countries

feel differently.

NONVERBAL COMMUNICATIONS 205

The area of nonverbal communication is fairly new and there is plenty more to be

discovered. With our growing knowledge of nonverbal communication, we may soon

be able to interpret it and use it to our advantage. It can help us communicate more effec-

tively with those around us. The old saying may still have some truth: “actions speak

louder than words.”

References

Fast, J. Body Language. No publication information given.

Myers, D. (1993). Exploring Psychology. Holland, MI: Worth Publishers.

| “Basics of Nonverbal Communication.” Psychcrawler

Journal of the Washington Academy of Sciences,

Volume 85, Number 2, 206-208, December 1998

You’ve Got A Friend In Me:

The Therapy of Listening

Cures Cases of Suicidal Feelings

Lacey Irby

McLean High School

McLean, Virginia

Imagine a room, dark and empty, except for the light of one candle. Lurking in the

shadows of this room is a girl. A chain reaction of problems has set off her emotions

leaving her weeping tears so silent, no one can hear. She does not want to be a prisoner

in hell’s realm, but she feels trapped and she thinks there 1s only one way to escape the

closing walls. Taking a staggered breath, the girl pulls a gun out of her jacket pocket.

The sound of the bullet chamber being clicked closed echoes around the empty room.

The girl places the gun to her head, for she is ready to end all the pain and misery in her

so-called life. She cannot pull the trigger. She blanks out for a second, then mindlessly

picks up the phone lying next to her and dials a number. Someone answers.

“Hello?”

“Uhh,” Kristin, the girl breaks down completely, “You’ve gotta help me.

I’ve got a gun to my head...”

“Put it down,” the girl on the other line interrupts. “Put the gun down.”

You can hear the loud crash of the gun as it is dropped to the concrete floor of the

room. The candle flame flutters, and almost goes out. The girl pours out her heart to the

teenager on the other end of the phone. She tells her how she hates being ignored and

being thought of as a freak. She explains why she sits in her dark room all day and all

night writing poetry. She says her life is useless because no one has a heart big enough

to care about her ideas. All during this time, the girl on the other end of the telephone

line just listens, and slowly begins to see a magnificently terrifying picture being painted

before her by this girl she thought she knew.

What is suicide? Why do more than one million young Americans attempt suicide every

year? How can these drastic actions be prevented? Questions like these plague everyone’s

thoughts. The truth is that suicide is a frustrating thing that everyone should have some

knowledge about in order to prevent it. First and foremost, suicide is the act of killing oneself

intentionally. Suicide is a cry for help — a way to escape life’s daily pressures. There are

quite a few forms of committing suicide, including doing drugs or alcohol, hanging, inhaling

or ingesting a toxic substance, stabbing with a knife, and (as in the scenario) using a gun.

In fact, sixty percent of the time people shoot themselves to end their lives.

YOU’ VE GOT A FRIEND IN ME 207

There are many causes for teenage suicide. Adolescence itself carries enough stress,

confusion, and other mixed feelings to make anyone feel as thought their world is a mess.

Mixed feelings certainly do not decrease if a teen has witnessed a divorce or death in

_ their family. Discombobulated homes and break-ups between boyfriends and girlfriends

are other causes. Depression and hopelessness are by-products of these reasons for suicide.

Many people who commit suicide do so on impulse, but one out of five people leave

a note. Suicide notes usually are clues to the fact that the writer had some major problems

_ that he or she could not handle. The writer felt alone and no one could ever understand.

It is also common for the writer of the note to ask for forgiveness and ask for others to

pray for him or her. Many ask God for forgiveness, too, and hope that He will under-

_ stand. Notes are commonly composed of disorganized thoughts.

The communication between victims of suicidal behavior and thoughts and those

very special, underestimated people in life that we refer to as “friends” is actually quite

a simple theory. People turn to each other because of a bond known as friendship, which

is linked to a concept known as trust. Seventy-five percent of teenagers in the United

States tell their closest friend(s) that they want to die before attempting to commit suicide.

If ever in that position, keep in mind that this suicidal persona turned to you because

they trust you. Remember to be a friend in this time of need. The best possible thing

you can do for this person is to listen, not preach, lecture or give advice. Make sure to

ask questions to clarify what is being said. Do not take it upon yourself to cure your

friend of their suicidal feelings; you are not a professional, but you can help by

contacting a trustworthy adult. Most of all, let your friend know that people do care and

he or she is not alone.

Even psychotherapists and counselors learn the importance of listening. After making

special notes of what a parent has said, a psychotherapist evaluates the patient’s self-

destructiveness. They analyze the situation and decide if the patient needs to be immedi-

ately hospitalized or should be put on an antidepressant drug. Without lecturing, psycho-

therapists try to change their patients’ outlook on life and try to help them realize

that suicide is not the answer to their problems and suicide is not the right way to deal

with problems. Running from fears does not make them go away; you must confront

them. The more people know about how to deal with the pressure and stress of life, the

less suicide attempts there will be. Adolescents need to realize that no one can perfectly

understand their feelings. We should not keep attempting to explain ourselves, but rather

just be open and honest. A true friend will understand and discover the real you if

you be yourself.

Go back to the scenario you were imagining before; the girl who tried to commit

_ Suicide finally realized people do care, and she found someone to keep her candle burning.

The other girl learned that listening is the best therapy and, in doing so, she gained a

best friend.

208 IRBY

aIGUStINV? &

“Yeah?”

“Thanks. Thanks for everything.”

“Hey! Hello? Welcome to the fact that you have friends!”

References

Heckler, R. A. (1994). Waking up, alive: The descent, the suicide attempt and the return to life. New York: Putnam.

Hermes, P. (1987). A time to listen: Preventing teen youth suicide. San Diego: Harcourt.

Leder, J. M. (1987). Dead serious: A book for teenagers about teenage suicide. New York: Atheneum.

Lester, D. (1989). Questions and answers about suicide. Philadelphia: The Charles Press.

Marcus, E. (1996). Why Suicide? Answers to 200 of the most frequently asked questions about suicide, attempted

suicide, and assisted suicide. San Francisco: Harper San Francisco.

Journal of the Washington Academy of Sciences,

} Volume 85, Number 2, 209-211, December 1998

‘Dear lan’’

Emily McDonald

Woodrow Wilson High School

Washington, D.C

Dear [an,

What can I say. . . | wish we could have had more time. I wish you could have seen

me graduate. I wish you could have seen me get married. I wish you could have seen

| me have babies. Well maybe you will, just in a different way. I wish everyone in the

_ world could have had the pleasure of experiencing your presence.

| , You were a special person. It’s a shame we couldn’t really get to know each other

| more directly, and not through updates from Mom and Dad. I’m so sorry you were turned

) away from our house when Dad and Sue were separating. I’m so sorry for all the episodes

_ you had to endure. I hope you know how painful it was for me to see you in that straight

jacket on your birthday. And how emotionally scarring it was for me to see you in the

handcuffs crying when they took you in for beating up Mom. And when we would take

_ you out and have to drop you off at the homeless shelter. You weren’t homeless! You

_ had a home! If I could have done anything about it, I would have kicked that bitch Sue

_ out myself to make room for you!

| You used to scare me. When you started using drugs, I was too young to fully under-

| stand what was going on. All I knew was that you were withdrawn from the family and

you were changing. I didn’t really like you being at Mom’s because you kind of gave

the impression of a time bomb ready to explode at any given moment. I used to watch

you sitting at the dining room table shaking from your medication and not being able

to utter a word. I feel so much resentment towards whoever was supposedly treating

you because they were giving you all the wrong shit! It seemed like you got worse when

_ you took the prescription drugs. Because of ignorance, I figured that the treatment you

were receiving would maybe have a positive impact as time went on, but this proved

not to be the case.

I apologize for the way I treated you. I guess I acted so distant from you because

that was the way you were with me. When we used to go visit you in Baltimore, Mom

_ would always try to get us to hug or at least talk, but neither one of us wanted to go first.

_ [knew that you had a hard time showing your affection so I didn’t want to force it on

you like Mom did. Now that you’re gone, I miss so many things that I just couldn’t stand

when you were here. For instance, your room was always so junky and smelly at Mom’s

210 McDONALD

but now I don’t know what I wouldn't give to have it back that way. I miss your leaving

the toilet seat up, I miss you making fun of Beverly Hills 90210. I miss you laughing

along with Beavis and Butthead. I even miss you occupying my T.V. for your stupid

baseball games. If [had known your time was going to be so limited, I would have done

things so differently.

I guess I can’t focus on what I should have done, because that’s in the past. I think

your absence makes me value my other relationships more. I wish I could say that your

absence has brought Jessy and I closer together, but I can’t. Jessy really has a mental

problem that I just can’t overlook and try to work around. She has to try to figure herself

out before she gets closer to anyone else. Your absence has affected her a lot as well,

I’m sure. She hasn’t really said anything —I guess that’s a similarity that you two possess

that I don’t. ’m the only one among us that really is able to express myself without hurting

myself in any form.

Although it’s hard to look at your death in a positive light because you made the

decision to have things that way, I really try to look at this positively. Maybe you just

weren’t meant to live a normal life. Maybe if you would have lived your life past the

time that you wanted, it would have been even more painful than it was before. And

wherever you are, I'm sure you’re at peace. I'm glad you don't have to deal with that tug-

of-war inside yourself and with drugs and the people who contributed to your unhap-

piness that weighed you down every day of your last years. I can’t be selfish and try to

make myself happy by suddenly making you reappear, when you are happier where you

are. I hope that when we have family gatherings and when one of us is having an impor-

tant moment, that you are able to share it with us.

Your funeral was beautiful. I couldn’t have imagined it better. There were people

who didn’t even have a seat because the room was so packed. I would have talked, but

when Dad started talking about when he used to pitch to you when you were little, I

broke down and I knew I wouldn’t be able to go up there in front of all those people.

Everyone seemed to feel guilt more than anything. I could especially see it in your old

high school buddies. They felt bad about alienating you when you started to go downhill

and not returning your calls when you were steadily making improvement. For that one

day Jessy actually went to Mom’s and mingled with the people. That is, she actually

spoke to Mom and Lora. Dad is having a hard time. So is Mom, but Dad has a harder

time dealing with his feelings, while Mom deals with feelings that aren’t there all the

time. She refuses to drive under your bridge. She thinks that I don’t face my feelings

about you, but I do. I just prefer to not express them in her presence because you know

how she gets. Coach Burkhead has dedicated a birdhouse to you which sits on top of

the hill looking over the baseball field. He says he talks to you almost every day. Sometimes

it saddens me when I see all the St. Albans boys growing up so sheltered and I can’t

help but fear one of them may end up the way you did. I’m not blaming you for it, it’s

just the way things turned out I guess.

“DEAR IAN” 211

I want to end my letter by saying that you are always in everyone’s heart that knew

_ you. I don’t think I go through a day without thinking about you at some point. You are

missed terribly and we all feel a sense of emptiness inside. Thank you for the talk we

_ had just two weeks before you died in which you opened up for the first time to me. I

will always regret not being able to get to know you better and your time on this earth

_ being so shortened. You will always be on my mind and in my heart. I don’t think that

anyone will ever understand why you jumped off that bridge, but unlike Mom, I’m not

going to focus on that. She tries to blame herself and think that there was something she

- could have done to prevent it. Well, I guess only you can be the judge of that, but I try

to tell her that she shouldn’t deal with your death in that way. Even though I am steadily

' moving on with my life, I want you to know that I will never forget you. I love you.

Your sister,

Emily

Journal of the Washington Academy of Sciences,

Volume 85, Number 2, 212-215, December 1998

Communicating with Extraterrestrials

Daniel Smolyar

Wheaton High School

Wheaton, Maryland

Introduction

The idea that life, especially life with intelligence, might exist in other parts of

the universe is a very old one and can be seen in writings as far back as fifth century

BC in the writings of Metrodorus of Chios and Lucretius. These early ideas were based

on an intuitive belief in the enormity of the universe and in what is now called the

mediocrity principle, namely, that there is nothing special about the Sun, the Earth, and

the human race.

While interest in the question of extraterrestrial life is at least as old as historical

civilizations, the modern SETI (Search for Extra-Terrestrial Intelligence) era can be defined

as beginning in 1959. In that year, Cornell physicists Giuseppi Cocconi and Philip

Morrison published an article in Nature in which they pointed out the potential for using

microwave radiation to communicate between the stars.

Presently, the SETI Institute is working on project Phoenix and the SETI league is

working on project Argus. Both projects attempt to find evidence of intelligence

elsewhere in the universe by searching for microwave signals.

Scientific Rationale

The sun is one of 2* 10!" stars of the galaxy (the Milky Way), and there are about

ior galaxies in the visible universe. The universe is always expanding and started with

the big bang about 15* 10° years ago. Every part of it is made of the same 92 chemical

elements and obeys the same laws of physics. So the probability that there is life on other

planets is high.

In the early 1960’s while working as a radio astronomer at the National Radio

Astronomy Observatory in Green Bank, West Virginia, Dr. Frank Drake developed an

equation to estimate the number of advanced technological civilizations currently

active in the Galaxy.

The Drake Equation: N=R*f(p)*n(e)*f()*fG)*f(e)*L, where,

N = The number of communicative civilizations.

R =Therate of formation of suitable stars.

COMMUNICATING WITH EXTRATERRESTRIALS 213

f(p) = The fraction of those stars with planets.

n(e) = The number of “earths” per planetary system.

fl) = The fraction of those planets where life develops.

fi) = The fraction life sites where intelligence develops.

f(e) = The fraction of planets where technology develops.

L = The “lifetime” of communication civilizations.

With this equation, it is estimated that N equals about 200,000 stellar civilizations,

that is, about one advanced civilization per 10° stars. The need to search at least 10° stars

| is why supporters of the Drake equation say that radio searchers have not yet produced

any positive results.

However, the uncertainties of all the factors in the equation are very large, thus there

is no unique solution to this equation. It is a generally accepted tool used by the scien-

| tific community to examine these factors.

Project Phoenix

Project Phoenix is the world’s most sensitive and comprehensive search for extrater-

restrial intelligence. Phoenix began observations in February 1995. It is an effort to detect

extraterrestrial civilizations by listening for radio signals that are either being deliber-

ately beamed our way or are inadvertently transmitted from another planet.

Thanks to its long history of cooperation with NSA, the SETI Institute is able to

capitalize on a $58 million government investment representing decades of work by scien-

tists and engineers. NSA had completed less than a year of a planned ten-year SETI exper-

iment when Congress, under strong pressure for deficit reduction, terminated the obser-

vations. Because the equipment and procedures were still in a ramp-up phase, not even

one-thousandth of the intended search had been conducted.

There are about 1000 stars targeted for observation by Project Phoenix. All these

stars are within 200 light-years distance. This project will take approximately five years

to complete.

Given so many targets to choose from, scientists on the project have chosen to concen-

trate on those stars from which a signal would be strongest, on the nearest stars, and on

those stars that are similar to our sun, near which is found the only known example of

life. For those stars like the Sun, the Phoenix Project scientists have also gone two steps

further. They have chosen to concentrate on the older stars (because they expect that

advanced life takes a long time to evolve) and the single stars among those (because

binary star systems--two stars in orbit around one another--cannot have planets in stable

orbits that will endure the gravitational effects of the companion stars). The stars comprise

three distance samples, each having a different character, in order to allow various stellar

environments to be examined.

214 SMOLYAR

Because millions of radio channels are simultaneously monitored by Phoenix, most

of the “listening” is done by computers. Nonetheless, astronomers are required to make

critical decision about signals that look intriguing.

Phoenix looks for signals between 1000 and 3000 MHz. Signals that are at only one

spot on the radio dial (narrow-band signals) are the “signature” of an intelligence trans-

mission. The spectrum searched by Phoenix is broken into very narrow | Hz-wide channels,

so two billion channels are examined for each target star.

Project Phoenix will use the largest radio telescopes on earth, including the Parks

210-foot telescope in Australia, the Mopra 22-meter telescope, the 140-foot telescope

in West Virginia, and the 1000-foot Arecibo telescope in Puerto Rico.

Project Phoenix also has to deal with man-made interference. As of mid-1996, Phoenix

had examined about one-third of its targets, but found no evidence of extraterrestrial

transmissions.

Project Argus

Perhaps the most ambitious radio astronomy project ever undertaken without

Government equipment or funding, Project Argus is an effort to deploy and coordinate

roughly 5000 small radio telescopes around the world, in an all-sky survey for microwave

signals of possible intelligent extraterrestrial origin. When fully operational, Project Argus

will provide the first-ever continuous monitoring of the entire sky, in all directions in

real time.

Project Argus is a key effort of the SETI League, Inc., a membership-supported, non-

profit, educational and scientific corporation. The League was established in 1994 to

further the scientific search for extraterrestrial intelligence. The SETI League 1s currently

developing the necessary hardware, software, protocols and procedures for distribution

to its members worldwide. The search phase of Project Argus began with five opera-

tional radio telescopes on Earth Day, April 21, 1996.

Project Argus will employ small, quite inexpensive amateur radio telescopes, built

and operated by SETI League members at their individual expense.

A typical amateur radio telescope can be built for a cost of a few hundred to a few

thousand dollars, depending upon the expertise of the builder. Only five thousand of these

smaller instruments are necessary to provide full sky coverage. The equipment, although

of modest sensitivity, will still be capable of detecting microwave radiation from

technologically advanced civilizations out to a distance of several hundred light years.

Other Forms Of Communication With Aliens

It is estimated that there are about 2*10*° stars in the known universe. Therefore,

the probability of intelligent life more highly evolved than our own is overwhelmingly

high. Then the question that arises is why it is not communicating with us. There are

COMMUNICATING WITH EXTRATERRESTRIALS 215

several possible answers; one is that there is no intelligent life, or that there are commu-

nication signals virtually everywhere, but we are not yet intelligent enough to recog-

nize them as such. So far, the only method that SETI organizations use to try to pick up

_extraterrestrials signals is radio telescopes.

| Electromagnetic signals, however, are in several ways less than ideal for communica-

tion over light year distances. They require very large amounts of energy, and some of the

signals are absorbed by the “dust” in interstellar space and by earth’s atmosphere. In addition,

_the receiving entity must know where in wavelength and in which direction to look.

It is being proposed that there are other types of signals. When an atom or molecule

| is in an exited state it eventually decays, normally emitting a photon. There is some half-

life of the excited state, and the probability of emission in any given direction is normally

uniform over 4s steradians. It is proposed that it is possible to change the instanta-

_neous probability of photon emission in a specific direction — while leaving the mean

probability of emission in that direction unchanged. It would be expected that the signal

‘source would be in a straight line, or nearly so, with the atom or molecule and the direc-

| tion of emission. For discussion purposes these signals will be called emission influ-

ence (EI) waves. It is being proposed that scientists could pick up these EI waves.

However, this is just a hypothesis and has not been tested yet.

Alien Communication With Us

For decades people have reported seeing UFOs that were believed to be from other

planets. But the absence of concrete evidence, the overwhelming number of fake pictures,

| and fanciful names like “flying saucer’ have deepened the reluctance of professional

| scientists to take the UFO seriously. Only a few have taken the trouble to investigate

this phenomenon with no results. It has been speculated that aliens have been trying

to communicate with earth for centuries. There are more than 1000 reported cases of

UFOs in the U.S. alone, but there are so many fake pictures that it is hard to take this

subject seriously.

References

Papagiannis, M. D. (1994). Extraterrestrial Intelligence. McGraw-Hill Inc.

(1997). Extraterrestrial Intelligence. The World Book Multimedia Encyclopedia.

(1997). A Postulated Method of Communication. Metacrawler.

Henry, T. (1995-97). SETI League FAQ Sheet. Metacrawler. SETI League, Inc.

: (1997). Target Star Selection.” Metacrawler.

(1998). Welcome to the SETI Institute. MVetacrawler. SETI Institute. 1998

en tt

(1995-1997). “What is the relationship between the SETI League and SETI Institute.’ Metacrawler, SETI

League, Inc.

“The UFO Paradox.” Mysteries of Mind, Space, and Time. 1992 (Ed.).

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DELEGATES TO THE WASHINGTON ACADEMY OF SCIENCES,

REPRESENTING THE LOCAL AFFILIATED SOCIETIES

PRE OUSLCANSOCICH ROM MINCHCA = fa ames ee aihg ce ces a Sues et cee e sata e bhewrs bee hae Tim Margulies

Pile nicany ASsOclaWonm Ol Physics: Teachers: soy. s.c'ooc Ge ke een a ee ee Wee bee ee Frank R. Haig

PeEMctde TINO CLAIIIC SOCLCUY 4 ew ks sie Foes sus alee od Ae Oe Ee eee ve oS w ine ne we Laurie George

Peete aupISMemes: SOCIELY = oe. one Le eas She ebb alvin e okie bee ae He ee Ramona Schreiber

American Institute of Aeronautics and Astronautics ...........4.........-0000- Reginald C. Smith

American Institute of Mining, Metallurgical, and Petroleum Engineers ............... Michael Greeley

i meV ICtCOTOlOSICAl SOCIELY 52 ached. Seen ces Beeb web bee eae Da eae wee A. James Wagner

MRR AMINEAC IE ales S OCI CU Ar nner ien A ace fe ea Sats y coe alin. coil GAS GEM) Gs ood teva Busia wien 34 oops Paul E. Thiess

Pe AneenyfOpaimological SOCICLY «2. .n2 2. eee icles oe ee wee ee eee eb es Kenneth L. Deahl

Senmeemecciciy of Microbiology 60.6... kw acco eee cee ceed de waevccuesness VACANT

nS OCICIYROl Civil EMPSINEEES: 2 oc.5 5 kee es ee ee deb eee ewe ee John N. Hummel

Pamemcan society of Mechanical Engimeers .......5...0 600. ee ee ee eee Daniel J. Vavrick

Pemeaeanesecicty on Plant Psychologists 26... ce ee ce ee eee eee twee eee VACANT

Manin cdcal SOCicty Of Washington 2. ce. eee Sb be ne ee eee eee eee eee ee Marilyn London

EN TEAST Ure. Ree hh eg ce in A ae ae era a le CPD ae Sod awa elo ME Toni Marechaux

Peemanonnor Computing Machinery 2.52... 0.050000 000 beens eke ect eeteeeaaas Lee Ohringer

esseciation for Science, Technology, and Innovation ........6......00000ccccceneeeves Isaac Welt

Pea OCIcty/Ol WaASIMNOION 00 be ee ee ee ee ee bee eee eee wads Janet W. Reid

Smenimraleeacicty Ol WaSiiNGlOM... .0- 5. 0s. ee ee oben ee eb eee he be beeen ee eee Ray Peterson

nee AM SOCIS HNO VWaSMNPIOM ..4cs cca ee ws ee ee ek eee ee wee ee ee lees Elise Ann B. Brown

eaemomeolumbia Institute of Chemists ........ 5.000.000 cee cee dace nea e cout aeons VACANT

morimictot Columbia Psychology Association-................ 0000 cece ceed eee aas David Williams

Mace Plneial IKeSOULCE SULVEYS TEAM: .. 6c). tee eee ee ee ee ne eee eee VACANT

Seem CIOIOSICAl SOCICLY <2 icc50)s nec n ee hee med eee bee eee eee e eens en Ronald W. Mandersheid

(2 SEDC STENCIL SOGIEL giosctGi eo dee cuss cn OCC Nene oc ci leaner tetra ic carrera ae VACANT

memtomolorical Society of Washington .......... 0.0.0. ce cece eee eee aes F. Christian Thompson

— SETLE ELSE SOSTSA IO) MANETS 0101 0) 0 ane Bob Schneider

Memmummnioloerical Society Of WaShIMSton . 2... 2 i ce et eee ee ee ee eeaees VACANT

erernieciesocicty Or Washington, DC 2. ec ccc ce et ee eee ee eben beenens Phillip Ogilvie

Bertuaismeedactors anG@ ET@OMOMICS SOCICLY 2... ce ee eet ee eee e ences Thomas B. Malone

mismme oi elcctrical and Electromics Engineers ..-.........2220000 ces eeees Rex C. Klopfenstein

MC HBL OOCMCCHMOLOPISES of... ccc bole este ee ee oe fe eee ce eee ea ee eee eee Isabel Walls

SE EDIS Cit ICIS OIE By OVTT TSS) Se ag Neal Schmeidler

BPO FPRIMSOCICHY OL AMECNCA, .. aoc. oc. chee onc baa vdeo ene a beset eeabe John I. Peterson

International/American Association of Dental Research ...................00 eee J. Terrell Hoffeld

era Miaiedly ASSOCIALION Of AMEEICA . oi cle nk ca to ee ee eee eee ee ees Sharon K. Hauge

mcaeansociciy.or the District of Columbia ..... 2.0.5.2. 56 52.5 cee shee dee eee ne ews Duane Taylor

DEO AMET NSULOMONMICKS, . a6) o. anmy. @ aie 8s wa lth Fale ice ache owas one Ce Oe ewe ee Harold Williams

Ate ME OO RAMI CHS OCICLY) ine e- ttn en ope eke can oye ends cree a land we RS aoa LDR ea oy aaa es VACANT

EEG SUUIGIISIRY CLIVE SR (S10 (C2) a tell ea ae ee William R. Graver

SED SILENCE) BA WETS) 01001 0) 0 ear VACANT

| Pease al Society OF WashiMS(OM) 3.2 6 cee wc eee ee eee ea ee eee eee ee te wen James Goff

Seen weiieGehenal Systems RESCAreM 4... a6 scene lee eo 6d be be ee ok be eben See aes VACANT

SELEY Ol ANIOOTEIeVCR TIM RGSS 7S) Cie aan er re a a Michelle Harvey

Paringgomamencan) Military EMPINECES yj 2. viene eee ee cee a ee we ee ee eee eee VACANT

eociety of Experimental Biology and Medicine (SEBM) ....................200008: C. R. Creveling

| Bebe SAO MANULACKUGING ENSIMNCEIS 5h. 44 6 sc cece eee ne ee eee Ce ede eee Pav dee dew en VACANT

Bee rainG OPN MITANSTCR SOCIEUY, «aaa cid ob le hoe batt Se RSs ed Gate sa Dea eee clades Clifford Lanham

| SR PMMUOTISLOLY Of SCIence CIID 2 24.26% she oad ae oes eee eae eke ve ee Albert G. Gluckman

| Washington Operations Research/Management Science Council ...................4.. John G. Honig

Seite rOneeaint Vechmical GrOUD 8.4.64 ce hon od wR ee he eee ee de ee Dee ee eee Robert Kogler

BE SNORE SOCICLY Ol PMGINCETS ~0.25 22. 5s oan edt se aha eke ene bee eee eee e ee Alvin Reiner

PSOE Mone SPALISUICAMSOCELY: oe. on, 2st ais ete oa Se ee ke oy eee ee ewes Michael P. Cohen

—

Delegates continue to represent their societies until new appointments are made.

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Be : VOLUME 85

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\v tr Number 3

: Jo u ma l of the December, 1998

WASHINGTON

ACADEMY..SCIENCES

ISSN 0043-0439

Ss Beh Ss inns AG

+ Apis

Re.

