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This is a response to the article in the August 2 "Viewpoints" column by Barry Blackwell, MD., titled "APA Leaders Overreacting to Managed Care Threat?"
In his polemic, Dr. Blackwell pillories our national organization and its leaders and flagellates its members who are attempting to deal with destructive managed care practices. His comments include all of the old iterations and inaccuracies that are used to justify the unregulated profit-driven excesses of managed care.
Clearly, psychiatric care has long been severely restricted in insurance policies. Very few patients want to be hospitalized; when they are, they need enough skilled care so that they can be discharged better able to resume life outside of the hospital. "Interminable psychotherapy" (the Woody Allen syndrome?), if it ever existed, has not been a covered service. Certainly, our experience with people who need psychotherapy is that they appreciate it when they need it and that they discontinue this painful exercise as soon as they do not. People with chronic illness need chronic care.
Simply put, managed care has demonized itself by its excesses. It is clear to us, who are trying to provide treatment, and to our patients that necessary care is commonly denied, delayed, deducted, disallowed in the pursuit of profit. Each round of contracts threatens to "tighten the screws" further, on coverage and fees.
APA is pursuing a policy of advocating for patients and their needs and this has always been a primary tenet in the APA Constitution.
The Committee on Managed Care is planning a national conference of patient advocacy organizations and other professionals equally concerned that treatment be adequate and appropriate. We have a policy of active intervention with managed care companies on behalf of patient treatment needs.
APA has been conducting the Managed Care Report Card survey of our members to help us assess current industry practices, has held seminars to assist our members, has had meetings with medical directors of managed care companies, and has taken many other initiatives to help our members and their patients.
APA has developed practice guidelines that describe medically appropriate care for a wide variety of psychiatric illnesses. We have been legislatively active in support of parity coverage for mental illnesses.
Our members should continue to support their APA and keep letting us know what their problems are in adapting to the shifting sands of managed care.
Edward Gordon, M.D.
Chair
APA Committee on Managed Care
On the corrosion of the quality of mental health treatment taking place in our country in the name of cost containment, I don't pretend to neutrality. In fact, the inadequacy of the positions taken by APA's national leadership in these matters had troubled me so greatly that I had resolved to resign from the organization if the membership had not chosen the way it did in last year's election.
Despite the disgust I felt in reading Dr. Blackwell's piece in the August 2 "Viewpoints" column, I find that I am glad to have read it, because if that is the kind of argument being made in favor of managed care activities as they have evolved in psychiatry, then those of us who are striving to defend our patients' and our own rights and to keep psychiatry a profession worth practicing will surely prevail.
Myron D. Brenner, M.D.
Pikesville, Md.
Dr. Barry Blackwell accuses our APA leaders of rhetoric and hyperbole, ascribing it to displacements of anxiety about our profession's future role in the medical marketplace. To whom was he referring? APA President Harold Eist, President-elect Herbert Sacks, or past president Jerry Wiener? I know each of them to be a dedicated psychiatrist who treats patients on a daily basis. They have personally observed the abuses of managed care, and each has eloquently argued that we must preserve the sanctity of the patient-physician relationship. Regardless of whomever Dr. Blackwell was talking about, it was improper for him to impute psychological defense mechanisms such as "displacements of anxiety" or projection to any APA leader for ethical and courageous advocacy against the abuses of managed care.
After telling us about the wonderful benefits of managed care, Dr. Blackwell insulted the integrity of the rest of our profession by implying that psychiatrists' concern for the impoverished and downtrodden is but a show of hypocrisy on the part of a wealthy elite who are bred to be in control. His normative prescription for our faulty attitude and breeding is that we accept responsibility for rationing care for our patients so that we will be in a position to negotiate with health care payers.
Those psychiatrists who criticize managed care do so on the basis of their clinical experience. They have found that most patients hate managed care because it deprives them of confidentiality, choice of psychiatrist, and the right to participate as full partners in making treatment decisions. Managed care is not a system of care at all, but an egregious market anomaly created by ill-advised changes to the tax and antitrust laws. It will go down in history as a scam of monumental proportions. While there is not a scintilla of valid evidence showing that managed care saves money for the nation as a whole, there is plenty to show that it ruins patients' lives, destroys academic institutions and hospitals, and erodes the ethical basis of practice.
APA is a diverse and creative organization composed of psychiatrists dedicated to advancing the treatment of mental illness. Scientific knowledge alone is insufficient for our task, for we can accomplish our goals only if we remain true to our ethical standards of advocacy for the dignity and well-being of our patients. If we now relinquish these ethical principles by surrendering to managed care, we will have not only squandered the moral legacy bequeathed to us by Benjamin Rush, but also abandoned our patients to a heartless and evil system founded on a single ethic--that of the bottom line.
