Until this year psychoanalysis had no paid lobbyist in Washington. Now it has two—James Pyles and Daniel Leach. Pyles represents the Coalition for Patients' Rights (CPR), a group formed in late 1993 by a number of analysts including several prominent leaders of The American. Although CPR is not officially part of The American, many in the group are APsaA members. CPR has concentrated its efforts on one goal, to obtain statutory protection for the right of patients and therapists to contract privately for analytic treatment.
Leach was hired by The American as the outgrowth of several years of work by the Committee on Government Relations and Insurance (CGRI). The committee, in contrast to CPR, pursues a number of goals: statutory protection of private contracting, protection from the abuses of managed care, protection of the right of any willing provider to participate in the new plan, and comprehensive mental health benefits under managed care at parity with other health care coverage.
At the newly formatted Meeting of Members held last May, analysts from around the nation were given the opportunity to hear each of these strategic perspectives in extensive detail. Pyles was introduced to the assembly by his brother, analyst Robert Pyles, a founder of CPR, who stressed the potential for harm when managed care intrudes into the analyst-patient relationship. “For many patients,” he noted, “this intrusion is a reenactment of the trauma which brought them into treatment in the first place.”
James Pyles then opened fire. “Don't think you're paranoid,” he quipped, “they're really out to get you!” As the several hundred members present put down their coffee cups and leaned forward, he continued: “As we sit, Congress is deciding the way you will spend the rest of your professional life.” He described his efforts to obtain assurances from the White House that the administrations Health Security Act of 1994 would guarantee therapist and patient the right to work together outside the new system. He recounted what had happened in the case of Medicare; the statute had made no mention of private contracting, neither permitting nor forbidding it, but the regulations putting the statute into practice had in fact forbidden it. In response to expressions of concern regarding this precedent, the Clinton people gave only vague assurances, in effect saying not to worry. However, at about this time Pyles learned of a congressman who had turned to the Congressional Research Service for an opinion. He was told by this independent legal research agency that the current version of the Clinton plan fails to guarantee the right of private contracting. In some cases it even makes such contracting a felony.
“Broadened coverage,” Pyles continued, “means nothing if managed care restricts the use of benefits.” He noted, in a discussion after the meeting, that Section 1422 of the Clinton bill prohibits supplemental insurance coverage for treatment of mental illness covered by the new plan (thirty psychotherapy sessions per year) and that Section 1406(d)2 prohibits “charging or collecting amounts that are payable by the health plan.” The intention, as in the case of Medicare, is to protect unwary consumers from waiving benefits to
which they are entitled. Unfortunately, these sections also set the stage for an analyst's nightmare. Imagine if managed care were to declare treatment no longer “medically necessary” after three sessions. Since the regulations forbid private treatment for covered services (here, psychotherapy up to thirty sessions) it could be a felony to provide sessions 4 through 30. This, Pyles explained, is why analysts need explicit statutory protection of the right to contract privately, both for services not covered by the new plan and for services covered under managed care.
Next up was Leach, who, introduced by Arthur Farley, new chair of CGRI, reviewed recent efforts to have language protecting private contracting included in the health care bill now in “mark-up” in the subcommittee chaired by Senator Edward M. Kennedy. Urging those present to contact their representatives and make their opinions known, Leach outlined the goals of CGRI:
Private contracting. The statutory guarantee of the freedom of patient and provider to contract privately outside the health care system without penalty, interference, or prejudice to the right to participate in the system.
Managed care protection. Regulation of managed care to safeguard an environment for effective treatment.
Any willing provider. The right to be treated by the therapist of one's choice, with open provider panels and a point-of-service option.
Parity of benefits. Nondiscriminatory access to care for the full range of mental illness, with reimbursement on the same basis as other medical treatment.
Having heard the two presentations, many members seemed puzzled. Pyles and Leach had conveyed similar but not identical messages, and each was asking for money. In response to questions it was learned that Pyles bills about $10,000 per month for his services, and Leach about $30,000. Pyles's work is paid for by CPR, which as of May had raised $70,000, while Leach's lobbying is paid for by The American. Voluntary contributions to support his efforts have been solicited by The American, and as of May $40,000 had been raised. Any shortfall would have to be met by funds from the organization's reserves.
Lee Brauer and George Allison next reported on the recent survey of analytic practice and noted that in Michigan the average number of analytic cases is 6.5. Non–training analysts there had a higher average than training analysts elsewhere. The average number of cases for the top seven societies was 4.7, and the overall national average was 4.0. Brauer urged those who had received questionnaires for the co-morbidity survey to return them at once.
Marvin Margolis then discussed the Michigan experience and emphasized the role of outreach and involvement with community groups. The Michigan Society is open to new ideas and often has adapted programs developed by other societies. He told of how the Society had mobilized analysts at all levels of training, as well as many friends of psychoanalysis, to form a foundation that raises $100,000 annually for the support of psychoanalytic activities in the community.
At the conclusion of the meeting, outgoing president Bernard Pacella commented on his term of office and his sense of fulfillment. Pacella handed over the gavel to incoming president Judith Schachter, who conferred honorary membership in The American on retiring administrative director Helen Fischer. Schachter then introduced the other new officers to those present, who had just participated in three hours of intense discussion about the future course of psychoanalysis and The American.