The fallowing is a condensed version of Dr. Clemens's report to the Meeting of Members delivered December 17, 1993.
These are perilous times for psychoanalysts and for all providers of health care. Current proposals for its reform promise a fundamental overhaul of the entire delivery system, and profit-driven managed care is already causing profound disruptions while mounting an all-out attack on psychoanalytic treatments. In all areas of health care, there is great anxiety and the prospect of economic distress.
Yet a time of turmoil is also a time of opportunity. The situation in Washington is changing daily; there is a distinct chance that reasonable voices will prevail in this fight, and that we can make a difference for our patients.
The Committee on Government Relations and Insurance has proposed three objectives for the Association, which were reaffirmed on December 16, 1993, by the Executive Council.
First, we will advocate for nondiscriminatory coverage for mental illness that is fully equal to that for all other illness. Our position is that psychoanalysis is a well-established, effective treatment for selected adult, adolescent, and child patients who suffer significant distress and disability due to certain Axis 1 and Axis II disorders (DSM-III-R) that do not respond to less intensive treatments. It should be available to all who need it, regardless of ability to pay. If full parity is unattainable now, we seek the best possible coverage for psychoanalysis and psychotherapy. In demanding an end to discrimination, we can join in the single principle that unites all of the constituencies now advocating for the mentally ill.
Second, we will vigorously seek to protect the environment for effective treatment. These are the fundamentals without which no treatment can take place: confidentiality and privacy, the security and continuity of the analyst-patient relationship in an environment free of harassment, and the patient's full participation in all decisions about his or her treatment. In addition, we are concerned that in managed care systems decisions be based on clinically appropriate criteria, that review be conducted by true peers, and that there be no financial incentive to withhold treatment.
Third, we will vigorously defend the freedom of analyst and patient to contract on a self-paying basis, if they choose, outside the system. There are many reasons for this, other than economic, that have to do with preserving the environment for effective treatment. This objective involves the fundamental rights of free speech and self-determination.
Partly because of diligent efforts by members of our committee, these three objectives have been incorporated in the American Psychiatric Association's twelve principles for health care reform.
The Clinton bill is the benchmark, yet the final product will be vastly different. There are strongly competing proposals in Congress and much no doubt will be left to regional health alliances and to the states. Although it is much too soon to know the final outcome, the present status is as follows. With regard to nondiscrimination, the actuaries have destroyed that likelihood in the Clinton bill, basing their conclusions on obsolete data. Clinton promises full nondiscrimination in the year 2001. The bill now proposes 30 visits with a 50% copayment and the possibility of a trade-off of four additional visits for one hospital day of coverage if this would keep a patient out of the hospital. However, in both the House and the Senate, working groups of influential lawmakers are seeking a definitive end to health-care discrimination against the mentally ill. The efforts of dedicated mental health professionals have made a difference.
Regarding our second principle, maintaining the environment for effective treatment, managed care firms are already creating a disaster, to the point that a backlash is occurring in public opinion. Representatives of The American and many others have conveyed concerns about managed care to both the White House and Congress. Ironically, the Clinton bill might be helpful in controlling overzealous managed care, by making health plans accountable to consumer-oriented health alliances.
CGRI has been closely following developments in regard to the third objective, the freedom to contract privately at one's own expense. The Clinton bill is vague in this regard, but it appears that this freedom is not infringed, and the White House has repeatedly assured us and the American Psychiatric Association that they have no intention of infringing it. Nonetheless, there is the glaring example of Medicare. We must be intensely vigilant about this freedom.
We are in a highly charged, fluid environment. This is no time to abandon any of our options in dealing with it.
Our resources are limited. The committees work has been greatly aided by Claire Coyne in developing extensive educational materials. Dedicated members have collected the best data available to show the cost benefits of psychotherapy. We desperately need more concrete, scientifically impeccable data, and for this reason I urge each of you who receives the research instrument being sent out by the Association this month to take the time to complete it: this is crucial to dispel common misconceptions of psychoanalysis.
Many members have responded to our Action Alerts and have written Congress of their concerns—passionate, articulate letters that convey great dedication to patient care. Under the direction of co-chair Arthur Farley, CGRI is working to strengthen the Legislative Action Network, as personal relations with members of Congress will be especially important. Our hardworking Washington contingent has been very effective in representing our cause. We have worked closely with the American Psychiatric Association, the Mental Health Liaison Group, and the other members of the Psychoanalytic Consortium. We have communicated with the American Psychological Association and the American Medical Association.
Nonetheless, we are amateurs. We desperately need professional guidance and assistance. Accordingly, the Committee has been authorized to select, and seek funding for, a government relations consultant. This action is crucial if we are to have a significant voice in the unfolding process.
It is easy to be frightened in this state of unparalleled upheaval in the health care system. We must remember that psychoanalysis can thrive in any environment that allows free speech and individual self-determination. We have something priceless to offer, and people will seek us out regardless of the constraints of the health care system. Beyond all else, we must maintain our integrity and the proper conditions for effective psychoanalytic treatment, and your Committee on Government Relations and Insurance is pledged to do exactly that.
Norman A. Clemens, M.D., chairs The American's Committee on Government Relations and Insurance.