Residents' Forum

Politics 101

By Alisa B. Busch, M.D.
Member-in-Training Trustee

There are enormous changes occurring in our health care system’s public and private sectors. We know they have implications for our training and the care we deliver, but how many of us really understand the various forces that are so quickly and significantly affecting our training and patient care? How can we make our voices heard in this sea of change? In this month’s Residents’ Forum, I will focus on some of the larger issues that we as psychiatrists in training are facing and what you can do about them.

I welcome your comments about this and other subjects. You may contact me by phone at (410) 955-5549, fax at (410) 614-5914, or e-mail at abbusch@erols.com. If you would like to contribute to the Residents’ Forum, please send me your double-spaced essays by fax or e-mail. All submissions will be considered.

The financing of health care in America is the culmination of several competing forces. Economics and politics dictate policy, which in turn shapes our clinical services, teaching, and research. Graduate medical education (GME) is funded through several mechanisms: Medicare, Medicaid (in some, but not all states), and private insurance companies. While Medicare and Medicaid make explicit payments for GME, the private insurance companies do not. Instead, they implicitly contribute by paying for the higher-priced services provided to their enrollees who are hospitalized in teaching hospitals rather than nonteaching hospitals.

The government, as a purchaser and provider of public goods, has an interest in fostering the missions of teaching hospitals, one of which is education. However, the government also considers itself to be only one of many payers into this system and therefore should not shoulder all of the costs associated with GME.

Managed care, with its emphasis on economics, does not necessarily share in this mission. Herein lies the conflict. Add the increasing political pressure to limit the cost of Medicare (which in August 1997 produced new Medicare law capping the number of residents for whom Medicare will contribute payments and providing financial incentives to training programs to decrease their residency slots), and it all adds up to the "GME squeeze." As if all of this weren’t pressure enough, consider that Medicaid and Medicare enrollees increasingly are being placed into managed care systems, and the grip tightens. Included in the debate about GME are concerns about workforce: specifically issues surrounding specialty training and international medical graduates.

What this all means in our day-to-day lives is that while we struggle with our clinical and educational responsibilities, our teaching programs are struggling with the following:

1. receiving less payment than previously for the same clinical services;



2. experiencing difficulty maintaining a traditional patient population base;



3. experiencing adverse selection, which increases the proportion of persons with chronic illnesses whom they serve and reimburses less for these more complicated "higher-cost" patients;



4. laying off personnel to decrease administrative costs;



5. pressuring faculty to increase clinical productivity/patient billing;



6. closing of clinical services; and



7. decreasing the number of residency slots.



It all can sound quite overwhelming. How can one make a stand for good patient care and quality education and research in the face of all these pressures? The key is in remembering what’s driving these changes: economics and politics. The federal and state governments are the only payers in this system. They control the funds, approve the contracts for Medicare and Medicaid beneficiaries, and, by doing so, make the policy that shapes our education, research, and practice. Cost and quality compete for consideration in this equation, but often policy decisions are made in a vacuum of clinical knowledge.

It is that vacuum that will destroy our profession and our patients’ quality of life. While many find the realization distasteful that politics and economics drive the system, it could also be viewed as our leverage for opportunity.

You have a variety of means at your disposal to effect change, both at the federal and state levels. At a minimum, support your professional organization. APA expends considerable resources to advocate for psychiatry and our patients—and it is effective. Your continued membership helps support that activity. If you know of colleagues who are not APA members, encourage them to join. Also, join at least one consumer group (such as the National Alliance on Mental Illness or the National Depressive and Manic-Depressive Association). Such consumer groups are also powerful advocates.

If you would like to be more active, keep abreast of the federal and state issues as they occur and get involved by contacting your district branch or APA’s Division of Government Relations or logging onto the APA Web site at www.psych.org. Many of our representatives, legislators, and their staff are uninformed about what it’s like to be a resident and how their policy decisions impact on health care. Learn who your representatives are—politicians are particularly attentive if they know you are one of their constituents. Even if you are not one of their constituents, or you are not an American citizen, you can still work with your district branch and join in its efforts to be an effective advocate.

Residents can make a difference. I saw it occur in my state legislature last year when a few resident psychiatrists testified and later were told how effective they had been in defeating a bill that would have granted prescribing privileges, unsupervised, to nurse psychotherapists (who would have had three credit hours of pharmacology as training). The residents invested about four hours in this activity—the time it took for them to travel to the state capital, testify, and return. On the national level, recently a resident wrote an op-ed piece in the New York Times describing why the government should pay for GME funding. That piece was extensively circulated and widely read on Capitol Hill. Our representatives, and their staffs, do take our input seriously.

All of these politics and activities may seem very removed from our lives. As residents and fellows, we have many demands that compete for our attention. We juggle the needs of our patients, our educational demands, and responsibility to family—all the while struggling to maintain our own sense of well-being. That’s a tall order. It’s very easy to ignore these other forces circling us, believing the battle isn’t ours to fight but rather belongs to those more senior (or more naturally politically inclined, or more experienced, or . . .).

I disagree. As the newest generation of psychiatrists, we have the most to lose when unwise policy decisions are made. We are the ones who will struggle in this system and this profession the longest. If we don’t get involved, we hurt ourselves and our patients, who, after all, are depending upon us to advocate for them.

One thing is for sure: If we don’t talk to our politicians and support our national and state psychiatric organizations or consumer groups, then the lobbyists for the insurance companies, and whoever else has a financial stake in these changes, will be the only voices heard. We can’t afford that, and our patients certainly can’t either.

An in-depth understanding of how the government contributes to the financing of GME in the United States is beyond the scope of this essay. However, if you are interested, I recommend that you contact the Association of American Medical Colleges’ Division of Health Care Affairs at (202) 828-0490 and request its booklet, "Medicare Payments With an Education Label: Fundamentals and the Future."