National Coalition of Mental Health Professionals and Consumers, Inc.

an educational foundation and advocacy organization serving mental health consumers and professionals

President’s Column                                           

June 2008888

 William McGillivray, PhD

We are roughly midway through the presidential season and healthcare reform is in the air once again, just like in 1992 and the early years of the Coalition. That was a much more hopeful time, or perhaps a more naïve time.  Once again, a Clinton may be responsible for putting together a healthcare plan for the nation.  Come to think of it, it could be the same Clinton! The challenges facing us today are at least the same as they were when the Coalition was founded. It will not come as a surprise to our members, however, that the Coalition’s resources in money and manpower have been substantially reduced over the last few years.  This is the first newsletter we have published in a year and our efforts have been largely confined to electronic communications with colleagues and organizations. I would like to take stock of where we are as an organization and where we as professionals and consumers are in the struggle to preserve privacy, quality, access and choice in mental health and substance abuse care.

What have we accomplished?

Many of you know what we accomplished in the early years of opposition to managed care intrusions into health care.  The National Coalition educated, alerted and energized many of us to fight for our profession and our craft.  We were (and are) the only mental health organization that speaks to the needs of both professionals and consumers and we had a powerful impact on our professional associations.  Sometimes subtle, sometimes strident, our voices were heard in our professional groups.  The American Psychological Association, for example, had to shelve plans to set up a Division of Managed Care. 

Over the last two decades, our professional organizations have come closer to recognizing the importance of the core values of the National Coalition.  The American Psychoanalytic Association (APsaA) has been particularly supportive and was a major supporter of the lawsuit against implementation of the HIPAA privacy rules.  The Coalition continues to be an active member of the Mental Health Liaison Group (MHLG), an association of all major mental health organizations that tracks legislation affecting mental health treatment and funding.

Although our efforts have resulted in mixed success, our organization is the only one, to my mind, that consistently addresses issues of privacy and confidentiality in mental health treatment.  Almost without exception, our professional groups are willing to compromise on this issue.  As noted above, only the American Psychoanalytic supported the lawsuit against HIPAA regulations.  The American Psychological Association (APA) reviewed the lawsuit and refused to join, calculating that the lawsuit would fail and would only alienate the Republican majority in Congress.  When asked about this failure to protect privacy, Russ Newman (of APA’s Practice Directorate) assured us that privacy protections in the individual states would continue to “trump” HIPAA disclosure rules.  The American Psychiatric did issue a position paper that was quite helpful in emphasizing the privacy of psychotherapy notes, but declined to support the lawsuit that was intended to support full guarantees for privacy for citizens.

Our professional organizations have been reluctant to challenge health information technology (HIT) laws meant to set up nationwide databases for health records, falling in line with the idea that these systems can somehow be made secure and holding out only for “guarantees” of security, when the only guarantee of security would be to have each citizen give permission to have records places in such a database.  While it is hard to accurately assess our impact, I do find that APA and other organizations have at least become more sensitive to the issues of privacy over the last few years (after bowing down to HIPAA).  MHLG did issue and alert to member organizations to protest the Health Insurance Marketplace Modernization and Affordability (HIMMA) law, which was defeated (see May 2006 President’s column).

What have we learned?

I think the most important thing we have learned is to focus much more narrowly on what is truly at stake.  In the early years of the Coalition, our efforts were often directed toward all mental health professionals, and indeed, all healthcare professionals and consumers.  We viewed the assaults of managed care as raining down equally on us all; and in many ways this was, and is, correct.  Over the years, however, it is clear that there remains a significant difference between medicine, broadly conceived, and psychotherapy and psychosocial interventions.  For reasons too complicated to address here, professionals who focus on physical treatment, that is drugs and surgery, have a fundamentally different position in the healthcare system and remain far less vulnerable to managed care than psychotherapists and others who focus on psychotherapeutic treatments

The National Coalition certainly welcomes the support of other professional and grassroots organization and seeks way to align our organization with them.  Dave Byrom, chair of our Liaison Committee (as well as former president) has been tireless in reaching out to healthcare activists in New York as well as across the country and has been a powerful voice for mental health care in these groups, groups that frequently overlook or even dismiss the need to incorporate mental health treatment as a core part of healthcare reform.  His role, however, is often an educative one, keeping mental health treatment “on the table.”

Our professional organization have tended to be more concerned with guild concerns that other professions might want to “poach” on their turf; or in the case of APA, want to “poach” on psychiatry’s turf by expanding prescription privileges to psychologists.  The Coalition remains focused on the need to protect all psychotherapists and the right of consumers to seek out any psychotherapist who offers privacy, choice, access and quality in mental health treatment.  This has resulted in our strategic alliance with AMHA and other groups that promote self-pay and other ideas for supporting independent practice of psychotherapy.