RRL

Issued Quarterly

at Washington, DC

CONTENTS

ae Articles:

PeVoOrduliomaine mamtonial Stahl 252.0. sa < oc eis ce we ce bee elo eet neh d a tee i

a= Cyrus R. Creveling, “President’s Report on the Academy

tis or WSR" as dia ced a age eay ido ote eee ee a 219

E . Cyrus R. Creveling, “Grover C. Sherlin: A Remembrance” ............. Me) |

ae MeWSANGeAMNOUNCEMEMIS 452). 4) GGG a as Bd Ge we Ve PS Sela ee Juspe)

Melissa Mahon, Nina Matheny Roscher, “Elizabeth Weisburger:

eric mba ameas Onc SWar enh cine 2 As os dk bh ce kOe OM Ae eA 235

Washington Academy of Sctences

Founded in 1898

EXECUTIVE COMMITTEE

President

Rex Klopfenstein

Secretary

Michael P. Cohen

Treasurer

Frank R. Haig

Past President

Cyrus R. Creveling

Vice President, Membership Affairs

Clifford Lanham

Vice President, Administrative Affairs

Marilyn R. London

Vice President, Junior Academy Affairs

Vacant

Vice President, Affiliate Affairs

Peg Kay

Board of Managers

John H. Proctor

Eric Rickard

Norman Doctor

Jerry Chandler

Janet Reid

Thomas E. Smith

REPRESENTATIVES FROM

AFFILIATED SOCIETIES

Delegates are listed on inside rear cover

of each Journal.

ACADEMY OFFICE

Washington Academy of Sciences

Room 811

1200 New York Ave., N. W.

Washington, DC 20005

Phone (202) 326-8975

FAX (202) 289-4950

Email was @aaas.org

Web www.inform.umd.edu/WAS/

EDITORIAL BOARD

Editors:

Thomas Bottegal

Marilyn R. London

Cyrus R. Creveling

The Journal

This Journal, the official organ of the Washing-

ton Academy of Sciences, publishes original

scientific research, critical reviews, historical |

articles, proceedings of scholarly meetings of |

its affiliated societies, reports of the Academy,

and other items of interest to Academy mem-

bers. The Journal appears four times a year

(March, June, September and December). The

December issue contains a directory of the cur-

rent membership of the Academy.

Subscription Rates

Memberships, fellows, and life members in good

standing receive the Journal without charge.

Subscriptions are available on a calendar year

basis, payable in advance. Payment must be

made in U.S. currency at the following rates:

U.S. and Canada ......: ... 2.233 $25.00

Other Countries ......) ) 52 3a 30.00

Single copies, when available........ 10.00

Claims for Missing Issues

Claims will not be allowed if received more

than 60 days after the day of mailing plus time

normally required for postal delivery and

claim. No claims will be allowed because of

failure to notify the Academy of a change of

address.

Notification of Change of Address

Address changes should be sent promptly to the

Academy Office. Such notification should

show both old and new addresses and zip

codes.

POSTMASTER: Send address changes to

Washington Academy of Sciences, Room 811,

1200 New York Ave., N.W., Washington, DC

20005.

Journal of the Washington Academy of Sciences (ISSN 0043-0439)

Published quarterly in March, June, September and December of each year by the Washington

Academy of Sciences, (202) 326-8975. Periodicals postage paid at Washington, DC and additional

mailing offices.

A Word from the Editorial Staff

1998 was the Centennial Year for the Washington Academy of Sciences. WAS

celebrated with several events and special projects, which are outlined in Dr. C. R.

Creveling’s President’s report in this issue. In this new century of WAS, the Journal of

the Washington Academy of Sciences will strive to honor the past and anticipate the

future. Upcoming issues include articles on electromagnetism, historic scientific

figures in Washington, DC, and trans-Pacific culture exchange, indicating the broad inter-

ests of our members and readers. The editors will be abstracting events and articles

_ from past issues of JWAS to remind us of the fascinating and noble lineage of our organi-

zation.

We will also be presenting current news about WAS members. To that end, we are

asking members to submit information about awards received and appointments made,

for publication in a current news section of the journal. Please send information to the

JWAS mailing address.

The editorial staff is seeking WAS Fellows who wish to participate in the publica-

tion of the Journal by reviewing manuscripts in their fields. The Journal receives scores

of manuscripts each year, and they all require peer reviewers. Please contact the Journal

(by mail), indicating your interest and specifying your area of expertise.

This issue includes an account of the May 1998 Awards Banquet, with photographs,

and the 1998 President’s Report; and the obituary of Past President and long-time Board

member Grover Sherlin; and a biography of chemist Elisabeth Weisburger.

On behalf of the Board of Managers and all members of the Academy, we thank

each of the contributors to the journal for their continued interest and their patience.

Marilyn R. London

Cyrus R. Creveling

Thomas Bottegal

Journal of the Washington Academy of Sciences,

, Volume 85, Number 3, 219-230, December 1998

President’s Report on the Academy

for 1998

Cyrus R. Creveling

Technology Development

National Institute of Diabetes, Digestive and Kidney Diseases

The Academy has taken many opportunities not only to celebrate our one hundred

_ years of service to the Washington Metropolitan scientific community but also to expand

our pubic image and strengthen our ties with our affiliated societies. We have accepted

as affiliates two additional societies, the District of Columbia Chapter of American Women

in Science and the World Future Society. We have expanded our international connec-

tions with new Fellows from Russia, Spain, the Republic of Georgia, Germany and

Canada. We have added 10 new domestic Fellows and 15 new members. I want to thank

the members of the Board of Managers who have worked hard and diligently to make

this a successful year. As my term of office comes to a close I would like to thank Rex

_ Klopfenstein and his work as chair of the nominating committee, Jim Spates for work

on the by-laws, and, of course, Norman Doctor and Elaine Honig who managed to keep

| the office functioning. Marilyn London and Eric Rickard are carrying out the arrange-

ments for the awards banquet this year. Marilyn London has also agreed to assume the

role of Editor of the Journal. Finally the Academy and I are especially grateful to John

Proctor and his centennial committee for engineering so many successful centennial

events. In keeping with the career of our founder, Alexander Graham Bell, the Academy

has pursued the theme of communications. The following events have marked 1998 as

a year of communication.

Music as a Means of Human Communication The year began on March 20th with

a centennial concert and reception at the National Presbyterian Church showcasing the

| Fairfax Chorus under the baton of Dr. Douglas Mears. The Chorus performed a magnif-

icent concert of Duruflé’s Requiem and Bernstein’s Chichester Psalms. Dr. Mears gave

_ apre-concert lecture on the importance of music as a means of human communication.

_ Following the concert the chorus provided the Academy with a bountiful reception. The

Academy is grateful for the cooperation of Dr. Mears and to Carol Dunlap, Managing

Director of the Fairfax Choral Society.

220 CYRUS R. CREVELING

Philadelphia Conference of AAAS The Washington Academy was represented by

the former President of the Academy, Dr. Frank Haig.

Washington Academy of Sciences: Past, Present and Future Dr. Ellis Yochelson wrote

a masterful essay on the early years and Presidents of the Academy which was published

in pamphlet form and in the Journal.

Hovercraft Competition The Junior Academy, under the leadership of Dr. Allen

Barwick, sponsored the Annual Hovercraft Competition, which is traditionally held on

the first Sunday in May at the Wheaton Ice Skating rink. The competition includes radio-

controlled and human-powered hovercraft events. In the last competition three high schools

placed: Quince Orchard, Maret, and Wilson High Schools. On December 13, 1998 a

meeting was held at the Tompkins School of Engineering, George Washington University

for high school students, teachers, parents, and engineering mentors to plan the 9th Annual

Hovercraft competition. Engineers were present to present the principles of hovercraft

design. A working remote-controlled hovercraft was available that students were

welcomed to fly.

A Gala Birthday Party On Wednesday, May 27th the Academy held its Annual Awards

Banquet at the Bethesda Naval Club. However, this year was different. In response to

the desire of the board, all of the Awards were presented to persons for outstanding lifetime

careers. After a bountiful meal and the cutting of the Academy’s Birthday Cake, Dr. Rita

Colwell presented award certificates to an impressive list of persons. They included:

The Bernice Lambert Award for the outstanding science teacher at the High School

level was presented to Dr. William Allen Barwick of the District of Columbia School

System.

The Leo Shubert Award for the outstanding science teacher at the college level was

given to Professor Emeritus Samuel Massie, of the Department of Chemistry at the United

States Naval Academy.

The award for outstanding contributions to Behavioral Science was presented to

Dr. Jane Goodall of the Jane Goodall Institute of Silver Spring, Maryland.

The award for outstanding contributions to the engineering sciences was presented

to Dr. Walter R. Beam for his contributions to industry, government, and education.

The award for outstanding contributions in the Physical Sciences was presented to

Dr. Mark Spano of the Naval Surface Warfare Center in recognition of his contributions

over the past decade to the experimental control of chaos.

The award for outstanding contributions to computer science was resented to Dr.

Robert Kahn and Dr. Vinton Cerf. While no single inventor is responsible for the “Internet”

it is agreed however that Dr. Kahn and Dr. Cerf are foremost among the “Internet pioneers”.

The award for outstanding contributions in the Mathematical Sciences was presented

PRESIDENT’S REPORT 1998 221

Dr. Allen Barwick (left) receives the Bernice Lambert award for outstanding science

teacher at the high school level from President Rita Colwell and Dr. C. R. Creveling.

_ Dr. Colwell congratulates Professor Emeritus Samuel Massie of the U.S. Naval Academy

on receiving the Leo Shubert Award for outstanding science teacher at the college level.

CYRUS R. CREVELING

222

comibelnntED

Le PILE

ineering

to the eng

ing contributions

he WAS award for outstandi

ives t

Colwell

Dr. Walter Beam rece

from Dr.

SC1ENCEeS

the award for outstanding

Dr. Mark Spano of the Naval Surface Warfare Center receives

contribut

ident Colwell.

from Pres

iences

in the physical sc

ions int

PRESIDENT’S REPORT 1998 223

_ President Colwell presents Dr. Robert Kahn with the award for outstanding contributions

to the field of computer science. Dr. Kahn and Dr. Vinton Cerf were given this award for

their pioneering work on the development of the Internet.

David Kotz accepts the award for outstanding contributions in the mathematical sciences

on behalf of his father, Professor Samuel Kotz of the University of Maryland. Professor

Kotz was in Russia at the time of the Awards Dinner.

224 CYRUS R. CREVELING

The award for outstanding contributions in the biological sciences is received

by Dr. Fenner A. Chace of the Smithsonian Institution.

Dr. Ellis L. Yochelson is presented the award for outstanding contributions to the history of

science and technology by Drs. Creveling and Colwell.

225

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Dr. Grace Ostenso is congratulated on receiving the award for outstanding contributions to

technology.

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Colonel Thomas Doeppner, forner Vice President for Affiliate Affairs, is congratulated by

President Colwell for having his name added to a plaque honoring outstanding service to

the Academy.

PRESIDENT’S REPORT 1998 227

a eS é

SR Neen 5 3

Past Presidents attending the May 1998 Awards Dinner. Back row: Walter J. Boek, John

S. Toll, Cyrus R. Creveling, Frank R. Haig, James E. Goff, and John H. Proctor. Seated:

John G. Honig, Alphonse F. Forziati, Rita R. Colwell, Jean K. Boek

to Professor Samuel Kotz of the Department of Mathematics and Statistics at the University

of Maryland. His son David Kotz accepted the award.

The award for outstanding contributions to the Biological Sciences was presented

to Dr. Fenner A. Chace, currently a Zoologist Emeritus at the Smithsonian Institution

National Museum of Natural History.

The award for outstanding contribution to the History of Science and Technology was

given to Dr. Ellis L. Yochelson from the Department of Paleobiology, Smithsonian Institution.

The award for outstanding contributions to the Environmental Sciences was to the

Honorable Gilbert Gude. Gilbert Gude, a previous member of the United States

Congress, has been an active force in conservation efforts.

The award for outstanding contributions to public health was presented to Dr. Joseph

Edward Rall in recognition of a life time of service as a practicing scientist, scientific

director of the National Institute of Diabetes and Digestive and Kidney Diseases

(NIDDK), and finally as the Scientific Director of the National Institutes of Health (NIH).

The award for outstanding contributions to Technology Policy was presented to Dr.

Grace Ostenso, for her many years of devoted service as a professional staff member of

the Committee on Science, Space and Technology of the United States Congress.

The award for outstanding contributions to National Science and Technology

Policy was presented to the Honorable Constance Morella for her effective efforts for

the promotion of science.

228 CYRUS R. CREVELING

The award for Outstanding and Distinguished Career in Science was presented to

Dr. Rita Colwell, President of the Washington Academy of Sciences and now Director

of the National Science Foundation. The entire Board of Managers nominated Dr. Colwell.

The evening ended with the address by Dr. Rita Colwell, “Global Climate and Human

Health: El Nino and Cholera.”

Russian Film Festival On June 11th the Academy was represented by Dr. John Proctor

and Dr. and Mrs. Creveling at a reception held at the Savoy Hotel for the directors and

artists of the Russian Film Festival.

Science and Engineering Apprentice Program The annual assembly of the student

apprentices was held at the George Washington University on August 14, 1998 under

the direction of Dr. Marilyn Krupsaw. As in the past many of the conveners who met

with the students in one of the study groups and listened to the student presentations

were Fellows and members of the Academy.

Centennial Reception for the Affiliated Societies On Wednesday, September 23, many

representatives of our affiliated societies attended a reception at AAAS. John Honig

and Peg Kay with the help of Elaine Honig made heroic efforts to contact the affiliated

with the result that many new faces were present. Dr. Creveling gave a welcoming speech

emphasizing the intent of the Academy to assist and meet jointly with the Affiliates

whenever appropriate. A very congenial evening was had by all.

Communication Technology Symposium On Monday October 19 the Academy

hosted a symposium at the Cosmos Club of Washington entitled “Humanizing and

Dehumanizing in Communication Technology. After a brief introduction by

C. R. Creveling, five presentations were made by the following participants:

Dr. Ronald Manderscheid, Washington Academy; Dr. John H. Proctor, Washington

Academy; Paul-Georg Gutermuth L.L.D., Head of Division, German Ministry of

Economics, Bonn; Academician Igor M. Makarov, Russian Academy of Sciences,

Moscow; and Professor Vil Rakhmankulov, Institute of Systems Analysis,

Moscow. A lively and spirited discussion and questions from the audience continued

for most of the afternoon. The symposium adjourned to a reception and dinner.

At the dinner a Certificate of Fellowship was presented to Paul-Georg Gutermuth.

The proceeding of the symposium will be published in the Journal of the Academy.

The Academy thanks Drs. Proctor and Manderscheid for their hard work in

this symposium.

Historical Society of Washington, DC A joint meeting of the Academy was held

with the Historical Society of Washington, DC. Academy fellows Frank Haig, C. R.

PRESIDENT’S REPORT 1998 229

Creveling and Peg Kay presented lectures on various aspects of the history of science

at the 25 Annual Conference on Washington DC Historical Studies in Washington. The

conference was held in the Martin Luther King Memorial Library on Friday, October

| 30th.

High School Essay Contest As part of the Centennial Year celebrations in keeping

with the career of our founder, Alexander Graham Bell, The Junior Academy of

Sciences sponsored a High School Essay Contest. Students from the 9th through 12th

grades submitted 1000 word essays on topics concerning “Communications Within and

Between All Levels of the Biological Hierarchy.” Over 100 papers were received from

12 schools. The panel of judges, including Norman Doctor, Rex Klopfenstein, C. R.

Creveling, Thomas Bottegal, Allen Barwick, and John Proctor, read them all and with

much debate selected 1st, 2nd, and 3rd Prize winners and three Honorable Mentions.

1st Prize: Elizabeth Barnwell, Richard Montgomery High School: “Communications:

Koko The Gorilla,” Teacher, Beverly Stross.

2nd Prize: Lily Simonson, Richard Montgomery High School: “Equus: The

Language of Horses,” Teacher, Beverly Stross.

3rd Prize: Anna Burrows, Wheaton High School: “Non-verbal Communication,”

Teacher, J. Dewey Brown.

Honorable Mention: Lacy Irby, McLean High School: “You’ve Got a Friend In Me,”

Teacher, Mrs. Demby Banbury.

Honorable Mention: Emily McDonald, Woodrow Wilson High School: “Dear Ian,”

Teacher, Mr. Fellows.

Honorable Mention: Daniel Smolyar, Wheaton High School: “Communications with

Extraterrestrials,’ Teacher, Mr. J. Dewey Brown.

The winners of the essay contest were presented with certificates and the prize money

at a Reception held at the National Press Club on Monday evening, November 9th. The

winners, their families and the sponsoring teachers and friends were present. A speaker,

Richard Thomas of Newsweek Magazine, presented a lively lecture on the essential role

of the press in democracies. The Academy appreciated the support for the essay contest

and reception donated by Vertech, Inc. and CleanScreen Corp.

Marie Curie Centennial A joint meeting and reception was held with the Washington

Section of the American Nuclear Society and the Washington-Baltimore Chapter of the

Health Physics Society. The speaker, Greta Dicus, Commissioner of the U.S. Nuclear

Regulatory Commission, discussed the research by Marie Curie which led to the

discovery of radium and polonium by Marie and Pierre Curie one hundred years ago in

1898, the same year that the Washington Academy began. A tour was arranged by the

Junior Academy for high school students to visit the AFFRRI reactor on the grounds of

the Naval Medical Center. Fifteen students were able to see the reactor. Their

230 CYRUS R. CREVELING

comments at the reception suggested that they were quite excited and impressed by the :

tour.

American Women in Science On February 10, 1999, the Academy will hold a joint

meeting with the DC Chapter of American Women in Science (AWIS) in the AAAS _

headquarters. |

As I write, I realize that there are only a few weeks left before I become one of the —

past presidents and like Dr. Colwell before me I will present the President’s Address in |

May. The title of my address will be “The Role of Endogenous Estrogens in the Etiology |

of Human Breast and Prostate Cancer.” |

Journal of the Washington Academy of Sciences,

| Volume 85, Number 3, 231-232, December 1998

~ Grover C. Sherlin: A Remembrance

Cyrus R. Creveling

Technology Development

National Institute of Diabetes, Digestive and Kidney Diseases

Grover Sherlin was one of the key contributors to the Washington Academy of

_ Sciences over many decades. To our deep regret he passed away at the age of 86,

succumbing to arteriosclerotic cardiovascular disease at his home in Hyattsville on January

be 33t999:

Grover Sherlin contributed more of his time and of his resources to the Academy

than any single person in its history. He served as its President (1973-1974), Secretary

and Treasurer. Since 1981 he spent innumerable hours volunteering his time performing

administrative tasks for the Academy. I remember when he sat in the little office at

_ National Graduate University for hours on end, entering each member’s information

laboriously into the Academy’s first Radio Shack computer. He checked all the zip codes,

and other information for errors. Grover Sherlin, as the most long-term and conscien-

tious member of the Board of Managers, was given the honor and responsibility to declare

a quorum at the beginning of each meeting of the Board.

More recently, he contributed his resources to make a permanent home of the

Academy in the new AAAS building a reality. He was one of three patrons of the Academy

and, in partial recognition of his contributions, was elected to be Vice-President

Emeritus and a permanent Member of the Board of Managers of the Academy for life,

the only individual ever so honored. In memory of his many contributions to the Academy,

a prize has been named after him to recognize individuals who have contributed most

to the Academy.

Grover Sherlin served on the Joint Board on Science and Engineering Education

since its inception in 1955 and was its President in 1977-1978. He also served as President

of the District of Columbia Council of Engineers and Architects.

Another one of his pet efforts over the last 50 years was his work on behalf of local

science fairs. He helped found science fairs and science fair associations in Prince

George’s County, Montgomery County, Calvert County, Charles County, and St.

Mary’s County in Maryland, and in the District of Columbia Public Schools. He served

as President of the Prince George’s County Science Fair Association. Each year, in his

honor, that association will award an all expense-paid trip to the International Science

232 CYRUS R. CREVELING

Fair for two freshmen. None of us will forget how he and his wife Margaret contributed;

many hours at each Science Fair to keep it running and the judges fed.

He was also a lifetime member of many professional organizations, including the |

American Association for the Advancement of Science, Philosophical Society of |

Washington, American Geophysical Union, American Society for Engineering Education,

Institute of Electrical and Electronic Engineers, National Science Teachers Association, |

American Society of Plumbing Engineers, District of Columbia Science Fair Association, —

and the National Geographic Society.

Grover Sherlin was born in Chattanooga, Tennessee, and raised in Little Rock,

Arkansas, where he attended Little Rock Junior College. In 1936 he graduated from the |

University of Arkansas with a degree in electrical engineering. After working on a |

construction crew for the Bell Telephone Company in Little Rock for eight months and

then for the U.S. Army Corps of Engineers, he ceme to Washington in 1939 to work as_|

a materials inspector for the Panama Canal Inspecting Engineers Office. In August 1947

he accepted a position as a hydraulic engineer at the National Hydraulics Laboratory of |

the National Bureau of Standards where he remained until his retirement in 1972. However,

he continued working at the Bureau as a rehired annuitant until he finally retired in 1976. |

His first wife of 36 years, Mary Bruce Sherlin, died in 1973, and his second wife

of 20 years, Margaret Mae Sherlin, died in 1995, after a lengthy illness. For 25 years |

he was a member of the College Park Church of God and cofounder of the Kensington |

Prayer Group. He is survived by his three children, eight grandchildren, fifteen great-

grandchildren, and one great-great-grandchild. |

Journal of the Washington Academy of Sciences,

, Volume 85, Number 3, 233-234, December 1998

News and Announcements

WAS Past President Rita Rossi Colwell became the Director of the National Science

Foundation in August 1998. Dr. Colwell was previously President of the University of

_ Maryland Biotechnology Institute and Professor of Microbiology at the University of

Maryland. She holds a B.S. in Bacteriology and an M.S. in Genetics, from Purdue

University, and a Ph.D. in Marine Microbiology from the University of Washington. Dr.

| Colwell is active in national and international research and teaching in the areas of marine

biotechnology and the molecular genetics of marine and estuarine bacteria.

Past Presidents Cyrus R. Creveling and Rita R. Colwell were inducted into the

: World Academy of Arts and Sciences in April 1999. The two were nominated for the

honor by John H. Proctor.

Upon his retirement in 1998 from the Naval Research Laboratories Dr. David L.

- Venezky donated funds to the Washington Academy to establish a student award for

_ excellence in science. The first Venezky Award was presented to Mr. Colin Barry at

_ the Chemistry Division of the Science and Engineering Apprentice Program held

_ August 11, 1999 at the Naval Research Laboratories. The title of Mr. Barry’s presen-

tation was “Matlab Graphical Interface for Classification Algorithms (MAGICAL):

Application to Early Warning Fire Detection”. Dr. Ron Shaffer of NRL was Mr.

Barry’s mentor. Two second prize awards were also selected; Mr. Graham Beaber

for “Drug Contamination of Currency” and Ms. Jenelle Baldwin for “Environmental

Contamination by Drugs: Inner-city vs. Suburban’. Both students served under Dr.

David Kidwell of NRL.

Past President John H. Proctor was named an Honorary Member of the Russian

Academy of Sciences in the spring of 1999.

Member Deaths Reported

1997 Hartmann, Dr. Gregory K.

Schneider, Mr. Sidney

Alexander, Dr. Benjamin H. Schulman, Dr. James H.

Baker, Dr. Arthur A. Sinden, Dr. Stephen Lee

E]-Bisi, Dr. Hamed M. Slawsky, Dr. Zaka I.

Forziati, Dr. Florence H. Spies, Dr. Joseph R.

Freeman, Mr. Alexander F. Traub, Col. (Ret) Robert

Frush, Dr. Harriet L. Weissler, Dr. Alfred

234

1998

Aldridge, Dr. Mary H.

Axilrod, Dr. Benjamin M.

Ballard, Mr. Lowell D.

Herman, Dr. Robert

Irving, Jr., Dr. George W.

Benefactors and Patrons (*) of the Washington Academy of Sciences

LOO)

* Alexander, Dr. Benjamin H. (LF)

Allen, Dr. J. Frances (EF)

Aronson, Mr. Casper J. (EMJ)

Beach, Dr. Louis A. (F)

Beckmann, Dr. Robert B. (EF)

Doeppner, Col. Thomas W. (LF)

Freeman, Mr. Andrew F.

Glover III, Prof. Rolfe E. (EF)

*Honig, Dr. John G. (LF)

Membership Statistics

Category

Fellow

Non-Resident Fellow

Emeritus Fellow

Life Fellow

Member

Emeritus Member

Life Member

Location

Maryland

Virginia

Other States

District of Columbia

Foreign

Address unavailable

Kessler, Dr. Karl G.

Mayor, Dr. John R.

McKenzie, Mr. Lawson M.

Mizell, Mr. Louis R.

Sanderson, Dr. John A.

Specht, Dr. Heinz

Tousey, Dr. Richard

Klopfenstein, Mr. Rex (F)

Manderscheid, Dr. Ronald W. (LF)

Perros, Dr. Theodore P. (F)

Specht, Dr. Heinz (EF)

Tamargo, Dr. Juan (NRF)

Tate, Mr. Douglas R. (NRF)

1998

Fearn, Dr. James E. (EFJ)

Shropshire, Jr., Dr. W. (LF)

34.9

8.5

2ae5

9.3 |

19.7 |

2.4

0.6 |

% |

46.0

19.3

16.0

12.8 |

4.5

ie!

Journal of the Washington Academy of Sciences,

, Volume 85, Number 3, 235-239, December 1998

Elizabeth Weisburger:

More Than a Chemist

Melissa Mahon and Dr. Nina Matheny Roscher

Department of Chemistry

American University

Washington, DC 20016-8014

Abstract

“A chemist has to have endurance, intelligence, a sense of responsibility and, well, strength,

and some curiosity too,’ (Weisburger, 1996). All of these traits are the characteristics that

Elizabeth Weisburger has and which enabled her to thrive in the field of chemistry and

especially chemical carcinogenesis. Her devotion to this field and her career have led to

numerous awards and honors. Weisburger’s life as a chemist also includes her work as a

teacher, editor, and, recently, a consultant.

“A chemist has to have endurance, intelligence, a sense of responsibility and, well,

strength, and some curiosity too,” (Weisburger, 1996). All of these traits are the charac-

teristics that Elizabeth Weisburger has and which enabled her to thrive in the field of

_ chemistry and especially chemical carcinogenesis. Her devotion to this field and her

career have led to numerous awards and honors. Weisburger’s life as a chemist also

_ includes her work as a teacher, editor, and, recently, a consultant (The Capital Chemist,

1996). Retired since the beginning of 1989, Weisburger has “been busier than ever”

"as she is the social chair in the division of Chemical Health and Safety, American

Chemical Society, and also consults when needed (Weisburger, 1996). Her long career

iS growing even more remarkable, as she still participates in numerous societies and

activities relating to the field.

