I am writing in regard to Dr. George H. Allison's memo of February 25, 1992, in which he urged members of The American to contact their U.S. Senators and Representatives regarding the discrepancy in the work relative value unit (RVU) assigned to Medical Psychoanalysis.
Having contacted my legislators (and Dr. Gail Wilensky of the Health Care Financing Administration) as requested, I began to reflect on the future of psychoanalysis in this country. It seems to me that physicians have entirely capitulated to our government in its takeover of the practice of medicine in the United States. I have spoken repeatedly to this issue in my local and state medical societies, as well as in the various committees of The American on which I have served. It dismays me that our efforts seem always confined to last-minute, after-the-fact attempts to reduce the damage from yet another arbitrary change in Federal regulations that impinge on our right to practice medicine as only we know best.
Approximately ten years ago I was playing golf with the young administrator of a small but progressive rural hospital who told me of a general meeting with his medical staff the previous evening. A former bureau chief from Washington who had been invited to speak reportedly told the staff that he was dismayed with the attitude of doctors in this country. “You doctors amaze me,” was the gist of what he said; “the government keeps inventing all these unreasonable regulations and making arbitrary changes in them for Medicare, and what do you do? You go out and try to make it work. When will you realize that they're laughing at you up there in Washington, because you will dance to whatever tune they play?”
My main concern is that the future of medical psychoanalysis might be that it has none, if national health insurance is brought to bear on us. I am not talking simply about the financial considerations raised in our recent letters and other communications to Washington. I have already had to refuse any more Medicare patients for one of two reasons: either (1) these patients have requested me to treat them without filing with Medicare, because they wanted to keep their treatment private, even if that meant paying the full price out of their own pockets; or (2) I have felt the need to protect my private patients' confidentiality by keeping their records off limits to Medicare and/or Champus, and their “practice pattern audits.” In regard to item 2, this battle was fought at a local psychiatric hospital in New Orleans approximately ten years ago. Medicare officials insisted on being able to review comparable records of private patients with names and other identifying information left intact. In the event of noncompliance, the government threatened to sanction the hospital and its medical staff by prohibiting any future participation in Medicare. Although the hospital strongly pressured the doctors to capitulate, the medical staff held firm in their opposition to Medicare's demand, and won the fight. Unfortunately, the same hospital and medical staff are even now having to fight this battle once again.
I feel it is not too late for organized medicine to stop giving ground and trying to appease those who are rapidly taking over our practices. It is time to say firmly that this is unacceptable and that we will not be a party to it. If we do not, I cannot imagine how any of us—if national health insurance is put into effect according to the Medicare model—could conduct medical psychoanalysis with all the governmental intrusions, arbitrary changes in rules, limited authorizations for treatment, and prohibitions against private direct payments from patients (even when the latter prefer it this way). Incidentally, I understand that our nonmedical psychoanalytic colleagues are not subject to Medicare rules, so these comments do not apply to them, at least not yet. In short, I hope we can all join together boldly to preserve the rights, freedoms and independence of the private practice of psychoanalysis in this country.
John R. Macgregor, M.D.