Another major thing we have learned is that it is damned hard to come to any consensus on the one best way to pay for mental health treatment.  From the beginning, our organization refused to endorse any specific plans for healthcare reform for two important reasons.  First of all, we found that there was no plan being proposed that came close to incorporating the four principles of our organization.  Although our founder, Karen Shore, and board member Kathie Rudy both developed model plans (available on our web site), and former board member Ivan Miller has a recent book detailing his ideas, we have yet to see a plan proposed by a political party or healthcare advocacy group that fully incorporates our core principles.  These principles have recently been restated and worked into a model document called Essential Elements of Mental Health and Substance Abuse Care and is available in this issue (pages 8-9) and on our web site.

We have planned to use this document as a “template” to review the healthcare plans of the presidential candidates, although one problem at this stage is that their plans, however ambitious, tend to be rather short on details, making it difficulty to directly compare and contrast their plans based on our core principles.  More on this later.

Secondly, the Coalition has been made up from the beginning with those who strongly favored government funding versus those who strongly critiqued any third-party involvement as a threat to our core principles.  This is probably the most important thing we have learned as an organization.  For me, if not for most of us, before managed care came to town insurance and insurance reimbursement were seen more or less as a simple affair and the only task for a clinician was to have access to patients with the “good insurance;” and the main task for our organizations was to promote our profession’s right to access insurance reimbursement (and to keep other professions locked out of same).  As managed care made inroads into our communities and practices, our main goal was to get back to where we were.

This is where many of our board members in the Coalition served an important role in educating us about the role of third-party reimbursement and the impact any such arrangement has on the therapeutic relationship.  Already noted above were Karen Shore and Kathie Rudy’s ideas on “fixing” insurance plans.  Peter Gumpert proposals with the establishment of the American Mental Health Alliance (AMHA) was another set of valuable ideas about how to structure the clinician’s relationship with insurance reimbursement.  Of course there were always psychotherapists who refused third-party reimbursement, insisting that the patient had to deal directly with his/her insurance company rather than involve the therapist in the arrangement.

Ivan Miller and current Coalition vice-president Michaele Dunlap have provided important alternative voices within the Coalition, addressing the questions of entrepreneurship and patient self-pay as a model for practice and practice development.  AMHA is the national organization that best represents this model and asks psychotherapists to see their work and craft as one that is best developed and promoted in a collegial association of likeminded clinicians who offer affordable services without third-party involvement.  This model is the only one so far that does meet the core principles of the Coalition, since it is only by jettisoning third-party involvement that patients can be assured that their privacy access and choice is guaranteed.  This model obviously leaves out many who cannot afford psychotherapy services, but the important challenge of this model is to unrealistic assumptions, often shared by patients (and therapists), that someone else should pay, just as someone else is to blame for their problems.  Many years ago, the chief psychiatrist at a local psychiatric hospital would lecture patients before leaving the hospital on their need to continue individual therapy, insisting that quality psychotherapy was at least worth the price of a good car and that a good care cost $10,000 (this was many years ago!) and two years of therapy would not cost that much.

Another important thing we have learned is to stay open-minded about who are your friends and who are your enemies.  (There is an unfortunate lesson about this on page 12 describing the plight of former board member Harold Eist’s struggle to maintain patient privacy.)  We have found, for example, that libertarian and conservative members of Congress are far more likely to be on our side on issues of privacy and that liberal and progressive politicians have tended to look favorably on programs such as Teen Screen and HIT legislation.

Where are we going?

Our organization continues to be seen as valuable and important by many professional and grassroots organizations.  Through our liaison work and our clear message, the Coalition does have an impact on policy development and position statements.  We have recently had more active involvement from members and colleagues on NCTalk, the Coalition list.  It is encouraging that members are bringing issues, questions and energy to bear on important questions of mental health and substance abuse treatment. We plan to track the healthcare reform debate as the presidential campaigns heat up.  Perhaps there will even be real debates on this issue.  More realistically, we hope to use the  “Essentials” document to educate our political leaders and to encourage our members and colleagues to distribute this document widely as a way to promote a consensus in the mental health community on the need for privacy, quality, access and choice in mental health and substance abuse treatment.

Please continue to read the rest of this issue and to respond to the ideas and concerns expressed by directly contacting me (drmacg@comcast.net) or starting a discussion on NCTalk.