Colin R. Wright, Ph.D.		Band-Aides for the Mind: Fixing America’s troubled mental health care system will take more than superficial solutions Dealing with insurers is less than therapeutic YOU ARE a psychologist. A new patient enters your office, but suddenly, a young woman pushes past the patient and stands in front of you, saying: Hello, my name is Tulip, and the person who just walked into your office is a “life” that is covered by the Aunt Fanny Managed Care and Storm Door Co. Aunt Fanny has agreed to pay part of this “life’s” bill. But Aunt Fanny knows you’ve been practicing “Woody Allen” therapy for years, so she has taken the socially responsible action of taking it upon herself to require certain things of you. Aunt Fanny is not someone to trifle with. She owes no allegiance to anyone except her stockholders, and she knows she can assure them a good return on investment and still be able to tell this “life’s” employer that the “life” is getting quality care — and no more of this “Woody Allen” stuff. Aunt Fanny has designated me to represent her. Both Aunt Fanny and I know better than you do what is needed here. The fact that we have never laid eyes on this “life” before, or run a private practice ourselves, is irrelevant. Understand that we do not practice medicine and do not claim to practice medicine. But also understand that I, and I alone, shall decide whether what you do, or intend to do, is medically necessary. Any harm which might come to this “life” is your responsibility and yours alone. After all, you are the “provider,” and it is you and not I who practices medicine. If you want this “life” to stay in your office, you must abide by certain conditions. You must accept the fact that: You will see this “life” X number of times (X = 1 to 6). Then you will get back to me and report what your diagnosis is, what you plan on doing and how long it’s going to take for you to do it. You will do this on this form and only on this form, and you will not see this “life” any more often than once per week, and for no more than an hour. Telephone calls will be allowed, but you will not be paid for any time that you spend on the phone with this “life,” or anyone else who plays any kind of role in this situation, including me — no matter how much time it takes. The time you spend on the telephone is of no value, according to Aunt Fanny, so you will not be compensated — even if it’s an emergency. You will tolerate the long voicemail menu that it takes to get through to me, and you will tolerate how difficult it can sometimes be to get me on the phone. My time and schedule counts; yours doesn’t. Remember, you’ve got all of this time on your hands now that you’re no longer seeing Woody Allen. You will not be paid to do any kind of psychological testing. I may not have any idea what tests you might think are necessary, but I do know better than you do what this “life” needs. You will be paid roughly 20 percent to 30 percent less than your usual and customary fee. I have decided what your time is worth, and You’ve been getting rich under the guise of helping people for far too long. You will also absorb the additional 20 percent or more that all of this paperwork adds to your overhead. You will report to me within 24 hours anytime this “life” has any kind of red flag complaint or conflict of interest with its employer —for example, any possibility of a discrimination, harassment or worker’s compensation claim. You will report to me within 24 hours if this “life” is placed on any kind of tranquilizers, sleeping pills or antidepressants, abuses any kind of drug, becomes involved in any kind of litigation, confesses to any knowledge of criminal activity, or decides that it wants to have one or more of its offspring seen. Or anything else we decide we want to know — after all, we’re footing (some of) the bill. Furthermore, you will not consider this to be any breach of confidentiality as I have a general release signed by this “life.” The fact that this is very general and really doesn’t inform the “life” what is being divulged doesn’t matter. “Informed consent” doesn’t apply to me because I don’t practice medicine. Besides, I’m just following the tradition established by corporations’ in-house benefit programs. And don’t worry, we know about how important confidentiality is. That’s one of the reasons why Aunt Fanny pays $31 million a year in California alone for lobbyists to see to it that no one can make her abide by the same rules that are required of you, so don’t bother to whine about it. While you may not withhold this information from me, you will accept the fact that I may withhold certain information from you about the conditions that apply here. For example, you cannot hold me responsible for paying you, even though I may have told you in advance that you will be paid; I can change my mind any time I feel like it. Our contracts are non-negotiable; we decide when and if we will honor them. You will never, ever complain to this “life” or to anyone else about Aunt Fanny, or she will see to it that you never see any of her “lives” again. Don’t bother me with the facts. Aunt Fanny doesn’t care about the many studies showing that when people get psychotherapy, their other health care costs go down. Therapy might well be good preventive care, but Aunt Fanny won’t profit from engaging in prevention programs. Our stockholders only care about immediate profit, and if our CEO promotes such non-profitable practices, they might even take away his multimillion-dollar income — and that would anger Aunt Fanny something awful. And drop that talk about evidence that it takes longer than we say to bring about lasting benefit. Posh-tosh. Our stockholders couldn’t care less, and, after all, while Aunt Fanny claims to be doing all of this for the social good, they have never made any such claim. Besides, we’ll do our own outcome studies. We’ll turn down lots of your requests because our medical director will not be able to find what he considers to be properly controlled studies published in his literature and won’t accept those in your literature. But for our own studies, we’re not going to bother ourselves with all of that unnecessary scientific hocus-pocus. If it fits nicely into an Excel spreadsheet, it’s good enough for us. And don’t try to tell us about your cost of doing business. Aunt Fanny is an M.B.A., and therefore an accomplished business person who knows all about health care. The fact that we’re going to force you to essentially underwrite our “lives,” by accepting fees that are below your costs of doing business, is simply evidence of what we’ve been saying all along: You’re a lousy business person, and we know what’s best for you. Oh, and one last thing — don’t bother to try to interest the lawmakers in any of this. You may have been getting rich with your Woody Allen thing, but you’ll never match our $31 million. Besides, we’ve got legislators in Sacramento who believe there’s no difference between selecting a doctor and subscribing to a newspaper. Also, if you attempt to get together with other “providers” to protest any of this, we’ll nail you to the cross for violating antitrust laws. Oops, I almost forgot one last thing. It’s a real honor to have someone with such a distinguished background on our provider list — and don’t ever forget that! Colin Wright, Ph.D., is a clinical psychologist who has practiced in San Jose for 30 years. He may be reached at colin@concentric.net This article was published in the Sunday, June 20, 1999 San Jose Mercury News and is reprinted with permission. It also was on the Division 42 Listserv.