Spring 2000 - IP; Washington Update

Advocacy
Welcome to the New Millenium/Pat DeLeon

Washington Update/Ronald F. Levant

**Advocacy**
	Welcome to the New Millenium/Pat DeLeon
	Washington Update/Ronald F. Levant

WASHINGTON UPDATE
Onward to the Future: Professional Psychology Evolves

I am writing this just before Christmas, 1999. As the year-end approaches I find myself increasingly ambivalent about technology. Let me say at the start that I am not a Luddite. I am duly impressed with the wonders of new technology. For examples, E-mail has transformed my life to the point that I almost never need to use the phone and can collaborate on writing, research, and action projects in ways I could not have imagined ten years ago. I am also astonished at new advances in biotechnology such as the recently announced electronic retina that can transmit visual images to the brain. On the other hand, I experience, as I am sure many of you do, that too frequent experience of a crash or bug that sucks up all sorts of time and destroys files, and that no one seems capable of explaining nor advising how to avoid in the future. The thing that really worries me is that we have become very dependent on this new technology yet few of us really understand it, even to the point of being able to know how to readily access truly knowledgeable assistance. One thing is for sure: it will be interesting to see how these remarks sound when they hit print, after 1/1/00.

Meanwhile, back in the realm of professional psychology, the last couple of months have witnessed some very interesting developments in the areas of managed care, primary care and scope of practice, the status of mental health services, and the treatment of serious mental illness.

Managed Care

The fight to roll back the abuses of managed care continues to gain strength. In late November, the REPAIR legal team headed by the anti-tobacco attorney Richard Scruggs filed class action lawsuits against five of the largest HMO’s, who collectively provide health care to 32 million U.S. citizens. The lawsuits charge Humana Inc., Cigna Corporation, Foundation Health Systems, PacifiCare Health Systems and Prudential (recently acquired by Aetna), with violations of both the RICO (the Civil Racketeer Influenced and Corrupt Organizations) and ERISA Acts. A month earlier the team had filed a similar lawsuit against Aetna. According to a report in PRNewsire, Scruggs commented: “We’re acting today to fix the broken promises the HMO industry has made to people who entrust their very lives to these companies.”

This action comes just as managed care gives the appearance of beating a hasty retreat, at least as judged by the actions of United Health Care. In early November, this company — the second largest HMO in the country — announced it was no longer requiring prior authorization for physician-ordered services. However, after folks had a chance to read the fine print, it was discovered that this did not apply to mental health services. It was also suggested that the company would make greater use of provider profiling to keep costs down.

Meanwhile in New England, Harvard Pilgrim Health Care, a major HMO in the region, has become insolvent, leaving 155,000 subscribers scrambling for health care coverage. This HMO was formed not too long ago by the merger of Harvard Community Health and Pilgrim Health Care, two very successful HMO’s. The Providence Journal observed:

“To say that the nation’s network for health coverage is headed for ruin is no exaggeration. We advise against panic, but there is no question that our society’s disorganized tangle of cross-subsidies, free-market mayhem and government inaction is leading to a collapse of the health-care system. If there is a silver lining in this dark cloud, it is the opportunity to start all over and create something simpler, fairer and cheaper.”

“One of the sadder aspects of the Harvard Pilgrim demise is that the HMO was a good one when it came to delivering health care. Its five health-care centers attracted a loyal group of subscribers. It would do things other insurers would not, such as write three-month prescription orders and mail drugs to people who couldn’t leave their homes. Was Harvard Pilgrim tripped up by a race to the bottom, where it had to unrealistically lower its premiums to compete with insurers that skimp on care?…”

“Today’s health-care system has become an elaborate shell game. Elderly and some poor people benefit from government subsidies for health care while more than 40 million taxpayers have no coverage at all. Older Americans enrolled in Medicare pay very high ‘market’ prices for medications, while insurance companies and foreign governments negotiate for bargain rates. Meanwhile, most working Americans have little control over the quality of their coverage. Their employers buy their insurance, and have strong economic incentives to go for the lowest premiums. And hospitals pass on the costs of caring for the indigent to paying customers. Premiums are rising by 10 to 20 percent, even as doctors and nurses find themselves keeping up on an ever faster treadmill of work.”

Primary Care and Scope of Practice

Psychology has been slow to get on the bandwagon of primary care and it is time for us to wake up and smell the coffee. Psychology is central to primary care. Here is exhibit one for this argument: In March, 1999, the American Board of Medical Specialties added the new specialty of Developmental and Behavioral Pediatrics, reflecting the increased interest pediatricians have in dealing with the underlying psychological problems that account for the lion’s share of their patients’ complaints. Furthermore, attaining primary care status cannot be that difficult. In early December, Illinois Blue Cross and Blue Shield announced a decision to let its HMO members to select a chiropractor as their primary care physician, in response to consumer demand.

