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

Chapter 13

Year of Fire

It has been several years since Dr. Eist became President of the American Psychiatric Association. Changes in the medical environment and in the attitude of patients, their families and the public may be significant enough to obliterate memories as to the situation before Dr. Eist took office in May of 1996

J.P Kassirer(22), Editor of The New England Journal of Medicine, has addressed physician discontent as follows: "Frustrations in their attempts to deliver ideal care, restrictions on their personal time, financial incentives that strain their professional principles, and loss of control over their clinical decisions are a few of the major issues." Dr. Kassirer remarks accompanied an article that showed that incentives that depend on limiting referrals or on greater productivity are likely to compromise care.

Before Dr. Eist led the APA, the working conditions for psychiatry were worse than in other specialties:

Psychiatric services had been carved out from other medical services in most managed care contracts, so that funds for psychiatric care were under intense scrutiny that led to severe reduction. It was later found that monies available for mental health care had been cut in half in the decade ending in 1998. No wonder why so many patients with mental disorders were left unattended.

Gag rules were expediently enforced. Many a psychiatrist got a phone call from a stern managed care bureaucrat after she had advised the patient about problems with benefits, medications or payments. Mental health professionals were expected to be compliant robots with no rights to personal opinions.

The "behavioral health carve-outs" became progressively isolated from the main stream of medicine, so that a psychiatrist had difficulty learning whether anybody else was involved in the patient's care. This was happening at a time when managed health care advocates were announcing that they had achieved integration of services.

In total disregard for laws protecting confidentiality, and as part of their campaign to increase inconvenience, the managed care companies developed increasingly large questionnaires about every possible event in the patient's life. The therapist had to complete and send to the insurance companies these long documents before a visit could be approved. Not infrequently, a long questionnaire would be followed by many more.

Secret guidelines for treatment were developed. A visit to a mental health professional could be denied for reasons explained in mysterious documents that were "trade secrets" and could not be shared with the victims.

Patients were forced to play musical chairs as the companies would start and close contracts with a number of professionals, so that a patient, no matter how helpful her relationship with the professional might be, would find that relationship curtailed on the occasion of a change in contracts. The patient herself had no say on the contracts. The negotiations were conducted exclusively by business representatives and insurance companies. So much for respect for the patients!!!

If a patient objected to being traded by the insurance company to another insurer without her consent, she was likely to lose the right to see her physician. She could still go to the office she liked, but could not use her "insurance" to pay for services.

Of major concern to professionals engaged in seeing patients was the horde of "health experts" who invaded the field, as administrators, investors, enforcers, inquisitors, profiteers or just moneychangers. There was a transfer of health money from those providing the services to those supervising, or just making easy profits out of their neighbors' suffering.

Even worse was the vociferous minority of colleagues who joined the managed care "revolution". Many of them became medical directors or consultants to HMOs, and soon were broadcasting their managed-care "expertise". A few of them still talk about the "wonders" of managed care.

In the years preceding Dr. Eist's election, many managed care advocates gained positions of power in the APA, which came to be seen by some clinicians as a bastion of support for managed care.

In the first part of the decade of the 1990s, the managed care companies would refer patients diagnosed by somebody else (often an unknown person with unknown credentials) to a psychiatrist who was asked to prescribe for the patient, while an unknown "therapist" would try to meet the patient's needs.

This arrangement would clearly destroy the psychiatrist's identity as captain of the ship, diagnostician, expert in differential diagnosis, psychotherapist, and team leader. In other words, the managed care strategies had a clear direction: the destruction of psychiatry as a profession.

In the late months of l995 and early months of 1996, Dr. Eist and his allies came to the conclusion that the war against the managed care invaders would take several years, that the main problem for psychiatrists was the demoralization resulting from constant retreat and compromise, and that the best attack needed a national movement that publicized, criticized and challenged managed care practices. This movement would focus on several points:

1) Flooding the APA with information about managed care; going to the whole nation to spread the most accurate news about managed care excesses; enlisting the help of every APA member in the anti-managed care campaign; attending every psychiatric and medical meeting to talk about managed care abuses.

2) Going to the patients, their families and the community at large to explain managed care and enlist everyone in the revolution about managed care practices. We note here that others had already started on their own the same action, and were ready to join us.