Elizabeth Weisburger was born on April 9, 1924, in Finland, Bucks County, PA.

| Shortly after she was born, her parents, Raymond Samuel Kreiser and Amy Elizabeth

(Snavely) Kreiser moved back to Lebanon County, PA (Grinstein, 1993). From that

time until the time Weisburger went to graduate school, the family grew with new

children, totaling ten Kreiser children in all. As Weisburger would succeed in the field

of chemistry, some of her siblings would also major in science fields.

Weisburger’s education came from Lebanon Valley College, where she received

_-a small scholarship. She majored in chemistry, but was also interested in biology

. (Grinstein, 1993). In 1944 she received her B.S. in chemistry, and the same year she

_Teceived a graduate assistantship in chemistry from the University of Cincinnati, where

she earned her Ph.D. in organic chemistry, three years later. For her work, Weisburger

was awarded an honorary D.Sc. from each institution (Cattell, 1994).

236 MELISSA MAHON, NINA MATHENY ROSCHER

Before Weisburger began her chemistry career, she held other jobs, not related to }

the chemistry field, during the summers. She started her working career making men’s

pajamas in Lebanon, PA (Weisburger, 1996). The next summer she began making |

women’s dresses. The following summer Weisburger worked at a poultry packing estab-

lishment. The summer before Weisburger went to graduate school, she worked at the |

Bethlehem Steel Forge Plant. There she inspected airplane cylinder barrels and bridge

pins (Weisburger, 1996). Working there allowed her to learn about practical metallurgy,

since she asked questions about what she was working on (Weisburger, 1996).

Going into chemistry was not easy for Weisburger, giving the prevailing attitudes

of both men and women. Weisburger believes, “there is less discrimination now. !

Probably, the most overt discrimination was in the physics courses I took. I would be |

the only female and there would be eight to ten other students, all males. So that was |

about the worst” (Weisburger, 1996). That was during Elizabeth’s undergraduate school

years, but during graduate school, there was not as much discrimination due to the fact

that it was wartime; consequently, women were accepted with graciousness (Weisburger,

1996). This was the same time that Elizabeth received her assistantship to attend the

University of Cincinnati. Even today Elizabeth believes that “women were not

promoted or given the laboratory chief jobs at NIH that they should have been”

(Weisburger, 1996).

Discrimination also played a role in the life of Weisburger’s sister. Her sister majored |

in chemistry, but was discouraged when she was not allowed to have a lab bench to do |

her research project because the benches were reserved for the men (Weisburger, 1996).

Later in life she married a physicist/electrical engineer. In spite of the discrimination

and the times, both male and female siblings of Weisburger found careers and jobs in |

various branches of chemistry, as well as in other science fields. A brother of |

Weisburger’s became an analytical chemist and works at Hershey Medical Center, while |

another brother became a biochemist. Two other siblings majored in biology, one |

becoming a Navy captain.

Not only do science jobs and careers abound within her immediate family, but they |

are also prevalent in her own family and her siblings’ families. Her siblings’ children |

have become electrical engineers, computer specialists, physicians, and teachers in |

science fields. Weisburger’s own children include a son who is a pathologist, a daughter |

who is a physical therapist, and another son who is a computer programmer. Weisburger’s |

children were not pushed into the fields they chose, but were encouraged through their |

own interests (Weisburger, 1996). However, Weisburger’s curiosity and interest in

chemistry might have helped sparked interest in the fields all of her relatives eventu- |

ally chose.

Weisburger’s long career led to some interesting experiments, exciting discoveries |

in chemistry, and some interesting trips. Weisburger saw that “chemistry was [a field |

where] there are lots of new things to be done and discovered” (Weisburger, 1996).

ELIZABETH WEISBURGER: MORE THAN A CHEMIST 237

| Because of this she chose chemistry as a career. This aspect of chemistry led her to

| realize that there are many fields that can be applied to chemistry, such as toxicology,

patents, and many others (Weisburger, 1996). Because of Weisburger’s job in the Public

| Health Service, she became very knowledgeable about the subjects she worked with

_ and she was often called upon to be a possible expert witness or reviewer. Her life as

/,aconsultant since she retired has led to some very interesting side trips, such as flying

to Seattle to appear in court (Weisburger, 1996).

During Weisburger’s career, she had many achievements. In 1973, she received

| the Public Health Service Meritorious Medal, for her work as a commissioned officer

| in the U.S. Public Health Service. Weisburger had always been interested in the mecha-

/ nism whereby environmental chemicals cause mutations and/or cancer (The Capital

| Chemist, 1981). This involved one of her primary research efforts directed at eluci-

| dation of carcinogenesis by aromatic amines and aminoazo dyes. She and her

_ coworkers also worked with metabolism and activation of other amines. Weisburger

was also involved in the selection of environmental chemicals to be tested for possible

} carcinogenic activity. These tests were among the first to show the carcinogenic effect

of certain pesticides, textile flameproofing agents, anti-knock agents, and others (The

| Capital Chemist, 1981).

All of these research efforts were recognized by the Hildebrand Award in 1981,

given by the Chemical Society of Washington. During this year, Weisburger also earned

| the Garvan Medal from the American Chemical Society. Weisburger, who held the

\ rank of Captain, also received the Distinguished Service Medal of the U.S. Public Health

! Service in 1985. Two years later she received the Professional Service Award from the

| Washington Professional Chapter of Alpha Chi Sigma, and two years after that in 1989

| she was awarded the Distinguished Scientist Award from the D.C. Chapter of the Society

| for Experimental Biology (Grinstein, 1993). In 1996, Elizabeth received the Stokinger

award from the American Conference of Governmental Industrial Hygienists for her

“contribution to the occupational health and safety profession and for her achievement

in the broad field of industrial and environmental toxicology” (The Capital Chemist,

1996).

| Another great achievement of Weisburger was her involvement with the Bioassay

| Program (Weisburger, 1996). Elizabeth states, “The thing that was perhaps the most

influential [in her life] was helping to start the bioassay program at the Cancer

Institute. In the bioassay program we tested compounds to see whether they might be

carcinogens. I was responsible for picking out the compounds to test and get the infor-

| mation” (Weisburger, 1996). Another achievement of Weisburger’s relates to her service

| and commitment to help others. She served on the Board of Trustees at Lebanon Valley

College, including as its chair. In recognition of her service and support, there is an

Elizabeth Weisburger Indoor Track at Lebanon Valley (Weisburger, 1996). “There was

a fund drive years back for a physical education building, when they opened the building

———E

238 MELISSA MAHON, NINA MATHENY ROSCHER

and had the dedication, [Weisburger] found out that they had named the indoor track |

after her” (Weisburger, 1996). Having a track named after her was just another honor |

she gained by working in the chemistry field. |

After all of these awards and accomplishments and forty years at the National Cancer |

Institute, Weisburger retired, but she still remains quite involved in the chemistry and |

science world. Her days are filled with many different activities and types of work, as |

she is a member of the American Society of Biological Chemists, Royal Society of

Chemistry, American Association for Cancer Research, Society of Toxicology, and many |

other chemical and toxicology societies. Weisburger has authored or co-authored |

numerous technical publications and serves on the editorial boards of several journals |

(The Capital Chemist, 1981). She reviews numerous reports and does a lot of editing

for various people and societies, such as the American Institute for Cancer Research

(Weisburger, 1996).

Weisburger’s life does not just revolve around chemistry, she greatly enjoys the |

outdoors (Weisburger, 1996). She has done quite a bit of hiking and still continues to

do so. She is active in clubs relating to the outdoors world, as she aids in the mainte-

nance of hiking trails (Grinstein, 1993). Elizabeth likes to do crossword puzzles, because

they are similar to complicated reactions. She enjoys baking, because it also is similar |

to laboratory work, (Weisburger, 1996). :

If the past could be relived Weisburger would still choose to be a chemist |

(Weisburger, 1996). She states, ““One of the problems is the public image of chemistry

in that people think that it is something associated with toxic waste and things of that

type. Chemists are currently having a harder time finding jobs, but there are so many

things that chemists can go into—patent law and information systems, library work,

toxicology, biotechnology and selling chemicals. There are lots of opportunities for

chemists” (Weisburger, 1996). Elizabeth Weisburger definitely found the opportuni-

ties and put her knowledge to work. Her career as a chemist allowed her to have influ-

ence over certain things, such as the Bioassay Program. She has had a long career as

a chemist, but her work in the field still continues today. She has achieved in the field

she chose to study and expanded her accomplishments many times over with the work

she has done; work that was not easy fora woman. Being a successful woman chemist,

alone, is a great accomplishment. As Weisburger continues to hike and figure out cross-

word puzzles, the chemistry field she has retired from has not quite been put to rest.

References

Cattell, J.ed. American Men and Women of Science: Physical and Biological Sciences 19th ed. (1994).

New York: Bowker Co.

“Elizabeth K. Weisburger, Ph.D. : Winner of Stokinger Award.” (1996). The Capital Chemist. March 1996: 7.

Grinstein, Louise S., Rose, Rose K. and Rafailovich, Miriam H. (eds.) (1993) Women in Chemistry and

ELIZABETH WEISBURGER: MORE THAN A CHEMIST 239

Physics: A Biobibliographic Sourcebook. Westport, CT: Greenwood Press.

_Marks, Cheryl. (1981). “Elizabeth Weisburger of N.I.H. Wins 1981 Hildebrand Award.” The Capital

Chemist. March 1981: 31.

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VOLUME 85

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December, 1998 _

ISSN 0043-0439

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Rey. Frank R. Haig, “The Global Symposium on Information Technology

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Silvio A. Bedini, “Edward Kiibel (1820-1896)

Rasmacion- Ce. Instrument Maker 2. 2. ees ee ec eee oe 247

Paul T. Arveson, “Gratuity in Nature and Technology” .................. 281

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Washington Academy of Sciences

Founded in 1898

EXECUTIVE COMMITTEE

President

Rex Klopfenstein

Secretary

Michael P. Cohen

Treasurer

Frank R. Haig

Past President

Cyrus R. Creveling

Vice President, Membership Affairs

Clifford Lanham

Vice President, Administrative Affairs

Marilyn R. London

Vice President, Junior Academy Affairs

Vacant

Vice President, Affiliate Affairs

Peg Kay

Board of Managers

John H. Proctor

Eric Rickard

Norman Doctor

Jerry Chandler

Janet Reid

Thomas E. Smith

REPRESENTATIVES FROM

AFFILIATED SOCIETIES

Delegates are listed on inside rear cover

of each Journal.

ACADEMY OFFICE

Washington Academy of Sciences

Room 811

1200 New York Ave., N. W.

Washington, DC 20005

Phone (202) 326-8975

FAX (202) 289-4950

Email was @aaas.org

Web www.inform.umd.edu/WAS/

EDITORIAL BOARD

Editors:

Thomas Bottegal

Marilyn R. London

Cyrus R. Creveling

Journal of the Washington Academy of Sciences (ISSN 0043-0439)

Published quarterly in March, June, September and December of each year by the Washington |

Academy of Sciences, (202) 326-8975. Periodicals postage paid at Washington, DC and additional |

mailing offices.

The Journal

This Journal, the official organ of the Washing- |

ton Academy of Sciences, publishes original —

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articles, proceedings of scholarly meetings of |

its affiliated societies, reports of the Academy, |

and other items of interest to Academy mem- |

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(March, June, September and December). The |

December issue contains a directory of the cur- |

rent membership of the Academy.

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| A Word from the Editorial Staff

This issue of the Journal includes a report from Dr. Frank Haig, former president of

the Academy, on the Global Symposium on Information Technology of Futuroscope held

‘in March of 1999 in France. In upcoming issues, we will have more reports from and

‘papers presented at international symposia on the impact on information technology on

global communications.

We also have an article by Paul Arveson on the concept of gratuity as applied to

several fields of science.

___ The third article is a historical perspective on the family of Edward Kiibel, who was

‘an instrument maker in Washington in the 19th century. We are pleased to publish this

article, written by Silvio Bedini, as part of the celebration of the 97th birthday of Frank

LA. Taylor, one of Kitibel's most successful grandchildren.

___ The editorial staff is still seeking WAS Fellows who wish to participate in the publi-

‘cation of the Journal by reviewing manuscripts in their fields. Please contact the Journal

\(by mail), indicating your interest and specifying your area of expertise.

On behalf of the Board of Managers and all members of the Academy, we once again

)thank each of the contributors to the journal for their continued interest and their patience.

Marilyn R. London

Cyrus R. Creveling

Thomas E. Smith

Journal of the Washington Academy of Sciences,

/ Volume 85, Number 4, 243-246, December 1998

The Global Symposium on Information

Technology of Futuroscope

A Summary by The Rev. Frank R. Haig, S.J.

Representative from the Washington Academy of Sciences

The Club of Rome, the European Commission, and UNESCO sponsored a meeting entitled

The Global Symposium on Information Technology of Futuroscope March 1-5, 1999. The

topic of the convention was Thinking Global, Feeling Local : Connectivity in the Information

Society. The Washington Academy of Science was invited to send a representative. Dr. Frank

| Haig, a former president of the Academy, was chosen to represent the Academy.

} From Monday, March 1, until Friday March 5, 1999 some 200 international

scholars, technologists, and interested people gathered just outside of Poitiers, France,

to discuss the effects of the new global information society that is currently forming

'world wide. Some 1000 visitors clicked into the website of the congress as it

| progressed. The objective of the symposium was to develop proposals of concrete projects,

_ supported by attractive presentation techniques and materials. The principal themes were:

governments and the globalization of the on-line citizenry; knowledge and training:

networking education and educating networks; and business in the 21st Century: finan-

cial and technical infrastructures of the networked economy. The location of the

) meeting has the bizarre name of Futuroscope. Futuroscope 1s, first of all, a park modeled

on Disneyland. It is, secondly, an industrial area that would like to imitate Silicon Valley.

| It is, finally, a dream of a place that can be a center of innovation, technological change,

and job creation.

| The Magic Triplet

Three words dominated the meeting: Europe, information, and sustainability. The

experiences of France, Germany, England, the USA, South Africa and other lands were

heavily discussed but the emphasis was on creating a world that would be influenced

' by European values. The emotional commitment to such structures as the European

Commission, the European Union, and the like was always evident in the conference

presentations.

The point of the meeting was to consider the society being formed worldwide by

the information revolution. Business was being restructured. Governments are being

244 FRANK R. HAIG

refashioned. Language and culture are being recreated; all as influenced by the infor- |

mation society into which the world, unconsciously but rapidly, is moving. Perhaps the};

major coloration that came from having such a meeting on the continent was the emphasis |

on sustainability. We cannot keep being as widely irresponsible as we are in energy and\y

Feemon on the limits of growth was very apparent.

The Prevailing Mood

The tone of the meeting reminds one of the fortunately fictitious gentleman who}

drowned recently in a crowded pool because, as he went down for the third time, he |

called for help in Esperanto and no one understood him. We are all, the conference speakers

seemed to feel, passengers on a cruise ship wildly hurtling through space where no one

is at the rudder so that cannot be sure at what place we will arrive or whether we will’

be happy to be there when we dock. This situation of desperate and onrushing confu-|

sion as the information age overwhelms us is what the meeting wanted to consider. For |

example, an earnest but worried authority, Mr. Didier Livio from France, agonized over}

the new concept of work. In the old days those who had a job came to a certain place, |

the office, at a certain time, nine to five, and produced a definite output. Nowadays, the

same workers take their portable computers and mobile telephone and set of fax!

numbers and go where they please whenever the spirit moves them, and produce an output

that is no longer clearly defined. Just how a manager directs this new group of employees |

and produces an esprit de corps is no longer known. |

An Expected but Unsettling Overtone

An American observer at the meeting could not miss a certain anxiety expressed by

many participants as to the dominance of the colossus from across the Atlantic, namely, }

the United States, in this information age under formation. The Internet is a prime example. |

America Started it, after all, and now most messages from anywhere to anywhere find |

themselves routed through the Commonwealth of Virginia. |

The concern goes beyond the Internet. One television producer from France, Gilles |

du Jonchay, pointed out that ninety percent of the images that appear in the news reports |

of international television are the work of two companies, Reuters of England and APTV |

of the United States. The explanation is not Anglo-American cultural imperialism but }

the rigidity of the control by the French government and the labor union of French journal-

THE GLOBAL SYMPOSIUM ON INFORMATION TECHNOLOGY 245

ists. The forces hobble the one French organization in the field, Agence France Presse,

/and have brought it into a state of crisis. Still the effect is a cultural dominance.

| The plenary sessions were frequently broken up into seminar type formats. In one

| of those afternoon meetings the opposition to the United States was so intense as to threaten

for a time the stability of the group. The charges against the United States began with

a distortion of American foreign policy by the needs of the Cold War which led the U.S.

"to support monstrous dictatorships in Africa, for example, because the dictators in question

.were buyable. They would, for a price, stand with the U.S. against the Soviet threat. An

example would be Mobutu, who was supported by America for years even though everyone

knew he oppressed his people. No one mentioned that Mobutu’s successor, L. Kubila,

does not seem to be much of an improvement.

The next objection concerned American foreign aid programs. Experts in Washington

-devise projects that they think will help underdeveloped people. They then consult the

-governments involved and the two impose some program on a local community. No

wegard is given as to sustainability so that when the program ends and no special funding

Jis available, the activity collapses and no effect is seen. No one thinks to ask the commu-

jnity what it needs and wants and will support. An example was given of a wonderful

| attempt to provide fresh clean water by digging a well. The community, however, had

used the local stream for its water supply and built up an entire culture around the gathering

bat the stream for social interaction. Nobody used the famous well. What that commu-

mity wanted, as a matter of fact, was a soccer field to provide recreation for the young

{boys who otherwise went chasing after the young girls and kept the teenage pregnancy

prate high.

The Internet itself was another example. The language of the Internet is English.

‘So the small villages in Africa find their local cultures obliterated by the communica-

tions revolution. Actually, a use of somewhat old-fashioned technology can avoid this

effect. In Zimbabwe, a large program is underway using portable radio transmitter. These

transmitters are taken to local villages and then the local people are encouraged to produce

| their own show in their own language.

The final critique of America really involved all the developed countries. It

centered on the boxes and boxes of guns America and the West sell to underdeveloped

bnations so that oppressive governments and their enemies can wipe out the defenseless

scitizens.

A real surprise came up, however, when the subject of the Peace Corps arose. Even

‘the harshest critics of America voiced profound admiration of the Peace Corps volun-

= Here is a program, the critics noted, that is ideal. The Peace Corps volunteers

‘really get down with the people and live among them and listen to them. The program

‘is even for America’s critics a model of what can be done by sensitive individuals.

246 FRANK R. HAIG

The Challenge of the New

The representative from Bertelsmann AG gave one of the most fascinating examples

of the challenges of the new age. He recalled in his address that, when Amazon.com

began its meteoric rise, the executives at Barnes and Nobles looked at the new company |

and concluded that the selling of books on-line would never go anywhere. People, after |

all, like to browse and to meet other readers interested in the same subjects that they

are. They forgot the primary lesson of all market research that convenience is the dominant |

factor. Now Bertelsmann has a one half share in the company. |

A Look into the Future

The global economic order today, one of the handouts distributed at the meeting !

insisted, is too much concerned with the short term. The result is the rich get richer and |

the poor get poorer and wealth has many ways to avoid its use in socially and environ-

mentally responsible ways. The European approach has a way out.

First, Europeans have a great confidence in government and its ability to intervene |

effectively in the structuring of society. The information age into which we are moving |

must respect the many cultures that exist, a problem where Europe has a great deal of |

experience even if it has not always been happy. Planning for the future must center on |

sustainability. An uncontrolled and undirected free market does not itself provide the

framework for development that is needed. It lacks the social welfare concern that Europe

has embodied.

A vision, therefore, that is socially responsible, culturally sensitive, and centered |

on sustainability has a real chance to build a society that can survive for generations to |

come. So the meeting concluded. Next year it is planned to go further.

Journal of the Washington Academy of Sciences,

' Volume 85, Number 4, 247-279, December 1998

EDWARD KUBEL (1820-1896)

Washington, D.C. Instrument Maker

With Notes on His Descendants

Having Careers in Science and Technology

Silvio A. Bedini, 4303 47th Street N.W., Washington, D.C. 20016-2449

Summary

In 1849 Edward Kiibel, at 29, a professionally trained instrument maker, arrived in

Washington from Bayreuth, Bavaria, and was employed by William Wiirdemann as foreman

| of his shop for twenty-five years. There he learned the value of interplay between the surveyor

or scientist who used the instruments and the craftsman who made them for their specific

purposes. Upon Wiirdemann’s retirement in 1874, Ktibel advertised the opening of his own

‘ shop where he lived in the same Capitol Hill neighborhood at 326-328 First Street N.E.

/ As had Wiirdemann, in his own shop he too stressed that he offered customized instruments

| in consultation with the sprofessionals who used them, and modified existing instruments

| to meet particular requirements.

Kiibel’s business was carried on by his son Ernest, who eventually moved his shop to

the rear of 325 First Street N.E. for a few years before accepting employment in the U.S.

Geological Survey’s (USGS) own shop. Edward’s other son, Stephen Kiibel, was engaged

by John Wesley Powell, director of the USGS, to create the section that reproduced the

Survey’s maps by copper plate engraving, which at that time became the standard for the

world.

Subsequent generations of Edward Kiibel’s family also were involved with the applica-

tion of technology to science in various professions, raising interesting unresolved questions

of how families persistently remain linked to variations of the same profession.

The establishment of the United States Coast Survey by President Thomas Jefferson

in 1807, followed by the appointment of Ferdinand Rudolph Hassler as the Survey’s

first Superintendent, had a major impact on the precision-instrument industry in the United

_ States. Hassler, a native of Switzerland, had hoped to see the best precision instrumentation

emulated in the United States, but found few if any sufficiently skilled craftsmen avail-

able there for full time employment. Accordingly, he sought them overseas and brought

highly-skilled European artisans to work in Washington for the Coast Survey, and

meanwhile in England he purchased a number of the instruments required for the Survey. !

248 SILVIO A. BEDINI

Hassler’s efforts opened the door to immigration for a number of well trained makers |

of mathematical instruments from several parts of Europe. Here they continued the tradi-

tions of fine craftsmanship of their own country, employing and developing these |

techniques in the United States to create a totally new tradition of mathematical instru- |

ment making. They were in a large part responsible for the demise of individual |

handcrafting and the development of multiple manufacture of precision instrumentation. |

The arrival of foreign-trained instrument makers at the time of government-

sponsored scientific endeavors provided a stimulus for the design and production of sophis- |

ticated astronomical instruments having scales graduated by original graduation or |

machine graduation that were required for determining latitude and longitude for |

national boundary and territorial surveys. Until the middle of the nineteenth century, |

only one or two American instrument makers were capable of original instrument scales.

As a_ consequence, reflecting circles, sextants, and similar precision instruments |

requiring graduation had to be sent to Europe or to England, where the invention of |

Jesse Ramsden’s circular dividing engine had initiated the age of mechanical gradua-

tion.

As other instrument makers began to reproduce and use the circular dividing engine |

and trained more craftsmen in its use, precision instruments came into more general use |

on both sides of the Atlantic. It was not until American makers could purchase or could |

construct their own dividing engines, however, that they could produce such precision |

instruments, but even then they had difficulty in competing with European prices. |

Hassler’s first full time employee in the Survey was William Wiirdemann (1811-_

1900) who had been trained in Germany and had emigrated to the United States in 1834. |

Hired as “Chief Mechanician of the United States Coast Survey” at a salary of one dollar |

a day, Wiirdemann remained in the Survey’s employment until 1849. He then resigned |

in order to establish his own shop as “Mathematical and Optical Instrument Manufacturer” |

to produce astronomical and geodetic instruments for the Survey and American colleges, |}

among other clients. His shop, a small building at the rear of a row of three-story houses |

which he owned and rented, was situated near his home in Washington at the corner of

Delaware Avenue and North B Street on Capitol Hill at the north edge of the United |

States Capitol grounds.

The first members of Wiirdemann’s staff were Edward Kiibel (1820-1896), desig- |

nated as his Chief Foreman, and another unidentified workman. Kiibel was a native of |

Bayreuth in the kingdom of Bavaria. Following a standard education in local secondary |

schools, he served an apprenticeship as a mechanician. Anxious to advance himself in |

his chosen career, he decided to travel. At the age of twenty-two he sought and was |

issued a passport in Munich by the “Minister of State and Foreign Affairs of the Royal |

House of Bavaria in the name of the King.” It enabled him to travel to the other states

of the Confederation of Germany, as well as to Austria, Belgium, Holland, England and |

Switzerland for the purpose of perfecting his mechanical skills. Seven years later, on —

EDWARD KUBEL - INSTRUMENT MAKER 249

. April 27, 1849, he sailed from Bremen to the United States. Arriving in New York, he

_ made his way to Washington, where he became Wiirdemann’s first employee.? (Figures

eles 3, 4, 5)

During this period, while Wtirdemann’s shop was producing fine theodolites and

zenith telescopes for the Lake Survey, it was often frequented by officers engaged in

| the various surveys. Among them was Professor Julius E. Hilgard, Assistant in charge

_ of the Coast Survey, with whom Wiirdemann became well acquainted. Recently Ktibel

Figure 1. Portrait of Edward Ktibel, in his early —_ Figure 2. Portrait of Edward Kiibel, in his later years.

years.

had been joined in the shop by Camille Fauth, another employee newly arrived from

Germany, and at about this time they were involved in the production of three theodo-

lites for primary triangulation, having circles 20 inches in diameter in fulfillment of a

contract with the Coast Survey at a reported cost of $12,000. Wiirdemann’s attempts

to graduate these instruments himself were unsuccessful and finally he had to take them

back to Germany to have them graduated there. In response to this constant need, one

of Wiirdemann’s first priorities became the design and construction of a new dividing

engine for his shop which could cut either degree or centesimal graduations. Ktibel

constructed it entirely of iron and steel, the base consisting of tripod, cylindrical axis

and circle, all made of cast iron. Since Ktibel lacked the required theoretical know]-

_ edge to complete the engine, however, Wiirdemann assigned it to George N. Saegmuller,

anew employee he had brought from England. Lacking facilities for graduating the engine

in his shop, Wiirdemann took it to Dresden to have it graduated by Gustav Heyde.*

In 1853 Kiibel married Magdalena Hirtz and on April 22, 1854 they became parents

250

Figure 3. Passport issued to Edward

Ktibel of Bayreuth at Munich on

October 20, 1842 by the Department

of State of the King of Bavaria,

permitting him to travel in the States

of the Confederation of Germany,

Austria, Belgium, Holland, and

England for the purpose of

perfecting himself in his craft.

Figure 4. Passage ticket of Edward

Kiibel dated April 27, 1849 for

passage from Bremen to New York.

SILVIO A. BEDINI

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EDWARD KUBEL - INSTRUMENT MAKER 251

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\Figure 5. Passport issued to Edward sang eas Saul chek ce al

| St a Civeult Court of ie 3 «Jor the Distsict of ie, hold for the County

' Ktibel by the U.S. State Department ¢ Washingtoa, az she City of Washinatoa, on the fi My Monday of Cele hee in the

Sear oF one Lond ape pomcand vight hnadsed aad £ftre and af the nlependenee of the

tin thie ne f

y to returm to Germany. United States. tis 4 O04 te

| ) RESENE

Ae fans ianchf ; Chief dudge.