Richard S. Epstein, M.D.
Bethesda, Md.
Dr. Blackwell seems impressed by the fact that managed care (as was said of Benito Mussolini) is succeeding in "getting the [psychiatric] trains to run on time" by regimenting and tidying the professional behaviors of a disorderly profession whose disorder he, as an academic, clearly scorns. At root here are very important questions about our future identity and our professionalism; what are the core differences between psychiatry as a profession, with a necessary independence and diversity of views, and the psychiatrist as a high-paid factory worker doing his repetitive, medieval piecework, meeting his "contract," doing the bidding of his managed care "foreman," drastically curtailed in his judgments about care, and constrained against advocating for his patients' needs--if they don't meet the managed care formula. It could be the realization of the worst nightmares of a Brave New World, and yet there are those in our profession who have clearly identified with the managed care aggressor and who fear that strong confrontation will lead to Armageddon.
What our profession desperately needs is to regain some of the ground we've lost in the managed care battles of the last few years. The first step in this recovery is to regain a strong sense of our professional caregiving identity, to reconnect with our self-respect as a valuable caring profession, and to repair the devastations to our morale, caused by the efforts of commercial interests to "re-engineer" us as docile employees of managed care. To my thinking, the present leadership of APA is right on target, precisely where it should be, steering its course by the true north of our profession: whatever action we take, now or in the future, must start with basics--Is it good for patients? We all stand or fall on the answer.
Jerome A. Collins, M.D.
Kennebunk, Maine
Dr. Blackwell's reputation for long dedication to the welfare of private as well as impoverished patients might bring temporary although undeserved respectability to the HMO and managed care companies he has recently joined.
But absolute commercial power can corrupt professionals absolutely. One wonders how long he will follow effective healing traditions and how much his participation in epidemic fraud and deprofessionalism is worth to him as a serious colleague. Isn't he objecting to APA leadership who would defend our patients not just against "early" (past) but current "errors" of physician-limited access, physician-rationing or triage, and physician-based care? Isn't he objecting to APA leadership that calls on us to merit trust that is essential to all healing relationships?
Selective denials of reality that allow Faustian pacts with managed care companies to "master capitation and risk management" will lose rather than gain our loyalty to patients. I expect or at least hope that he will rapidly develop insight and join Dr. Eist's campaign for moral leadership before his reputation and his captive patients are seriously harmed.
Henry E. Payson, M.D.
Norwich, Vt.
My first reaction was, "Who translated his article from the original Martian?" Dr. Blackwell's experience is so different from mine that an interplanetary explanation seemed possible. Yet I remember meeting him in my hometown, Milwaukee, where my family and friends seem to share my experience rather than Blackwell's. No, Wisconsin is not another planet, so how can such different "truths" be understood?
I prefer to treat a few Medicaid patients for free, forgoing the $9.87 per outpatient visit. I am economically comfortable, although I am aware I must work harder and endure more frustration to maintain my standard of living. That standard is better than most; but, frankly, it is not at the level of many neighbors with my level of education and skill, and it is well below that of managed care executives. Other Americans may suffer more downsizing, but were first-class passengers on the Titanic better off than those in steerage?
I confess I want enough control to treat my patients properly. I am not fond of responsibility without power. Perhaps one reason past abuses of for-profit hospitals have been curbed is that some of their physician executives have simply moved to managed care organizations. Like Jesse James, they know where the money is.
I know enough constructivist epistemology to know that my personal biases determine my slice of "Truth." That problem applies equally to managed care operatives. Greed can also lead them to distort facts and skew treatment decisions. My bias may lead to overtreatment and theirs to "overprofit."
Some of the different "truths" available to Dr. Eist and his predecessors may have to do with their professional perspectives. The structure of organized medicine tends to select leaders from academia or industry, that is, salaried physicians who struggle through the trenches of administration and cannot possibly spend 40 hours a week with patients. As a busy clinician, Dr. Eist has been unique in earning his income mainly through personally delivering patient care. The result is two very different perspectives about what is really happening to patients.
We all must consider our biases and find our best, albeit limited, slant on the truth and optimal clinical care. Unlike Dr. Blackwell, it is my opinion that Dr. Eist and other current leaders have done much to protect the welfare of our patients.
Howard S. Baker, M.D.
Philadelphia, Pa.
I happen to agree with the APA leaders who condemn the practices of a number of managed care companies that are severely depriving many patients of adequate services. I cannot believe there is a psychiatrist who is in private practice and has not directly witnessed such abuses.
