struggle

main | table | intro| 1 | 2 | 3| 4 | 5 | 6 | 7 | 8 | 9 | 10 | 11 | 12 | 13 | 14 | 15 | 16 | 17 | 18 | *

Chapter 10

The Struggle for the Soul of the APA

This is one of several chapters that explore the evolution of thinking within the American Psychiatric Association (APA) during the managed care invasion.(17)

Our comments take into account the emergence and ascendance to power of the Business Groups on Health.(18)

Much of what we say in this book refers to the progressive transfer of decision making power on health from the employee to the employer. The wage freeze of l943 led to the addition of health care coverage as a fringe benefit. Health care expenditures increased in the 1960s, and grew much faster than general inflation until recently.

In 1974, The Business Roundtable, representing the chief executive officers of the largest USA corporations, created the Washington Business Group on Health, which in turn served as a promoter in the creation of local employer health groups.

In the l980s, business concerns shifted health costs to employees by increasing the employees' deductibles and co-payments while reducing coverage, or, specially among small employers, by not offering health coverage.

Though Business Groups gradually became influential in reducing expenses, employers also participated in studying the value of adequate health care in the work place. Some employers, many in the health field, also sought coalitions with physicians and other health professionals. The result was confusion as to what each group was trying to do for or against the others.

APA members were not free from confusion, simply because there was an utter contradiction between what they were seeing at their offices (reduction of necessary care, denial of services, denial of compensation for services provided, increasing harassment of physicians and patients), and what the glossy brochures of the HMOs said about preserving and enhancing quality.

APA members who were following trends in business, insurance coverage and services provided, had no doubt that a struggle was inevitable between those who believed the glowing statements put out by the business community and those who believed that the drive towards cost reduction was creating severe pain among many patients. Some situations were worrisome to many:

In the early 1990s, the recently created Pacific Business Group on Health (PBGH) began to negotiate on a standard set of benefits to be offered by participating HMOs. In 1995, PBGH reduced premiums an average of 9.2% below l994 premiums. From 1995 through 1997, PBGH got a 14% reduction in HMO rates. This was a clear indication that employers could obtain extraordinary results if the focus was on reducing costs...while paying little heed to the needs of patients or to the worries of physicians.

Extraordinary reductions in services in the late 1980s and early 1990s proved that the worries were clearly justified. The percentage of health care costs for combined psychiatric services, for example, decreased from 9% in 1989 to 3-4% in 1996. Around the same period, in absolute terms outlays for psychiatric services were down 54%.

In the early 1990s, APA members started looking at the association for help in creating a survival strategy that should protect our right to diagnose and treat our patients. Two different approaches became increasingly obvious: One would seek a compromise within the system. The second would fight the system.

Dr. Mary Jane England, Treasurer of the American Psychiatric Association, former Department of Social Services Commissioner in Massachusetts, former President of the American Medical Women's Association, and President of the Washington Business Group, was nominated in 1994 for APA President.

Dr. England, a child and adolescent psychiatrist, an enthusiastic advocate for children and women's issues and an expert in health problems at the work place, was seen by many as the ideal lead supporter of psychiatric patients in the midst of oppressive impositions by managed care.

Dr. Harold Eist, also a child and adolescent psychiatrist, twice President of the Washington Psychiatric Association, President of the American Association of Private Practice Psychiatrists and a community psychiatrist, saw little merit in any compromise. He advocated for a clean break from the coalition of business, insurance companies and managed care companies, and became a petition candidate running against managed care.

The campaign in the fall of l994 gave a chance to the three candidates, including Dr. James Shore, a distinguished psychiatry leader and educator, and Chairman of the Department of Psychiatry at the University of Colorado, to explore the scientific, professional and economic future of psychiatry.

Dr. England had a substantial number of followers because of the social values she had advocated throughout her professional career, her brilliant record in Massachusetts, her excellent performance as an APA officer, and her value as the psychiatrist who had the best knowledge about the inside strategies of the business community.

