SHAPING THE FUTURE OF MENTAL HEALTH CARE: 
LET YOUR VOICE BE HEARD!

Presentation by:
Karen Shore, Ph.D.
Founder and Past-President
The National Coalition of
Mental Health Professionals And Consumers, Inc.
June 22, 2001
New York City

We have a number of folks who are here because they are mental health patients or family members.  We also have a number of mental health professionals.  Policy-makers often don’t fully trust the professionals because they think that the categories of patients and professionals are two distinct groups.  They are not.  Many mental health practitioners, myself included, are advocating so vehemently because they know emotional pain from both sides of the treatment room and they know what sufficient, high-quality mental health care is from their own experience as patients.

WHY WE NEED TO ELIMINATE THE MANAGED CARE (MC)
INDUSTRY AND ITS CONTROL OVER MENTAL HEALTH CARE. 

Due to under-treatment, the MC industry is responsible for keeping people in pain whom we could heal, and they are responsible for many, many unnecessary suicides and deaths.

MC is responsible for demoralizing a nation of clinicians, forcing them to work in ways they find unethical or abhorrent and by reducing their incomes to fees that were decent in about 1980, damaging them personally and making them too poor to fight the industry effectively.  This is a standard “starve the enemy” tactic.

MC is destroying professional education because now almost all graduate programs and residencies teach only short-term, symptom-focused methods of therapy, feeling they must “train students for the marketplace” rather than for the complex people with complex problems who will seek their help.

 here is what we need in our mental health system:

We must provide the seriously mentally ill with high quality mental health care.  People with serious mental illnesses want to live productive, satisfying lives.  They deserve treatment that can help them do that.  The mentally ill should be living in their family’s homes, their own apartments, or in group homes, not in the streets, the woods, or in prison.  Treatment should be done in offices, clinics, and hospitals, and not left to the prison system!

We must also provide high quality mental health care for people with emotional problems who do not have a serious mental illness.  These folks are disparagingly called the “worried well” to make people think that they need little treatment.  Untreated and under-treated emotional problems lead to medical over-utilization, school problems, prejudice, anger, and hatred; to physical, emotional, verbal, and sexual abuse; to bullying and to kids who bring weapons to school.  They lead to teenage pregnancy, substance abuse, road rage, overeating, smoking, anorexia and bulimia; to problem employees, absenteeism, on-the-job accidents, lowered productivity, and sexual harassment.  They lead to violent crime, vandalism, theft and robbery, and to white collar crimes like cheating and tax evasion and fraud. They lead to poor choices of mates and to messy divorces that devastate children.  Plain and simple, people do not hurt other people when they are emotionally healthy.

You see, almost all our nation’s social problems are largely mental health problems.  We would save vast amounts of money in so many other areas and we would have safe and caring communities if we would just put what was needed into high quality mental health care.  

HOW WE NEED TO SET UP OUR MENTAL HEALTH CARE SYSTEM. 

1.  We need to consider that spending 10% or 14% of the GDP on health care may be a good thing for our people, and that spending 10-20% of the health care dollar on mental health would greatly reduce spending on medical care and ameliorate most of our social problems.

2.  We must end all employer involvement in health care.  Employers now have too much control over patients because they pay the premiums and choose the health plans, and with managed care, employers are defining and making decisions about what mental health care should be about, and this is absurd and unacceptable.

3.  We must remove profit-making corporations from health care.  Like employers, insurance company executives are also defining mental health treatment and making decisions that patients and their clinicians should make.

4.  We must replace the MC industry.  Regulation will never be enough to make MC ok because MC is run by bullies. You cannot just regulate bullies and expect them to behave kindly.  They will take advantage of the mental health patient in any way possible. Bullies must be removed from power. 

5.  In any plan, we must preserve the patient’s right to the Three Fundamental Freedoms of choice, privacy, and control. 

6.  Choice means no lists of “preferred providers” that manipulate and coerce patients and clinicians.  We must abide by the International Code of Ethics which states that practitioners shall not accept conditions of service that do not ensure their professional independence. Clinicians must be free of coercion, fear, and economic intimidation to be able to do what is best for their patients. 