The points made by Dr. Blackwell are not supported by evidence:
1. Managed care has not contained health care costs. Health care costs continue to increase while fewer people receive less care and for-profit corporations siphon money that could have gone to care. Dr. Blackwell could make a case for reduction of costs when he could prove that now we have fewer direct or indirect expenses produced by mental illness.
2. Dr. Blackwell is not correct in indicating that managed care defined levels of care or medical necessity. Levels of care go back to long before people started finding ways of denying care by claiming lack of medical necessity. Many of those who have studied the concept of "medical necessity" have accepted that this is a mantra that has been used to simply deny care.
3. Dr. Blackwell is wrong in thinking that the idea of a continuum of care came from managed care. Anybody who has been in community psychiatry from the 1960's knows that the concepts did not come from managed care, but from those interested in taking care of the chronically ill, the severely ill, and the poor.
4. Though excesses in for-profit private hospitals may have abated, it would be difficult to see how managed care produced the change. Those who recall the scandals of the past and their results would actually blame other forces for the drastic action taken to reduce excesses. Managed care, though, has not eliminated for-profit hospital chains, and there is actually new evidence that for-profit chains are alive and well in many parts of the country (New England Journal of Medicine 335:362-367, 1996).
5. Probably there was never "unmanaged care" in this country. There would probably be a universal acknowledgement that the introduction of computer technology and community standards contribute to provide the best care to the most patients. This is quite different from what some for-profit managed care companies have done in some of the programs.
I want to applaud the leadership of APA for a strong and sturdy position against the excesses of managed care. I want to encourage others who feel like me to write to Psychiatric News and express their feelings.
Rodrigo A. Munoz, M.D.
San Diego, Calif.
When will the pendulum stop swinging wildly? When will we find the rational middle gray zone and stop living indefinitely and unproductively in black and white? Dr. Blackwell makes some valid points. Undoubtedly there have been excesses and abuses in the private practice, fee-for-service, arena. But undoubtedly there have been and continue to be excesses and abuses in the managed care approach as well. Anyone--and there are many--practicing ethical, quality, intensive psychotherapy oriented toward a positive and enduring change is painfully aware of this. Managed care devalues this treatment. Hassles are pervasive. All one needs to do is look at the earnings of top-level managed care administrators to know that monies are in fact being diverted away from care itself.
It seems to me that Dr. Blackwell indulges in the very rhetoric and hyperbole of which he accuses others. Was it really necessary to take a potshot at psychoanalysts to make his point? Moreover, he would have us believe that the primary motive for the current level of angst rife throughout our profession today is mercenary. Hardly! I am certainly unaware that psychiatrists live the high lifestyle per se. If psychiatrists' major motivation were to make money, they would undoubtedly not have chosen medicine in general and psychiatry in particular.
Why don't we make the excesses and abuses the enemy rather than attack one another depending on what form of health care delivery we are utilizing? That conclusion seemed so logical consequent to the panel discussion on ethics and managed care at the annual meeting recently (Psychiatric News, June 21). Contrary to Dr. Blackwell's conclusion that we are worried about our profession's role in the marketplace, I am convinced that the overwhelming majority are concerned about our profession and our role, and the continuing availability and delivery of competent, effective psychiatric treatment.
I love this profession. And I am passionate about my work doing intensive psychotherapy with challenging and compromised patients--and making a real difference in their lives. I know that often less will not do! And managed care is a threat to the mental health profession in this regard. I don't want psychiatry to be marginalized and constricted. I am not concerned about my welfare, economic or otherwise; I am very concerned about the mental health of our society.
Perhaps if managed care becomes truly ethical, constricts costs genuinely without sacrificing quality, and includes the whole range of effective mental health treatments, then we can all work together constructively. I don't want private practitioners, or anyone, doing unnecessary, prolonged, ineffective treatment. And I don't want managed care interfering with the provision of necessary, effective treatment that truly affects meaningful and lasting mental health.
If we can integrate what is valid and clinically ethical from the perspective of each facet of this debate, everyone will come out ahead. Our patients will heal--and our profession will remain viable and prosper.
Barry M. Goldmuntz, M.D.
Colorado Springs, Colo.
The contrasting views on HMO's in the August 2 issue deserve comment. One is a series of catastrophic events in the lives of humans, as described by our president, Dr. Harold Eist. The other is a coolly presented, logical argument that APA leaders are overreacting to managed care.