Varied & Mendel % z i

aereene i tric de

Aug aby Mreven Vg ttre 4 / Marsha

tite ¢¥ Uhi1¢ th ~ Check

iis tte Regoad oc Piobendarss of the sanne Court, noag vilioss, bee thet eas to wit

Be it Remembered, That heretofore, to wit ; the iG day af te eee atu

ia the year of our Lonl ame thousand othe hanced and pif at the County of Washi sake

worekud, appeared CA oud hall ~ se a native of LOL 11077 10

aged about oie t SF > ~ yeary, bearing allegiance

Paes ae gs Dye wag! )~ ~

to the Ineeg as Waiver AL Se RA ON ee ere

dare eonsrathd tom ATO Tt Cis Ais oe “ z aad arrived at

ye nie ~~ ~ --- ya the 15% ~ dayot ttre e ~—~

bs tae seo of oa Lod une thyaand eight hundred and 77> fy dei ~ — and intends to settle at

AVaeh Lits, eX ee. whe nee ine 3 and in open Court reported himself

tor Nevenasnisacedy, and declared on oath, thot it is bona fide his intention to become a Crrizes or tHE

Usirrp Starrs. and to renounce forever all allegiagee aud fidelity to any foreign filet Poteniste, State, oF

Serenity. whasever, anil particularly to ke /Zi2¢ 4 of qi hi va 44 ‘“ —~ = _

edt nip vie Ne aD: to an fawy of Congreys im such casemade and provided.

“ And now. t Bwit, ba sis day of fi. Lith tf my in the year of our

Lord one thousand He | is hye} ji RE appears again® ips Court here, the ssid

CAtvacd He of aad exhibits to the Court, here, a certificate of his

Report and Voclaratios afore ig aad it « appearing to the satisfaction of the Court, by the cath¢ of a

NVel lense Vacr dane Attire eS Ries eee — Le citizenf of the United

A . we

Slates. that the «ad Ed wach Micke rg Pee Re tree has resided within the

limits and onder Ure jurisdiction of the United Sauces tor FIVE YEARS, last past, without baying been ont of

the ‘Territory of the United States during dat time, sand one year last past, within the limits and under the juris-

ction of this Court; and that during that tine, he bas behaved ay a man of good moral character, attached to

the prinesples of the Constitution of the United Ssates, and swell disposed to the good onler and lappiness of

the <aine. % 3

And the said & dt vat d We t ee € ~- in open Court here maker

Osih that hie wil support the Constitution of the United Sues, and that le doth absolutely and entirely renounce

aud abpure ail allegtance.and fidelity to ili zn Pence, Porentate, State, or Sovereignty, whatever, and

zxrticnlarly fo tive Piacg ap AS UA? oa aol eng Re eee ie

-— se ys ~ ~ > ic wont y was belore a Subject.

fz is thereupon ordered by the Court here, that the snd € De Vat $ ks he SELES

by ADMITTED A CITIZEN OF THE UNITED STATSS ; ay he is accordingly athmitted a Citi-

aen of the Caited States, asrcestly to the laws of Congress in such case made and provided.

Iv Tresvimony that the foregoms is truly taken from the Records of the

Proceedings of the seal Const, 1 have Jus aie pace my name, and affixed the

Figure 6. Certificate of citizenship aogier i Bie. pies

issued to Edward Kiibel, February 12, j )} / ii hi

1855, Washington, D.C. with William Lied Me

Wiirdemann appearing as sponsor.

252 SILVIO A. BEDINI

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Figure 7. The Kiibel genealogical record from the family’s Holy Bible.

of a son, Edward Frederick. In the following year Kiibel initiated proceedings for |

becoming a United States citizen, and on February 12, 1855 he was granted citizenship. |

Wiirdemann appeared as his sponsor and testified to his moral character as well as to his | |

required residency within the jurisdiction of the Circuit Court of the United States for the | |

District of Columbia.5 (Figure 6) |

On November 16, 1856, the widowed Kitibel married again, to Josephine Hartbrecht, |

formerly of Eberbach, Baden, in St. Mary’s German Catholic Church in Washington. |

In due course they became the parents of four sons, Stephen Joseph, Ernest Philip, George |

Frederick and Emil Adrian, and three daughters, Mary, Josephine Mary and Anna Clara. —

Two of the infants, Mary and George each died at the age of two; and Emil, who had |

On April 11, 1857, Edward Kiibel purchased property on the west side of First Street |

N.E., between C and D Streets North, described as the north half of Lot numbered 8 in |

Square 684. In the absence of identifying street numbers in the deed or on maps thus

far available, itis likely that this was the property known as 326-328 First Street N.E.,

where in 1874 Kiibel would advertise the location of his own residence and instrument- |

making business. |

Although until 1869, while working for Wiirdemann, Edward Kiibel had listed his |

home address as 343 First Street N.E., apparently in about 1870 he moved his large —

and growing family to 326-328 First Street N.E. and begun to make modifications to |

the buildings to accommodate the installation of his shop. In the Washington Directory

EDWARD KUBEL - INSTRUMENT MAKER 253

for 1870 he is listed simply as “Instrument Maker, Ist between C and D, N.E.,” which

is judged to refer to his move.’

Kiibel planned with foresight and timeliness, for in 1874, the year that Wiirdemann

/retired, Kiibel announced his own shop, advertising in The American Journal of

Science and Arts:

Edward Kubel

326 and 328 First Street, Northeast, Washington, D.C. For twenty-five years

foreman with Wm. Wiirdemann, continues to manufacture, the class of

Astronomical and Geodetical Instruments formerly made by Mr. Wiirdemann.®

| Kiibel’s two adjoining houses at 326 and 328 First Street N.E., within walking

| distance of the offices of the Coast and Geodetic Survey as it was renamed in 1878,

served him well, one as the family residence, the other as the shop on the ground floor,

) with shop supplies and domestic storage on the floors above.

) Ten years later the shop, which now employed 7 to 8 skilled workmen and boasted

| a 4-horse power gas engine supplying power for all the tools, produced a formidable

line of surveying and astronomical instruments. Included among the shop’s tools was

_a dividing engine bearing the nameplate of Edward Kiibel and believed to have been

‘made by him.

This essential tool of the maker of scientific instruments served the instrument-making

| Kiibels and was last sighted in about 1962 in the shop of a later Washington maker. It

' would have been a desirable addition to the Kitibel tools and instruments preserved in

| the Smithsonian Institution, which recently acquired Kiibel’s instrument maker’s lathe

| having the name plate “Vorm August Hamann / J. Goldmann / Berlin.” Edward Kiibel

and his son Ernest used this lathe in the shop at 326-328 First Street N.E., and Ermest

continued to use it thereafter for the remainder of his career. After small electric motors

became available, Ernest motorized the lathe while carefully preserving the original foot

treadle and the rod that connected it to the crankshaft of the lathe. (Figures 8 and 9)

| Among Edward Ktibel’s employees was Andrew Kramer, who began to work in

| Ktibel’s privately owned shop in about 1886, as an unpaid apprentice. Later Kramer

worked for Kiibel as a paid employee. Then, in 1892, he was hired to help make models

for Samuel P. Langley, aviation pioneer and Secretary of the Smithsonian Institution.

_ Eventually Kramer progressed to building delicate instruments for measuring the heat

_ radiation of the sun, with which Langley was experimenting. He continued to work in

_ the same shop at the Smithsonian Institution under Langley’s successor, Charles G. Abbot,

until he retired in 1953. Kramer kept with him a small neatly boxed lodestone, which

he highly prized and described as the graduation present he received from Kiibel to mark

the completion of his apprenticeship. Kramer kept the lodestone handy for magnetizing

compass needles.? (Figure 10)

254 SILVIO A. BEDINI

Figure 8. Edward Kiibel’s screw-cutting lathe, labelled ““Vorm: August Hamann/ J. Goldmann Berlin’.

Gift of Frank A. Taylor. National Museum of American History, Smithsonian Institution.

Figure 9. Headstock of Edward Kiibel’s lathe. National Museum of American History,

Smithsonian Institution.

(ee

EDWARD KUBEL - INSTRUMENT MAKER 255

Figure 10. Andrew Kramer, shown in the instrument shop of the Smithsonian

Institution’s Astrophysical Observatory, in about 1959.

Meanwhile Edward Kiibel’s wife, Josephine Hartbrecht Kiibel, had her own program

_ of apprentices. She aided young German women to immigrate and become established

in the United States. These young women were willing to be trained and to begin as

domestic servants. They probably were recommended by Josephine’s friends in her native

Eberbach, Baden. They were trained as working members of the Ktibel family, and when

they had become fully trained and practiced in the English language, they found ready

employment.

In time most of the young women married, and in later years two or three of them

who were of an age with Josephine and Clara Ktibel would return to visit and to show

their children. It was family lore that Josephine Hartbrecht Ktibel eventually became

disenchanted with this mission when some of her trainees left before she considered them

to be fully trained, and she discovered that a neighbor a few houses away was operating

an employment agency from her house and was finding work for the trainees for a fee.

In about 1882, the Kiibels acquired new neighbors when Nathaniel Terry Taylor II

rented a newly constructed house at 332 First Street N.E. and moved in with his wife

and three children. Taylor, formerly a Detroit banker who had been ruined in the collapse

of his father’s bank in the panic of 1873, had come to Washington as a representative

_ of The Detroit Free Press. When the Taylors arrived at First Street, their son Augustus

256 SILVIO A. BEDINI

was thirteen and the Kiibel’s daughter Josephine was ten. In 1895 Josephine and Augustus

were married. In writing about his life much later, Augustus Taylor remembered First

Street as a mud road with cobblestone gutters, and that Roth’s brewery was on the same

block.

Edward Kiibel continued to make instruments principally for the Federal govern- |

ment including its agencies in the states. His major clients were the Coast Survey and |

the Lake Surveys, for which he produced telescopes, transit instruments, dipleidoscopes, |

theodolites, solar attachments, prismatic transits, altitude instruments, gravity pendu- |

lums, leveling instruments, gradientors, sextants, magnetometers, spectrometers, spectro- |

scopes, and micrometers, among others. (Figure 11)

One of the instruments made by Edward Kiibel for the Coast Survey in about 1875, |

is presently in the collection of the Smithsonian Institution, transferred from the

Geological Survey in 1907. It is an 8-inch theodolite having a graduated circle reading |

by vernier to 10 seconds, and a telescope 18 inches in length with extra eyepiece, sunshade |

and spirit level. The diagonal reflector slides over the telescope’s objective and was used

as a reflector for night work, a lamp or lantern being held near it. It was described in

the records of the Geological Survey as being of “a type used by Wheeler, Hayden, Powell }

and the Geological Survey until 1900, after which it was discarded for a new style, which |

read by micrometer to 2 seconds of arc. Instruments of this general character are used |

all over the world for measuring horizontal angles between distant points. Bench marks

thus established by triangulation and completed by precision leveling became controls

for detailed mapping.”’!9 (Figure 12) |

Among Kiibel’s most popular products was a relatively inexpensive heliostat

commonly used by microscopists and photographers. It is an instrument featuring a mirror

moved by clockwork for reflecting the sun’s rays in a fixed direction. Kiibel’s heliostat |

was designed and patented by Reuel Keith (1826-1908). Upon graduation from

Middlebury College in 1845 at the age of nineteen, he found employment as an astro- |

nomical observer at the Naval Observatory in Washington. After leaving the Observatory

in 1853, Keith worked as a government surveyor until he resigned on July 11, 1856. In |

the early 1870s Keith was identified as a “professor of mathematics” living in |

Georgetown.!! (Figure 13) |

The invention was announced in The American Naturalist in 1877:

KEITH’S HELIOSTAT. — A new heliostat, designed by Professor Keith, is now |

made by Edward Kiibel, of 326 First Street, Washington, D.C. It is an excellent model,

simplified without loss of efficiency, and no doubt the best instrument for the use of micro-

scopists who require direct sunlight, for photography, blue-cell work, or any other purpose.

It seems a full substitute for the expensive imported instruments. Its cost is $50.00. !2

EDWARD KUBEL - INSTRUMENT MAKER 257

Figure 11. Convertible double gravity pendulum made by Edward Kitibel for the U.S. Weather Bureau.

National Museum of American History Cat. No. USNM 316,876.

Figure 12. Surveyor’s theodolite for measuring horizontal and

vertical terrestrial angles. Serial number 172, made by Edward Kiibel

c. 1875 for one of the Federal geological and geographical surveys of

the territories.

The instrument was advertised variously as “Keith’s Heliostat” or “Keith’s American

Heliostat.” One of the first of the “Keith’s Heliostats” made by Ktibel was purchased

by Dr. Joseph J. Woodward, Assistant Surgeon of the Armed Forces Institute of

Pathology. He used it at the Army Medical Museum in the mid-1870’s for photographing

histological preparations by sunlight. His use of it was described in The American Journal

of Science and Arts (September 1866) and in his report on an improved method of

photographing histological preparations by sunlight that was published on June 9, 1871.}3

In 1878 this heliostat owned by Woodward was borrowed by Albert A. Michelson,

a young instructor at the U.S. Naval Academy. Michelson used it for his earliest exper-

iment with the speed of light, the circumstances of which were reported in an article

about his experiences while teaching his first class at the Academy. He had just returned

258 SILVIO A. BEDINI

PQ BEIOS WA, 2

This Instrument is similar in principle to the expensive instrument

of Foucault and for most purposes equal to it in efficiency. It is very

simple in use and construction. The microscopist who has a sunny

window and a time piece, can at any time, in a few minutes bring a

sunbeam upon the object in his microscope and keep it there for several

hours and obtain results which can be as easily and cheaply obtained

in no other way.

‘The photographer can copy, with the aid of the blue cell, any

object in the microscope or any object requiring the same sort of

illumination.

It also enables the physicist or experimenter with sunlight, to study,

without interruption any object for which he requires that light in a

constant direction, Only one size is made, of which the mirror is

three inches in diameter. ‘The whole instrument weighs about four

pounds and is packed in a neat box. The placing of the instrument in

position is very easy and requires but one or two minutes. Full in-

structions accompany each. ‘The instrument also answers the purpose

of a sundial.

Manufactured by

Ernest Kibel,

826-328 FIRST STREET, N. E.,

: WASHINGTON, D. C.

Figure 13. Ernest Ktibel’s advertising brochure for his “Keith

American Heliostat.”

from a cruise on the frigate U.S.S. Constellation in the winter of 1877-1878, when

Commander William Sampson assigned him to teach a physics course for advanced

students at the Academy, suggesting that he begin with a demonstration of Foucault’s

measurement of the velocity of light, made with a rotating mirror. Although Michelson

protested that he knew little about the method or background of the experiment, he was

advised to brush up and take over the class.

As Michelson prepared for his first class, he was astonished to learn that only three

men in all of history — the French physicists Armand Hippolyte Luis Fizeau, Jean Bernard

Foucault, and Marie Alfred Cornu — had ever attempted to find the speed of light by a

terrestrial measurement. In the course of demonstrating the method used by Foucault,

Michelson discovered certain faults in his procedures. It was essentially by the intro-

EDWARD KUBEL - INSTRUMENT MAKER 259

duction of a lens between the rotating and plane mirrors that Michelson was enabled

to increase the path of light to 1000 feet, permitting a greater deflection of the returning

beam. To assemble the necessary equipment, he ransacked every laboratory storeroom

at the Academy and set his students to work constructing mountings and adapting all

existing apparatus to his purpose. !4

Finally, Master Michelson wrote to the Army Medical Museum in Washington in

March 1878 and requested the loan of Woodward’s heliostat for his experiment on light.

In view of the common use of the heliostat in Michelson’s time, the young scientist would

naturally think of it as a means of providing the steady beam of light he would need in

his experiment. Accordingly, the instrument was loaned, and although Michelson’s

resulting apparatus was rudimentary at best, having been assembled by himself at a cost

of ten dollars, his demonstration succeeded. He returned the heliostat in July, commenting

_ on the correctness of its operation. “I am glad to learn of the successful termination of

your experiment,’ Woodward wrote, “and can assure you that the maker of the little

_ instrument will be pleased when I tell him of the praise you bestow upon it.” Several

months later Michelson again wrote to Woodward requesting the price of a Keith

American Heliostat. Woodward replied that it “can be obtained of Edward Kiibel, 328

1st Street, N.E. in Washington, D.C. The price is $50.-; mine, with an extra sized mirror,

cost I think $5.- extra.’”’!5

The experiment was reported by Michelson in a one-page paper entitled “On a

Method of Measuring the Velocity of Light,’ published in 1878. Written at the age of

When Edward Kitibel opened his state-of-the-art instrument shop at 326-328 First

Street N.E. in 1874, it soon became a convenient resource for the specialists in

Washington agencies and institutions requiring scientific instuments. Whatever their needs

were — consultation, design, estimates of time and costs — all were available within

walking distance for most of them.

At the time he established his own shop, Edward Kiibel already was a twenty-five

year veteran of the instrument-making business, and subsequently his shop enjoyed a

decade of free enterprise and prosperity. It lasted until the Federal government began

to acquire the land it required for the construction of the Union Station, the railroad

tunnel to the south, the first Senate Office Building, and the park between the Station

and the Capitol. Edward Kiibel was required to sell to the government the land and build-

ings at 326-328 First Street N.E. which housed Ernest Ktibel residence and shop.

Inasmuch as the U.S. Geological Survey was one of Kitibel’s principal clients, it inter-

vened to ensure that Kiibel could occupy the premises and continue his business there

until demolition of the buildings would begin. Consequently, Ernest Kiibel became an

employee of the Geological Survey and for the next six years, from 1884, the Survey

became the nominal operator of his business.!7

Edward Kiibel resigned from the Geological Survey in 1892 and appears to have

260 SILVIO A. BEDINI

Figure 14. A “Keith American Heliostat” made by Edward Ktibel for Dr. Joseph J.

Woodward of the Surgeon General’s Office and borrowed by Master A. A.

Michelson.

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Figure 15. Explanatory drawing of heliostat made by K. H. Robinson of the Army

Medical Museum.

EDWARD KUBEL - INSTRUMENT MAKER 261

relinquished at the same time the conduct of his shop’s business to his son, Ernest. Edward

Kiibel died in 1896. Funeral services were held at the family residence at 326-328 First

Street N.E. and he was buried in St. Mary’s German Catholic Cemetery in the Ktibel-

Hartbrecht plot. Edward Kiibel’s widow and his son Ernest were named executors of

his estate. In his last will and testament, dated December 24, 1895, Edward specified

that “All the tools, implements, and machinery used by me in my business, I give and

bequeath to my son Ernest Kiibel.’” His German instrument maker’s screw-cutting lathe

also passed to Ernest. Edward bequeathed the house at No. 327 First Street N.E. to his

daughter Josephine, who was married to pharmacist Augustus C. Taylor, and No. 323

he left to his younger daughter, Anna Clara. He also left to Ernest the middle one of

three houses he owned, his home at 325 First Street N.E. Ernest continued the instru-

ment-making business in the same location until he moved his shop to a new building

erected in the rear of the house at 325 First Street N.E.!8 (Figure 16)

Figure 16. Monument to Edward Ktibel in St. Mary’s

German Catholic Cemetery, Washington, D.C.

262 SILVIO A. BEDINI

CHILDREN OF EDWARD KUBEL

Who Pursued Careers Related to Science and Technology

A number of Edward Kiibel’s descendants also engaged in occupations related to

science and technology in one form or another. The oldest of these was Edward

Frederick Kubel (1854- ? ), son of Edward Kitibel’s first marriage, who was born in

Washington on April 22, 1854, and as a young man moved westward to the Washington

Territory. Olympia was the first of the cities on Puget Sound to be equipped with a telegraph

connection and it was said that the first message sent over the newly installed line from

Washington, D.C. announced the re-election of Abraham Lincoln. Young Kiibel was hired

as its first telegraph operator, and apparently kept the position for some time.

Meanwhile, in the litthe community of Steilacoom, a young woman named Clara

Viola Light had been taught to use the telegraph, and to while away the tedious hours

she and Kiibel frequently practiced by exchanging a variety of messages. These brisk

telegraphic communications eventually changed from business to personal and finally

to romantic conversations. It was some time before they met, however, but not long after

they did, they were married, on May 8, 1879. Soon thereafter Ktibel was promoted to

a better position and subsequently they moved to San Francisco.!?

Stephen Joseph Kiibel (1858-1936), the eldest son of Edward Kiibel and his second

wife, Josephine Hartbrecht Kiibel, was born in Washington on April 2, 1858. He attended

private and public schools in Washington, including Gonzaga College High School, and

continued his study of music at the Scharwenke Conservatory of Music in Berlin. Being

also gifted in drawing, while in Berlin he became interested in the art and science of

cartography and map engraving. In later years Stephen would refer to the period from

1874 to 1878 as the years during which he devoted himself to mastering cartography

and map engraving. (Figure 17)

Back in Washington once more in 1875 at the age of seventeen, Stephen was

employed at the U.S. Geological and Geographical Survey of the Territories. This was

one of the direct predecessor agencies of the U.S. Geological Survey with which Stephen

would later enjoy a career of forty years. In 1876 he joined the staff of the Hydrographic

Office of the U.S. Navy as a cartographer. He returned to Berlin for two years in 1883-

1885 to serve in the cartographic division of the Prussian general staff where he had

the opportunity to study alternative processes of map reproduction. While in Berlin

Stephen married Louise Griffith of Milford, Delaware on July 5, 1884. Upon their return

to Washington, Stephen resumed his employment with the Hydrographic Office.

For three years from 1887 Stephen worked independently employing his own staff

of engravers and printers. He received contracts let by the Public Printer and produced

satisfactory work for the Survey, the Coast and Geodetic Survey and the Hydrographic

Office. On February 14, 1890 Major John Wesley Powell, then director of the Survey,

appointed Stephen Kiibel Chief Engraver of the U.S. Geological Survey to organize a

map production plant. It was from this beginning that subsequently grew the estab-

EDWARD KUBEL - INSTRUMENT MAKER 263

Figure 17. Portrait of Stephen Joseph Kiibel. Figure 18. Unusual portrait of Stephen Joseph

Kiibel as Chief Engraver by A. R. Meissner, 1910,

incorporating geodetic contour lines.

lishment he created and that he directed until his retirement forty-two years later. His

starting salary was $2,400 a year. During the reduction-in-force that occurred in 1892,

Powell reduced his salary to $2,200, but restored it to the original amount in the following

year.29 (Figure 18)

In early 1901, at the request of its division of graphic arts, Stephen Kiibel prepared

a special exhibition for the Department of the Interior to demonstrate the Survey’s methods

of surveying, computing, drafting, printing, and distributing of topographic and geologic

maps. The exhibit was displayed that summer at the Pan-American Exposition held in

Buffalo. It was while visiting the Exposition on September 6th that President McKinley

was shot by an anarchist and died a week later.

In 1909 Stephen Kitibel was sent to the International Map Committee meeting in

London as the United States delegate, and from 1911 he was listed also as chief of the

Geological Survey’s Division of Engraving and Printing, responsible for the produc-

tion of maps by copper engraving, with a salary peaking at $5,600 in 1928. His graphic

arts exhibits for expositions held in the United States and overseas earned him many

medals and diplomas. In the opinion of one of his former associates (a man who estab-

lished national map making programs for a number of major countries), the quality of

the engraved maps of the USGS set the standard for the world. It was a matter of family

264 SILVIO A. BEDINI

pride that Stephen Ktibel was a handsome man and that his portrait was printed in the

‘encyclopedia’ — the identity of which not presently known — as the example of the

typical Bavarian male. (Figure 19)

Music was a high priority in Stephen’s life. He was widely recognized and respected

as an organist and church choir director, and a beautiful music room in his handsome

home at 10th and East Capitol Streets N.E. was in frequent use for sessions of chamber

music with friends whose company he enjoyed. He was an active member of the Capitol

Yacht Club and his long, twin-engined Hudson River glass cabin cruiser, the Louise K,

was a conspicuous part of the evening and weekend boating scene on the Potomac. Stephen

Kiibel retained the position of Chief Engraver until his retirement in 1932. He died in

Washington on March 2, 1936.7!

Ernest Philip Kubel (1864-1936), the second son of Edward Ktibel’s second

marriage, and Stephen Kitibel’s brother, was born in Washington on June 3, 1864. After

attending local schools, he served an apprenticeship with his father and continued to

work with him until the latter’s retirement. On June 6, 1894 Ernest married Pauline A.

Lerch in St. Mary’s German Catholic Church in Washington, and they became parents

of two daughters, Marie and Margaret. Following his father’s retirement in 1895, Ernest

succeeded to the business, continuing it as before, producing the same wide range of

geodetic and astronomical instruments. His name appeared in the city directory for the

first time in that year, with his shop address at 326-328 First Street N.E. and his home

listed at 325 First Street N.E. (Figure 20)

At various times between 1892 and 1898 Ernest Ktibel was engaged by astrophysicist

Samuel P. Langley, Secretary of the Smithsonian Institution and administrator of the

Astrophysical Observatory, to produce scientific instruments for his pioneering research

on solar radiation and human flight in heavier than air machines.22

Among the instruments that Kiibel made to Langley’s specifications was a

“galvanometer (tracks)” for the study of solar radiation that Langley had ordered with

a due date of April 1, 1892. Further experiments led Langley to cancel the order as the

instrument was no longer required, and asked for the return of the drawings. Two years

later Ktibel produced a seismoscope and a plane table that Langley sent to Japan. In

November 1898 Kiibel and several of his workmen were employed by Langley to clean

and re-lacquer several instruments in the Observatory. In the same year Langley

purchased a small photo-siderostat for $50.00 which subsequently was modified by Kiibel

in order to reduce a tremor in the mirror support. In addition to two heliostats, Kiibel

also provided Langley with a mirror 5 inches in diameter and 1/2 inch in thickness for

$2.50 to be used with one of them, in addition to a mirror case, rods and brace and a

spectroscope for the other. (Figure 21)

More than two decades after Michelson’s experiment, another heliostat was required

for use by the Army Medical Museum’s micro-photographic unit, leading to a request

to Ernest Kiibel from Dr. William Gray of the Surgeon General’s Office to modify an

EDWARD KUBEL - INSTRUMENT MAKER 265

| Figure 19. U.S. Geological Survey offices in

the Adams Building, Washington, D.C.

Stephen Kiibel is shown sharing his office

with his son Herbert.

Figure 20. Portrait of Ernest Kiibel, while

employed by the U.S. Geological Survey.

266 SILVIO A. BEDINI

instrument they owned for use in the latitude of Manila. Ktibel advised that the changes

would cost $20.00. In a letter Major Walter Reed informed the Surgeon General, “I have

the honor to state that there is in this building a heliostat arranged for the latitude of

Washington, which was formerly used by the late Surgeon J. J. Woodward, U.S.A. I learn

that by an expenditure of about $20.00 this heliostat can be changed to the latitude of

Manila, viz:- 14° 36’ North. As a heliostat is necessary for the micro-photographic outfit

for Manila, I would respectfully suggest that I be authorized to have the above alter-

ations made. A new heliostat would cost about $50.00.”

