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That's what former APA president Alan Stone, M.D., asserted at APA's 1997 annual meeting in San Diego in May in the presentation "The Future of Ethics in Managed Care."
Emphasizing that individual physicians have no market power whatsoever in a health care system now given over to corporate control, Stone disputed the aggressive optimism that was the hallmark of the tenure of immediate past APA president Harold Eist, M.D.
Citing Eist's presidential address in San Diego_and summarizing its message with the slogan "We are winning! We are winning! We are winning!"_Stone told psychiatrists, "Well, I am here to tell you: We are losing! We are losing! We are losing!"
Physicians and patients, Stone suggested, are up against much more than the simple greed of insurance companies against which Eist has inveighed.
An entrenched entrepreneurial culture in health care_with roots going back to the 1940's, when employers became the predominant providers of health insurance, and abetted more recently by years of deregulation under Republican presidents_has permitted the corporate takeover of medical decision making, Stone said.
With no market power, physicians cannot hope to counter the for-profit sale of health care with ethical arguments, Stone said.
"We are in a free-market health care economy," Stone said. "That means we are struggling against Wall Street.
"Market forces now have their teeth in health care," he continued. "This is about who can provide care for the least number of dollars and get away with it. [Entrepreneurs] want to get as many members enrolled as possible, then sell the health plan to quadruple their profits. Unless you face that, you are whistling Dixie."
The ethical standards of the past offer nothing of assistance to physicians working in a medical environment now transformed by Wall Street. Neither threats of litigation nor righteous indignation can stop the "competitive race to the bottom," he said.
Stone, who is the Touroff Glueck Professor of Law and Psychiatry at Harvard University, said the reduction in hospital lengths of stay and psychotherapy visits is producing a surplus of psychiatrists_disagreeing, again, with Eist and other APA leaders who have insisted that psychiatry is a shortage specialty.
Those who are employable will be increasingly relegated to dispensing medication, he said.
Stone's prognosis sounded bleak, but he did offer psychiatrists a radical alternative to marginalization: accept a diminished salary in exchange for spending more time with patients. Rather than threatening a largely futile war against the forces of Wall Street, Stone said that psychiatrists who want to do psychotherapy should form their own networks and offer their quality services in exchange for lower pay.
"The problem is that we seem locked into demanding the same salary, while prices are cut everywhere else," he said.
Stone said he could imagine a group practice paying a psychiatrist to do psychotherapy with patients_instead of paying psychologists and social workers_if the psychiatrist was willing to take $80,000 instead of $150,000.
Stone was joined in the symposium by incoming APA secretary Paul Appelbaum, M.D., incoming APA Assembly Speaker Jeremy Lazarus, M.D., and Harold J. Bursztajn, M.D.
They agreed with Stone that the current health care environment places physicians in an unprecedented ethical quandary, for which traditional ethical guidelines will not be helpful.
Appelbaum, who is the A.F. Zeleznik Professor and chair of psychiatry at the University of Massachusetts Medical Center, countered the argument put forward by some that capitation will put psychiatrists back in control of clinical care.
The argument underestimates the ethical risks posed by putting physicians in a position in which they stand to gain financially from withholding care, he said.
Whatever control over care that might be gained through capitation is "dwarfed by the problems that arise when risk is passed down to physicians," he said.
"I believe that capitation is not the answer to our problems with managed care," he said. "Indeed, from an ethical perspective, it only threatens to make our problems worse."
Appelbaum was echoed by Stone, who said, "The bad news is that when doctors run managed care plans, they behave just like business people running managed care plans."
Saying that "the ethical paragons of yesterday are the outliers of tomorrow," Stone described a for-profit takeover of American health care that has rendered the ethical traditions in which most physicians were schooled all but obsolete.
Consequently, the most impassioned protests against managed care's worst excesses_"gag clauses," for instance_are likely to be futile, he suggested.
"We can make a big fuss about them, but basically if you are going to complain about the health plan you are in, you will find at the end of the year that you are no longer a member of the health plan," Stone said.
Similarly, he called parity for mental health care "an illusion": regardless of what kind of benefit a policy provides, the actual provision of care must still be approved by the managed care company, he said.
Stone noted that believers in the benefits of competition in health care imagine that a free market will produce quality at an affordable price_similar to the way in which, ideally, a free market system encourages the production and sale of well-built, affordable cars.
Yet Stone said that such a model assumes consumers_in this case, patients_can make informed choices about their care.
Because patients can never truly be informed consumers, the relationship between the physician and the patient is a fiduciary one, based on trust.
Any ethical system of health care must recognize that relationship of trust, Stone said: thus, the unethical nature of a system that would permit a physician to profit from withholding care.
"My own view is that medical ethics goes back to exactly what Harold Eist says it goes back to_the doctor-patient relationship," Stone said. "That relationship is the basic building block of trust in medicine. All of our ethical obligations derive from that relationship to our patients."
He characterized as "very dangerous" the notion that, instead of being advocates for individual patients, physicians should be stewards of society's resources.
"Being responsible to covered lives is not the same thing as being responsible to a particular patient," he said.
Stone disputed the claim by "apologists" for managed care that the evolving systems of health care will more equitably allocate care, while conserving resources.
Instead, he claimed, managed care is producing "welfare medicine for the middle class."
When all is said and done, Stone concluded, "We will perhaps cut health care costs, but we will be left with a system in which the values we believe in will be totally outmoded."
(Psychiatric News, July 4, 1997)