Bob Pyles, president of the American, opened the Executive Council meeting in Washington, D.C., with news of the political activities scheduled for the week [see page 3]. The critical issue of privacy was emphasized. Warren Procci, representing the Committee on Government Relations and Insurance, reported that the committee endorsed the Leahy-Kennedy Bill in the Senate and the Markey Bill in the House of Representatives as the best bills protecting privacy at this time. While these bills are not an absolute reflection of the Association's ideals on privacy and confidentiality, they come closest to the APsaA's principles.
Earlier in the week, fifty APsaA members from nineteen Congressional districts attended a workshop to help them communicate effectively with their legislators, particularly on the issue of privacy. These meetings signal the beginnings of a grassroots APsaA effort. In the future, the American can be in a much better position to have an influence on issues that are of concern.
Rep. Barney Frank (D-Mass.) spoke to the council [see page 5]. He elucidated the context in which the privacy issue was being decided. He felt that citizens in this country unwisely begrudge adequate financing of medical care. We ought to be working to reduce the need for medical care by minimizing the circumstances that lead to illness and injury, Frank said, but once people become ill and need medical care, it is a great mistake to act as if the cost is a bad thing and has to be reduced.
Representative Frank believes that if we were to adequately fund medical services in this country, there would be far less demand for private medical information. In the 1997 balanced budget act, $115 million was taken out of what would otherwise have been spent on Medicare over a five-year period, to pay for a capital gains tax cut. Frank said that medical costs have increased because we are buying a quality of medical care which didn't exist twenty years ago. His remarks were well received by those present.
Aaron Primack, medical director of the Center for Health Plans and Providers within the Health Care Financing Administration (HCFA), spoke to the Executive Council regarding HCFAs audit policies. Audits came about because of a feeling that the government was not being accountable and just spending money. About 5,000 records were reviewed to see what CPT code was used and what payment was made, and an error rate was established. In the first year, an error rate of 14 percent was found, coming to a total of $23 billion. By the third year the rate was down to 7 percent or $12 billion. Primack assured council members that audits almost never result in dire consequences.
Primack stated that Medicare is not looking to cut its payments, but rather to pay out according to what is reasonable and necessary. He said that privacy is understood and respected by the Medicare administration. If records of a certain patient are being investigated, Medicare will never ask for records of other patients to determine an attempt to defraud. He stated that non-Medicare records would only be inspected if there was an intent to defraud the government, but he had never heard of that happening.
Photo by William Jeffrey
Jim Pyles of Powers, Pyles, Sutter & Verville, the firm representing the APsaA in its government relations, updated the Council on legislative matters. He said that if the wrong privacy bill passes in Congress, patients would have to give their consent to the routine and wholesale disclosure of their medical information. Some 60 percent of American citizens, said Pyles, would rather retain privacy than to give it up to get better quality health care. The APsaA's position is that privacy is essential for good quality health care but absolutely critical for psychoanalysis and psychoanalytic psychotherapy.
Pyles also spoke about “Oasis,” a data collection effort of HCFA during the past several years, in which every Medicare-certified Home Health Agency had to require every patient to divulge more than 450 pieces of personal information. This information was to be reported to the state and federal government and would be maintained in a databank for three years in a fully identifiable form. This information was supposed to allow HCFA to decide what care was excessive, so as to limit its financial risk, and was regarded by HCFA as a quality improvement measure. These records would include personal information regarding whether one felt depressed or hopeless or had thoughts of suicide.
Such a requirement would severely curtail access to health care because patients would be much less likely to seek care if they had to disclose such information. HCFAs position was that if a patient did not answer even one of the items, HCFA would terminate care. HCFA eventually suspended this policy, but during the period it was in effect, patients would not give the information to the nurses, and in order to avoid terminating care the nurses made up answers to the questions. Ironically, there is no problem with the quality of home health care, and patients report greater satisfaction with it than with any other service provided by Medicare.
Pyles felt that the fundamental difference between the various pending privacy bills is the issue of consent — the extent to which the patient has the power to decide what information will be disclosed. The Leahy Bill seems to protect that consent the best. Consent, in legal terms, means a concurrence of wills, a voluntary agreement. Submission under fear or terror does not amount to real consent. The threat of loss of health care coverage amounts to submission. The Council almost unanimously supported the Leahy Bill.
The report of the Committee on Certification and Membership was given by Jonah Schein. The committee was formed following extensive e-mail discussion on certification. The committee hopes to make a complete report to Council at the December meetings. The committee is considering several changes:
Any active member (certified or non-certified) would be eligible to run for all non-Board offices.
There would be two categories of by-laws amendments. One, requiring the approval of two-thirds of active members, would make changes to the by-laws that do not affect the structure and/or function of the Board. The second category of changes, requiring a two-thirds vote of certified members, would be those that would have an effect on the structure and/or function of the Board. These amendments would include but not be limited to (1) changes pertaining to eligibility for training,
establishment of standards for training in psychoanalysis, and standards for approved institutes, and (2) the establishment of criteria for certification. The Executive Committee would decide which category a proposed by-laws change would fit into.
