Resisting Managed Care From Within.
Paper Presented at the Private Practice Committee Meeting in Toronto on 6/1/98.
    I thank Dr. Michael Hughes for inviting me to here. I
also thank the colleagues of the APA Internet List Mem2Mem
for their suggestions and criticisms.

    Before I start, let me make some things clear. I have
been basically a clinician for more than thirty years. I have never been
interested in becoming anything else than a solo practitioner. I never
wanted to be an economist, businessman, entrepreneur, group or network
owner, manager, reviewer, executive or investor in the "health care

    I dislike the direction the US Health System is taking. I am
distressed by the way the Managed Care Organizations are dealing with us,
solo practitioners. I don't condone, legitimize or support their methods.
I am dismayed to see our profession being used and abused by these
corporations that are ripping off big profits by denying needed services
to our patients. It may be too late for us to fight back but being here
today is proof that I still believe in our power to change things.

    We, American psychiatrists, seem to be missing an important point.
The world's view of health care is changing. Health care - once
considered a privilege for those who could afford it - is becoming a
right. All industrialized nations have accepted this principle and are
trying to develop quality and affordable health care for all citizens.

    Regretfully the United States is the only country that has not yet
moved in this direction. I trust that sooner or later it will do so,
under pressure from the American people. But it is unlikely that
Americans will be pushing for a return to the private practice/charity
model that they knew in the past. For no other reason they simply can't
afford it. They want to share costs, risks and to have universal access.
So it seems that a third party payer will be unavoidable for the majority
of Americans. The question for us psychiatrists is this: what kind of
health system do we want for our patients and our profession?

    Some colleagues have advised me not to go into what I am about to say
for fear that I will lose your support. But I will say it anyway. As
Managed Care Organizations grow and become more perverse, a Single Payer
System becomes more attractive. In a Single Payer we will remain as
private practitioners. We will be competing on the basis of our good
services to patients, and not on our willingness to compromise care
in order to maximize MCOs' profits. Like De Tocqueville once said:
"Americans always do the right thing, after trying everything else".

    We must support a health care system that will respect our profession
and our patients. We can't think only of our immediate needs. We must look
at the forest without limiting our attention to individual trees. This is
how we can win the battle of public relations for the American people.

    But while we still don't have the Single Payer System I am hoping
for, what would we be doing? We can band together and resist these
corporations from within in the name of good psychiatric practice. Not
by choice we, solo providers, are trying to cope with these corporations
while serving a growing number of insured patients. The strain on us is
overwhelming. The abuse we take is not fading. Under this perverse system
our patients and us are now considered the enemies.

    Some months ago when writing treatment reports for MCOs, I felt alone
trying to fight back these unreasonable and greedy people. I carefully
weighed my options. I could resign from their panels, and work as a
non-participant provider or only with private patients. I then realized
that in either case I would be shifting costs to patients who have already
been paying their insurance premiums, many of them unable to afford an
extra cost. But worse, and quite ironic, the Managed Care Organizations
would be all too glad to continue to collect their premiums without
having to pay for their treatments.
    Even if we all became full time private practitioners, we would still
have to deal with this difficult question: what kind of care should be
available for patients who are not able to afford private care? I believe
that we, as a profession, owe an answer to the American people.

    We, solo MCO providers, can get together with other private
practitioners because we have the same goals: good psychiatric treatment.
As an organized group, we can have a greater impact in the corporate
decisions that are affecting our practices. 

    My proposal is simple. I am asking the APA to allow MCO Solo Providers
to have our own committee to share concerns and strategies to resist MCOs
from within.

    To conclude, let me illustrate some of the issues that this committee
could work on:

1. Confidentiality.

2. Unionizing.

3. How to reach the insured so they understand where we stand. 

4. The Single Payer.

5. A centralized credentialing database for all MCOs.

6. One uniform Treatment Plan for all MCOs.

7. Computerizable Treatment Plans.

8. Any willing provider.

9. No referrals from MCOs to individual providers or groups. Patients will
   be advised to choose among all providers.

10. Greater flexibility on the approval of changes in treatment plans.
    One contact person in each MCO for each provider.

11. "Authorizations" for at least 12 sessions each time.

12. Psychiatrists be allowed to do medication checks, psychotherapy
    or both.

13. No capitation programs.

14. Many others.

Thank you.