It will be no surprise to you that I choose to make my comments about the current life of psychologists in the world of managed care. As part of my presidential initiative I created a Task Force on Managed Care with Divisions 42 and 29 combining forces. This task force with my co-chairs Stanley Graham and Jeffrey Barnett set as its mission to be a "strike force" against the managed care industry by publicizing its unethical, unfair, and business oriented behavior which not only took over control of our practices but diminished patient quality of care. Three of my presidential columns in The Independent Practitioner were mostly devoted to rallying our troops to not lay down and die or identify with the aggressor. It is very easy to assume the posture of the enemy when you are frightened of losing your job, and resign you autonomy. It keeps you working even if you aren't happy with your work. In the recent Division 42 survey conducted by our Past President Michael Murphy, 69.5% of the respondents reported highly negative effects from the impact of managed care and 87.5% reported no positive effects. The negative impacts on the practice were decreased income, increased paper wok, and increased contact with third parties. 81.6% said that confidentiality is compromised in the managed care system. 86.2% found that managed care setting of caps on number of sessions interfered with the services they delivered.

These are only part of the data that I have reported to you. For a fuller account of the research, contact Randy Phelps in the APA Practice Directorate. The data is based on work done on two doctoral dissertations by Wendy Shoemaker and Caren DeBernardo at Indiana State University.

In talking with my colleagues around the country I hear a great deal of grumbling, resignation, anger, and dissatisfaction with their work in this managed care system. They discourage their children from entering the field and they look to earlier retirement. Incomes are down and there is bewilderment as to why the business driven interests do not value our profession and respect our patients. When profit is the motive and cost containment the mechanism, you force therapy into abbreviated models only. There is no attention paid to the fact that 25% of our population have been emotionally and physically abused as children and that trauma survivors cannot be treated with abbreviated models. Now, many folks prefer to be treated in just a few sessions. Many folks prefer not to form a relationship with their therapist and work through more chronic and deeper problems but are looking for "quick fixes". If there were such a thing, I would want it also. There are self-anointed prophets in our profession who proclaim that the solo practitioner is a dinosaur. This was predicted 15 years ago. The membership of Division 42 (and we are the largest division in APA) runs contrary to that prediction. They survey data shows that 83% of our member are in solo practice. They obviously haven't gotten the message. Why are they still doing this thing if that's not the way the world is going? The latest issue of the National Psychologist has two articles by entrepreneurs who are wealthy as managed care directors. They organize psychologists into multidisciplinary groups and get contracts to provide services to capitated lives. They are business men who are also psychologists. 83% of us are small business people and don't spend our time administering a managed care company. The ones who do advise us to get on board and do like they are doing. They seem to be happy. We seem to be depressed. We are being told we are a greedy bunch who want to keep things as they were in the golden days of indemnity insurance and haven't adjusted to the new economic climate. What is the new economic climate?

The rising costs of health care galvanized legislators and business people into assuming the leadership in curtailing costs. When business takes over an industry they do it ruthlessly, because empathy, feelings, and consideration are not part of the business lexicon. Enormous profits can be made when business takes over. It comes out of the professionals' pockets and the patients. The CEO of a managed care company had the highest salary of any CEO in America last year. The weirdest thing about this economic climate is that the costs of outpatient therapy over the last 10 years have been flat! I was shown this data by an actuarial psychologist who worked for a large national insurance company. Inpatient costs have skyrocketed which gives a false picture of the outpatient scene. Our patients are put on rationed sessions which saves money. Do our patients know they are being rationed and not getting what they need? I don't think so. We know it and it discourages us. Our patients think something is the matter with them if they don't get betting in the prescribed six sessions. If we have to ask for more sessions they feel they aren't productive enough or maybe the therapist isn't expert enough if he/she can't get the job done in that time. Thus the cost containment mentality interferes with therapy in very fundamental ways. The folks who suffer most under this regime, in addition to our patients, are the therapists who practice with a psychodynamic frame of reference. We approach the patient as more than a bundle of symptoms. Symptoms are like the proverbial iceberg. 10% is showing and 90% is hidden underneath. (The 90% includes unconscious processes, the character structure of the patient, the history that is relevant, and unknown motivations that the patient is only dimly aware of). Before any underlying material surfaces the patient must feel a certain degree of trust and safety. That takes time to develop. The therapist has to earn the patient's trust. It isn't automatically given. Forcing a time limit encourages looking at the symptom only without reference to underlying processes and puts a burden on the therapy which impedes its development. As a result, managed care has taken the Relationship out of therapy and made it into a mechanical act. This doesn't work. People require a relationship as the matrix for the process to unfold. Now much of what I've said here today isn't new to you. You've read it before. But I believe, as president of this division, that it is important for you to hear it from me. How can we maintain our practices in the face of the these conditions and what is being done to fight back?

