The essential reality each of us in The American must face is that in the current political climate our profession is in grave danger. Were the Clinton bill to pass without modification, the healing art to which we have devoted our lives would vanish with the stroke of a pen.
Our greatest danger is denial; it seems difficult to imagine that in this country such basic freedoms as the right of individuals to make their own health care choices could be abrogated. Yet that freedom is precisely the target of managed care firms, which yield enormous profits and are often owned by giant corporations including pharmaceutical firms. It has been perceived, correctly, that the political “weak link” in the health care delivery system is the health care professional. Historically, we have been apolitical, protected by public respect for our profession.
Now we are faced with systematic exploitation of our patients and ourselves. Our experience with managed care has made several points clear. (1) Most of these systems are in fact covert mechanisms for the rationing of health care and the limiting of both access and cost at the expense of quality, through use of the euphemism “medical necessity.” (2) The managed care premise rests squarely on the coercion of both patient and professional; managed care firms speak openly of achieving captive “populations” of patients and health care professionals. As one managed care official put it, “You don't understand. We own you.” (3) A case manager in front of a computer screen limits care where the therapist, faced with a suffering patient, cannot; the therapist is, however, often left with the liability.
Colleagues in Minnesota and other states already face severe regulatory incursions, and this is only the beginning. Our best hope is to achieve protective legislation at the federal level. The Coalition for Patients' Rights (CPR) is the only advocacy group which has continuously championed the right to private contracting for psychoanalysis and psychotherapy as its principal objective. The American's Executive Council, at its meeting in Philadelphia on May 19, expressly endorsed the goals and efforts of CPR in seeking to preserve that right.
The ground swell of support for CPR and its goals has been phenomenal. CPR has received endorsements from many societies and institutes, including Boston, Chicago, New Orleans, North Carolina, the Philadelphia Association,
PINE, San Francisco, and Southern California. Boston and PINE have formed committees to facilitate the health care reform advocacy effort. CPR has also been endorsed by a growing number of state psychiatric societies, including those of Massachusetts, Colorado, and Vermont. In addition, CPR has established relations with many local groups. CPR of Massachusetts has already been formed and is working in conjunction with the national organization to advocate for reforms at the state level.
In visits to Capitol Hill and the White House, CPR has asserted the right to private contracting as the single most crucial issue in preserving quality care. It is very likely that managed care will be a major part of whatever health care plan is ultimately passed. The members of CPR feel that psychotherapy and psychoanalysis cannot operate successfully under a managed care format. Case management, with its regulations and breaches of confidentiality, is antithetical to the very instrument of psychodynamic therapy, the special relationship between patient and therapist.
CPR points out to officials that because managed care is essentially cost-driven, there is every incentive to limit the amount of care allowed. Under such a system, extremely brief therapy, group therapy, or psychopharmacology are the only treatment forms available. Long-term psychotherapy and psychoanalysis are bound to be eliminated or unreasonably compromised. It is essential, therefore, to guarantee the right of patient and therapist to make their own independent arrangement, free from regulation and case management.
It is CPR's position that it is not necessary to purchase health care security at the price of individual freedom.
We have visited scores of legislators' offices and have in general received a surprisingly positive response. Unfortunately, the White House is another matter. It has become increasingly clear that at the heart of the Clinton administration's plan and strategy is a chillingly coercive ideology that would force all health care through a highly regulated system.
We have been able to educate legislators about the problems of managed care and the need to protect quality of care by preserving the right of individuals to contract privately. Once that central principle is clearly established, we then argue for expanded outpatient mental health coverage. To advocate for extended coverage without this “safety valve” is a potential trap for both patient and therapist. We have argued for “point-of-service” options which allow insurance benefits to be used in private contracting. We have acquainted legislators with the central problem of managed care, namely, that it is almost irrelevant how many outpatient visits are authorized in theory; in reality the patient is likely to be granted very few, often being limited to two or three visits a year.
CPR has employed the Washington firm of Powers, Pyles, Sutter, and Verville to represent and assist us in our lobbying efforts. This firm works exclusively with health care law, representing health organizations and practitioners. Partner James C. Pyles has worked exclusively in health law in the Washington area for the last twenty years. By making use of his extensive knowledge and contacts, CPR has been able to be effective and remarkably cost-efficient.
Members of Congress have quickly grasped and fully appreciated that the goal of CPR, rather than being economic in nature, is to preserve quality of care through freedom of choice. We have been able to represent effectively how these two principles are inextricably intertwined. To date, our efforts have met with considerable success. We have received specific commitments from the sponsors of most of the health care bills on the Republican side to include our legislative language guaranteeing private contracting.
During the week ending May 20, CPR, working in conjunction with Jay Cutler of the American Psychiatric Association and others, achieved two important victories. First, the Senate Labor and Human Resources Committee adopted amendments to the president's Health Security Act guaranteeing the right of private contracting. These amendments, proposed by Senator Judd Gregg, Republican of New Hampshire, were the result of close cooperation by the senator's staff, CPR, and the American Psychiatric Association.
Robert L. Pyles, M.D., is president of the Coalition for Patients' Rights.
Second, the House Labor Management Relations Subcommittee approved an amendment to the Clinton bill proposed by Representative Gene Green, Democrat of Texas, that “preserves the right of individuals to make payments directly to a health care provider that is legally authorized to provide the services.” CPR has been working with the subcommittee staff and with Representative Green and other members of the subcommittee to get this and even more explicit language included in the subcommittee's bill.
In a third significant development, CPR, through Jay Cutler of the APA, has obtained an opinion issued by the Congressional Research Service (CRS), an arm of the Library of Congress, which conclusively supports the concern, raised by CPR since the beginning of the year, that the president's bill would destroy the right of individuals to contract privately for outpatient psychotherapy. The opinion finds that under that bill health care providers who seek to contract privately with individuals could be prosecuted for health care fraud and subjected to criminal and civil penalties. This could happen even if the individual were enrolled in a health plan with a fee-for-service or point-of-service option.
The opinion also illustrates a subtle trap in which psychotherapy advocacy groups are in danger of becoming ensnared. At least three congressional committees or subcommittees have recently included amendments providing broadened coverage of adult and child psychotherapy, but only at the cost of greater control by health plans relying on managed care and utilization review. As the CRS opinion shows, access to psychotherapy outside a managed care health plan is eliminated, unless the right to private contracting is expressly preserved, as coverage under the health plan is broadened.
In fact, we have found that many legislators are quite willing to include expanded coverage, even parity, knowing that as long as a severe regulatory system is in place, care and cost will remain limited. For the same reason, the administration appears to be vigorously opposing our efforts to ensure private contracting, because it represents the only true alternative to forcing all health care through an externally regulated faucet.
Through continuous and exhaustive efforts, CPR has developed a series of key relationships in both houses of Congress. In critical recent developments, CPR has succeeded in getting most of its protective legislative language included in the Mitchell bill in the Senate, and through intensive contacts with congressional leaders is in a strong position to have the language included also in the final version of the House bill.
The Steering Committee of CPR feels that we are seeing a healthy revolutionary effort on the part of our organizations and members to organize themselves to influence political reform. It is our intention that CPR act as a continuing political action committee, working in conjunction with The American and other individuals and groups, to preserve and enhance the delivery of quality psychoanalysis and intensive psychotherapy for the foreseeable future.
Both as individual analysts and in our psychoanalytic organizations, we are moving into a new era. The health care reform crisis has come upon us with little warning, catching us ill prepared. Yet we have moved with unprecedented quickness to create the necessary structures for action. In meeting this threat we have learned much about what we must do to positively represent our profession, both to the public and in the political process. We will learn much, much more.