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The meeting was chaired by APA President Harold Eist, M.D., who asked the participants to focus on issues that unite the two associations rather than divide them. But Sacks, who became APA president at the end of the annual meeting, pressed the issue as one of quality of care that needs to be resolved if there is to be full cooperation between the two associations.
"Where do the American Psychological Association's president and Board of Trustees stand on this issue?" asked Sacks. He criticized the role played by psychologist Patrick DeLeon, Ph.D., in influencing federal legislation and pointed to a recent review of the Department of Defense's psychologist prescribing training program conducted by the federal General Accounting Office (GAO). That review found, said Sacks, that psychologists were not competent to prescribe psychoactive medications.
Norman Abeles, Ph.D., president of the psychological association, rebutted Sacks's characterization of the GAO report, but stressed the need for collaboration.
"Let me urge that we continue to work in areas on which we can agree, and that we work on our differences privately, rather than publicly," he commented. Both psychologists and psychiatrists have "some common aims related to providing effective services to those who seek us out. But as a researcher in the area of aging, I want to stress that research is vital, and collaborative research is crucial, and we need to focus on our scientific base. I'm more than willing to engage in a dialogue that will lead to constructive solutions to our differences, just as prior dialogue has set the stage for cooperative efforts."
The GAO concluded that "the Department of Defense has demonstrated that [it] can train clinical psychologists to prescribe psychotropic medications, and these psychologists have shown that they can provide the service in the military health services system," said Abeles. "PDP [Psychopharmacology Demonstration Project] graduates successfully worked in the system of military treatment facilities. I didn't want to get into this, but since it was raised, I had to [respond]."
Dorothy Cantor, Psy.D., a past president of the psychological association, pointed to mutual efforts between the two associations in shaping federal parity legislation. Together the two associations represent thousands more mental health care practitioners than either alone, a formidable group to which legislators must pay heed, said Cantor. The two associations can work together to pursue both legislative initiatives and litigation. Managed care, said Cantor, "truly represents greed and avarice." The attitude of managed care is summed up by a seminar held by one company, titled "short-term care for long-term patients," she commented.
Whatever differences the two associations have, it is "crucial that we leave those outside," she urged. "Together, collaboratively, we will protect the American public."
APA's Sacks concurred, noting that "we professionals must have a community of interests in protecting quality of care." Whatever differences remain, there is an opportunity now for collaboration, he concluded.
The issue of discriminatory care of the mentally ill unites the two groups, said Abeles. "I truly believe that together the mental health community will end this discrimination."
It is in the mutual interest of both groups to disseminate scientific evidence supporting the efficacy of treatment and to fight managed care, said Martin Seligman, Ph.D., president-elect of the psychological association. Although "squabbles" are inevitable, "our very survival" depends on successful collaboration, he said.
Seligman said that he envisioned the two associations joining with the federal government to "regulate and accredit" managed care in the future. Absent such action, regulation and accreditation will fall to those outside the community of caregivers, he contended.
It is critical for the two associations to "continue our intense collaborative efforts to get our real needs before the people," remarked Eist. "United we will be successful; divided it's guaranteed we will fail."
If legislators perceive complaints about managed care as merely the griping of entrenched interest groups seeking to enrich themselves, it will lack credibility, Eist said. But together, the combined members of the two associations will be both credible and effective.
One dissenter in the audience criticized Eist's view of managed care as "a caricature." Markham Kirsten, M.D., of Fresno, Calif., who works for Kaiser-Permanente, one of the largest and oldest HMO's, warned that focusing only on the abuses of managed care was counterproductive.
"I am very disturbed that energies are being wasted in a witch hunt against the HMO's," said Kirsten. "I think the battle here should not be against HMO's, but against bad care."
Eist reacted angrily. Managed care companies have spread misinformation about the extent of overutilization under fee-for-service systems, said Eist. "It's a damned lie," he said loudly. Data show that 80 percent of patients used only eight or fewer sessions even when they had generous mental health benefits, Eist said. If managed care companies are not unduly limiting care, "I want to know why Congress is now working on laws to set limits on their depredations," Eist added.
Seligman also replied to Kirsten. "I believe that Kaiser psychologists and psychiatrists should see the fight that we're engaged in today as something very much to their benefit. When Kaiser and other HMO's limit quality of care by limiting duration of care for complicated disorders, by outsourcing care to master's level and bachelor's level people, you can't function well. You can't function optimally within that system. I believe the fight we're fighting now is a quality-of-care fight that will help you as well as the American people."
Sacks pointed to the abuses of National Medical Enterprises, since bought out, which used deceptive advertising to lure patients and then held many who were not suffering from serious disorders in the hospital against their will until their insurance ran out. He also noted that a recent study in the Journal of the American Medical Association comparing treatment of the elderly by fee-for-service doctors with that of HMO's found that the fee-for-service setting provided the elderly with much better care.
This "doesn't suggest that all HMO's are entities incompetent and full of greed themselves," said Sacks. "That's not the case." HMO's including Kaiser-Permanente, Puget Sound, and Harvard Pilgrim are nonprofit, "but it is well known in the world of health policy that their mental illness benefits are rather minimal," Sacks observed.
The outcry will grow as "more and more people are exposed to the consequences of limiting of care" by those other than their physicians or psychologists, concluded Cantor.
(Psychiatric News, July 4, 1997)