I am reminded of the understanding, during the cold war days of potential nuclear devastation, that it was the rational people, those who controlled the devices, from whom we had the most to fear. They could rationally decide that the situation called for one decision only: push the button.
Managed care is not the problem of a flash killing, but it may well be a longer term mass killing, as implied in Dr. Eist's data. So let's pay attention.
Dr. Blackwell's viewpoint has a great deal to say about finances but nothing about people, except to seem to chastise psychiatrists for living among the upper-middle class. He cannot imply that psychiatrists live with the upper classes when psychiatric incomes are now at the bottom of the medical income ladder. Psychiatrists, more than any other type of medical specialist, may now be practicing as though it were a calling, because the money is not there.
Ironically, those psychiatrists who practice under conditions imposed by managed care and those who take on the few psychiatric positions allowed in managed care are being paid higher incomes than therapy-oriented practitioners, if job advertisements are to be believed. Their main task is to prescribe, leaving the little allowed therapy to be performed by social workers, at much lower salaries. So I wonder whether Dr. Blackwell and the medical school department in which he is a professor are benefiting by managed care? If his livelihood is secured or enhanced by managed care, he is not entitled to depreciate those whose incomes are being hurt.
Which leaves the issue that he does not address. Which system better serves patients and their personal, not monetary, needs? Dr. Blackwell does not even touch the question, other than to imply that patients are kept beyond their needs for treatment. This is an interesting way to present the complaints against private-sector, nonmanaged care, because it is really the other side of the same coin, is it not?
No doubt some patients might be discharged safely from treatment earlier than they are. No doubt economic biases lead psychiatrists, other physicians, and especially hospitals to prolong care beyond the basic, bare needs of treatment. But at least this tendency speaks to protecting patients from the unexpected by being overly careful. In contrast, the economic needs of managed care dictate that higher risks be undertaken for the sake of the economic desires of management. It is only in the potential pocketbook of patients that managed care serves patients, not in their health care needs.
Here in California we have already had extensive experience with advanced managed care. To the rest of the country, especially in the Midwest, I say watch out! Colleagues in the other parts of the country seem to hold to the idea, from their current experience, that managed care is somehow negotiable. That's not how we have experienced it here.
Dr. Blackwell reminds me of the expression about excessive economic preoccupation. One can come to know the cost of everything and the value of nothing.
Melvin Mandel, M.D.
Pacific Palisades, Calif.
Where, oh where, has Professor Barry Blackwell been for the past few years? Perhaps in some ivory tower hideaway, evidently remote. His is a very nice, high-sounding mind game, but the reality is something quite different.
Ninety percent of my colleagues are now working for a clinic or an HMO. Their job is mostly to say, "Hello. . . .Goodbye. . . .See you in another month," with a prescription as the passport. Immune to "downsizing"? Try telling patients about the "benefits" they enjoy (all thanks to managed care).
Try attending an APA or related convention, a seminar at a good school. With tuition, room, meals, transportation, and so on, try getting by for less than about $2,500 or thereabouts.
Try buying a new textbook of psychiatry in the neighborhood of $250. Try a few good newsletters at $50 to $100 a throw. Try to stay current with subscriptions to a few of the better publications. Try finding the time to stay current in your reading and at the same time answer your patients' needs. Try a shot at advertising in the Yellow Pages of the local telephone book. In my neighborhood it takes three phone books to cover the territory.
What about the patients who "forgot their checkbook"? What about the hassle with phone calls, always a pro bono affair? What about secretarial services and the interminable requests for prescription services? What about the continuing increased state and related fees for the tools of practice? What about the cost of insurance, with all the varieties now necessary as well as the legal backup services?
I find it next to impossible to believe that Professor Blackwell is anywhere near the ballpark of reality. His exaggerations are ghastly. Where is the "wealth" in psychiatry? I practice because I want to practice, but the restrictions make it increasingly difficult to practice a really satisfactory and well-structured plan of procedure. Regardless of how costly in terms of time and counterproductive detail, we must now provide a diagnostic code for all procedures, however beneficial to patient management (and prophylaxis) a more liberal arrangement might be.
It is evident to me (and most of my colleagues) that patient care, considerations of compassion, and the benefits of the doctor-patient relationship are an enormous sacrifice to Professor Blackwell's highly regarded managed care package. Accountability is one thing; to kill the benefits of a fine profession and subspecialty is another.
To believe for an instant that giving control to the insurance company or the HMO or letting managed care run the game is beneficial to anyone other than the insurance executive is naive beyond the outer reaches of imagination. There are alternatives.
Stanley E. Prentice, M.D.
Englewood, N.J.
(Psychiatric News, September 20, 1996)