The number of active members required to propose an amendment to the by-laws by petition would be increased from ten to fifty.
There was a good deal of discussion about these possibilities.
Treasurer Newell Fischer focused on the operating budget of the American. Income is up, but operating expenses are also up. However, in the last few years, there has been a surplus, and some of that has been invested. Executive Council spending has increased, and BOPS spending has remained relatively constant. Support expenses for the Central Office have also remained fairly stable. Membership numbers have increased, including the number of candidates.
Leon Hoffman, co-chair of the Committee on External Credentialing, indicated that meetings with the Consortium have become more cordial and there are no threats of lawsuits in the air.
Elise Snyder, chair of the Membership Committee, gave the “Lost Lambs Report.” She found 650 people who were eligible to be full members but who had never joined the American. They were called by as many as three or four people who explained the benefits of APsaA membership. They were offered a one-year free subscription to JAPA, a one-year free subscription to the International Journal of Psycho-Analysis, and reduced dues for joining the American. The committee expected to recruit about thirty-five people, but at latest count 113 people had joined.
Otto Kernberg, president of the IPA, addressed the Council. A major initiative of the IPA is its interregional conferences where distinguished clinicians meet with local psychoanalytic societies. The IPA is also working to reduce its overall administrative costs, which could save about $200,000 per year. Another major initiative is to renovate psychoanalytic education. The Committee on Psychoanalysis and Society is helping to relate psychoanalysis to the intellectual, academic, and cultural environment via the media. A strong effort is being made in scientific research. Kernberg extended a cordial invitation to attend the International Congress in Santiago, Chile.
Judy Chertoff, chair of the Committee on Council, presented a draft of the briefing book prepared for councilors. It covers fiduciary responsibilities, the structure and function of the Executive Council, comments on committee functions, and standard formats for-committee reports.
DeWitt Montgomery of the Committee on Executive Council Structure and Function reported on the task of coordinating some seventy committees of the Council. The committee aims to improve communication between the committees and the Council. The committees would be assigned to related sections. Section meetings could be held at each national meeting. Concerns were raised about whether this would add another layer of bureaucracy. A vote to implement this on a trial basis was approved.
The Joint Committee on Issues of Homosexuality was represented by chair Susan Vaughan. She read a proposed position statement of the committee. It stated that the origins of sexual orientation are not well understood and that same-gender sexual orientation cannot be assumed to represent psychopathology. The statement went on to say that an anti-homosexual bias often contributes to a sense of stigma and self-criticism in people of same-gender sexual orientation. Psychoanalytic interventions with patients of same-gender orientation should be directed at understanding meanings without assuming heterosexual orientation to be the norm. The statement concluded that directed efforts at changing sexual orientation often result in an increase in punitive self-criticism. The statement was fully supported by the Board and will be discussed by societies before a final vote in December.
Nancy Brehm, president of the Affiliate Council, reported that candidates are very interested in learning about the activities of the Board and Council. The Affiliate Council supports the initiative to give candidate members of the APsaA the vote. Dues from affiliate members represent more than $100,000 in income for the APsaA. Drew Clemens pointed out that members-in-training in the American Psychiatric Association have had the vote for ten years, and there have been no difficulties.
Chair Dorothy Holmes spoke for the Committee on Honorary Membership and Awards. Charles Brenner was nominated for an award for his distinguished contributions to psychoanalytic education, the first award of its kind; Lester Luborsky was nominated for distinguished contributions to psychoanalytic therapy research. Both nominations were approved by Council.
Leon Hoffman of the Subcommittee on Marketing described four areas in public information and marketing in which the committee works: media releases, a marketing plan to increase membership in various categories, a long-term strategic priority plan, and coordinating the various product marketing efforts.
Harvey Rich reported that the American Psychoanalytic Foundation has about a half-million dollars. The Foundation donates about $60,000 annually, and operating costs are about $27,000 a year.
Chair Erik Gann reported on the Committee on Psychoanalytic Practice. He said that only 61 percent of the membership responded to the 1996 survey on psychoanalytic practice.
Suggestions have been made to conduct a survey every five years, with a major survey done only every ten years, rather than briefer surveys done more frequently. Gann made it clear that no society's data are released in any form without the permission of the president of that society. This restricts the committee from using the data for any further research purposes and from helping any particular society where the level of practice is not as successful as in other societies.
Elected to the editorial board of JAPA were Dale Boesky, Charles Spezzano, Humphrey Morris, Bob Glick, Mel Lansky, and Eric Marcus. Elected to the Exploratory Nominating Committee were Eric Gann and Leon Hoffman. Don Meyers was chosen to be the representative to the IPA House of Delegates.
Gerald Melchiode of the Joint Ad Hoc Committee on Student Associates asked the Council to change the status of this committee to a standing committee. This was approved. He announced the Edith Sabshin Award [see page 14]. The committee plans to have ten winners a year for this award. This was also approved.
Prudy Leib, chair of the Committee on Fellowship, recommended fifteen applicants for the 1999–2000 fellowship group. The committee plans to include academics in the Fellowship in the future.