The History of Being Called a “Provider”
Jack Wiggins
(This is from an email sent to the Div 42 email group and republished with permission. Eds.)
Dear Karen [Shore] and all that object to being called a “provider.”
Karen, I still have you T-shirt emblazoned with the words, “Warning: Managed Care May Be Hazardous to Your Health.” You wrote an eloquent speech. It was timely and was moving in its presentation. However, your associating the word “provider” with managed care is somewhat of an anachronism although the term “provider” is used by managed care. My following comments are not to be critical of your remarks but rather to supply clarification and background history of the use of the inelegant term “provider” for a better understanding for those new to the profession.
As near as I can recall, the term “provider” first came into use among the Congressional staffers when trying to draft the Medicare legislation in the 1960’s. Staffers quickly learned that there was a plethora of professions to deal with and groped for a non-pejorative umbrella term to deal the health professions without giving any one preference or penalty.
“Provider” was the term selected and all professions, including psychology, clamored to be included in the “provider” classification. (For more information about the Medicare experience for psychology, see Nick Cummings’ article on the National Alliance website at http://nappp.org )
When psychologists were not included in Medicare or other insurance reimbursement plans — and were not even licensed in many states — other means of statutory and regulatory recognition of psychological services were sought. In a meeting with Dean Krebs at Aetna who was in charge of Aetna’s FEHBA program (Federal Employees Health Benefits), Gene Shapiro and I determined that the insurers were seeking a way to recognize psychological services in “health care” without reimbursing educational services and marriage counseling in the process. I suggested that psychology could register psychologists that were providing health services and asked if Aetna and other insurers would accept these psychologists’ services as being eligible for reimbursement. He agreed that this was what the insurance industry needed to include psychologists in their insurance contracts. Thus, the idea of the National Register of Health Service Providers in Psychology was born. (I chose this title because it was self explanatory in cache’ terms of that time and “provider” was a term that was acceptable to the insurance industry.) The APA Committee on Health Insurance (COHI) began working on the development of the definition of a ‘psychological health service provider’ and how to establish the registry. Remember, almost half of these psychologists to be registered did not have a license with a scope of practice. My term as Chair of COHI expired. I am eternally grateful that Gene was able to finish the job of making psychology a health profession.
“…All professions clamored to be in the “Provider” classification”
Up until the development of the National Register, psychology was listed by the US Department of Labor as a Social Science. Sadly, the Bureau of labor Statistics in their Occupational Outlook Handbook still lists psychology as a Social Science but does acknowledge that some psychologists work in doctors’ offices and have limited prescriptive authority in LA and NM. (This is description of psychological services by the Department of Labor could be a special project for Division 42.)
Karen, is right that “provider” has taken on a negative connotation for psychologists since managed care “mental health carve-outs” include Masters level therapists in their provider panels. In order to distinguish psychological care from care provided by other disciplines, psychology must have strong advocacy for and by psychological practitioners. This is why the National Alliance of Professional Psychology Providers was formed. Yes, the term “provider” is in the title but, arguably, this term has greater valence in writing contracts and legislation than “practitioner or practice” in this time of evidenced-based treatment. Since the National Alliance’s name with its necessary qualifiers has been chosen already, I simply ask that you focus on the purpose of the National Alliance. The Alliance’s goal is to form meaningful relationships between psychology and like-minded organizations. Go to the National Alliance’s website at http://nappp/org and check out the purposes and advocacy efforts of the Alliance.
Some of you have visited the Alliance’s website or have seen Nick Cummings’ name on the Board of the National Alliance. Many of us are very angry about how psychologists are dealt with. Some hold Nick Cummings solely responsible for what has happened in managed care. I was there throughout the development of third party reimbursement and have a different view. The Committee on Health Insurance saw this revolution coming and established a “peer review”system to help control costs. Other professions were forming preferred provider organizations and offering their professions services to business corporations. Psychology tried to do this too but was thwarted by major debates with academics about whether psychologists should be licensed or reimbursed for their services by third party payers. I know these old debates sound passe’ but they continue today.
These internecine battles regarding licensing and insurance in meetings and on APA Council resulted in the formation of an external advocacy group the Council for the Advancement of Psychological Professions and Sciences (CAPPS) that was unfettered by the internal dissension within APA. Nick Cummings, Rog Wright and Ernie Lawrence conceived of this organization in response to COHI’s call for greater advocacy from APA. CAPPS was highly successful as an advocacy organization until APA formed a competing advocacy organization promoted by academicians Association for the Advancement of Psychology (AAP). The APA Committee on Relations between APA and CAPPS, with apt acronym of CRAPACAPPS, cut off financial support to CAPPS by the machiavellian effect of dividing members on whether to support AAP or CAPPS. As a result funding for advocacy dried up in this confusion.
Some advocacy did survive in CAPPS merger into AAP. AAP’s 24 person Board was comprised of only 1/3 practitioners and 2/3 academics and never regained the élan of CAPPS. Nick, Rog and Ernie were not to be on the merged AAP/CAPPS Board. Rog remained active in APA and Nick was elected President of APA. This occurred at the time of the passage of the Employee Retirement Income Security Act (ERISA) that negated state insurance laws and left health insurance unmanaged by states. This disastrous federalization of control of health care benefits ironically gained the euphemistic title of “managed care.” As President of APA, Nick was keenly aware of these developments and attempted to move APA into this market. APA would have had to give up its 501 c-3 tax status but was too divided to consider creating a 501 c-6 companion organization to accomplish this. Nick then obtained a federal grant that successfully demonstrated his medical cost offset findings in the state health plan of Hawaii.
Congress responded to the economic crisis in health care costs in the 1980’s by enacting HMO laws that authorized master level health providers to provide crisis intervention counseling in HMOs. This undercut the position of psychology even further. Corporations were given authority to set up their own health care plans for their employees. Businesses were turning to third party administrators to design and manage their health care plans. This was the spirit of the times and Nick Cummings formed a partnership with the inventor of the MRI who knew little about health care but had money to invest. This partnership became American Biodyne.
Biodyne grew exponentially in this heady climate of forming HMO’s. Biodyne was not the only company that carved out mental health care but it was the only one that offered unlimited mental health benefits. Patients were seen promptly and provided with a broad range of benefits with few restrictions. Biodyne psychologists were given staff privileges in hospitals and were able to direct the care of their patients during their hospital stay. Psychologists were trained in psychopharmacology and managed medications. Individual and group psychotherapy, psycho-education and family counseling were available as needed. In four years Biodyne grew to serve 14 million people with about 10,000 psychologists providing services. Biodyne was highly successful and won contract over contract over its competition. But, as it happens in the business world, if you can’t beat your competition you try to buy them out. Since there was money to be made, Nick was given an offer he could not refuse or match. Biodyne was sold to a pharmaceutical company to become just another managed care carve-out. Nick did not sell psychology out. Instead, it was Biodyne that got psychologists into the managed health care market by demonstrating their value in health care. Without Biodyne, most of the psychotherapy done today would be by master level technicians under the direction of psychiatry. This is my view of what has occurred.
It is true that Nick Cummings has profited handsomely from his efforts in psychology and public health but he did the old fashioned way, he earned it. I realize this is contrary to what many have been told about Nick Cummings. Regardless of your opinions of Nick Cummings, the “inelegant” term of “provider” and how all of this transpired, please carefully review the website of the National Alliance at http://nappp.org. Then, judge for yourself how the Alliance can meet your needs as a practitioner of psychology. If you would like to advocate for something, let us know.
Jack Wiggins is a past president of both APA and Div 42. He is now deeply involved in obtaining prescription privileges for psychologists and lives in Arizona.