Reed sent the Medical Department’s heliostat to Kiibel requesting that it be changed

from the Washington latitude, 38° 53’ N., to that of Manila, 14° 36’ N. and that a 4-inch

mirror be substituted for the existing one. Kiibel’s response was delayed several weeks

due to illness. After examining the instrument, Ktibel explained that “in using your helio-

stat to reconstruct it will cost more than I agreed to as it is one of the old style & consid-

erable cost of repair, and partly an experiment.” Accordingly, Major Reed ordered a new

instrument which was delivered in December 1899.23

A dirty window in the shop at the rear of 325 First Street N.E. offended the house-

Keeping sensibilities of Ernest’s sisters and they frequently threatened to enter the shop

and wash it for him. The dirty window was home to his spiders which wove the webs

from which Ernest took the strands he needed for the cross-hairs in the telescopes of

the instruments he made or repaired. He nurtured his spiders and stoutly resisted any

threats to clean their window. Most surveying instruments employing telescopes

require cross-hairs to define their line of sight. Cross-hairs at the time of the Kiibels

were usually made of very thin wire or a single strand of spider-web. The cross-hairs

were precisely and tautly secured in the focal plane of the optical system where the image

of view (the surveyor’s rod, a light or a star) would appear. The most common config-

uration is of one vertical and one horizontal cross-hair, intersecting at the center of the

focal plane.

Ernest Kitibel continued to maintain his own shop for a number of years, producing

new instruments and repairing others for the Geological Survey as well as other

agencies of the Department of the Interior. His name appeared in the Federal Official

with salary increases from $1,800 to $2,400.24 (Figures 22, 23, 24, 25)

When in about 1917 the Department of the Interior completed the construction of

its first building at 18th and C Streets N. W., Kiibel helped plan an instrument shop which

was included in the plans for the building, and held a senior position in its operation.

He brought some of the tools and equipment from his own shop to help furnish it, including

his late father’s instrument-making lathe. After Ernest’s retirement from the Department

of the Interior, he continued to work in his own shop on special assignment and performed.

repair work until his death on November 25, 1936, which marked the end of the Edward

Kitibel-Ernest Kitibel instrument making. (Figure 26)

EDWARD KUBEL - INSTRUMENT MAKER 267

Figure 21. A “Keith American Heliostat” made by Edward Kitibel for Samuel P.

Langley’s experiments with solar radiation. Signed on hour dial and twice on base

“Edward Kiibel Math. Inst. Maker Washington, D.C.” National Museum of American

_ History, Cat. No. USNMo 211,531.

Figure 22. The Hooe Iron Building at 1324-1334 F.

Street N. W. in Washington, D.C., where the “National

Center” of the U.S. Geological Survey was housed from

1884 to 1917, next to the “new” Ebbitt Hotel.

268 SILVIO A. BEDINI

|-US.GEOLOGICALSURVEY.| 1832

Figure 23. Entrance to the offices of the

“National Center” U.S. Geological Survey

in the Hooe Iron Building at 1324-1334 F

Street, N. W.

Figure 24. The Adams Iron Building at

1333-1335 F. Street N. W. in which the

Engraving and Printing Division of the

U.S. Geological Survey was situated.

EDWARD KUBEL - INSTRUMENT MAKER 269

Figure 25. Print room of the U.S. Geological Survey in the Adams Building.

Figure 26. Building of the Department of the Interior on the block between 18th and 19th and E

and F Streets, N.W. Constructed 1915-1917, it served as the “National Center” of the USGS from

1917 to 1974 and is now the General Services Administration Building.

270 SILVIO A. BEDINI

Emil Adrian Kubel (1869-1894), son of Edward Kiibel, was born in Washington, ~

D.C. on April 15, 1869. He was an accomplished violinist and took his music seriously.

He enjoyed popularity for his solo performances at music club recitals and at the engage-

ments of the dance orchestras with which he played. He had an antic side exemplified

by his sledding down the 13th Street hill on his fiddle case. He chose dentistry to be his

life’s work and thus is included among his father’s descendants who pursued scientific

interests. He died in Washington on January 19, 1894 at the age of twenty-four.

From the mid-nineteenth century, Edward Kiibel’s family and descendants were

Washington, which had been founded in large measure by the immigrant scientific instru-

ment makers who came to the United States to work for the U.S. Geological Survey,

but also in the city at large. Edward Kitibel’s children, including those not particularly

interested in science or technology, actively participated in the music life of the city,

particularly in church music.

GRANDCHILDREN AND GREAT-GRANDCHILDREN

OF EDWARD KUBEL

Who Also Pursued Careers Related to Science and Technology

GRANDCHILDREN

Herbert Graham Kibel (1888-1918), Stephen Ktibel’s son, was the first of the

third generation, born in Washington on February 19, 1888. Following an education in

local schools, in 1910 he spent a year in Germany studying photo-mechanical engraving

techniques with the firm of Klimsch & Co. in Frankfurt. Returning to the United States,

he was employed by the U.S. Geological Survey for several years. In World War I, Herbert

became a pilot in the U.S.A. Aviation Corps with the rank of 1st Lieutenant in the Corps

of Engineers. He was engaged in balloon and aeroplane survey mapping at the Signal

Corps Aviation School at Call Field, Wichita Falls, Texas. Becoming ill with pneumonia

in the course of his work, he died on December 30, 1918, and was buried in Arlington

National Cemetery.2° (Figure 27)

Edward Carrier Taylor (1897-1982) grandson of Edward Ktibel and son of

Augustus C. And Josephine Kiibel Taylor was born at 327 First Street N.E. on February

2, 1897. He attended public schools and after graduation from McKinley Manual Training

High School he worked as a machinist at the Firth-Stirling plant in southeast Washington,

making munitions for the British Army. When the United States entered World War I,

Taylor enlisted and served most of the war with the French Army in advanced positions

as an ordnance sergeant in charge of a small mobile machine shop repairing and re-issuing

American small arms used by the French.

EDWARD KUBEL - INSTRUMENT MAKER 271

TECHNISCHE

LEHR-& VERSUCHS-ANSTALT

firPhotomechanische Verfahren von

(Cy

S) e

gt:

eee ee Sab ie ae oe soe se a me tn tw sa se se em

Herr Herbert G. Kiibel aus Washington besuchte unsere Lehranstol*

+ oumeen somechanieche Verfahren vom 29. Marz 1940 bis 9. Marz 1911, um

sich weiter suszubdilden. Er weilte zunachst ca. 4 Monate in der phot

graphischen Abteilung, wo er sich mit der Anfertigung von Strich~ und

Rasternegativen beschéftigte, des weiteren sit Kollodium-EBmguisigqn go-

wohl fiir Schwarzautotypie wie fiir den Drei- und Mehrfarbendruck ar-

peitete und ferner das Arbeiten mit frockenplatten, teilweise auch

fiir den indirekten Dreifarbendruck, erlennte.

Sodann erhielt Herr Kabel Unterricht in Zink-, Autotypie und

freifarben-Aetzung. Hiereuf briernte er noch die Photolithographie,

direktes und indirektes Verfahren auf Stein, Zink und Atupiaiua.

Herr Kibel verfolgte seine Studien mit Fleiss und Geschick, do

7 talt in allen Verfahren gute Beeultate

Figure 27. Certificate issued to Herbert oe Ae

aufzuweisen hatte.

G Kubel for completion of one year of ; Unsere besten Wiinsche nebielten ihn. : ie

studies in photo-engraving at Klimsch & Pt: bide

Co. In Frankfurt, March 10, 1911.

After the war’s end Taylor obtained the degree of B.S. in Mechanical Engineering

at the Catholic University of America, and upon graduation he was employed by the

Riley Company in Worcester, Massachusetts, makers of mechanical coal stokers for firing

the steam boilers of power plants and other large users of steam. After several years with

Riley, Taylor recognized the need for an industrial stoker that was smaller than the smallest

of the Riley line. Taylor designed the stoker he had in mind, and when Mr. Riley decided

that it was for a market in which he was not interested, Taylor and a Riley colleague,

Wilbur Whitty, left Riley’s employ and formed the Whitty Company. Their first plant

was one floor in a loft building on the Boston waterfront.

Taylor devoted his entire career to development of the Whitty Company. After Whitty

left the Company amicably in the early years to seek his fortune in New York, the company

weathered the Depression years and prospered during World War II and the postwar years.

Later, when “cheap oil’ destroyed the market for coal-burning equipment, Taylor expanded

the company’s line of fans, flue dampers, and screw conveyors that he had designed as

accessories for the stoker. After partial retirement due to illness, Taylor sold the business

to a prominent manufacturer of steam boilers. He died in Florida in 1982.

Frank Augustus Taylor (1903- ), grandson of Edward Ktibel and son of Augustus

C. Taylor and Josephine Ktibel was born in Washington at 327 First Street N.E. He

attended public schools and worked in his father’s drug store. Graduating from McKinley

272 SILVIO A. BEDINI

Figure 28. Lieutenant Herbert G. Kiibel (facing forward) at

airbase about to make a balloon ascent.

High School in February 1921, he obtained work with a U.S. Geological Survey mapping

party in Pennsylvania. In 1922 he was employed by the Smithsonian Institution to maintain

exhibits and to make models for new displays in the ageing Arts and Industries Building,

a part of the U.S. National Museum.

There Taylor joined a group determined to improve this already popular museum.

He also enrolled in evening classes at the George Washington University. Later Taylor

earned the B.S. degree in Mechanical Engineering from the Massachusetts Institute of

Technology (1928) and the LI.B degree from Georgetown University Law School (1934).

He was promoted to curator of the Division of Engineering in 1932 and participated in

two successful Federal make-work projects of the Depression years which extended the

Smithsonian’s outreach and preserved useful historical records. (Figure 28)

After World War II Taylor directed the program to revitalize exhibits in the National

Museum and initiated the planning for a new building for the museum still housed in

the Arts and Industries Building. In 1958 the museum was named the Museum of History

EDWARD KUBEL - INSTRUMENT MAKER 2713

_ and Technology with Taylor as its director. The building for the Museum of History and

Technology was opened in January 1964. Soon after the opening of this museum, Taylor

| became director of the U.S. National Museum. Later, when all museums of the

Smithsonian were individually named national museums, the MHT was named the

_ National Museum of American History and Taylor became Director General of all the

_ Smithsonian Museums. He retired in 1971 but continued on as an adviser until 1984.

In 1989 the Regents of the Smithsonian named a hall in the National Museum of

| American History “the Frank A. Taylor Exhibition Gallery.’ Among other awards that Taylor

: received are the Joseph Henry Medal, the Katherine Coffey Award, the National Civil Service

| League Career Award and the Philippine Liberation Medal with one Bronze Star.2®

Elizabeth Josephine Taylor (1906-1986), granddaughter of Edward Ktibel and

: daughter of Augustus C, and Josephine Ktibel Taylor, was born at 327 First Street N.E.,

| Washington, D.C. on January 4, 1906. She attended public schools on Capitol Hill and

upon graduation from McKinley Manual Training High School she had earned a schol-

_ arship to Syracuse University. Her parents urged her to consider a college closer to

| Washington and she entered the Maryland Agricultural College at College Park. She was

"active in student affairs including a substantial role in promoting and planning the construc-

_ tion of the AOP sorority house. This was one of the first constructed during the enlarge-

ment of the campus that was soon to become the University of Maryland.

After graduation Taylor taught science at the Calvert County High School in Prince

| Frederick, Md. Although she taught for only two years, Taylor always recalled the experi-

ence as a rewarding one, taking particular pride in the fact that the legendary and long

_ serving Comptroller of the State of Maryland, the late Hon. Louis L. Goldstein, was a

_ student in her class. Mr. Goldstein remembered her and invited her to the fifty-first reunion

of the class, which he hosted at his estate, Oakland Hall.

| After returning to Washington and to a job or two in the private sector, Taylor took

a position in the District of Columbia government as Statistician in the Health

Department. She held the title of Statistician until her retirement, although in later years

she was conducting a substantial part of the department’s administration. During World

| War II, Taylor devoted most of her weekends to work at the USO. She was unmarried,

| and died in 1986.

| Edward Kiibel Dougherty (1912- _), grandson of Edward Kiibel and son of Edward

F. and Clara Ktibel Dougherty, was born in Washington, D.C. on December 17, 1912.

He completed eight years at St. Paul’s Parish Elementary school and four years at St.

Johns College High School, both in Washington. At the Massachusetts Institute of

| Technology, he graduated with a degree of B.S. in Electrical Engineering. He completed

_ his education at the University of Pennsylvania’s Wharton School with the degree of

_ Master of Business Administration.

Dougherty was employed by the Westinghouse Electric Corporation for three years

(1939-1942) before entering active military service in the U.S. Navy Reserve. He served

274 SILVIO A. BEDINI

as Lt. Cmdr. Contracting Officer, Bureau of Ships, Washington, D.C. from 1942 to the

war’s end in 1946. |

After the end of World War II, Dougherty returned to the Westinghouse Electric

Corporation in Philadelphia, engaged in engineering and sales of large electrical |

apparatus until his retirement in 1975. In retirement, Edward Dougherty lives in Florida. |

He has three daughters, all married, and four grandchildren.

GREAT-GRANDCHILDREN

John Kiibel Farnsworth (1916-__ ), is the first member of the fourth generation of |

the Kiibel family to have distinguished himself in scientific activities. Stephen Ktibel’s |

grandson and a great-grandson of Edward Kiibel, is the son of John and Florence Kiibel

Farnsworth. He was born on December 13, 1916 in Shanghai, China, at the Victoria |

Nursing Home in the English Concession in that city. He attended Bancroft Elementary

School, Powell Junior High School and Central High School, all in Washington, D.C.,

and graduated from the latter in 1935. In World War II he served in England with the |

U.S. Army. In 1949 the U.S. Air Force recalled Farnsworth to active duty and entered |

him in a course to provide him with a B.S. degree in Meteorology. This was reduced to |

a two year course in the essential subjects in order to have him qualified by the American

Meteorological Society for certification as a Professional Meteorologist. |

This was the beginning of Farnsworth’s 15-year career as an Air Force weather officer. |

He earned a B.S. degree in Meteorology by attending the University of Illinois at |

Champaign part time while instructing full time at Chanute Air Force Base. In his final |

assignment at Nellis Air Force Base, Las Vegas, he was successively weather officer, |

staff weather officer, and weather detachment commander. During the Korean War he

served a year as weather forecaster at Taequ Air Base in South Korea. While stationed |

there he was awarded the Air Force Commendation Ribbon. Farnsworth retired in 1964 |

after many years of military service. |

In retirement Farnsworth has worked in a number of positions reflecting his interest |

in the environment, notably a position with the San Diego County Air Pollution :

District.27

Herbert Graham Farnsworth (1919-1981), brother of John Farnsworth, Jr.,

graduated from McKinley Manual Training High School in Washington. After one year |

at Devitt Preparatory School, Herbert qualified for the Army Air Corps. He soon became |

an instructor in the program, which was rapidly expanding to prepare more pilots for a

possible war, and later was assigned to train other flight instructors. While based at Turner

Field in Albany, Georgia, he set a world record for transitional flying while checking |

out instructors on B-25 Billy Mitchells; he flew 220 hours in 25 days, made 643 landings

and covered approximately 44,000 miles (based on an average airspeed of 200 miles an

hour). Turner Field director of training, Colonel Howard C. Stelling, indicated in press

EDWARD KUBEL - INSTRUMENT MAKER 275

_ reports that the average flier would take six months to compile as many hours. After

the war, Herbert Farnsworth pursued a career in commercial aviation with Delta Air Lines,

_ and frequently was the first Delta pilot to fly new aircraft, volunteering to bring newly

acquired equipment from Lockheed and Boeing installations in California to Delta opera-

tions headquarters in Atlanta, Georgia. As base air chief pilot for 1,000 pilots based in

_ Atlanta in the 1960s, he continued to perform takeoff and landing checks. In the early

1970s, Delta management decided to relieve base chief pilots of this added instructor

workload; Herbert chose to return to flying rather than remain in a desk job, and completed

his career with Delta, flying transcontinental and international routes for the expanding

airline. He served on Delta’s Master Executive Council of the Air Line Pilots Association

(ALPA), and represented Delta pilots on contract negotiating committees. He was a

member of various ALPA national committees, including the All Weather Committee,

developing policies for instrument flying, drawing on his broad experience in testing

and training pilots in the use of instruments for navigation. He also contributed to recom-

mendations for Federal regulations of flying with the safety committee of the Air Transport

Association. Two of Herbert’s children, his daughters Florence Louise Farnsworth and

| Anne Garry Farnsworth, continued the family’s interest in science and technology, both

winning positions in National Science Foundation programs in mathematics during high

school, both becoming Westinghouse Science Talent Search finalists, and receiving Bausch

& Lomb Science Awards at graduation. In the 1970s, Florence created an early

computer-based map routing system for the Detroit school system, and in the 1980s,

_ Anne introduced computer mapping for yellow pages usage analysis for the publishing

——— i ee ee.

arm of BellSouth Telecommunications.

John Carrier Taylor (1932- _), son of Edward Carrier Taylor, grandson of Josephine

Kiibel Taylor, and great grandson of Edward Kiibel, was born in West Roxbury (Boston),

Massachusetts on July 5, 1932. After graduating from Boston’s famed Latin School, he

earned the degree of B.S. in Mechanical Engineering from Cornell University in 1954.

Taylor was ordered to active duty with the Army in Korea and there was given the task

of designing, building, and then commanding a center that processed Army ordnance

parts and vehicles prior to returning them to the United States after the end of the Korean

War. After completion of his military service, he entered the employ of the Army and

Air Force Exchange Service, where he developed and published standards and criteria

for equipment and buildings used worldwide by the Exchange Service. Taylor became

the Deputy Director of Engineering for the Exchange Service, where at retirement, he

had enjoyed a career of 32 years.

Joan Josephine Taylor (1940- _), youngest of Edward Kiibel’s great-grandchil-

dren is his great-granddaughter, granddaughter of Augustus C. and Josephine Ktibel Taylor,

and daughter of Virginia M. and Frank A. Taylor. She was born in Washington on

December 18, 1940 and attended Lafayette Elementary School and Woodrow Wilson

High School. She obtained a degree of B.S. in Anthropology at the University of

276 SILVIO A. BEDINI

Pennsylvania, and went on to graduate studies at the University of Cambridge, England, -

earning a Ph.D. degree in European Prehistory. She specialized in the application of science —

to archeology by writing her dissertation on prehistoric goldwork.28

To achieve this, she joined the Arbeitsgemeinschaft fiir Metallurgie, in Stuttgart,

Germany, where trace elements in gold objects were being analyzed in an attempt to :

identify more significant archeological groups. At present she leads a team in a |

artifacts made from them by using Laser-Ablation Inductively Coupled Plasma Mass |

Spectroscopy, this time to ascertain areas of prehistoric manufacture and trade throughout —

the British Isles and Western Europe. |

After being appointed head of the Department of Prehistoric Archeology in 1976, |

and in between research, she developed the application of science to archeology at the —

University of Liverpool as the John Rankin Reader of Prehistoric Archeology and Director _

of the Institute of Prehistoric Sciences and Archeology, now subsumed into the larger |

School of Archeology, Classics and Oriental Studies. With emphasis in the Institute on —

the Geophysical applications to archeology, the analytical techniques applied to materials, |

pollen analysis and Uranium Series Dating, the Department of Archeology was recog- |

nized by the British government as being one of the top six in the United Kingdom. |

From the middle of the nineteenth century many talented German instrument makers |

migrated to the United States, to fulfill the need for precision instrumentation for which |

they had been trained, and provided the foundation for the mechanization of their manufac- |

ture. They settled in various parts of the country, including Rochester, New York, St. Louis, |

Missouri and Washington, D.C., where they worked for the scientists and surveyors

employed by the federal government. Among the first immigrant craftsmen was William

Wiirdemann and another was his foreman Edward Kiibel, who worked in Washington |

from 1849 until his retirement in 1892. For some years he was assisted by his son Ernest |

Ktibel who subsequently succeeded him and another son, Stephen Ktibel, also played an 7

important role in the development in the USGS. The Kiibel might almost be considered i

a dynasty in the field of scientific endeavors. It would be of interest to know how many |

other American families can trace a similar continuous involvement with science and

technology over a period of one and a half centuries. Accounts of the professions of

the subsequent four or five generations unquestionably adds to the endless debate of |

whether there are generation-linked predispositions or leanings to particular professions, |

or whether conditional abilities passed on by exposure from an early age through cultural |

and social experience pre-determines aptitudes and directions towards a profession.

Certainly the age-old endless debate among educationalists about “genetic vs. cultural |

learning” is not resolved here. No doubt both interact, but the nature of the close-knit

Kiibel families suggests that from a very early age explanations of how things worked, |

how science could be applied to daily problems, and a general awareness of technology |

no doubt conditioned each successive generation from a very early age. An attitude also

EDWARD KUBEL - INSTRUMENT MAKER 277

prevailed within the family that appropriate higher education was essential to bring out

the best in an individual’s aptitude and ability, ultimately leading to the profession of

his or her choice. This encouragement inevitably led successive generations to apply

| themselves in individual ways to the sciences linked to topography, weather, instru-

mentation, engineering, and even science-based archeology. As demonstrated by the

short professional biographies of subsequent generations, family archives have an impor-

tant role in tracing this heritage; in this instance, an important contributing factor was

_ the long career of one of Kiibel’s great-grandsons at the Smithsonian Institution, where

Edward Kiibel’s lathe and some of his instruments are preserved.

References

—

. Florian Cajori, The Chequered Career of Ferdinand Rudolph Hassler. First Superintendent of the United States

Coast Survey (Boston: The Christopher Publishing House, N.D.) pp. 79-92; 179; A. Hunter Dupree, Science

in the Federal Government. A History of Polices and Activities (Baltimore: Johns Hopkins University Press,

1986), pp. 29-33.

2. Charles Smart, The Makers of Surveying Instruments in America Since 1700 (Troy, N.Y.: Regal Press, 1962,

pp. 170-71; Steven Turner, “William Wtirdemann: First Mechanician of the U.S. Coast Survey,” Rittenhouse,

vol. 5, No. 4, April 1992, pp. 97-110.

3. Smart, p. 98; Silvio A. Bedini, Thinkers and Tinkers. Early American Men of Science (Charles Scribner’s Sons,

1975), pp. 367-69; Kiibel Papers, documents relating to career, passport, notice of arrival, and receipt for passage,

courtesy of John Farnsworth.

4. Smart, pp. 146-47, 45-46; George N. Saegmuller, The Story of My Life 1847-1934 (Privately printed, N. P.,

N. D.), pp. 12-14; Turner, pp. 97-99; “Description of an Automatic Dividing Machine, arranged for use in the

Coast Survey Office, by Joseph Saxton, Assistant in the Office of Weights and Measures, Washington, and

constructed by William Wiirdemann, mechanician, Coast Survey Office,’ Journal of the Franklin Institute, Third

Series, vol. XII, 1846, pp. 258-61. This dividing engine is presently in the collections of the National Museum

of American History, Smithsonian Institution.

5. Kiibel Papers, Edward Kiibel’s citizenship paper; Kiibel family Bible. Courtesy of Frank A. Taylor.

6. [Elmer E. Barton], Historical and Commercial Sketches of Washington and Environs. Our Capital City “The

Paris of America” Its Prominent Places and People (Washington, D.C.: E. E. Barton, 1884), p. 246; Kiibel

Papers, family Bible, courtesy of Frank A. Taylor.

7. Edward Kiibel was listed in the Washington city directories from 1858 through 1864 and again from 1867 through

1870, and also in 1896.

8. American Journal of Science and Arts, 3rd series, November 1874, vol. 6, No. 47, following p. 404, and December

1874, No. 48, following p. 484. Kiibel advertised his Keith Heliostat also in Engineering News, vol. 10, 1883.

9. “Andrew Kramer, 90, Made Instruments for Smithsonian,” Obituary notice, The (Washington) Evening Star,

August 11, 1959.

10. Copied by George C. Maynard from labels from the U.S. Geological Survey attached to the instrument, December

Poor.

11. Reuel Keith (1826-1908) graduated from Middlebury College in Vermont in 1845 and immediately upon

graduation received his appointment as a U.S. Navy’s Corps of Professors of Mathematics. Coming directly

from Middlebury College, he was assigned to the U.S. Naval Observatory as an astronomical observer. He left

the Observatory in 1853, worked as a surveyor for the next several years and resigned from the service on 11

July 1856. He was one of five authors of Zones of Stars observed at the United States Naval Observatory with

the Meridian Transit Instrument in the Years 1846, 1847, 1848, and 1849 (Washington: Government Printing

Office, 1872). Courtesy of Stephen J. Dick, History of the United States Naval Observatory, in manuscript;

Diana Fontaine Maury Corbin, A Life of Matthew Fontaine Maury, U.S.N. and C.S.N. (London: Sampson

Low, Marston, Searle & Rivington, 1888), p. 48.

278 SILVIO A. BEDINI

12. “Keith’s Heliostat,’ The American Naturalist, vol. XI, 1877, p. 758; “Keith’s Heliostat,’ American Journal

of Microscopy, vol. 3, 1878, p. 58; Carl Seiler, “Photography as an Aid to Microscopical Investigations,”

Proceedings of the National Microscopical Congress, Held at Indianapolis, Inc. August 14th to 19th, 1878,

and of the American Society of Microscopists, Held at Buffalo, N.Y. August 19th to 24th, 1879 (Indianapolis,

1880), p. 59; Allan A. Mills, “Portable Heliostats (Solar Illuminators),“* Annals of Science, vol. 43, 1986, pp.

369-406. A heliostat is an instrument consisting of a mirror moved by clockwork for reflecting the sun’s rays

in a fixed direction. In Michelson’s time the heliostat was widely used by photographers, microscopists and

physicists. He would naturally think of it as the source of the beam of light he would require for his experi-

ment.

13. Joseph J. Woodward, “On Photo-micrography with the highest powers, as practised in the Army Medical

Museum,” The American Journal of Science and Arts, Second Series, vol. XLII (Whole No. XCID), nos. 124-

126, 1866, pp. 189-95; Joseph J. Woodward, Report on an Improved Method of Photographing Histological

Preparations by Sunlight (Washington: Army Medical Museum, June 2, 1871), vide p. 4 et seq.; George E.

Davis, Practical Microscopy (London: David Bogue, 1882), pp. 214-15.