Dr. Shore was easily the psychiatrist who had influenced psychiatric education to the largest degree in a number of years through his activities as leader of key APA components, as Director and then President of the American Board of Psychiatry and Neurology, as the author of a number of publications on the future of education, and as the chair of a major psychiatric department.

Dr. Eist was an early opponent of managed care. Both as a leader of the Washington Psychiatric Association and of the private practice psychiatrists, he had insisted that he and others who had developed key psychiatric services for the poor in Washington, D.C., and elsewhere, should lead the charge against the insurance companies and their HMOs before it was too late. He saw the campaign as a wake-up call for physicians and patients.

The campaign debates helped sharpen the issues and establish differences in perception. An increasingly larger number of APA members became aware that they could not stay idle and should be for or against the new order. Even so, they had difficulty accepting that they were facing a long and difficult struggle against a powerful force. At this time, in late l994 and l995, many still hoped that an intense struggle might not be necessary, and both business and the insurance industry would correct their ways on their own.

Dr. Eist's close allies believed that the time for compromise might never have existed, that managed care was intent on destroying the practice of psychiatry, that the insurance companies were prepared to fight a vigorous war, and that only an arduous and persistent attack would throw them back.

The campaign saw much shifting and repositioning so that the contending groups gradually were more clearly established and more committed to their issues. Dr. Eist came to believe that he had gradually evolved into the leader of an anti-managed care group that could become a majority of the APA members.

At the end, Dr. England won the election. Dr. Eist was second. As a result of the process, a growing group of APA members had crystallized their opposition to the strategies of the business community. They were likely to follow Dr. Eist into victory in a new campaign. The movement against managed care had become a reality in the American Psychiatric Association.

main | table | intro| 1 | 2 | 3| 4 | 5 | 6 | 7 | 8 | 9 | 10 | 11 | 12 | 13 | 14 | 15 | 16 | 17 | 18 | *

©2000 Munoz and Eist, The People v. Managed Care


main \| table \| intro\| 1 \| 2 \| 3\| 4 \| 5 \| 6 \| 7 \| 8 \| 9 \| 10 \| 11 \| 12 \| 13 \| 14 \| 15 \| 16 \| 17 \| 18 \| *

	Chapter 10 The Struggle for the Soul of the APA

	This is one of several chapters that explore the evolution of thinking within the American Psychiatric Association (APA) during the managed care invasion.(17)

	Our comments take into account the emergence and ascendance to power of the Business Groups on Health.(18)

	Much of what we say in this book refers to the progressive transfer of decision making power on health from the employee to the employer. The wage freeze of l943 led to the addition of health care coverage as a fringe benefit. Health care expenditures increased in the 1960s, and grew much faster than general inflation until recently.

	In 1974, The Business Roundtable, representing the chief executive officers of the largest USA corporations, created the Washington Business Group on Health, which in turn served as a promoter in the creation of local employer health groups.

	In the l980s, business concerns shifted health costs to employees by increasing the employees' deductibles and co-payments while reducing coverage, or, specially among small employers, by not offering health coverage.

	Though Business Groups gradually became influential in reducing expenses, employers also participated in studying the value of adequate health care in the work place. Some employers, many in the health field, also sought coalitions with physicians and other health professionals. The result was confusion as to what each group was trying to do for or against the others.

	APA members were not free from confusion, simply because there was an utter contradiction between what they were seeing at their offices (reduction of necessary care, denial of services, denial of compensation for services provided, increasing harassment of physicians and patients), and what the glossy brochures of the HMOs said about preserving and enhancing quality.