It is very important that psychology be viewed as a primary health care profession. As a specialty profession in the field of mental health care, we deal primarily with the people who self-identify as having psychological problems and who have access to a mental health specialist, which is just a fraction of those who need psychological services. As a primary health care profession we would be able to serve the much larger group of people who do not self-identify as having a mental health problem. The Cartesian world view, which separates mental health from physical health, is breaking down, and as a result psychology has a tremendous opportunity to evolve into a premier primary health care profession. At the very least this would put psychologists on the front lines of health care, working collaboratively with physicians and nurses. The more visionary — if less probable — perspective is that health care should be reorganized so that psychologists serve as primary caregivers at the gateway to the health care system, functioning to diagnose and treat the more prevalent psychological problems, and referring to medical physicians when indicated.

Meanwhile, medicine continues to lose its rear-guard battle against expanding the scope of practice of other health care professionals. Two stories are worthy of note. Neil Osterweil discussed the expansion of the scope of practice of Pharm.D.’s into psychiatry in an article in Healtheon/WebMD dated 11/29/99. The article quoted Paul Fink, M.D., from Temple University School of Medicine, who said: “In terms of psychiatry, the psychologists have psychotherapy, the pharmacists have medication, and the psychiatrists can go hang themselves out to dry.” The second was an article in the Dayton Daily News on 11/18/99 which reported that the “chief anesthesiologist at the National Naval Medical Center was relieved of his command last week for refusing to place specially trained nurses in charge of administering anesthesia to some patients.”

The Status of Mental Health Services

A major break-though on this front came with the release of U.S. Surgeon General David Satcher’s report in mid-December, the first ever to focus on mental health. This report put the spotlight on the fact that nearly half of all Americans diagnosed with a severe mental illness do not receive needed care because of stigma and financial barriers. Though some have complained that the report was overly medical and did not do justice to psychology and psychosocial interventions, I do think it is very noteworthy that mental health has risen this far on the radar scope of the U.S. Surgeon General. In an article in the Washington Post on 12/13/99, Marc Kaufman reported:

“While Surgeon General David Satcher makes no direct recommendations — except that people with mental disorders should seek help — he does support calls for full “parity” in mental health coverage, saying it is “an affordable and effective objective.” Over the summer, President Clinton required all federal employee health plans to offer the same coverage for mental disorders as for other illnesses, but many other private plans still offer considerably less mental health protection.”

The Treatment of Serious Mental Illness

Finally, I think it is noteworthy that, at least in one state, the decades-long policy of de-institutionalization and neglect may be coming to an end. According to a New York Times report on 11/10/99, N.Y. Governor George E. Pataki announced a plan to stop the practice of emptying the state mental hospitals and called for spending an additional $125 million for supervised housing and other community-based services. Many psychologists recognize that de-institutionalization, which was conceived in the humanitarianism and the idealism of the Community Mental Health Movement, has been a stark failure overall (although there have been some success stories here and there). With the clarity of 20/20 hindsight, we can see that there was insufficient investment in community-based care and psychological rehabilitation to make it work. There was also an over-reliance on psychoactive medications, which (again in retrospect) was terribly short-sighted given the lack of adequate care systems designed to prevent relapses due to non-compliance. In the end, the deinstitutionalization movement succeeded in emptying the beds of the state mental hospitals and filling the streets and jails with chronic mental patients.

However, the reversal of de-institutionalization in NY is coming for all the wrong reasons, namely public fear following several high-profile violent assaults committed by people diagnosed with serious mental illness (despite the evidence that only a small fraction of persons diagnosed with serious mental illness commit violent crimes). William Hammond reported in the Schenectady Daily Gazette on 11/10/99:

“In the wake of a state report criticizing the psychiatric care received by alleged subway pusher Andrew Goldstein, Gov. George Pataki announced Tuesday a series of initiatives designed to help mental patients live safely in the community. Pataki said the state Office of Mental Health would suspend downsizing its psychiatric centers, increase its oversight of privately run treatment programs and invest $125 million in new housing and “intensive case managers” for mentally ill people living in the community. The announcement came four days after the publication of a report by the state’s Commission on Quality of Care for the Mentally Disabled, which found that hospital officials repeatedly discharged Goldstein to an unsupervised apartment in the months before he allegedly attacked Kendra Webdale, despite his history of not taking his medication and becoming violent… Goldstein stands charged with the murder of Webdale, but his recent trial ended with a hung jury.”

Ronald F. Levant, Ed.D., A.B.P.P., is Recording Secretary of the American Psychological Association. He was the Chair of the APA Committee for the Advancement of Professional Practice (CAPP) from 1993-95, a member of the Board of Directors of Division 42 (1991-94), and a member of the APA Board of Directors (1995-97). He is Dean, Center for Psychological Studies, Nova Southeastern University, Fort Lauderdale, FL.