7.  While confidentiality of records is a must, we must also protect personal privacy, which is a different concept.  Personal privacy requires that insurers get no personal information beyond a diagnosis.  It means no pre-authorization and no case reviews unless fraud or abuse is suspected.  Men and women have told me that the pre-authorization utilization review process, where information about their particular problems and symptoms must be divulged to the insurer, makes them feel like they are being mentally raped.  This is damaging to patients and it forces clinicians to go against their own ethics and betray their patients’ sense of privacy.  And my fellow Democrats, please take note.  Every Single Payer proposal I have seen uses this same kind of utilization review. I myself cannot tolerate these procedures as a patient and would not be able to get treatment under these single payer proposals.  If it were illegal to pay out-of-pocket or I couldn’t afford to, I could not get treatment at all.  As a therapist, I could not ethically participate in a single payer plan that uses pre-authorization and utilization review, and I would likely have to leave the field or work illegally.  Planners must understand how harmful intrusion into the contents of therapy can be.

8.  Patients must control decision-making.  This means no managed care.  It also means that all forms of generally accepted treatment be reimbursable, including psychodynamic therapy and psychoanalysis.  I have seen single payer plans that only reimburse cognitive-behavioral therapy.  All generally accepted forms of therapy need to be available and need to flourish for the health of our people.

9.  There should be no for-profit insurers.  A single payer plan might achieve this, though there are significant problems with Medicare and single payer proposals.  Another idea is to have a system of consumer-run not-for-profit association plans.  Each plan would have only one lifetime limit for medical and mental health combined. All plans would have open enrollment with no limits on pre-existing conditions, allowing people who use up their lifetime limit with one association plan to go to another. 

10.  If patients and clinicians are to retain decision-making power and privacy, then we will need cost-control mechanisms that are internal to the patient, balancing freedom with responsibility for costs.  For mental health office visits, we can achieve cost control and retain freedom by having a fixed dollar insurer reimbursement for each visit, with a sliding scale co-pay, negotiated by the patient and clinician.  Government could also kick in part of a co-pay for the poor, the disabled, and those with serious mental illness.  Regional boards could list reasonable fees ranges to guide the patient and prevent price gouging.  If we don’t encourage patients to be cost conscious, someone else will make their decisions for them.  I fear that parity laws might prevent experimentation with new ideas.

11.  A system of fixed fees as in managed care, Medicare, and Single Payer proposals, is detrimental to quality care.  Why?  Because in our field, some people end training with their masters, doctorates, and MDs.  Others feel that their degree is only the beginning, and they may spend 2, 5, 10 years or more and up to $80-100,000 beyond their degrees to take advanced training.  Patients need professionals to get advanced training and professionals need to be able to afford it.  We need a system where clinicians can base their fees on location, talent, training, and experience that also keeps treatment affordable to all.

12.  There is an unfortunate side effect of parity legislation that needs to be corrected:  As we predicted, data is showing that people are getting less treatment with parity than before parity because the MC industry discontinued all its non-parity but unmanaged benefits and put all outpatient treatment, including out-of-network benefits under managed care.  That means short-term therapy and intrusion into personal privacy for everyone. Parity laws must assure that people can choose an unmanaged non-parity alternative that may be limited in reimbursement, but allows them to remain in treatment as long as they need and to protect their sense of personal privacy.  Also, with this option, clinicians who find MC unethical won’t have to work in a way they believe is unethical and harmful. 

13.  No insurance plan should ever prohibit any patient from paying completely out-of-pocket if he or she wants absolute privacy, and it should never be illegal for a practitioner to treat a person who is in pain and wants privacy!

  CONCLUSION

Ethicist Joan Callahan said that finding the most economic solution to a problem may not be to find a morally permissible solution to that problem. MC is not a morally permissible solution, and neither is any plan that deprives patients of choice, privacy, and control over treatment decisions.

The goal of our health plan should be to ensure that the United States is a medically and mentally healthy nation capable of creating a non-violent, caring, compassionate society.  We all need safe, supportive, and caring places in which to live, grow, learn, work, and play.  We should strive to give every child a mentally healthy and mature parent; every employer mentally health employees; every employee a mentally health and mature employer; and every community honest, concerned, involved and caring citizens.

Because almost all our social problems are really mental health problems, there is no better investment in America than accessible, high quality mental health care for all.                                                               

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