	APA members who were following trends in business, insurance coverage and services provided, had no doubt that a struggle was inevitable between those who believed the glowing statements put out by the business community and those who believed that the drive towards cost reduction was creating severe pain among many patients. Some situations were worrisome to many:

	In the early 1990s, the recently created Pacific Business Group on Health (PBGH) began to negotiate on a standard set of benefits to be offered by participating HMOs. In 1995, PBGH reduced premiums an average of 9.2% below l994 premiums. From 1995 through 1997, PBGH got a 14% reduction in HMO rates. This was a clear indication that employers could obtain extraordinary results if the focus was on reducing costs...while paying little heed to the needs of patients or to the worries of physicians.

	Extraordinary reductions in services in the late 1980s and early 1990s proved that the worries were clearly justified. The percentage of health care costs for combined psychiatric services, for example, decreased from 9% in 1989 to 3-4% in 1996. Around the same period, in absolute terms outlays for psychiatric services were down 54%.

	In the early 1990s, APA members started looking at the association for help in creating a survival strategy that should protect our right to diagnose and treat our patients. Two different approaches became increasingly obvious: One would seek a compromise within the system. The second would fight the system.

	Dr. Mary Jane England, Treasurer of the American Psychiatric Association, former Department of Social Services Commissioner in Massachusetts, former President of the American Medical Women's Association, and President of the Washington Business Group, was nominated in 1994 for APA President.

	Dr. England, a child and adolescent psychiatrist, an enthusiastic advocate for children and women's issues and an expert in health problems at the work place, was seen by many as the ideal lead supporter of psychiatric patients in the midst of oppressive impositions by managed care.

	Dr. Harold Eist, also a child and adolescent psychiatrist, twice President of the Washington Psychiatric Association, President of the American Association of Private Practice Psychiatrists and a community psychiatrist, saw little merit in any compromise. He advocated for a clean break from the coalition of business, insurance companies and managed care companies, and became a petition candidate running against managed care.

	The campaign in the fall of l994 gave a chance to the three candidates, including Dr. James Shore, a distinguished psychiatry leader and educator, and Chairman of the Department of Psychiatry at the University of Colorado, to explore the scientific, professional and economic future of psychiatry.

	Dr. England had a substantial number of followers because of the social values she had advocated throughout her professional career, her brilliant record in Massachusetts, her excellent performance as an APA officer, and her value as the psychiatrist who had the best knowledge about the inside strategies of the business community.

	Dr. Shore was easily the psychiatrist who had influenced psychiatric education to the largest degree in a number of years through his activities as leader of key APA components, as Director and then President of the American Board of Psychiatry and Neurology, as the author of a number of publications on the future of education, and as the chair of a major psychiatric department.

	Dr. Eist was an early opponent of managed care. Both as a leader of the Washington Psychiatric Association and of the private practice psychiatrists, he had insisted that he and others who had developed key psychiatric services for the poor in Washington, D.C., and elsewhere, should lead the charge against the insurance companies and their HMOs before it was too late. He saw the campaign as a wake-up call for physicians and patients.

	The campaign debates helped sharpen the issues and establish differences in perception. An increasingly larger number of APA members became aware that they could not stay idle and should be for or against the new order. Even so, they had difficulty accepting that they were facing a long and difficult struggle against a powerful force. At this time, in late l994 and l995, many still hoped that an intense struggle might not be necessary, and both business and the insurance industry would correct their ways on their own.

	Dr. Eist's close allies believed that the time for compromise might never have existed, that managed care was intent on destroying the practice of psychiatry, that the insurance companies were prepared to fight a vigorous war, and that only an arduous and persistent attack would throw them back.

	The campaign saw much shifting and repositioning so that the contending groups gradually were more clearly established and more committed to their issues. Dr. Eist came to believe that he had gradually evolved into the leader of an anti-managed care group that could become a majority of the APA members.

	At the end, Dr. England won the election. Dr. Eist was second. As a result of the process, a growing group of APA members had crystallized their opposition to the strategies of the business community. They were likely to follow Dr. Eist into victory in a new campaign. The movement against managed care had become a reality in the American Psychiatric Association.