3) Going to the state legislatures, to Congress, and to the executive branch to request effective support for patients and their families. At this time, only a minority of legislators, much fewer than in later years, were willing to take the challenge. The executive was still recovering from the Republican success of l994, and unavailable for the managed care fight.

4) Using in support of psychiatric patients the emergent interest of the legal profession in issues regarding managed care. Many lawyers were increasingly aware of two developments: business practices of managed care companies were similar enough to surmise they had had many communications that basically created a cartel against the patients.

Another development was the increasing awareness that the mentally ill were subjected to treatment denials that were leaving a long trail of injured people who would seek redress in the courts.

In a campaign that lasted many months, Dr. Eist visited most of the APA District Branches to obtain support for decisive action against managed care. He addressed the APA Assembly several times, discussed new plans in detail with key components, and led the Board of Trustees into initiatives that supported a litigation fund, new anti-managed care legislative initiatives at the state and federal levels, and a new communication system, both formal and informal, to transmit new information about managed care excesses.

Dr. Eist approached leaders of the mental health professions, of advocacy groups and of interested community groups to initiate and maintain a large anti-managed care coalition that is still growing as of this writing. This has been a most rewarding effort for all of those who can see the legislators change their positions as the public becomes better informed of abuses and mistreatment by managed care.

The connection with Joe Sahid, the lawyer who leads the class action suit against the "behavioral health carve-outs" was started by Dr. Eist, and has grown since his presidency. So have multiple interactions with lawyers who have followed the example of Bryan Welch in taking the side of the patients against managed care oppression (We again refer to Mr. Sahid and Mr. Welch on the chapter on The Warriors. Mr. Welch has clarified our thinking on legal issues regarding ERISA and anti-trust problems)

Those who have studied events during Dr. Eist's APA Presidency have agreed that he galvanized the association against managed-care, succeeded in restoring the moral of many dispirited colleagues, and created a growing sense that managed care maneuvers could be defeated if all those concerned united their forces and efforts.(23)

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


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	Chapter 13 Year of Fire

	It has been several years since Dr. Eist became President of the American Psychiatric Association. Changes in the medical environment and in the attitude of patients, their families and the public may be significant enough to obliterate memories as to the situation before Dr. Eist took office in May of 1996

	J.P Kassirer(22), Editor of The New England Journal of Medicine, has addressed physician discontent as follows: "Frustrations in their attempts to deliver ideal care, restrictions on their personal time, financial incentives that strain their professional principles, and loss of control over their clinical decisions are a few of the major issues." Dr. Kassirer remarks accompanied an article that showed that incentives that depend on limiting referrals or on greater productivity are likely to compromise care.

	Before Dr. Eist led the APA, the working conditions for psychiatry were worse than in other specialties:

	Psychiatric services had been carved out from other medical services in most managed care contracts, so that funds for psychiatric care were under intense scrutiny that led to severe reduction. It was later found that monies available for mental health care had been cut in half in the decade ending in 1998. No wonder why so many patients with mental disorders were left unattended.

	Gag rules were expediently enforced. Many a psychiatrist got a phone call from a stern managed care bureaucrat after she had advised the patient about problems with benefits, medications or payments. Mental health professionals were expected to be compliant robots with no rights to personal opinions.

	The "behavioral health carve-outs" became progressively isolated from the main stream of medicine, so that a psychiatrist had difficulty learning whether anybody else was involved in the patient's care. This was happening at a time when managed health care advocates were announcing that they had achieved integration of services.

	In total disregard for laws protecting confidentiality, and as part of their campaign to increase inconvenience, the managed care companies developed increasingly large questionnaires about every possible event in the patient's life. The therapist had to complete and send to the insurance companies these long documents before a visit could be approved. Not infrequently, a long questionnaire would be followed by many more.

	Secret guidelines for treatment were developed. A visit to a mental health professional could be denied for reasons explained in mysterious documents that were "trade secrets" and could not be shared with the victims.