14. Dorothy Michelson Livingston, “Michelson in the Navy; the Navy in Michelson,” United States Naval Institute

Proceedings, vol. 95, No. 6, No. 796, June 1969, pp. 72-79, vide 76-77; Robert A. Millikan, “Biographical

Memorr of Albert Abraham Michelson 1852-1931,” National Academy of Sciences of the United States of America

Biographical Memoirs, vol. XIX, Fourth Memoir, 1937-1938, pp. 121-146; Dorothy Michelson Livingston,

The Master of Light. A Biography of Albert A. Michelson (New York: Charles Scribner’s Sons, 1973), pp. 45- |

66; Principal Documents Relating to the Survey of the Coast of the United States: and the Construction of |

Uniform Weights and Measures for the Custom Houses and States (New York: 1834-1836), vol. 2, passim. |

15. U.S. Naval Academy, Archives. Michelson Museum Accession Form File No. X- 450; Catalogue Cards M-

422, M-423, M-424, M-903, M-912; Armed Forces Institute of Pathology, Medical Museum and Library,

Manuscripts Division. Letter Book 1879, Calendar of Incoming Letters; Letter Book 1899, Calendar of Incoming

Letters; Harvey B. Lemon, “Albert Abraham Michelson: the Man and the Man of Science,” The American Physics

Teacher, vol. 4, No. 1, February 1936, pp. 1-9.

16. Albert A. Michelson, “On a Method of Measuring the Velocity of Light,’ American Journal of Science and

Art, vol. 3, No. 15, 1878, pp. 394-95; “Velocity of Light (Preliminary Announcement),”’ Nature, vol. 18, 1878,

p. 195; “Experimental Determination of the Velocity of Light,’ Proceedings of the American Association for

the Advancement of Science, 1879, pp. 124-60.

17. Thomas G. Manning, U.S. Coast Survey vs. Naval Hydrographic Office. A 19th- Century Rivalry in Science

and Politics (Tuscaloosa/London: University of Alabama Press, 1988), p. 25; communication from Clifford

M. Nelson, U.S. Geological Survey, January 26, 1995.

18. Kiibel Papers, last will and testament of Edward Kiibel, December 24, 1895, courtesy Mr. Frank A. Taylor.

The three houses were purchased in more recent times by the Veterans of Foreign Wars, and torn down to prepare

the site for building its national headquarters. Before construction began, however, the land was purchased by

the government to construct a parking lot for staff at the Senate Office Building.

19. Richard and Floss Loutzenhizer, “Romance Blooms with Dots and Dashes,” in Town on the Sound. Stories

of Steilacoom, edited by Joan Curtis, Alice Eatson, and Bette Bradley (Steilacoom: Steilacoom Historical Museum

Assn., ND), pp. 89-90. Their children included Philip and Frederick, who later lived with Clara in Pasadena.

Clara visited in Washington in the period 1910-1915 but there is no further information at hand about Edward

F. Ktibel or their children.

20. “Kiibel, Stephen Joseph,’ Who Was Who in America, vol. I, 1897-1942 (Chicago: Marquis Who’s Who, 1960),

p. 694; Mary C. Rabbitt, Minerals, Lands, and Geology for the Common Defense and General Welfare. Volume

2, 1879-1904 (Washington: U.S. Government Printing Office, 1980) pp. 193, 318.

21. Smithsonian Institution Archives, Record Unit 34, Office of the Secretary, Exchange of 11 letters between

Ernest Kiibel and office of Secretary Samuel P. Langley 1892-98.

22. Charles D. Walcott, “Biographical Memoir of Samuel Pierpont Langley 1834-1906,” National Academy of‘

Sciences Biographical Memoirs, vol. VII, 1912, pp. 247-68; Smithsonian Institution Archives, Record Unit |

33, Office of the Secretary 1865-1891, outgoing correspondence, vol. 1.22, p. 218, 466, unit 34, vol. 1.30, p. |

193, vol. 11.1, p. 138, vol. 6.1, p. 115, vol. 11.1, p. 180, 421, vol. 11.2, p. 13, vol. 11.3, p. 14, vol. 11.3, p. 36,

Record Unit 31, box 40, folder 3, vol. 6.7, p. 87, 96.

23. Federal Official Register, 1901-1909.

24. Letter from Klimsch & Co., March 10, 1911, confirming the completion by Herbert Graham Kiibel of one

year of studies in photo-engraving with Klimsch & Co.

EDWARD KUBEL - INSTRUMENT MAKER 279

25. Frank A. Taylor, “Growing Up on Capitol Hill,’ Records of the Columbia Historical Society of Washington,

vol. 50, 1980, pp. 508-21; Herman Schaden, “Smithsonian’s Mr. Museum,” The (Washington) Evening Star,

June 4, 1968, p. C-4.

26. Letter from John Farnsworth, Jr. to Frank A. Taylor, September 20, 1995.

27. Joan J. Taylor, Bronze Age Goldwork of the British Isles (Cambridge: Cambridge University Press, 1980).

Acknowledgments

The writer gratefully acknowledges the assistance of the many who have assisted in the preparation of this

paper, including Linda Corbin, Librarian, U.S. Naval Observatory; William Cox, Assistant Archivist, Smithsonian

Institution Archives; Alice S. Creighton, Head, Special Collections and Archives U.S. Naval Academy; Steven J.

| Dick, Historian, U.S. Naval Observatory; Alan Hawk, Historical Collections, National Museum of Health and

| Medicine, AFIP; Peter Liebhold and Stephen J. Turner, National Museum of American History, Smithsonian

|| Institution; Joseph McGregor, Photographic Librarian, Photographic Library, U.S. Geological Survey, Denver,

I Colorado; Michael Rhode, Archivist, National Museum of Health and Medicine; Deborah J. Warner, National

| Museum of American History, Smithsonian Institution; Joy Werlink, Librarian, Washington State Historical Society;

Ellis L. Yochelson, U.S. Geological Survey; and Clifford M. Nelson, Staff Geologist, U.S. Geological Survey,

‘Reston, Va., who has been an invaluable source on Geological Survey history.

| Most particularly the greatest debt is owed to Frank A. Taylor, Washington, D.C., who has made available

»a large number of family papers and records, and shared his personal reminiscences, and to his daughter, Joan J.

Taylor.

‘Illustration Credits

| p Figure 1. Courtesy of Mr. Fred Farnsworth.

Figures 2, 3,5, 6, 7, 16, 17, 26, 27, 28. Courtesy of Frank A. Taylor.

| Figure 4. Courtesy of Mr. John K. Farnsworth.

Figures 8, 9, 11, 14,15, 29. Courtesy of the National Museum of American History, Smithsonian Institution.

| Figures 18, 22, 23, 26,. Courtesy of the Photographic Library, U.S. Geological Survey.

' Figure 12, 13. Courtesy of the Armed Forces Museum of Pathology.

Figures 19, 20, 25. Courtesy of the U.S. Geological Survey.

‘Figure 10. Courtesy of the Smithsonian Institution Archives.

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Journal of the Washington Academy of Sciences,

Volume 85, Number 4, 281-289, December 1998

Gratuity in Nature and Technology

by Paul T. Arveson

Abstract

Frequently in science, we encounter patterns or structures in one field that have parallels

in a different, apparently unrelated field. Because of the inherently cross-disciplinary nature

of this subject, sometimes the parallels can go unrecognized for a long time. One of these

patterns is often referred to as “levels of reality”, or “levels of explanation”. This “laminar”

structure of our knowledge implies that there is some general feature or characteristic that

separates systems into distinct and irreducible levels or dualities. Here this feature is identi-

fied as what Jacques Monod called gratuity and it brings together in one brief summary a

variety of ways in which we observe gratuity in both natural and man-made systems.

Monod’s insight was that a living cell is a very special kind of machine, in which its infor-

mation content is free and unconstrained by the cell itself. In DNA, there is no energetic

preference for one set of nucleic acids over any other; the sequence is an arbitrary code, as

far as the cell is concerned. Rather, the cell’s processes are analogous to the relationship

| between a computer’s software and its material substrate. In a computer, the sequence of

numbers and letters in the software are not constrained but are free from the structure of the

| computer’s hardware. So we are faced in these cases with systems that cannot be described

in simple mechanistic terms of cause-and-effect. Their behavior is governed not from “below,”

| but rather from “above.” In the following sections, several examples of gratuity and its appli-

cation in widely diverse fields are described.

‘Introduction

| This article draws parallels between the manifestations of “levels” in biochemistry

and computer science (computer networks and computers themselves). A common idea

found in these fields is Monod’s concept of ‘gratuity.’ Many theories in other fields are

not considered here but are recognized to be relevant to this concept, including for example

(quantum physics (wavelike behavior of atomic interference reported by Berman, 1997),

the brain (theory of neuronal group selection, Edelman, 1994), social animals: Holland

) (1995), ecology: Gell-Mann (1994), and economics: Anderson (1987); Arthur et al. (1997).

Technology has drawn many fruitful lessons from biology; it is now suggested that organi-

_zational management could also benefit from such cross-disciplinary learning.

{

—

282 PAUL T. ARVESON

Gratuity in Biochemistry

Jacques Monod won the Nobel prize for his elucidation of the process by which gene

expression is regulated in biosynthesis, a process called the operon model. I will not |

describe the whole model here, but quote Monod’s own analysis of the concept from °

Chance and Necessity (1971): |

“There is no chemically necessary relationship between the fact that beta- |

galactosidase hydrolyzes beta-galactosides, and the fact that its biosynthesis is |

induced by the same compounds. Physiologically useful or rational, this relation- |

ship is chemically arbitrary — gratuitous, one may say.” :

We are in the habit of describing chemical processes in terms of cause and effect.

That won’t work for this process. It is not deterministic in a simple, mechanical way. |

Monod identifies the relationship as one of “gratuity”: |

“The fundamental concept of gratuity — i.e. the independence, chemically |

speaking, between the function itself and the nature of the chemical signals control- |

ling it — applies to allosteric enzymes. ... Between the substrate of an allosteric

enzyme and the ligands prompting or inhibiting its activity there exists no chemi- |

cally necessary relationship of structure or of reactivity. The specificity of the |

interactions, in short, has nothing to do with the structure of the ligands; it is entirely

due, instead, to that of the protein in the various states it 1s able to adopt, a struc-

ture in its turn freely, arbitrarily dictated by the structure of a gene.

“From this it results — and we come to our essential point — that so far as |

regulation through allosteric interaction is concerned, everything is possible. An

allosteric progein should be seen as a specialized product of molecular |

engineering, enabling an interaction, positive or negative, to come about

between compounds that are chemically foreign and indifferent to this reaction. |

“Tn a word, the very gratuitousness of these systems, giving molecular evolu-

tion a practically limitless field for exploration and experiment, enabled it to |

elaborate the huge network of cybernetic interconnections which makes each |

organism an autonomous functional unit, whose performances appear to

transcend the laws of chemistry if not to ignore them altogether.” |

So the essential aspect of gratuity is a kind of independence or transcendence; the |

freedom of a system’s behavior from being constrained by its parts. Such a system can |

act to control a signal without altering it, or as a transparent channel for a signal. In |

biochemical ‘signals’ of the operon model, the DNA fully determines the products formed, }

but when they are formed is under the control of a process at a ‘higher level’ in the system.

“Microscopic cybernetics” is Monod’s own phrase by which he suggests analogies

between biology and computer circuits. Features of the operon model include positive |

and negative feedback regulation (enzyme induction and coordinate repression). He even |

GRATUITY IN NATURE AND TECHNOLOGY 283

showed how two interacting operons can form a stable oscillator Gust as two dual-input

. NAND gates can be connected to form a flip-flop circuit):

**... both interations of the repressor are noncovalent and reversible, and that,

in particular, the inducer is not modified through its binding to the repressor....

Thus the logic of this system is simple in the extreme: the repressor inactivates

transcription; it is inactivated in its turn by the inducer. From this double negation

| results a positive effect, an ‘affirmation’.... The logic of biological regulatory

systems abides not by Hegelian laws but, like the workings of computers, by

| the propositional algebra of George Boole.”

PELs

This was written in 1970; Monod was already aware of the relevance of cell biology

| to computer operations via Boolean algebra. Cross-disciplinary research of this kind

_ continues; some of the most interesting work is being conducted by workers at the Santa

Fe Institute, including Murray Gell-Mann (1994), Stuart Kaufmann (1996), and John

| Holland (1996). See also the excellent survey by Waldrop (1992).

To illustrate, the following table shows a scheme that identifies the “levels of organi-

zation” of living things.

| Table 1. Independent Layers in Biological Systems

| ecosystem with numerous species

species

individual organism or phenotype

organs

. cell and organelles

. nucleus *

. operons and RNA mediated synthesis

. DNA code

. molecules and bonds

PNWAUNDAN wo

* A very recent addition to examples of gratuity is the discovery that a cow egg can

support the development of another mammalian species, if its nucleus is substituted for

the cow’s (Dominko and First, 1998).

| Gratuity in Telecommunication Networks

Gratuity is established in computer network protocols by distributing network

functions among a series of layers; wrapping the data in packets with headers containing

layer-related information; and limiting interaction between the layers to that involving

the headers. In transmission, starting from the top layer, each lower layer adds its own

284 PAUL T. ARVESON

header to the data sent to it, and on reception each higher layer strips off a header and |

sends the data to the next layer. These processes are described by various technical terms,

but all are related to the general principle of gratuity, where the data are independent of |

the frame or header. Here are some examples: |

— Frame relay, the X.25 standard, creates frames around packets of data.

— The Internet Protocol (IP) establishes tunneling of IP packets through foreign-

networks. |

— Sometimes large data packets have to be broken up to fit through a network,

and then reassembled; this is called transparent fragmentation in IP or segmen-

tation in ATM.

All these are equivalent to wrapping a message in a sealed envelope. This is done :

at the expense of lost bandwidth, but has many advantages: service over a connection-

less network; error detection; receipt acknowledgment; standardized packet handling; |

guaranteed quality of service; security, etc.

Layering also has two distinct advantages for the design of networks: it facilitates |

development of the protocols, and it simplifies their functional components (hardware :

and software). Advanced protocols like ATM take thousands of pages to document; |

such complexity would be impossible for humans to manage without being able to limit

the information required at any given layer. |

The OSI (Open Systems Interconnection) model is traditionally used to illustrate |

the arrangement of layers in networks. The identification of functions in each layer differs |

depending on the particular set of protocols used, because the original OSI model is

somewhat idealized. Below is shown a practical example of layer designations, applic- |

able to an advanced network with TCP/IP running over an ATM subnet:

Table 2. Example of Layers in a Computer Network (TCP/IP over ATM).

6. Application layer - HTTP, FTP, Telnet, email, etc.

5. Transport Control Protocol (TCP) Layer - manages the network

4. Internet Protocol (IP) Layer - network addressing and routing

3. ATM Layer - several sublayers for switching and routing

2. Data Link Layer - error detection, framing, flow control

1. Physical Layer - cables, switches, voltages etc.

Gratuity in Computer Technology

Maurice Wilkes, one of the early pioneers of computer science, has recently (1995)

written a concise retrospective on its early history. This little book is helpful in separating

‘

GRATUITY IN NATURE AND TECHNOLOGY 285

_ significant changes from all the hype and clutter. Wilkes notes three crucial turning points

_ in computer development; all had something to do with gratuity.

Unlike other kinds of machines, a computer’s function is to process data; it doesn’t

matter what physical form the hardware takes, as long as its logic is correct. In describing

the conversion of computers from vacuum tubes to transistors, Wilkes remarks on the

smoothness of this transition with a beautiful simile: “It was as though the foundations

of a cathedral were being wholly renewed, while services were going on in the choir

_ and the organ was playing.”

Another achievement led to what Wilkes called “the software avalanche”: the appro-

| priate segregation of hardware tasks from software tasks. Some early computers used

, parallel arithmetic processors in order to save calculation time, at the expense of more

complex programming. Later, to simplify programming the change was made to a single

_CPU to allow a single instruction stream for all operations. Operations were slower,

but this saved programmer time. It also “made possible the development of modern

software with its layer upon layer of complexity.”

A key to this development was the realization that computers could be used to prepare

and edit their own programs. The use of index registers allowed subroutines to be called

a ——

to simplify programming efforts. Then a team led by Grace Hopper at UNIVAC devel-

oped a “compiler” that expanded program pseudocode into machine code. Wilkes (1952)

independently suggested a similar concept. At that point, languages more readable by

humans could be developed, including FORTRAN, COBOL, ALGOL, BASIC, and PL/1

_ during the 1960s. The syntax of these languages was based on human needs, not the

——————— I

ee — eee

machine’s; this is a third historical example of gratuity.

Wilkes’ “software avalanche” led to higher-level computer languages, including

complex compilers and hardware simulators used to design more advanced computers.

Whenever systems support their own growth in this way, the growth rate is exponen-

tial. This is why we have observations such as Moore’s law, which describes the “doubling

time’ of computer processing power every 18 months.

Another significant application of gratuity is the concept of ‘object oriented

languages’ such as Smalltalk, invented at the Palo Alto Research Center in the early 1970s.

An object “is a self-contained software package consisting of its own private informa-

tion (data), its own private procedures (private methods) that manipulate the object’s

private data, and a public interface (public methods) for communicating with other objects”

(Fingar, 1996). In this methodology, a programmer’s task is not so much with writing

lines of code as with assembling a set of pre-defined objects for a task.

The hiding of internal information within objects is called encapsulation. To use

an object, you only need to know what messages the object can accept. The advantage

of encapsulation is that objects can be combined, changed, and reused without having

to rewrite any internal code. This is clearly an application of gratuity, where the ‘insula-

tion’ of internal source code from the high-level object language is strictly enforced.

Hos

;

286 PAUL T. ARVESON

Further layers continue to be developed in computer technology, as the systems |

by the designer or user continues to be the only feasible way to develop systems of this |,

complexity. Hence, we see system descriptions with increasing numbers of layers. -

Computer technology using objects is now expanding to create higher levels of sophis- —

ticated system “architecture” in organizations. Norman Simenson, a veteran software |

tecture” (1997):

‘An architecture is a partitioning scheme, or algorithm, that partitions all of the

system’s present and foreseeable specifications into a workable set of cleanly bounded |

‘buckets’ with nothing left over. That is, it is a partitioning scheme that is exclusive, |

inclusive, and exhaustive. Ideally, each bucket will be a standalone partition. A major |

purpose of the partitioning is to arrange the elements in the buckets so that there is a

minimum of message exchanges needed among buckets. In both software and hardware, |

a good bucket can be seen to be a meaningful ‘object’.” :

This definition clearly entails gratuity, albeit in different language. Below is a table

describing one scheme suggested scheme for layers of information technology that might |

be deployed in a future business enterprise (upper layers from Fingar, 1996). |

Table 3: A Scheme for Layers in an Enterprise Information System

14. Agents: sequencing of workflows, events.

13. Events: representations of actions that initiate or influence business scenarios. |

12. Scenarios: Assemblage of entities representing a business function or process |

(transactions, orders). |

11. Entities: tangible and conceptual problem domain subjects (people, trucks),

associations (marriage, employment) and roles (manager, clerk). |

. Intrinsics: Technology and problem domain for independent base classes |

(money, size, etc.)

Technology encapsulation: CORBA, DCOM, (persistence, lifecycle, etc.)

Object-oriented languages, models, and development environments

Graphical user interfaces (computer-human interfaces), input/output data

Source code layer (text)

Assembler language layer

Machine language layer (binary codes)

Boolean algebra, binary logic

Circuit layer: gate arrays, registers, read-only memory, buses etc.

Physical layer: physical laws and materials parameters

—

ey ee ee! a ee ee

GRATUITY IN NATURE AND TECHNOLOGY 287

The Emerging Language of Gratuity

It is noteworthy that the word ‘levels’ is ametaphor. Although the word is commonly

‘used to refer to separated functions in complex systems, in most cases the ‘levels’ do

not have any physical existence. In a computer, only the bottom one or two layers are

physical; the rest are in software. In the case of computers, it may be more appropriate

‘to use another metaphor, such as a “chain” of functions, or even better, a nested series

of “shells,” as in a set of babushka dolls. (In fact, in the UNIX context the word “‘shell”’

is often used.) In more complex systems, the relationships are more “weblike’’;

‘ultimately in our technological systems we are reconstructing ourselves, i.e., our biolog-

ical bodies and ecosystems.

In network terms we may describe biological gratuity by saying that the DNA is

the data packet to be sent; the chromosomes (headers) encapsulate the data, and other

top-layer functions control when and how often the packet is sent. This is a “top-down”

‘process. On the other hand, the structure and function of all the products are ultimately

determined by the DNA, 1.e., “bottom-up.” There is an asymmetrical interdependence,

‘or “metadependence” of information coming from above and below the synthesis layer.

‘In computer terms, we could say that the user or the top-level program determines what

“actions occur, even though we “know” that the immediate cause is electric signals in

the physical layer. Among software engineers, this low-level reality tends to be repressed

into the unconscious, and in place of the user, new kinds of top-level gratuitous objects

‘continue to be developed, such as “agents,” “avatars,” “daemons,” etc. Perhaps the end-

‘point of “computer system” development is Data, the android in Star Trek — he knows

| everything, but (unlike HAL of 2001) he has no ambition.

‘Management Applications: How to Get Organized

There are many other ways in which the concept of gratuity can be observed in nature

and technology. Rather than continue with technical examples, I wish to discuss the

potential relevance of gratuity to the practical problems of managing complex organi-

zations. In modern enterprises such as the federal government or large corporations,

| managers often are overwhelmed at the complexity they are expected to comprehend

and lead. The common phrase for this is ‘information overload’ and this may lead to

frustration, stress and cynicism. However, nature demonstrates that although such tasks

are extremely difficult, they are not fundamentally impossible. They just have to be divided

up and delegated appropriately. In the operon model and many other biochemical

processes that science has elucidated, gratuity limits information by isolating (or encap-

‘sulating) functions from each other, allowing only a few carefully defined inputs and

outputs to pass, thus creating “layers.” Some kinds of data will pass transparently through

a layer; some kinds will originate in each layer. But the net effect is to simplify the entire

288 PAUL T. ARVESON

system’s behavior and its presentation at the top layer, where strategic decisions

affecting the entire system can be made — whether that system be a jaguar (Gell-Mann’s

example) or a corporation’s growth strategy.

Taking this lesson from biochemistry and technology, we conclude that managers

should not try to “micromanage’ operations of low-level business units on a continuing |

basis. Rather, they should establish metrics to monitor the efficiency (cycle time, produc- —

tivity) and effectiveness (relevance to mission or strategy) of each unit. Then they should

monitor these metrics, and leave the internal functions to adapt and improve at will

(freedom or ‘gratuity’ is established within each unit). In order to limit the data flows —

to prevent information overload, measurements should be aggregated at each level of |

organization. In other words, strategic planning and reengineering studies should find

ways to limit data, as well as to deliver it. |

Bureaucratic organizations may have over a dozen levels in their chain of command. -

If a level does not add value (i.e., create new information), it is only a transparent or

agencies to ‘flatten’ their organizational structure by removing layers of middle manage- |

ment. In addition to reducing costs, a useful goal of this reengineering process is the

appropriate allocation and isolation of functions and simplification of their linkages. By |

applying gratuity, it is possible at least in principle to build systems or organizations of

ever-increasing complexity without getting bogged down in information overload or ineffi-

ciency.

References

Anderson, P. W., Arrow, K. J., and Pines, D., eds. (1988). The Economy as an Evolving Complex System. Santa

Fe Institute Studies in the Sciences of Complexity, 5. Redwood City, CA: Addison-Wesley.

Arthur, B., Durlauf, S. N., and Lane, D., eds. (1997). The Economy as an Evolving Complex System II,

Proceedings. Santa Fe Institute Studies in the Sciences of Complexity. Santa Fe, NM: Santa Fe Institute.

Berman , P. R. (1997). Illustration of “the wave nature of matter objects independent of the complexity of their

internal structure.” Atom Interferometry, ed. Paul R. Berman, Academic, reviewed in Physics Today, Dec

1997, pPp- 68-70.

Dominko, T. and First, N. (1998). “Cow Eggs Play Crucial Role in Cloning Effort” , The Washington Post, Jan. |

19, 1998, p. Al. (University of Wisconsin at Madison).

Edelman, G. M. (1987). Neural Darwinism: The Theory of Neuronal Group Selection. New York: Basic Books. |

Fingar, P. ed. (1996). Next Generation Computing: Distributed Objects for Business. New York: SIGS Books &

Multimedia.

Gell-Mann, M. (1994). The Quark and the Jaguar.: Adventures in the Simple and the Complex. New York: W. |

H. Freeman.

Wesley).

Jacob, F. et al. (1961). J. Mol. Biol. 3, 318.

Jacob, F. et al. (1964). Comptes Rendus Acad. Sci. Paris 258, 3125.

Kaufmann, S. A. (1996). At Home in the Universe: The Search for the Laws of Self-Organization and Complexity. .

New York: Oxford University Press. ,

Monod, J. (1972). Chance & Necessity. New York: Vintage Books (Random House).

GRATUITY IN NATURE AND TECHNOLOGY 289

Simenson, N. F. (1997). The Architect's Roles and Responsibilities. American Programmer, July 1997.

- J

| Waldrop, M. (1992). Complexity: The Emerging Science at the Edge of Order and Chaos. New York: Touchstone

Books (Simon & Schuster).

Wilkes, Maurice V. (1995). Computing Perspectives. London: Morgan Kaufman Publishers.

