I attended medical school at Columbia's College of Physicians and Surgeons in the early 1960s and found myself in a very stimulating environment, but one in which the faculty looked down upon anyone not planning a career in research, either basic or clinical. Practicing physicians were disparagingly referred to as “LMDs” (for local medical doctors). Organized medicine in any form was demeaned, especially the AMA. The organization was seen as politically and socially conservative, scientifically irrelevant, and professionally out of touch.
Where once most physicians in the country belonged to the AMA, the membership base gradually eroded, driven by increasing dues and disagreements over policies. Physicians either left or did not join. In time, the AMA began to change. It opened up its ranks to younger physicians, became more involved in public health issues, and increased and broadened specialty society representation in the House of Delegates, the policymaking body of the AMA. The current AMA president, Ronald M. Davis, is one of the youngest in its history, a preventive medicine specialist. From 1984-87 he was a resident physician AMA trustee. Throughout its decline and effort to recreate itself, the AMA continued to be a major force in publishing, medical education, and medical ethics.
Policy decisions about issues of payment for health care have always been a divisive issue in the AMA. In insurance, it is ultimately a zero sum game with each specialty looking out for its own turf. If the academic centers were disdainful of the AMA, many in the psychiatric and psychoanalytic community were actively hostile because of a host of issues. But our shunning of the AMA muted our voice in the debate over insurance policy issues and we have paid a price for that.
The advent of managed care and its effect on practicing specialists in every field has been a significant factor in changing the views of the AMA. Psychoanalysts and psychiatrists have a powerful incentive to form alliances with other specialties to address the many abuses that were inflicted on patients and the physicians caring for them. The AMA has been engaged in significant legislative initiatives at the state and national levels to reform managed care since the mid 1990s, when I became a member of the Maryland AMA delegation. Though I have lent my voice to that chorus, I am only one of many. The AMA also has provided assistance in many of the court battles that have brought all of the largest managed care companies, and their mental health carve outs, under judicial oversight. The battle is not over but the momentum has shifted.
Aside from arbitrary denial of payment for psychoanalysis and intensive psychotherapy, one of the ways managed care abused patients in the mental health sector was its intrusion into patient privacy and confidentiality through endless reporting requirements. Instead of trusting physicians, or requiring second opinions for a course of treatment, or asking professional peer review organizations to evaluate outliers, managed care companies decided to assume an important clinical function, i.e., the responsibility for deciding about a course of treatment and its termination or continuance. To do this, it demanded very sensitive information. This had the effect of frightening patients who had no idea who was seeing this information, nor how securely the information was being handled.
There has been egregious mishandling of records by reviewing companies. A GAO study (Sept. 9, 2006) revealed “more than 40 percent of federal contactors and state Medicaid agencies experienced a recent privacy breach involving personal health information.” We do not know what the rate is in the private insurance sector but the New York Times (Dec. 3, 2006) reported that the civil rights office in the Department of Health and Human Services “has received more than 22,000 complaints under the portability law…since 2003; allegations of ‘impermissible disclosure’… among the most common…But the civil rights office has filed only three criminal cases and imposed no civil fines.”
The AMA developed significant policy on privacy and the confidentiality of medical records and is currently extending it to issues involving electronic medical records. AMA policy is not law and cannot mandate insurance companies to behave responsibly. It does, however, set a professional standard, which physicians can use as leverage with insurers and to engage legislators. This is another battle to which I have lent my voice and vote.
How did I get here? Partly by chance. In 1980 a friend asked me to give a talk to the Baltimore County Medical Association, and invited me to join, which I did. My membership also included the state medical association and the AMA. A short time later, I was asked to chair a committee and was later elected president of the Baltimore County Medical Association, which led to my taking a more active part in state activities and a term as president of the state medical society. In 1997 I was selected to serve on the Maryland AMA delegation.
Although the psychiatric presence in the AMA House of Delegates has grown, there remain relatively few analysts in it. (I am the only one affiliated with either APsaA or IPA.) It is important that analysts join the AMA and make their voices heard. Specialty groups, like the American Psychiatric Association, tend to be dominated by academics and are often focused on research and teaching; practice issues tend to take a back seat. The AMA has developed a more practice-oriented focus in keeping with its founding purposes. My dream is that one day APsaA will have a seat in the AMA House.
Tom Allen, M.D., is a member of the AMA House of Delegates and fellow of the American Psychiatric Association. He is associate clinical professor in psychiatry, University of Maryland Medical School, and assistant clinical professor of psychology, George Washington University.