	Patients were forced to play musical chairs as the companies would start and close contracts with a number of professionals, so that a patient, no matter how helpful her relationship with the professional might be, would find that relationship curtailed on the occasion of a change in contracts. The patient herself had no say on the contracts. The negotiations were conducted exclusively by business representatives and insurance companies. So much for respect for the patients!!!

	If a patient objected to being traded by the insurance company to another insurer without her consent, she was likely to lose the right to see her physician. She could still go to the office she liked, but could not use her "insurance" to pay for services.

	Of major concern to professionals engaged in seeing patients was the horde of "health experts" who invaded the field, as administrators, investors, enforcers, inquisitors, profiteers or just moneychangers. There was a transfer of health money from those providing the services to those supervising, or just making easy profits out of their neighbors' suffering.

	Even worse was the vociferous minority of colleagues who joined the managed care "revolution". Many of them became medical directors or consultants to HMOs, and soon were broadcasting their managed-care "expertise". A few of them still talk about the "wonders" of managed care.

	In the years preceding Dr. Eist's election, many managed care advocates gained positions of power in the APA, which came to be seen by some clinicians as a bastion of support for managed care.

	In the first part of the decade of the 1990s, the managed care companies would refer patients diagnosed by somebody else (often an unknown person with unknown credentials) to a psychiatrist who was asked to prescribe for the patient, while an unknown "therapist" would try to meet the patient's needs.

	This arrangement would clearly destroy the psychiatrist's identity as captain of the ship, diagnostician, expert in differential diagnosis, psychotherapist, and team leader. In other words, the managed care strategies had a clear direction: the destruction of psychiatry as a profession.

	In the late months of l995 and early months of 1996, Dr. Eist and his allies came to the conclusion that the war against the managed care invaders would take several years, that the main problem for psychiatrists was the demoralization resulting from constant retreat and compromise, and that the best attack needed a national movement that publicized, criticized and challenged managed care practices. This movement would focus on several points:

	1) Flooding the APA with information about managed care; going to the whole nation to spread the most accurate news about managed care excesses; enlisting the help of every APA member in the anti-managed care campaign; attending every psychiatric and medical meeting to talk about managed care abuses.

	2) Going to the patients, their families and the community at large to explain managed care and enlist everyone in the revolution about managed care practices. We note here that others had already started on their own the same action, and were ready to join us.

	3) Going to the state legislatures, to Congress, and to the executive branch to request effective support for patients and their families. At this time, only a minority of legislators, much fewer than in later years, were willing to take the challenge. The executive was still recovering from the Republican success of l994, and unavailable for the managed care fight.

	4) Using in support of psychiatric patients the emergent interest of the legal profession in issues regarding managed care. Many lawyers were increasingly aware of two developments: business practices of managed care companies were similar enough to surmise they had had many communications that basically created a cartel against the patients.

	Another development was the increasing awareness that the mentally ill were subjected to treatment denials that were leaving a long trail of injured people who would seek redress in the courts.

	In a campaign that lasted many months, Dr. Eist visited most of the APA District Branches to obtain support for decisive action against managed care. He addressed the APA Assembly several times, discussed new plans in detail with key components, and led the Board of Trustees into initiatives that supported a litigation fund, new anti-managed care legislative initiatives at the state and federal levels, and a new communication system, both formal and informal, to transmit new information about managed care excesses.

	Dr. Eist approached leaders of the mental health professions, of advocacy groups and of interested community groups to initiate and maintain a large anti-managed care coalition that is still growing as of this writing. This has been a most rewarding effort for all of those who can see the legislators change their positions as the public becomes better informed of abuses and mistreatment by managed care.

	The connection with Joe Sahid, the lawyer who leads the class action suit against the "behavioral health carve-outs" was started by Dr. Eist, and has grown since his presidency. So have multiple interactions with lawyers who have followed the example of Bryan Welch in taking the side of the patients against managed care oppression (We again refer to Mr. Sahid and Mr. Welch on the chapter on The Warriors. Mr. Welch has clarified our thinking on legal issues regarding ERISA and anti-trust problems)

	Those who have studied events during Dr. Eist's APA Presidency have agreed that he galvanized the association against managed-care, succeeded in restoring the moral of many dispirited colleagues, and created a growing sense that managed care maneuvers could be defeated if all those concerned united their forces and efforts.(23)