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MR. LOWELL E. CAMPBELL 14000 POND VIEW RD, SILVER SPRING, MD 20905 (F)

DR. EDWARD W. CANNON 18023 - 134TH AVE, SUN CITY WEST, AZ 85375 (M)

MR. HERBERT LIONEL CARES, JR. 411 GRANVILLE DR, SILVER SPRING, MD 20901 (M)

MR. WILLIAM M. CARPENTER SRI INTERNATIONAL, 1611 NORTH KENT ST, ARLINGTON, VA 22209 (M)

DR. DANIEL B. CARR 9930 RAND DR, BURKE, VA 22015 (F)

DR. WILLIAM R. CARROLL 4802 BRD BROOK DR, BETHESDA, MD 20814-3906 (EF)

MR. MATTHEW J. CERRONI 12538 BROWNS FERRY RD, HERNDON, VA 22070 (M)

DR. RANDALL M. CHAMBERS 2704 WINSTEAD CIR, WICHITA, KS 67226 (NRF)

MR. JERRY CHANDLER 837 CANAL DR, MCLEAN, VA 22102-1407 (F)

DR. ALPHONSE CHAPANIS 5 HAMPSHIRE WOODS CT, TOWSON, MD 21204-4304 (F)

DR. HARVEY R. CHAPLIN, JR) . 1221 WEST LEIGH DR, CHARLOTTESVILLE, VA 22901 (F)

DR. DAVID ARTHUR CHERNIN DAVIS SQUARE, 51 HOLLAND ST, SOMERVILLE, MA 02144 (M)

DR. CURTIS G. CHEZEM 3378 WISTERIA ST, EUGENE, OR 97404-5930 (EF)

DR. ESTHER NAGN-LING CHOW 7420 BRICKYARD RD, POTOMAC, MD 20854 (F)

DR. GALE W. CLEVEN 2413 S EASTERN #245, LAS VEGAS, NV 89104 (EF)

DR. THOMAS LYTTON CLINE 13708 SHERWOOD FOREST DR, SILVER SPRING, MD 20904 (F)

DR. GIDEON MARIUS CLORE LAB OF CHEMICAL PHYSICS, BLDG 5, RM 132 NIDDK,

NIH, BETHESDA, 20892 (F)

MR. JOSEPH F. COATES PRES., COATES & JARRETT, INC., 4455 CT AVE, NW, SUITE A-500,

WASHINGTON, DC 20008 (M)

DR. TIMOTHY P. COFFEY NAVAL RESEARCH LABORATORY, CODE 1001, WASHINGTON, DC 20375-5000 (F)

DR. MICHAEL P. COHEN 555 NEW JERSEY AVE, NW, NCES, RM 408, WASHINGTON, DC 20208-5654 (M)

DR. RITA R. COLWELL DIRECTOR, NATL SCIENCE FOUNDATION, 4201 WILSON BLVD, RM 1205,

ARLINGTON, VA 22230 (LF)

DR. JAMES COMAS NIST, BLDG 225, RM A-305, BUREAU DR, GAITHERSBURG, MD 20899 (F)

DR. WILLIAM J. CONDELL, JR. 4511 GRETNA ST, BETHESDA, MD 20814 (EF)

MR. EDWARD McD. CONNELLY 11915 CHEVIOT DR, HERNDON, VA 22070 (F)

DR. KENNETH W. COOPER 4497 PICACHO DR, RIVERSIDE, CA 92507-4873 (EF)

DR. LEON N. COOPER DIRECTOR, INST FOR BRAIN AND NEURAL SYSTEMS, BROWN UNIV, PROVIDENCE,

RI 02912 (LF)

MRS. EDITH L.R. CORLISS 2955 ALBEMARLE ST, NW, WASHINGTON, DC 20008-2135 (LF)

MR. JOHN J.F CORRIGAN 11768 OWENS GLEN WAY, NORTH POTOMAC, MD 20878 (M)

MR. LOUIS COSTRELL 15115 INTERLACHEN DR, APT 621, SILVER SPRING, MD 20906-5641 (F)

DR. CYRUS R. CREVELING 4516 AMHERST LN, BETHESDA, MD 20814 (F)

DR. JOHN K. CRUM 1155 16TH ST, NW, WASHINGTON, DC 20036 (F)

DR. DOUGLAS G. CURRIE DEPT OF PHYSICS, UNIV OF MARYLAND, COLLEGE PARK, MD 20742 (M)

REV. C. L. CURRIE, S.J. PRES, ASSN JESUIT COLL & UNIV, ONE DUPONT CIR, NW #405, WASHINGTON, DC

20036 (F)

DR. JOHN WILLIAM DALY CHIEF, LAB OF BIOORGANIC CHEMISTRY, BLDG 8A, RM 1A-15 NIH, BETHESDA,

MD 20892 (F)

DR. ROBERT E. DAVIS 1793 ROCHESTER ST, CROFTON, MD 21114 (F)

MR. ANDREW V. DAVIS 4201 MASS AVE, NW #332, WASHINGTON, DC 20016 (M)

DR. ROLAND DE WIT 11812 TIFTON DR, ROCKVILLE, MD 20854-3538 (F)

DR. KENNETH L. DEAHL USDA - ARS - BARC WEST, BELTSVILLE, MD 20705 (F)

293

DR. GEORGE E. DEAL 6800 FLEETWOOD RD, APT 1101, MCLEAN, VA 22101 (EF)

DR. ROBERT L. DEDRICK 1633 WARNER AVE, McLEAN, VA 22101 (F)

CDR. HAL P. DEMUTH 118 WOLFE ST, WINCHESTER, VA 22601 (NRF)

DR. RICHARD D. DESLATTES, JR 610 ASTER BLVD, ROCKVILLE, MD 20850 (F)

DR. STANLEY DEUTSCH 7109 LAVEROCK LN, BETHESDA, MD 20817 (EF)

~ MR. NORMAN DOCTOR 6 TEGNER CT, ROCKVILLE, MD 20850 (EF)

COL. THOMAS W. DOEPPNER 8323 ORANGE CT, ALEXANDRIA, VA 22309 (LF)

MRS. JOHANNA B. DONALDSON 3020 NORTH EDISON ST, ARLINGTON, VA 22207 (EF)

MS. EVA G. DONALDSON 3941 AMES ST NE, WASHINGTON, DC 20019 (F)

DR. ROBERT J. DOOLING 13615 STRAW BALE LN, GAITHERSBURG, MD 20878-3994 (F)

DR. SATYA D. DUBEY 7712 GROTON RD, WEST BETHESDA, MD 20817 (EF)

DR. DICK DUFFEY CHEM-NUCLEAR ENGINEERING DEPT, UNIV OF MARYLAND,

COLLEGE PARK, MD 20742 (LF)

MR. JAMES A. DUKE 8210 MURPHY RD, FULTON, MD 20759 (LF)

DR. RAYNOR L. DUNCOMBE 1804 VANCE CIR, AUSTIN, TX 78701 (NRF)

MR. JOHN E. DUPONT PO BOX 358, NEWTOWN SQUARE, PA 19073 (NRF)

DR. ARJAN DURRESI 925 CITY PARK AVE, COLUMBUS, OH 43206 (M)

DR. STANLEY EVAN EDINGER APT #1400 SOUTH, 5901 MONTROSE RD, ROCKVILLE, MD 20852 (F)

DR. GRAEME EISENHOFFER 5803 WILMETT RD, BETHESDA, MD 20817 (F)

_ DR. MILTON PHILIP EISNER 1565 HANE ST, MCLEAN, VA 22101-4439 (F)

DR. HASSAN EL KHADEM DEPT OF CHEMISTRY, AMERICAN UNIV, WASHINGTON, DC 20016-8014 (EF)

DR. BURTON Y. ENDO 1010 JIGGER CT, ANNAPOLIS, MD 21401-6886 (EF)

MR. WILLIAM JOHN ENTLEY 5707 PAMELA DR, CENTREVILLE, VA 22020 (F)

MR. PAUL C. ETTER 16609 BETHAYRES RD, ROCKVILLE, MD 20855-2043 (F)

DR. ROBERT F. FARMER C/O AKZO NOBEL CHEMICAL, 300 S RIVERSIDE PLAZA,

CHICAGO, IL 60606 (NRF)

MR. JOSEPH A. FAULKNER 2 BAY DR; LEWES, DE 19958 (NRF)

DR. WILLIAM R. FAUST 1665 HEATHER LN, HUNTINGTON, MD 20639-4108 (NRF)

DR. ROBERT E. FAY 6621 1OTHST B-1, ALEXANDRIA, VA 22307 (F)

JON D. FAYE 4004 QUEENSBURY RD, HYATTSVILLE, MD 20782-3049 (M)

DR. JAMES E. FEARN 374 NORTH DR, SEVERNA PARK, MD 21146 (EF)

DR. RICHARD A. FERRELL 6611 WELLS PARK WAY, UNIV PARK, MD 20782 (EF)

DR. ROBERT FINKELSTEIN ROBOTIC TECHNOLOGY, INC, 10001 CRESTLEIGH LN, POTOMAC, MD 20854 (M)

DR. JOEL L. FISHER 4033 OLLEY LN, FAIRFAX, VA 22032 (M)

DR. DAVID R. FLINN 330 SILVER HILL CIR SE, SALEM, OR 97306 (NRF)

DR. NANCY FLOURNOY 4712 YUMA ST, NW, WASHINGTON, DC 20016-2048 (NRF)

MR. HERBERT H. FOCKLER 10710 LORAIN AVE, SILVER SPRING, MD 20901 (F)

DR. SAMUEL N. FONER 11500 SUMMIT WEST BLVD, NO 15B, TEMPLE TERR, FL 33617 (EF)

DR. RICHARD H. FOOTE HC 75, BOX 166 L.O.W., LOCUST GROVE, VA 22508 (NRF)

DR. ALPHONSE F. FORZIATI 2235 OLD HAMILTON PL, GAINESVILLE, GA 30507-6900 (EF)

DR. JUDE E. FRANKLIN 7616 CARTERET RD, BETHESDA, MD 20817-2021 (F)

DR. ERNEST R. FREEMAN 5357 STRATHMORE AVE, KENSINGTON, MD 20895-1160 (F)

DR. MOSHE FRIEDMAN 4511 YUMA ST, NW, WASHINGTON, DC 20016 (F)

DR. GEORGE T. FURUKAWA 1712 EVELYN DR, ROCKVILLE, MD 20852 (F)

DR. WILLIAM W. GAGE 10 TRAFALGAR ST, ROCHESTER, NY 14619-1222 (NRF)

MR. DONALD J. GANTZER 43891 STRONGHOLD CT, ASHBURN, VA 22011 (M)

DR. DAVID GARVIN 18700 WALKER’S CHOICE RD, NO 807, MONTGOMERY VILLAGE, MD 20886-2557 (EF)

DR. GUILLERMO C. GAUNAURD 4807 MACON RD, ROCKVILLE, MD 20852-2348 (F)

MS. LAURIE GEORGE 1 1306 BENT CREEK TERR, GERMANTOWN, MD 20876 (M)

DR. ABOLGHASSEM GHAFFARI 7532 ROYAL DOMINION DR, WEST BETHESDA, MD 20817 (LF)

MR. JEROME GIBBON 311 PENNSYLVANIA AVE, FALLS CHURCH, VA 22046 (M)

MR. JAMES GIRARD THE AMERICAN UNIV, DEPT OF CHEMISTRY, WASHINGTON, DC 20017 (F)

DR. HAROLD GLASER 1902 BERRYMAN ST, BERKELEY, CA 94709-1919 (EF)

PROF. ROLFE E. GLOVER III 7006 FOREST HILL DR, HYATTSVILLE, MD 20782 (EF)

MR. ALBERT G. GLUCKMAN 11235 OAKLEAF DR, NO 1619, SILVER SPRING, MD 20901-1305 (EF)

DR. ROBERT L. GLUCKSTERN 801 DROHOMER PL, BALTIMORE, MD 21216 (EF)

294

DR. JAMES F. GOFF 3405 - 34TH PL, NW, WASHINGTON, DC 20016 (EF)

MS. ELAINE KALSTEIN GOLDBERG 719 HARRINGTON RD, ROCKVILLE, MD 20852 (F)

DR. A. MORGAN GOLDEN 9110 DRAKE PL, COLLEGE PARK, MD 20740 (EF)

DR. CALVIN GOLUMBIC 6000 HIGHBORO DR, BETHESDA, MD 20817 (EM)

MR. ROBERT J. GOODE 2402 KEGWOOD LN, BOWIE, MD 20715 (EF)

DR. RUTH E. GORDON 9405 QUILL PL, MONTGOMERY VILLAGE, MD 20879 (EF)

DR. WILLIAM R. GRAVER S AIC, 2-3-1, 1710 GOODRIDGE DR, MCLEAN, VA 22012 (M)

MR. M. L.GREENOUGH GREENOUGH DATA ASSOC, 616 ASTER BLVD, ROCKVILLE, MD 20850 (F)

DR. VICTOR M. GRISHKEVICH VISHNEVSKY INST OF SURGERY, B SERPUKHOVSKAYA UL27,

113093 MOSCOW, RUSSIA (NRF)

DR. ANGELA M. GRONENBORN 5503 LAMBETH RD, BETHESDA, MD 20814 (PF)

DR. VICTORIA C. GUERRERO 10627 PATTERNBOND TERR, SILVER SPRING, MD 20902 (M)

DR. PRADEEP KUMAR GUPTA 8301 ARLINGTON BLVD #405, FAIRFAX, VA 22182 (F)

DR. PAUL-GEORG GUTERMUTH 1I.M. WINGERT #28, 53604 BAD HONNES, GERMANY (NRF)

DR. HARVEY HACK OCEAN SYSTEMS, NORTHROP GRUMMAN CORP, PO BOX 1488, M.S. 9105,

ANNAPOLIS, MD 21404 (F)

DR. EDWARD HACSKAYLO 7949 N SENDERO UNO, TUCSON, AZ 85704-2066 (EF)

DR. EDWARD O. HAENNI 7907 GLENBROOK RD, BETHESDA, MD 20814-2403 (F)

MR. GEORGE H. HAGN 4208 SLEEPY HOLLOW RD, ANNADALE, VA 22003-2046 (LF)

REV. FRANK R. HAIG, SJ LOYOLA COLLEGE, 4501 NORTH CHARLES ST, BALTIMORE, MD 21210 (F)

MR. KENNETH A. HAINES 900 N. TAYLOR ST #1231, ARLINGTON, VA 22203-1855 (F)

DR. WALTER J. HAMER 407 RUSSELL AVE, #305, GAITHERSBURG, MD 20877-2889 (EF)

DR. RUDOLPH A. HANEL 3881 BRIDLE PASS, ANN ARBOR, MI 48108-2264 (EF)

MR. WILLIAM E. HANFORD, JR. 5613 OVERLEA RD, BETHESDA, MD 20816 (M)

MR. JAMES W. HARR 180 STRAWBERRY LN, CENTREVILLE, MD 21617 (F)

DR. JANET W. HARTLEY 3513 IDAHO AVE, NW, WASHINGTON, DC 20016-3151 (EF)

MS. MICHELLE HARVEY 734 15TH ST, NW, SUITE 420, WASHINGTON, DC 20005 (M)

DR.CARYL P. HASKINS 1545 18TH ST, NW, SUITE 810, WASHINGTON, DC 20036 (EF)

DR. GEORG H. HASS 7728 LEE AVE, ALEXANDRIA, VA 22308-1003 (EF)

DR. SHARON K. HAUGE MATH DEPT, UDC, 4250 CONNECTICUT AVE, NW, WASHINGTON, DC 20008 (M)

DR. HERBERT HAUPTMAN THE MEDICAL FOUNDATION OF BUFFALO, 73 HIGH ST, BUFFALO,

NY 14203-1196 (EF)

MRS. ELIZABETH D. HAYNES 4149 25TH ST, NORTH, ARLINGTON, VA 22207 (M)

DR. GEORGE HELZ WATER RESOURCES RESEARCH, 3101 CHEMISTRY BUILDING,

COLLEGE PARK, MD 20742 (M)

MR. FRANCIS L. HERMACH 15101 GLADE DR #3E, SILVER SPRING, MD 20906-1527 (F)

DR. W. RONALD HEYER AMPHIBIAN AND REPTILE, M.S. 162, SMITHSONIAN, WASHINGTON, DC 20560 (F)

DR. EUTHYMIA D. HIBBS 7302 DURBIN TERR, BETHESDA, MD 20817 (M)

MR. LABLOU HICHAM 94 RUE ALLAL BEN ABDELLAH, CASABLANCA, MOROCCO (M)

DR. BRUCE F. HILL MOUNT VERNON COLLEGE, 2100 FOXHALL RD NW, WASHINGTON, DC 20007 (F)

DR. WALTER J. HILLABRANT 1927 38TH ST, NW, WASHINGTON, DC 20007 (M)

MR. JOSEPH HILSENRATH 9603 BRUNETT AVE, SILVER SPRING, MD 20901-3232 (F)

DR. ROBERT B. HOBBS 9707 OLD GEORGETOWN RD, #1414, BETHESDA, MD 20814 (EF)

DR. J. TERRELL HOFFELD 11307 ASHLEY DR, ROCKVILLE, MD 20852-2403 (F)

GARY M. HOLAHAN 10000 TENBROOK DR, SILVER SPRING, MD 20901 (M)

DR. ARIEL HOLLINSHEAD 3637 VAN NESS ST, NW, WASHINGTON, DC 20008-3130 (EF)

MR. WILLIAM L. HOLSHOUSER PO BOX 1475, BANNER ELK, NC 28604 (NRF)

DR. JOHN G. HONIG 7701 GLENMORE SPRING WAY, BETHESDA, MD 20817 (LF)

MR. LARRY A. HOOVER 1541 STABLEVIEW DR, GASTONIA, NC 28056-1658 (M)

DR. IRWIN HORNSTEIN 5920 BRYN MAWR RD, COLLEGE PARK, MD 20740 (EF)

DR. JOHN HORNSTEIN 10123 HEREFORD PL, SILVER SPRING, MD 20901 (M)

DR. EMANUEL HOROWITZ 1 4100 NORTHGATE DR, SILVER SPRING, MD 20906 (EF)

DR. COLIN M. HUDSON 143 S WILDFLOWER RD, ASHEVILLE, NC 28804 (EF)

DR. JAMES E. HUHEEY SOURWOOD MOUNTAIN SCIENTIFIC, 215 TUCKER LN, LENOIR CITY, TN 37771 (LF)

DR. RUSSELL HULSE PLASMA PHYSICS LABORATORY, PRINCETON UNIV, PO BOX 451,

PRINCETON, NJ 08543 (LF)

——

eS I - a

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7 — ;

295

MS. LANIS. HUMMEL 1709 SO BRADDOCK AVE, #134, PITTSBURGH, PA 15218 (M)

MR. JOHN N. HUMMEL 952 WATERBURY HEIGHTS DR, CROWNSVILLE, MD 21032 (M)

DR. BURTON G. HURDLE 6222 BERKLEY RD, ALEXANDRIA, VA 22307 (F)

_ DR. WOODLAND HURTT 11403 EASTOOD CT, HAGERSTOWN, MD 21742 (EM)

MR. GEORGE L. HUTTON 1086 CONTINENTAL AVE, MELBOURNE, FL 32940 (EF)

DR. KIKI IKOSSI-ANASTASIOU 2245 COLLEGE DR #200, BATON ROGUE, LA 70808 (M)

DR. GEORGE R. IRWIN 7306 EDMONDSTON AVE, COLLEGE PARK, MD 20740 (EF)

DR. JO-ANNE A. JACKSON 14711 MYER TERR, ROCKVILLE, MD 20853 (LF)

DR. MARILYN E. JACOX 10203 KINDLY CT, MONTGOMERY VILLAGE, MD 20886-2557 (F)

MR. HENRY M. JAMES 6707 NORVIEW CT, SPRINGFIELD, VA 22152 (M)

DR. ARTHUR S. JENSEN CHAPEL GATE 1104, OAK CREST, 8820 WALTHER BLVD, PARK VIEW, MD 21234 (LF)

DR. ROBERT W. JERNIGAN 14805 CLAVEL ST, ROCKVILLE, MD 20853 (F)

DR. DANIEL P. JOHNSON PO BOX 359, FOLLY BEACH, SC 29439 (EF)

DR. PHYLLIS T. JOHNSON 4721 EAST HARBOR DR, FRIDAY HARBOR, WA 98250 (EF)

_ DR. EDGAR M. JOHNSON 5315 RENAISSANCE CT, BURKE, VA 22015 (LF)

MR. ALLEN B. JOHNSTON 31 S. ABERDEEN ST, ARLINGTON, VA 22204 (M)

DR. DANIEL B. JONES 3422 IBIS DR, ORLANDO, FL 32803 (M)

DR. HOWARD S. JONES, JR. 3001 VEAZEY TERR, NW, APT 1310, WASHINGTON, DC 20008 (LF)

DR. SHUNG-CHANG JONG AMER TYPE CULTURE COLLECTION, 10801 UNIV BLVD, MANASSAS,

VA 20110-2209 (LF)

DR. GARY BLAKE JORDAN 13392 FALLENLEAF RD, POWAY, CA 92064 (LM)

DR. ROMAN DE VICENTE JORDANA BATALLA DE GARELLANO 15, ARAVACA, 28023 MADRID, SPAIN (NRF)

DR. HANS E. KAISER 433 SOUTHWEST DR, SILVER SPRING, MD 20901 (M)

DR. PEDRO R. KANOF 1669 32ND ST, NW, WASHINGTON, DC 20007 (M)

DR. C.A. KAPETANAKOS 4431 MACARTHUR BLVD, WASHINGTON, DC 20007 (EF)

DR. ARTHUR A. KARELIN VISHNEVSKY INST OF SURGERY, DEPT OF BIOCHEMISTRY, BOLSHAYA,

SERPUHOVSKAYA, 27, MOSCOW 113811, RUSSIA (NRF)

DR. SHERMAN KARP 10205 COUNSELMAN RD, POTOMAC, MD 20854-5023 (F)

MS. PEG KAY 11260 ROGER BACON DR, SUITE 105, RESTON, VA 20190 (F)

DR. LARRY KEEFER 7016 RIVER RD, BETHESDA, MD 20817 (F)

DR. HARRY R. KEISER NATL HEART, LUNG & BLOOD INST, BLDG 10, RM 8C-103, MSC1754, NIH,

BETHESDA, MD 20892-1754 (F)

DR. BERNHARD E. KEISER 2046 CARRHILL RD, VIENNA, VA 22181 (F)

DR. RAKHIM M. KHAITOV INSTITUTE OF IMMUNOLOGY, 24-2, KASHIRSKOYE SHOSSE, MOSCOW, 115478,

RUSSIA, CIS (NRF)

DR. NODAR KIPSHIDZ 9 ANJAPARIDZE ST, TIBLISI 380079, REPUBLIC OF GEORGIA (NRF)

DR. KENNETH L. KIRK NIH, BLDG 8, RM B1A-02, BETHESDA, MD 20892 (F)

DR. JOSEPH H. KIRKBRIDE, JR. 1001 DEVERE DR, SILVER SPRING, MD 20903 (F)

DR. CYRUS KLINGSBERG 1318 DEERFIELD DR, STATE COLLEGE, PA 16803 (EF)

MR. REX C. KLOPFENSTEIN 4224 WORCESTER DR, FAIRFAX, VA 22032-1140 (F)

DR. JOHN KOERNER U.S. FDA DIV OF CARDIO-RENAL, DRUG PRODUCTS, 5600 FISHER LN, HFD-110,

ROCKVILLE, MD 20857 (M)

DR. VLADIMIR A. KOUZMINOV VIA ALDO MORO 72, QUARTO D’ ALTINO, VENICE, ITALY (NRF)

DR. STEPHEN KROP 960 OLD CUTLER RD, VIRGINIA BEACH, VA 23454 (EF)

DR. JEROME KRUGER 619 WARFIELD DR, ROCKVILLE, MD 20850 (EF)

MRS. MARYLIN KRUPSAW 346 OAK HARBOUR DR, JUNO BEACH, FL 33408 (LF)

DR. WILLIAM JOHN LACY 9114 CHERRYTREE DR, ALEXANDRIA, VA 22309-2905 (LF)

MS. CATHERINE LAMAZE 14821 COLES CHANCE RD, GAITHERSBURG, MD 20878 (F)

MR. CLIFFORD E. LANHAM PO BOX 2303, KENSINGTON, MD 20891 (F)

MR. MICHAEL J. LAVINE 9992 MARSHALL POND RD, BURKE, VA 22015 (M)

DR. ROGER H. LAWSON 10613 STEAMBOAT LANDING, COLUMBIA, MD 21044 (F)

_MR. ALAN L. LEINER 850 WEBSTER ST, APT 635, PALO ALTO, CA 94301-2837 (EF)

DR. PETER P. LEJINS 7114 EVERSFIELD DR, COLLEGE HEIGHTS ESTATES, HYATTSVILLE,

MD 20782-1049 (EF)

DR. PAUL LEWIS LENTZ 5 ORANGE CT, GREENBELT, MD 20770 (EF)

DR. E. NEIL LEWIS MOLECULAR BIOLOGY SECTION, BLDG 5, RM 233, NIH , BETHESDA, MD 20892 (F)

296

DR. HERBERT L. LEY, JR. 4816 CAMELOT ST, ROCKVILLE, MD 20853 (EF)

MR. LOUIS F. LIBELO 9413 BULLS RUN PARKWAY, BETHESDA, MD 20817 (LF)

DR. JULIUS LIEBLEIN 5901 MONTROSE RD APT S800, ROCKVILLE, MD 20852-4751 (EF)

DR. ROY P. LINDQUIST, P.E. 3435 VALEWOOD DR, OAKTON, VA 22124-1616 (F)

MR. LEE LING 1608 BELVOIR DR, LOS ALTOS, CA 94024 (EF)

DR. CONRAD B. LINK 407 RUSSELL AVE, #813, GAITHERSBURG, MD 20877 (EF)

DR. MORLEY LIPSETT 1529 WHITESAILS DR, RR1, Z-62, BOWEN ISLAND, BC VON 1G0 CANADA (NRF)

DR. J. DAVID LOCKARD BOTANY DEPT, UNIV OF MARYLAND, COLLEGE PARK, MD 20742 (EF)

MS. MARILYN LONDON 4890 BATTERY LN, APT 121, BETHESDA, MD 20814 (M)

MRS. BETTY JANE LONG 416 RIVERBEND RD, FORT WASHINGTON, MD 20744-5539 (F)

MR. TOM H. W. LOOMIS 11502 ALLVIEW DR, BELTSVILLE, MD 20705 (M)

DR. THOMAS E. LOVEJOY SMITHSONIAN INSTITUTION, 1000 JEFFERSON DR, SW, RM 320, WASHINGTON,

DC 20560 (F)

DR. HANS J. LUGT 10317 CROWN POINT CT, POTOMAC, MD 20854 (EF)

DR. ERNEST LUSTIG ROSSITTENWEG 10, D-38302 WOLFENBUTTEL, GERMANY (EF)

DR. ROBERT J. LUTZ 17620 SHAMROCK DR, OLNEY, MD 20832 (F)

PROF. JEFFREY W. LYNN 13128 JASMINE HILL TERR, ROCKVILLE, MD 20850 (F)

MR. HARRY B. LYON 7722 NORTHDOWN RD, ALEXANDRIA, VA 22308-1329 (M)

DR. JOHN W. LYONS 7430 WOODVILLE RD, MT AIRY, MD 21771 (NRF)

DR. ROBERT P. MADDEN A-251 PHYSICS BLDG, NIST, GAITHERSBURG, MD 20899 (NRF)

ACAD. IGOR M. MAKAROV CHIEF SCIENTIFIC SECRETARY, RUSSIAN ACADEMY OF SCIENCES,

14 LENINSKI PROSPECT, 11790, GSP1 MOSCOW, V-71, RUSSIA CIS (NRF)

DR. THOMAS B. MALONE 20856 WATERBEACH PL, STERLING, VA 20165-7407 (M)

DR. RONALD W. MANDERSCHEID 10837 ADMIRALS WAY, POTOMAC, MD 20854-1232 (LF)

MS. TONI MARECHAUX PO BOX 23188, WASHINGTON, DC 20026-3188 (M)

DR. TIMOTHY P. MARGULIES U.S. EPA, MAIL CODE 6602J, WASHINGTON, DC 20460 (M)

DR. EDWARD J. MARTIN, P.E. 7721 DEW WOOD DR, DERWOOD, MD 20855 (M)

DR. THOMAS A. MAZZUCHI OPERATIONS RESEARCH DEPT, 4794 CATTERIC CT, FAIRFAX, VA 22032 (F)

MR. GORDON W. McBRIDE 8100 CONNECTICUT AVE, APT 506, CHEVY CHASE, MD 20815-2813 (EF)

DR. JAMES R. McNESBY 13308 VALLEY DR, ROCKVILLE, MD 20850 (EF)

MR. BUFORD K. MEADE 20510 FALCONS LANDLING CIR, #1109, STERLING, VA 20165-7596 (EF)

MR. THOMAS W. MEARS 2809 HATHAWAY TERR, WHEATON, MD 20906 (F)

