Although I could not have appreciated it at the time, in retrospect, it has become clear to me that I had the privilege of training in what surely was “the golden age” of health care in this country. The centrality of the doctor/therapist-patient relationship was unquestioned. Confidentiality and privacy of medical information was inviolate and required the specific permission of the patient for its release.
No more. The doctor/therapist-patient relationship is specifically under fire for being a primary driver of health care costs. There is enormous pressure to completely phase out the “fee-for-service” health care system. Individual health care information has become a marketable commodity as electronic medical records make the wide distribution of private information almost inevitable.
Our practice survey of 2011 makes it clear just how unique we are as a profession. Over 80 percent of the income of our members comes from private practice and fewer than 20 percent are willing to serve on managed care insurance panels. What this means is that we are squarely in the crosshairs of government and insurance sponsored pressures to reform health care. We are at once the most endangered species, and the best example of the importance of the centrality of the doctor/therapist-patient relationship, as well as the effectiveness of fee-for-service health care. We are truly the canary in the coal mine.
I can think of two personal examples to illustrate just how far we have fallen.
In 1962, I was a third-year student at Harvard Medical School, assigned to Children's Hospital for a pediatric rotation. The pediatric resident I was assigned to was Martha Carpenter. (I still remember her name.) A six-year-old boy had been admitted who was dying of a bacterial meningitis that none of our medicines seemed to be able to treat. The message from all of our instructors was in essence, there is a solution, and it's your job to find it no matter how long it takes.
Carpenter and I stayed up all night trying different histological stains to identify the organism. I remember vividly at 5:00 a.m. we tried an unusual stain preparation, and saw the distinctive dumbbell shape of the Klebsiella bacteria. Putting the boy on the proper antibiotic had him conscious and recovering within hours.
This would be unlikely to happen today. Too autonomous and too expensive.
By contrast, I had a recent health care experience myself. I developed complications to major knee surgery and had to be hospitalized on an emergency basis at one of the leading Harvard affiliated hospitals in Boston. As I recovered, I was stunned to see, up close and personal, what health care has become, even in this supposed mecca of academic medicine. I hardly ever saw a doctor, maybe for a total of five minutes over the entire four days. The nurses and nurses' aides seemed permanently attached to computers on rolling dollies. Their visits to my room consisted mostly of standing with their back to me, entering data into the computer. Doctors were almost never available because they were confined to a glassed-in room, with a series of computers in front of each of them. They spent their entire time hunched over their computers, entering data. I began to realize that health care had become almost completely depersonalized. I received much better care at a small community hospital far away from the teaching centers of Boston medicine.
The destruction of what was arguably the finest health care system in the world began in 1973 with the “managed care act” during Richard Nixon's administration. This act has been called “Richard Nixon's revenge on the American people.” Managed care itself was originated by Dr. Paul Ellwood, Jr., and his think tank in Jackson Hole, Wyoming. Ellwood's father was a general practitioner who he felt spent too much time with his patients. Ellwood came to regret the creature that he had hatched.
From the very beginning, the idea of managed care was to get a “manager” in between the health care professional and the patient. Medical decisions would be made by someone who had no particular commitment to the patient and would be made entirely on objective and financial grounds. This developed into the corporatization of health care. The computer, and, for us, the Diagnostic and Statistical Manual of Mental Disorders (the DSM V), have “objectified” health care delivery even further.
As health care professionals, we are subjected to an increasing mountain of bureaucracy, to the point where, as I witnessed, far more time is spent on entering data or filing proofs of therapeutic efficacy than actually seeing individual patients or clients. Physicians in particular have been targeted, and are subjected to such measures as “Maintenance of Certification,” which requires expensive and often useless courses to be taken in order to provide presumed proof of competency. In some areas this is being linked with the ability to renew one's license in what is called “Maintenance of Licensure.” Expertise in using electronic medical records is one of the requirements.
If one participates in insurance panels, payment is “value based,” which means that cookbook formulas for treating various conditions have to be followed and documented. In addition, patient feedback for satisfaction is often required. A particularly egregious example is the new CPT codes required by Medicare.
Bob Pyles, M.D., is president of the American Psychoanalytic Association.