As always, I welcome your thoughts on this column. You can most easily contact me via email: Rlevant@aol.com

Ronald F. Levant, Ed.D.

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				WASHINGTON UPDATE Onward to the Future: Professional Psychology Evolves I am writing this just before Christmas, 1999. As the year-end approaches I find myself increasingly ambivalent about technology. Let me say at the start that I am not a Luddite. I am duly impressed with the wonders of new technology. For examples, E-mail has transformed my life to the point that I almost never need to use the phone and can collaborate on writing, research, and action projects in ways I could not have imagined ten years ago. I am also astonished at new advances in biotechnology such as the recently announced electronic retina that can transmit visual images to the brain. On the other hand, I experience, as I am sure many of you do, that too frequent experience of a crash or bug that sucks up all sorts of time and destroys files, and that no one seems capable of explaining nor advising how to avoid in the future. The thing that really worries me is that we have become very dependent on this new technology yet few of us really understand it, even to the point of being able to know how to readily access truly knowledgeable assistance. One thing is for sure: it will be interesting to see how these remarks sound when they hit print, after 1/1/00. Meanwhile, back in the realm of professional psychology, the last couple of months have witnessed some very interesting developments in the areas of managed care, primary care and scope of practice, the status of mental health services, and the treatment of serious mental illness. Managed Care The fight to roll back the abuses of managed care continues to gain strength. In late November, the REPAIR legal team headed by the anti-tobacco attorney Richard Scruggs filed class action lawsuits against five of the largest HMO’s, who collectively provide health care to 32 million U.S. citizens. The lawsuits charge Humana Inc., Cigna Corporation, Foundation Health Systems, PacifiCare Health Systems and Prudential (recently acquired by Aetna), with violations of both the RICO (the Civil Racketeer Influenced and Corrupt Organizations) and ERISA Acts. A month earlier the team had filed a similar lawsuit against Aetna. According to a report in PRNewsire, Scruggs commented: “We’re acting today to fix the broken promises the HMO industry has made to people who entrust their very lives to these companies.” This action comes just as managed care gives the appearance of beating a hasty retreat, at least as judged by the actions of United Health Care. In early November, this company — the second largest HMO in the country — announced it was no longer requiring prior authorization for physician-ordered services. However, after folks had a chance to read the fine print, it was discovered that this did not apply to mental health services. It was also suggested that the company would make greater use of provider profiling to keep costs down. Meanwhile in New England, Harvard Pilgrim Health Care, a major HMO in the region, has become insolvent, leaving 155,000 subscribers scrambling for health care coverage. This HMO was formed not too long ago by the merger of Harvard Community Health and Pilgrim Health Care, two very successful HMO’s. The Providence Journal observed: “To say that the nation’s network for health coverage is headed for ruin is no exaggeration. We advise against panic, but there is no question that our society’s disorganized tangle of cross-subsidies, free-market mayhem and government inaction is leading to a collapse of the health-care system. If there is a silver lining in this dark cloud, it is the opportunity to start all over and create something simpler, fairer and cheaper.” “One of the sadder aspects of the Harvard Pilgrim demise is that the HMO was a good one when it came to delivering health care. Its five health-care centers attracted a loyal group of subscribers. It would do things other insurers would not, such as write three-month prescription orders and mail drugs to people who couldn’t leave their homes. Was Harvard Pilgrim tripped up by a race to the bottom, where it had to unrealistically lower its premiums to compete with insurers that skimp on care?…” “Today’s health-care system has become an elaborate shell game. Elderly and some poor people benefit from government subsidies for health care while more than 40 million taxpayers have no coverage at all. Older Americans enrolled in Medicare pay very high ‘market’ prices for medications, while insurance companies and foreign governments negotiate for bargain rates. Meanwhile, most working Americans have little control over the quality of their coverage. Their employers buy their insurance, and have strong economic incentives to go for the lowest premiums. And hospitals pass on the costs of caring for the indigent to paying customers. Premiums are rising by 10 to 20 percent, even as doctors and nurses find themselves keeping up on an ever faster treadmill of work.” Primary Care and Scope of Practice Psychology has been slow to get on the bandwagon of primary care and it is time for us to wake up and smell the coffee. Psychology is central to primary care. Here is exhibit one for this argument: In March, 1999, the American Board of Medical Specialties added the new specialty of Developmental and Behavioral Pediatrics, reflecting the increased interest pediatricians have in dealing with the underlying psychological problems that account for the lion’s share of their patients’ complaints. Furthermore, attaining primary care status cannot be that difficult. In early December, Illinois Blue Cross and Blue Shield announced a decision to let its HMO members to select a chiropractor as their primary care physician, in response to consumer demand. It is very important that psychology be viewed as a primary health care profession. As a specialty profession in the field of mental health care, we deal primarily with the people who self-identify as having psychological problems and who have access to a mental