MS. RUTH MELLEN 6338 EDGEMOOR LN, ALEXANDRIA, VA 22312-1528 (M)

DR. ALLEN J. MELMED 732 TIFFANY CT, GAITHERSBURG, MD 20878 (F)

DR. TAY KIANG MENG 821C UPPER EAST COAST RD, SINGAPORE 466613 (M)

DR. ROBERT E. MENZER 1611 ALLISON ST, NW, WASHINGTON, DC 20011-4213 (F)

DR. GARY S. MESSINA 4201 CATHEDRAL AVE, NW, WASHINGTON, DC 20016 (F)

MRS. CARLA G. MESSINA 9800 MARQUETTE DR, BETHESDA, MD 20817 (F)

MS. GERALDINE MILES 66 CHAPEL TOWNE CIR, BALTIMORE, MD 21236 (M)

DR. LANCE A. MILLER 7403 BUFFALO AVE, TAKOMA PARK, MD 20912 (F)

MR. RAYMOND D. MINTZ OFF OF INF & TECH, US CUSTOMS SERVICE 3.5 B, 1300 PA AVE,

NW, WASHINGTON, DC 20229 (F)

MR. GARY MITCHELL 1740 PINE VALLEY DR, VIENNA, VA 22182 (M)

DR. DON MITTLEMAN 80 PARKWOOD LN, OBERLIN, OH 44074-1434 (EF)

MR. TOM MOFFAT NIST, BLDG 225, RM B-166, GAITHERSBURG, MD 20899 (M)

DR. J. ANTHONY MORRIS 23E RIDGE RD, GREENBELT, MD 20770 (M)

DR. ALAN MORRIS, P.E. 5817 PLAINVIEW RD, BETHESDA, MD 20817 (EF)

F. K. MOSTOFIL M.D. 7001 GEORGIA ST, CHEVY CHASE, MD 20815 (F)

DR. RAYMOND D. MOUNTAIN 5 MONUMENT CT, ROCKVILLE, MD 20850 (F)

DR. MICHAEL J. MUMMA 210 GLEN OBAN DR, ARNOLD, MD 21012 (F)

DR. WALLACE P. MURDOCH 65 MAGAW AVE, CARLISLE, PA 17013-7618 (EF)

DR. CHARLES R. NAESER 6654 VAN WINKLE DR, FALLS CHURCH, VA 22044 (EF)

DR. ARVIN K.N. NANDEDKAR DEPT OF BIO-CHEMISTRY, COLL OF MEDICINE NGPA, HOWARD UNIV,

RM 3430, WASHINGTON, DC 20059 (M)

MRS. EVELYN S. NEF 2726 N ST, NW, WASHINGTON, DC 20007 (M)

297

| DR. ARKADI NEKRASOV BLDG 1, 420 FLAT, KUNCEVSKAJA ST HOUSE 4, 121351 MOSCOW

RUSSIA CIS (NRF)

| DR. WERNER G. NEUBAUER 8410 WESTFAIR CIR, NORTH, GERMANTOWN, TN 38139-3275 (EF)

DR. MORRIS NEWMAN 1050 LAS ALTURAS RD, SANTA BARBARA, CA 93103 (NRF)

|, DR. TERRELL L. NOFFSINGER 5785 BOWLING GREEN RD, AUBURN, KY 42206 (EF)

| MR. KARL H. NORRIS 11204 MONTGOMERY RD, BELTSVILLE, MD 20705 (EF)

_DR. JOHN J. O’HARE 1 08 RUTLAND BLVD, WEST PALM BEACH, FL 33405-5057 (EF)

| DR. JOHN A. O’KEEFE 4309 ROSEMARY ST, CHEVY CHASE, MD 20815 (EF)

MS. E. MARILYN OBERLE 58 PARKLAWN RD, WEST ROXBURY, MA 02132 (EM)

| DR. P.W. OGILVIE 1227 FRANKLIN ST, NE, WASHINGTON, DC 20017 (F)

_ MR. LEE OHRINGER 5014 RODMAN RD, BETHESDA, MD 20816 (F)

DR. HIDEO OKABE 6700 OLD STAGE RD, ROCKVILLE, MD 20852 (F)

DR. V. SUSIE F OLIPHANT 910 LURAY PL, HYATTSVILLE, MD 20783 (M)

DR. FRED ORDWAY 5205 ELSMERE AVE, BETHESDA, MD 20814-5732 (F)

| DR. HANS J. OSER 8810 QUIET STREAM CT, POTOMAC, MD 20854-4231 (EF)

ACAD. YURI S. OSIPOV PRESIDENT, RUSSIAN ACADEMY OF SCIENCES, 14 LENINSKI PROSPECT,

11790, GSP1 MOSCOW, V-71, RUSSIA CIS (NRF)

| MR. WILLIAM ALLEN OSTAFF 10208 DRUMM AVE, KENSINGTON, MD 20895-3731 (EM)

DR. LEWIS PANNELL LABORATORY OF ANALYTICAL CHEMISTRY, BLDG 8A RM 1A-15, NIH,

BETHESDA, MD 20892 (F)

DR. RAJA PARASURAMAN DEPT OF PSYCHOLOGY, CATHOLIC UNIV, WASHINGTON, DC 20064 (F)

| DR. HENRY MCILVAINE PARSONS HumRRO, 66 CANAL CENTER PLAZA, ALEXANDRIA, VA 22314 (F)

|| DR. D.G. PATEL 11403 CROWNWOOD LN ROCKVILLE, MD 20850 (F)

| DR. ELVIRA L. PAZ 172 COOK HILL RD, WALLINGFORD, CT 06492 (EF)

| DR. THEODORE P. PERROS 5825 3RD PL NW, WASHINGTON, DC 20011 (F)

_ MR. ALLEN PERRY PO BOX 2774, RESTON, VA 20195-0774 (M)

MR. RAY PETERSEN 5828 BLACKHAWK DR, FOREST HEIGHTS, MD 20745 (M)

MR. JOHN I. PETERSON NIH, BLDG 13, RM 3N17, BETHESDA, MD 20892-5766 (M)

ACAD. REM V. PETROV VICE PRESIDENT, RUSSIAN ACADEMY OF SCIENCES,

14 LENINSKI PROSPECT, 11790, GSP1 MOSCOW, V-71, RUSSIA CIS (NRF)

DR. RAYMOND L. PICKHOLTZ 3613 GLENBROOK RD, FAIRFAX, VA, 22031-3210 (F)

DR. GEORGE F. PIEPER 3155 ROLLING RD, EDGEWATER, MD 21037 (EF)

MR. ALAN O. PLAIT 8550 PARK SHORE LN, SARASOTA, FL 34238-3316 (EF)

MR. RICHARD M. POKRASS 43979 URBANCREST CT, ASBURN, VA 22011 (F)

DR. HARVEY R. POLLARD DEPT OF ANAT & CELL BIOLOGY, USUHS, NAVAL MEDICAL CENTER,

BETHESDA, MD 20814 (F)

DR. JULIUS S. PRINCE 7103 PINEHURST PARKWAY, CHEVY CHASE, MD 20815 (F)

DR. DIANNE K. PRINZ 1704 MASON HILL DR, ALEXANDRIA, VA 22307 (F)

DR. JOHN H. PROCTOR, 308 EAST ST, NE, VIENNA, VA 22180 (LF)

DR. C. NICHOLAS PRYOR 3715 PROSPERITY AVE, FAIRFAX, VA 22031 (F)

DR. ROBERT H. PURCELL 17517 WHITE GROUNDS RD, BOYDS, MD 20841 (F)

MR. THOMAS N. PYKE, JR. 4887 N 35TH RD, ARLINGTON, VA 22207 (F)

MR. RODERICK S.QUIROZ 4520 YUMA ST, NW, WASHINGTON, DC 20016 (EF)

MR. JACOB RABINOW 6920 SELKIRK DR, BETHESDA, MD 20817 (F)

MR. CHARLES A. RADER 1101 PACA DR, EDGEWATER, MD 21037 (EF)

DR. GEORGE T. RADO 818 CARRIE CT, MCLEAN, VA 22101 (EF)

A.K. RAJAGOPAL CODE 6860.1, NAVAL RESEARCH LAB, WASHINGTON, DC 20375 (F)

DR. VIL Z. RAKHMANKULOV INST FOR SYSTEMS ANALYSIS, PROSPECT 600-LET OCTJABRIA, 9,

MOSCOW 117312, RUSSIA CIS (NRF)

DR. DAVID E. RAMAKER 6943 ESSEX AVE, SPRINGFIELD, VA 22150 (F)

DR. MAYNARD J. RAMSAY 3806 VISER CT, BOWIE, MD 20715 (F)

_ DR. NORMAN F. RAMSEY, LYMAN PHYSICS LABORATORY, HARVARD UNIV, CAMBRIDGE, MA 02138 (LF)

DR. ROBERT L. RAUSCH P.O. BOX 85447, UNIV STATION, SEATTLE, WA 98145-1447 (NRF)

MR. CHARLES RAVITSKY 1505 DREXEL ST, TAKOMA PARK, MD 20912 (EF)

_ PROF. EDWARD F. REDISH 6820 WINTERBERRY LN, BETHESDA, MD 20817 (F)

298

DR. JANET WARNER REID 6210 HOLLING DR, BETHESDA, MD 20817 (F)

DR. JANET W. REID SMITHSONIAN INSTITUTION, DEPT OF INVERTEBRATE ZOOLOGY, MRC-163,

WASHINGTON, DC 20560 (F)

MR. ALVIN REINER 11243 BYBEE ST, SILVER SPRING, MD 20902 (F)

DR. JAMES J. RHYNE 2704 WESTBROOK WAY, COLUMBIA, MO 65203 (NRF)

DR. SUEANN RICE 6728 FERN LN, ANNANDALE, VA 22003 (M)

MR. ERIC C. RICKARD SRI INTERNATIONAL, 1611 NORTH KENT ST, ARLINGTON, VA 22209-2111 (M)

DR. RICHARD RICKER 16549 SIOUX LN, GAITHERSBURG, MD 20878 (F)

DR. ROBERT WILLIAM RIDKY 622-A NORTH TAZEWELL ST, ARLINGTON, VA 22203 (F)

DR. GORDON K. RIEL NSWC CD 682, BETHESDA, MD 20817-5700 (LF)

MR. ALFRED J. ROACH AMER. BIOGENETIC SCIENCES, INC, 1385 ACKRON ST, COPIAGUE, NY 11726 (NRF)

DR. MARY LOUISE ROBBINS TATSUNO HOUSE, A-23, 2-1-8-OGIKUBO, SUGINAMI-KU,

TOKYO 167 JAPAN (EF)

DR. A. F ROBERTSON 4228 BUTTERWORTH PL NW, WASHINGTON, DC 20016 (EF)

DR. NINA M. ROSCHER 10400 HUNTER RIDGE DR, OAKTON, VA 22124-1616 (F)

DR. WILLIAM K. ROSE 10916 PICASSO LN, POTOMAC, MD 20854 (F)

DR. DAVID ROSENBLATT 2939 VAN NESS ST, NW, APT 702, WASHINGTON, DC 20008 (EF)

DR. JOAN R. ROSENBLATT 2939 VAN NESS ST, NW, APT 702, WASHINGTON, DC 20008 (EF)

DR. AZRIEL ROSENFELD 847 LOXFORD TERR, SILVER SPRING, MD 20901 (F)

PROF. PETER H. ROSSI 34 STAGECOACH RD, AMHERST, MA 01002 (EF)

DR. RICHARD B. ROTHMAN 8508 CARLYNN DR, BETHESDA, MD 20817 (F)

MR. JOHN E. ROTHROCK 6100 WESTCHESTER PARK DR, #1013, COLLEGE PARK, MD 20740 (M)

MR. ISRAEL ROTKIN 11504 REGNID DR, WHEATON, MD 20902 (EF)

DR. EMILE RUTNER 34 COLUMBIA AVE, TAKOMA PARK, MD 20912 (M)

DR. ADNAN A. SAAD 8647 OAK CHASE CIR, FAIRFAX STATION, VA 22039 (M)

DR. ALBERT W. SAENZ 6338 OLD TOWN CT, ALEXANDRIA, VA 22307 (F)

DR. ROALD Z. SAGDEEV DEPT OF PHYSICS, UNIV OF MARYLAND, COLLEGE PARK, MD 20742-4111 (F)

MR. THOMAS T. SAMARAS 11487 MADERA ROSA WAY, SAN DIEGO, CA 92124 (M)

DR. VICTOR J. SANK 5 BUNKER CT, ROCKVILLE, MD 20854-5507 (F)

DR. ROBERT M. SASMOR 4408 NORTH 20TH RD, ARLINGTON, VA 22207 (F)

MR. CARTER “BUZZ” SAVAGE 2730 UNIV BLVD, SUITE 900, WHEATON, MD 20902 (M)

MR. THORNDIKE SAVILLE, JR. 5601 ALBIA RD, BETHESDA, MD 20816-3304 (LF)

DR. JAMES M. SCHALK 7 OAKLAND DR, PATCHOGUE, NY 11772 (EF)

MR. MILTON S.SCHECHTER 10909 HANNES CT, SILVER SPRING, MD 20901 (EF)

DR. ALBERT I. SCHINDLER 6615 SULKY LN, ROCKVILLE, MD 20852 (F)

MR. NEAL F. SCHMEIDLER OMNI ENGR & TECHNOLOGY, INC, 7921 JONES BRANCH DR #530,

McLEAN, VA 22102 (F)

DR. CLAUDE H. SCHMIDT 1827 NORTH 3RD ST, FARGO, ND 58102-2335 (EF)

DR. MARIAN M. SCHNEPFE POTOMAC TOWERS, APT 640, 2001 N. ADAMS ST,

ARLINGTON, VA 22201 (EF)

DR. JAMES F. SCHOOLEY 13700 DARNESTOWN RD, GAITHERSBURG, MD 20878 (EF)

MS. RAMONA SCHREIBER 2910 COLLINS AVE, SILVER SPRING, MD 20902 (M)

STEPHEN A. SCHROFFEL 1129 PARK ST, NE, WASHINGTON, DC 20002-6317 (F)

DR. WARREN W. SCHULTZ 4056 CADLE CREEK RD, EDGEWATER, MD 21037-4514 (LF)

MR. TED SCHUTZBANK CHILDREN’S HOSPITAL, 111 MICHIGAN AVE, NW,WASHINGTON, DC 20210 (M)

DR. DAVID B. SCOTT 761 ALLIANCE DR #437, VIRGINIA BEACH, VA 23454 (EF)

MR. BOURDON F. SCRIBNER 7210 RIVER CRESCENT DR, ANNAPOLIS, MD 21401-7727 (EF)

DR. GLENN T. SEABORG 1154 GLEN RD, LAFAYETTE, CA 94549 (EF)

DR. MARC M. SEBRECHTS 7012 EXETER RD, BETHESDA, MD 20814 (F)

DR. FREDERICK SEITZ ROCKEFELLER UNIV, 1230 YORK AVE, NEW YORK, NY 10021 (NRF)

MRS. ELAINE G. SHAFRIN 800 4TH ST SW, NO. N702, WASHINGTON, DC 20024 (F)

MR. GUSTAVE SHAPIRO 3704 MUNSEY ST, SILVER SPRING, MD 20906 (F)

MR. GROVER C. SHERLIN 4024 HAMILTON ST, HYATTSVILLE, MD 20781 (LF)

DR. STEFAN SHRIER 624A SOUTH PITT ST, ALEXANDRIA, VA 22314-4138 (F)

DR. W. SHROPSHIRE, JR. OMEGA LABORATORY, PO BOX 189, CABIN JOHN, MD 20818-0189 (LF)

DR. DAVID M. SILVER APPLIED PHYSICS LABORATORY, 1110 JOHN HOPKINS RD, LAUREL,

MD 20723-6099 (M)

299

DR. BARRY G. SILVERMAN GEORGE WASHINGTON UNIV, STAUGHTON HALL, RM 206,

WASHINGTON, DC 20052 (F)

DR. ROBERT SIMHA DEPT MACROMOLECULAR SCI, CASE WESTERN RESERVE UNIV, CLEVELAND,

OH 44106-7202 (EF)

DR. LEWIS SLACK 2104 TADLEY DR, CHAPEL HILL, NC 27514-2109 (EF)

MS. JANET SLOVIN USDA CLIMATE STRESS LAB, BLDG 046-A, BARC-WEST, 10300 BALTIMORE AVE,

BELTSVILLE, MD 20705-2350 (M)

_ DR. THOMAS E. SMITH DEPT OF BIOCHEMISTRY & MOLECULAR BIOL, COLL OF MEDICINE,

HOWARD UNIV, WASHINGTON, DC 20059 (F)

MS. MARCIA S. SMITH SCIENCE POLICY RESEARCH DIV, CONGRESSIONAL RESEARCH SERVICE,

LIBRARY OF CONGRESS, WASHINGTON, DC 20540-7490 (LM)

MR. REGINALD C. SMITH 7731 TAUXEMONT RD, ALEXANDRIA, VA 22308 (M)

MR. EDWARD L. SMITH 18475 HAVN CT, NE, POULSBO, WA 98370-7668 (NRF)

MR. BLANCHARD D. SMITH, JR 2509 RYEGATE LN, ALEXANDRIA, VA 22308 (F)

_ MR. DAVID L. SODERBERG 403 WEST SIDE DR APT 102, GAITHERSBURG, MD 20878 (M)

DR. RICHARD M. SOLAND SEAS, GEORGE WASHINGTON UNIV., WASHINGTON, DC 20052 (LF)

DR. HELMUT SOMMER 9502 HOLLINS CT, BETHESDA, MD 20817 (EF)

DR. ROBERT J. SOUSA 168 WENDELL RD, SHUTESBURY, MA 01072 (NRF)

DR. WILLIAM J. SPARGO 9610 CEDAR LN, BETHESDA, MD 20814 (F)

-MR. JAMES E. SPATES 8609 IRVINGTON AVE, BETHESDA, MD 20817 (LF)

_ DR. A.F. SPILHAUS, JR 10900 PICASSO LN, POTOMAC, MD 20854 (F)

DR. GEORGE F. SPRAGUE 5320 FOX HOLLOW RD, EUGENE, OR 97405-4049 (EF)

’ BRIANR. STANTON 12150 ISLAND VIEW CIR, GERMANTOWN, MD 20874 (F)

_ MS. IRENE A.STEGUN 62 LEIGHTON AVE, YONKERS, NY 10705 (NRF)

| DR. KURT H. STERN 103 GRANT AVE, TAKOMA PARK, MD 20912-4636 (EF)

_ DR. LOUIS J. STIEF CODE 690, NASA GODDARD SPACE FLIGHT CENTER, GREENBELT, MD 20771 (F)

_ DR. ROBERT D. STIEHLER 3234 QUESADA ST, NW, WASHINGTON, DC 20015-1663 (EF)

DR. MANYA B. STOETZEL SYST ENTOMOLOGY LAB, RM 100, BLDG 046, BARC-WEST USDA,

BELTSVILLE, MD 20705 (F)

| DR.SIMON W. STRAUSS 4506 CEDELL PL, CAMP SPRINGS, MD 20748 (LF)

_ DR. JOSEPH SUCHER 8 LAKESIDE DR, GREENBELT, MD 20770 (F)

: | DR. ROBERT W. SWEZEY 17203 CLARKS RIDGE RD, LEESBURG, VA 20176 (F)

_ DR.ALAN O. SYKES 304 MASHIE DR, VIENNA, VA 22180 (EM)

_ DR. HERBERT TABOR NIDDK, LBP, BLDG 8, RM 223, NIH, BETHESDA, MD 20892 (F)

| DR. CONRAD TAEUBER 10 ALLDS ST, NASHUA, NH 03060 (EF)

: DR. JUAN TAMARGO GUZMAN EL BUENO 100, 3 A, 28003 MADRID SPAIN (NRF)

DR. ICHIJI TASAKI 5604 ALTA VISTA RD, BETHESDA, MD 20817 (F)

MR. DOUGLAS R. TATE CAROLINA MEADOWS VILLA #257, CHAPEL HILL, NC 27514-8526 (NRF)

ALBERT N. TAVKHELIDZE, ScD 52, RUSTAVELI AVE, 30008, TBLISI, REPUBLIC OF GEORGIA (NRF)

DR. DUANE TAYLOR 8300 CORPORATE DR, LANDOVER, MD 20785 (M)

MR. WILLIAM B. TAYLOR, P.E. 4001 BELLE RIVE TERR, ALEXANDRIA, VA 22309 (M)

| MR. MAURICE J. TERMAN 616 POPLAR DR, FALLS CHURCH, VA 22046 (EM)

| DR.F. CHRISTIAN THOMPSON 6611 GREEN GLEN CT, ALEXANDRIA, VA 22315-5518 (LF)

| DR.JOHN S. TOLL WASHINGTON COLLEGE & UNIV OF MD, 6609 BOXFORD WAY, BETHESDA, MD 20817 (F)

DR. PAUL F. TORRENCE NIDDK, LAC, BLDG 8, RM B2A-02, NIH, BETHESDA, MD 20892 (F)

DR. CHARLES H. TOWNES DEPT OF PHYSICS, 366 LE CONTE HALL #7300, UNIV OF CA, BERKELEY,

CA 94720-7300 (LF)

DR. CHARLES E. TOWNSEND 3529 TILDEN ST, NW, WASHINGTON, DC 20008-3194 (F)

MRS. MARJORIE R. TOWNSEND 3529 TILDEN ST, NW, WASHINGTON, DC 20008-3194 (LF)

DR. LEWIS R. TOWNSEND 8906 LIBERTY LN, POTOMAC, MD 20854 (M)

_ DR. JAMES H. TURNER 4927 FALCON BLVD, PORT ST JOHN, FL 32927-3030 (EF)

_ DR. PAULE. TYLER 1023 ROCKY POINT CT NE, ALBUQUERQUE, NM 87123-1944 (EF)

DR. DOUGLAS H. UBELAKER DEPT OF ANTHROPOLOGY, NATL MUSEUM OF NAT HISTORY,

SMITHSONIAN INSTITUTION, WASHINGTON, DC 20560 (F)

DR. HERBERT UBERALL 5101 RIVER RD, APT 1417, BETHESDA, MD 20816 (EF)

DR. J. E. UHLANER 4258 BONAVITA DR, ENCINO, CA 91436 (EF)

300

MS. MARIANNE P. VAISHNAV PO BOX 2129, GAITHERSBURG, MD 20879 (LF)

DR. HAROLD P. VAN COTT 8300 STILL SPRING CT, BETHESDA, MD 20817 (EF)

DR. ANDREW VAN TUYL 1000 W NOLCREST DR, SILVER SPRING, MD 20903 (F)

DR. PETER F. VARADI APT 1606W, 4620 NORTH PARK AVE, CHEVY CHASE, MD 20815 (EF)

DR. DANIEL J. VAVRICK 500 GREENBRIER CT - APT 204, FREDRICKSBURG, VA 22401 (F)

DR. FLETCHER P. VEITCH, JR. PO BOX 513, LEXINGTON PARK, MD 20653 (NRF)

DR. VALERY F. VENDA DEPT OF MECH & INDUS ENGR, UNIV OF MANITOBA, WINNIPEG,

MB CANADA R3T 5V6 (M)

DR. ARTHUR VON HIPPLE 265 GLEN RD, WESTON, MA 02193 (EF)

MR. A. JAMES WAGNER 7568 CLOUD CT, SPRINGFIELD, VA 22153 (F)

DR. THOMAS A. WALDMANN 3910 RICKOVER RD, SILVER SPRING, MD 20902 (F)

MS. ISABEL WALLS NATL FOOD PROCESSORS ASSOC, 1401 NEW YORK AVE, NW #400,

WASHINGTON, DC 20005 (M)

DR. RONALD W. WAYNANT 13101 CLAXTON DR, LAUREL, MD 20708 (F)

DR. RALPH E.WEBB 21-P RIDGE RD, GREENBELT, MD 20770 (F)

DR. EDWARD J. WEGMAN 157 SCIENCE - TECHNOLOGY I, CTR COMPUT STAT, MS 4A7,

GEORGE MASON UNIV, FAIRFAX, VA 22030 (LF)

DR. JOHN WEINER 8401 RHODE ISLAND AVE, COLLEGE PARK, MD 20740 (F)

DR. ARMAND B. WEISS 6516 TRUMAN LN, FALLS CHURCH, VA 22043 (LF)

DR. ISSAC WELT 117 NEDGEWOOD ST, ARLINGTON, VA 22201-1102 (M)

DR. GLEN W. WENSCH 413 S RISING RD, CHAMPAIGN, IL 61821 (EF)

DR. WILLIAM P. WERGIN 10108 TOWHEE AVE, ADELPHI, MD 20783 (F)

MR. MICHAEL W. WERTH 14 GRAFTON ST, CHEVY CHASE, MD 20815 (EM)

LCDR JAMES T. WESTWOOD, USN (Ret) 5608-34 WILLOUGHBY, NEWTON DR, CENTREVILLE, VA 20120 (M)

DR. HOWARD J. WHITE, JR 8028 PK OVERLOOK DR, BETHESDA, MD 20817 (EF)

DR. WOLFGANG L. WIESE 8229 STONE TRAIL DR, BETHESDA, MD 20817 (F)

DR. PETER F. WIGGINS 1016 HARBOR DR, ANNAPOLIS, MD 21403 (F)

DR. HAROLD ARLEN WILLIAMS 818 RICHMOND AVE, SILVER SPRING, MD 20910 (M)

DR. HAROLD WILLIAMS 818 RICHMOND AVE, SILVER SPRING, MD 20910 (M)

DR. DAVID WILLIAMS GEORGETOWN UNIV MED CTR, DEPT OF PSYCHIATRY, 3750 RESERVOIR RD, NW,

WASHINGTON, DC 20007 (M)

DR. RAYMOND M. WILMOTTE 2512 QUE ST, NW, WASHINGTON, DC 20007 (LF)

MR. WILLIAM K. WILSON 1401 KURTZ RD, MCLEAN, VA 22101 (LF)

WILLIAM W. WINTERS 6825 CAPRI PL, BETHESDA, MD 20817-4209 (M)

DR. RUTH G. WITTLER 2103 RIVER CRESCENT DR, ANNAPOLIS, MD, 21401-7271 (EF)

DR. ROBERT D. WOLFF DEPT OF CIVIL ENGINEERING USAF, 1260 AIR FORCE, PENTAGON,

WASHINGTON, DC 20330 (M)

DR. HATTEN S. YODER, JR GEOPHYSICAL LABORATORY, 5251 BROAD BRANCH RD, NW,

WASHINGTON, DC 20015-1305 (EF)

MR. CHARLES E. YOUMAN 4419 N 18TH ST, ARLINGTON, VA 22207 (M)

MR. CHARLES YOUNG 6808 ROLLING RD, SPRINGFIELD, VA 22152 (M)

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REPRESENTING THE LOCAL AFFILIATED SOCIETIES

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neem omputime Wachimery ....... 22.608. ee ee eee eee eee Margaret Williams

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