These codes became a requirement as of January 1 of this year. The problem for therapists is that the codes do not fit anything that we actually do. I know of no one, including myself, who has managed to get reimbursed, because the codes are incomprehensible. Medicare representatives seem as confused as everyone else and can offer little direction. There is every incentive not to accept Medicare patients, except that some states are considering required participation in Medicaid and Medicare as a condition for licensure.
Medical decisions would be made by someone who had no particular commitment to the patient and would be made entirely on objective and financial grounds.
We will soon see the full implications of the Affordable Care Act (ACA), which will create even more pressure to phase out fee-for-service health care. The act grants sweeping new powers to the IRS to oversee compliance with the new law. It does not give one a feeling of comfort to learn that the IRS has already accessed 60 million medical records in California seeking information on a single person. Interestingly, we have seen groups central to the passage and implementation of ACA arranging to exempt themselves from being covered by it. This includes Congress, the major unions, and the IRS itself.
From our position of having a superb health care system that was the envy of the world under the fee-for-service model, we have become the most expensive health care system in the world. The United States spends two-and-a-half times more per capita for health care than any other industrialized nation. We have also fallen to somewhere around mediocre in the quality of our care compared to these other nations.
The reason for all this is twofold. One is that the “management” costs are exorbitant due to inefficient bureaucracy. The other is that the whole managed care model is absolutely and totally antithetical to human nature. I have always particularly admired the founding fathers, and especially James Madison, often called the “Father of the Constitution.” Madison specifically rejected “management” as being against the inherent nature of man. Instead he created a system of “checks and balances,” which rely on individual autonomy and liberty. Managed care, by contrast, is all about the centralization of power and the deprivation of individual choice, substituting a kind of corporate fascism for what has always been the cornerstone of good health care, the doctor/therapist-patient relationship.
Should the government attempt to control groups? Madison argues that “such a remedy…is worse than the disease” because it would eliminate liberty. Any government attempting to do this would be battling against the core of human nature.
Rather than engage in such a hopeless effort, sooner or later bound to fail, Madison's solution is to create a structure, in this case a representative democracy that would include all groups and all opinions. Everyone has a voice. The safeguard upon which Madison relies is that an educated people would generally make a reasonable majority decision. that is, the goodwill of educated people can be trusted. This is the bedrock principle on which our Constitution stands and which was finalized at the Constitutional Convention in Philadelphia in 1787.
Madison goes further. He argues that the primary purpose of the Constitution is to protect citizens from the government. He recognizes that those in power will be motivated to pass laws to perpetuate and centralize their power, as we see increasingly in managed health care.
In looking at our health care system through the vision of Madison, it is bound to fail, because incentives are entirely in the wrong direction. Citizens and health care professionals are deprived of the ability to make decisions and find creative solutions. The central principle is that citizens and health care professionals cannot be trusted and must be “managed.”
Most enduring laws are built on, rather than frustrate, human nature. In the Declaration of Independence, it is stated that all men are endowed by their creator with certain unalienable rights and among them are “life, liberty and pursuit of happiness.”
The trend throughout the history of our nation is expansion of individual rights and autonomy—equal protection under the law, elimination of slavery, desegregation of schools, voting rights for women and minorities, and interracial marriage. Laws that restrict individual rights and freedoms do not fare as well, for example, the 18th amendment adopted in 1920 prohibiting “the transportation, manufacture of or sale of intoxicating liquors,” which was repealed by the 21st amendment adopted in 1933. While defending the use of intoxicating liquors might be difficult, it is clear that the public did not want the federal government making that decision for them. The same must be even truer of purchasing health care.
As psychoanalysts, we are a primary example of the importance of the privacy and autonomy of the therapist-patient relationship. Our profession cannot operate in a situation of coercion and control. The essence of “free association” is that it aims for freedom. We are perhaps in the most advantageous position to speak for the importance of maintaining a vigorous fee-for-service system.
In preservation of the physician/therapist-patient relationship the desires and expectations of patients are reflected in the standards of professional ethics dating back to the fifth century B.C. Fee-for-service medicine preserves individual freedoms and public expectations regarding the provision of health care, and it is up to us to fight to preserve those freedoms.