health specialist, which is just a fraction of those who need psychological services. As a primary health care profession we would be able to serve the much larger group of people who do not self-identify as having a mental health problem. The Cartesian world view, which separates mental health from physical health, is breaking down, and as a result psychology has a tremendous opportunity to evolve into a premier primary health care profession. At the very least this would put psychologists on the front lines of health care, working collaboratively with physicians and nurses. The more visionary — if less probable — perspective is that health care should be reorganized so that psychologists serve as primary caregivers at the gateway to the health care system, functioning to diagnose and treat the more prevalent psychological problems, and referring to medical physicians when indicated. Meanwhile, medicine continues to lose its rear-guard battle against expanding the scope of practice of other health care professionals. Two stories are worthy of note. Neil Osterweil discussed the expansion of the scope of practice of Pharm.D.’s into psychiatry in an article in Healtheon/WebMD dated 11/29/99. The article quoted Paul Fink, M.D., from Temple University School of Medicine, who said: “In terms of psychiatry, the psychologists have psychotherapy, the pharmacists have medication, and the psychiatrists can go hang themselves out to dry.” The second was an article in the Dayton Daily News on 11/18/99 which reported that the “chief anesthesiologist at the National Naval Medical Center was relieved of his command last week for refusing to place specially trained nurses in charge of administering anesthesia to some patients.” The Status of Mental Health Services A major break-though on this front came with the release of U.S. Surgeon General David Satcher’s report in mid-December, the first ever to focus on mental health. This report put the spotlight on the fact that nearly half of all Americans diagnosed with a severe mental illness do not receive needed care because of stigma and financial barriers. Though some have complained that the report was overly medical and did not do justice to psychology and psychosocial interventions, I do think it is very noteworthy that mental health has risen this far on the radar scope of the U.S. Surgeon General. In an article in the Washington Post on 12/13/99, Marc Kaufman reported: “While Surgeon General David Satcher makes no direct recommendations — except that people with mental disorders should seek help — he does support calls for full “parity” in mental health coverage, saying it is “an affordable and effective objective.” Over the summer, President Clinton required all federal employee health plans to offer the same coverage for mental disorders as for other illnesses, but many other private plans still offer considerably less mental health protection.” The Treatment of Serious Mental Illness Finally, I think it is noteworthy that, at least in one state, the decades-long policy of de-institutionalization and neglect may be coming to an end. According to a New York Times report on 11/10/99, N.Y. Governor George E. Pataki announced a plan to stop the practice of emptying the state mental hospitals and called for spending an additional $125 million for supervised housing and other community-based services. Many psychologists recognize that de-institutionalization, which was conceived in the humanitarianism and the idealism of the Community Mental Health Movement, has been a stark failure overall (although there have been some success stories here and there). With the clarity of 20/20 hindsight, we can see that there was insufficient investment in community-based care and psychological rehabilitation to make it work. There was also an over-reliance on psychoactive medications, which (again in retrospect) was terribly short-sighted given the lack of adequate care systems designed to prevent relapses due to non-compliance. In the end, the deinstitutionalization movement succeeded in emptying the beds of the state mental hospitals and filling the streets and jails with chronic mental patients. However, the reversal of de-institutionalization in NY is coming for all the wrong reasons, namely public fear following several high-profile violent assaults committed by people diagnosed with serious mental illness (despite the evidence that only a small fraction of persons diagnosed with serious mental illness commit violent crimes). William Hammond reported in the Schenectady Daily Gazette on 11/10/99: “In the wake of a state report criticizing the psychiatric care received by alleged subway pusher Andrew Goldstein, Gov. George Pataki announced Tuesday a series of initiatives designed to help mental patients live safely in the community. Pataki said the state Office of Mental Health would suspend downsizing its psychiatric centers, increase its oversight of privately run treatment programs and invest $125 million in new housing and “intensive case managers” for mentally ill people living in the community. The announcement came four days after the publication of a report by the state’s Commission on Quality of Care for the Mentally Disabled, which found that hospital officials repeatedly discharged Goldstein to an unsupervised apartment in the months before he allegedly attacked Kendra Webdale, despite his history of not taking his medication and becoming violent… Goldstein stands charged with the murder of Webdale, but his recent trial ended with a hung jury.” Ronald F. Levant, Ed.D., A.B.P.P., is Recording Secretary of the American Psychological Association. He was the Chair of the APA Committee for the Advancement of Professional Practice (CAPP) from 1993-95, a member of the Board of Directors of Division 42 (1991-94), and a member of the APA Board of Directors (1995-97). He is Dean, Center for Psychological Studies, Nova Southeastern University, Fort Lauderdale, FL. As always, I welcome your thoughts on this column. You can most easily contact me via email: Rlevant@aol.com
		Ronald F. Levant, Ed.D.
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