Michael Freeny is a Longwood psychotherapist and author of a novel, Terminal  Consent, that is based on the managed-care industry. He wrote this article  for the Sentinel.

Americans seem to be yawning through the political debate on rights for patients in managed-care health-insurance plans and how to safeguard their privacy.

All that patients really want is to see a competent, trustworthy doctor at an affordable price to obtain effective treatment.

Is that so hard?

The short answer is "yes." It has become very hard.

The rules of medicine have changed dramatically under managed care. There are new players, new demands and hoards of marketing people who want a piece of  your intimate medical data.

I am a health-care provider, specifically a psychotherapist, a guardian of some extremely sensitive patient secrets. Historically, the degree of legally protected privacy afforded psychological and substance-abuse treatment records has been higher than that for any other medical condition except the human immunodeficiency virus condition.

My clients could suffer tremendous damages if their secrets were revealed. Drug use, sexual proclivities, marital stresses, irrational fears, thoughts of death and other personal misfortunes can only be discussed openly when patients believe their privacy is protected.

Yet many new people are now party to treatment. Case managers, utilization review nurses, insurance administrators and auditors are involved. They have tremendous power in treatment decisions, overriding the doctor if necessary. These people are largely paid not by the insurance company, but by the patient's employer. I must share my clinical authority and the patient's
privacy with this new crowd.

Are they trustworthy?

I don't know.

I do know that I practice under well-established laws that hold me accountable. I can be sued for malpractice -- for bad clinical judgments, inappropriate release of client data, abandoning patients and falsifying records.

Additionally, my regulatory board can suspend or revoke my license if I violate these rules. This creates a clear standard of accountability for me to both the patient and the state. I'm required by law to put the patient's interest ahead of my own. This kind of legal overhead and risk management increases the expense of providing health care.

The insurance people who are now part of the treatment team don't work under the same standards. They are not sworn to secrecy, nor are they required by statute or professional regulators to put the interests of the client ahead of profit.

If they mess up a claim, confuse the dates of service or provide the wrong diagnosis, it's a critical error. If I do the same thing, it's fraud or malpractice.

My new insurance partners differ from me in their financial structure. The more service I provide, the more money I make. However, insurers, who ultimately control the purse strings, usually have a a prepaid, fixed-dollar budget. Each and every patient visit reduces their profit, taking away money they've already been paid. Insurers basically make money by not providing care.

This issue is played out everyday when doctors and insurers try to determine what is medically necessary for the patient. But under federal law, insurers enjoy broad immunity from malpractice suits. This is part of the debate in Congress.

Thus, when a doctor calls to get authorization to treat a patient, he or she will often speak with a nonlicensed "care manager" who, literally, may have no medical training. The doctor will say the patient has a medical problem and needs a particular treatment. The care manager will punch the data into a computer, and either that person, or the computer itself, will decide if treatment is medically necessary.

However, there is little accountability for their "medical" decision. If the insurance company denies care and the patient gets sicker, or even dies, the care manager and the insurance company cannot be sued for malpractice. This is what the issue of "suing HMOs" is all about.

As you can imagine, paying semi-skilled clerks to make non-accountable medical decisions is certainly cheaper than a paying a doctor. Many people in medicine feel that this ethical slight-of-hand is the way managed-care plans have been able to reduce the cost of medical care.

And, in fact, the managed-care revolution has greatly reduced medical inflation during the past decade by hundreds of billions of dollars. A portion of that money eventually has found its way back to the insured.

But these savings have come with serious non-monetary costs. Insurers can routinely restrict access to care with impunity, because there are no serious repercussions for denied care. Often, an appeals process is of little help, for the appeal may be only to the insurance company, itself. Frustrated patients may just give up, pay out of pocket, or argue the worthiness of their claims.

Even if the treatment is approved, there remains the issue of privacy. If you think your sensitive records are kept safe in a locked file cabinet, you're wrong again. America has migrated to the electronic patient record. Patient data is flying all over the Internet, from provider to insurer, to be stored in massive computer databases.

For example, the Medical Information Bureau is an insurance industry-sponsored warehouse of health, life and disability claims. Your sensitive medical data goes there. And there are lots of companies bidding for the right to use this medical data.

As a psychotherapist, it is flatly illegal for me to sell or reveal patient secrets, yet some insurance companies may be making big profits from personal medical data by selling it to businesses for marketing purposes.

There is another question here, also. If employers are paying the insurance companies, does that give your boss access to you medical secrets?

Depending upon the integrity of the insurer, employers can obtain a report ranging from total health-plan usage to specific, individual treatment information.

For patients seeing a psychotherapist, employers may feel a compelling need to know which employees are at risk of violence, drug abuse or sexual harassment. As a psychotherapist, I can't give this information to them without the patient's permission. But I'm required to give it to the
insurance company, and after that I have no control.

And sadly, under current law, neither does anyone else.

Remember that, under current law, the insurance industry is not doing anything illegal. Medical privacy and practitioner competency are expensive. Data sales and financially driven medical decisions made by clerks are common ways to reduce health-care cost.

We are in the midst of a prolonged revolution. In the next few years, Americans will get to decide, or let someone else decide, what kind of accountable health-care system they want.

Remember that the next time you are bored by a story about politicians debating health-care legislation.