APA's Approach and Division 42's Approach

APA takes the position through its Practice Directorate that we must do many things to fight managed care. Expanding our practice base, legal and regulatory activities, marketing activities, and public education. For example, they have been intimately involved in the lawsuit brought by the New Jersey Psychological Association against MCC, one of the large MC companies. The suit goes to the heart of the clinical decisions. The suit does much more than simply try to reinstate seven psychologists who were dropped from the panel for "incompatibility with managed care". The funds raised for the suit came from many sources. APA put up $40,000. The suit will ultimately cost $15,000. The rest has come from other associations, individuals, and NJPA. The judge hasn't ruled on whether it will go to court or to arbitration and we requested a court trial. We want the world to know what's going on.

The marketing campaign is aimed at the public to arouse their desire for psychological intervention. We are very proud of that campaign which has won the Silver Anvil Award for the best PR campaign by an association. The campaign has shifted to the state associations who are slowly organizing their own public education efforts with materials from APA.

APA has been involved in lobbying and supporting legislation that puts regulatory mechanisms on the MC industry which is fundamentally unregulated. This is an ever present effort to help legislators understand the abuses of MC. A new law in Texas puts clinical decisions in the hands of clinicians or else the MC company must assume responsibility for decisions that they formerly claimed was the responsibility of clinicians. But of course, the MC company was making major decisions, such as type of therapy, length of therapy, frequency of therapy etc.

Then there is the issue of medical necessity which is the MC industry's buzz word for determining whether the therapy will be reimbursed or not. They reveal no criteria for making that decision and none of their decisions are under public scrutiny. They also seem unaware of how emotional well being impacts on physical well being and vice versa. These are some of the areas that legislation can correct and APA is diligent about going after this.

APA does not take the position that MC is fundamentally immoral and unethical because they feel that's not a useful place to fight. They leave that fight to other groups. Division 42 is one of those other groups. The National Coalition of Mental Health Professionals and Consumers is another such group. The "Summit" is another such group. The latter group which was spearheaded by our former APA President, Dorothy Cantor (who received this Division's Psychologist of the Year Award for 1996) is an organization of all the Mental Health Association Presidents who wrote a Patients Bill of Rights spelling out what patients are entitled to and publicizing this. I can assure you that there isn't an MC company anywhere who isn't violating those rights routinely. The National Coalition is led by Karen Shore. (Who will receive Division 42's Psychologist of the Year Award for 1997). She has led the fight to get rid of MC and is circulating a petition in this issue to send to President Clinton expressing our outrage at the way MC has been operating and offering alternatives. Division 42 is fighting back with my Task Force on Managed Care whose purpose is to publicize the ills of MC and get psychologists, the public, and other professions and consumers aroused to look for other ways to help people in trouble rather than the "cost containment" ways which undermine therapy. Letters to the Editors, articles published (see particularly Ivan Miller's articles on the flawed research on which MC supposedly bases its decisions regarding treatment, in the December 1996 issue of Professional Psychology), interviews with reporters to tell our story etc. I have been criticized for being naive that these efforts are doomed because MC has big bucks and we don't. My sense is that there has been a public outcry and Congress is listening. There are over 100 bills in the hopper to put controls on this unregulated industry. My sense is also that it will take time for these efforts to pay off but we must not let up.

These groups are fighting more out in the open than APA. Our methods differ but our purpose is the same. There are those who believe we should be working to expand our practices and not waste our time fighting an industry that will soon be replaced by something else. I can respect that point of view, but I cannot in good conscience sit back while our autonomy, our prestige, and our moral posture are being attacked. That is not me and if I recall my campaign pledge to you it was built on the idea that we must fight back. I won the presidency with a strong supportive base and you got what you asked for.

Is There a Future for Professional Psychology?

First, let me say the same question was asked 35 years ago when states were involved in securing licensure legislation. There were a hardy bunch of activists who organized the effort in every state and state after state passed the legislation. It took 20 years to become successful in NJ. Our licensing act came into being in 1967. Next came Freedom of Choice Legislation which was passed first in NJ in 1968. We were on a roll and success begat success. The rest of the country followed suit and state associations were becoming stronger and able to learn how to influence the body politic. If you could attend one of the yearly State Leadership Conferences organized by the Practice Directorate you would discover an enormous amount of energy in the attendees, all of whom are actively engaged in furthering organized psychology's presence in the health world. You know those folks are going to get things done. I love the work I do. I know my work is helpful to my patients and my students and their patients. I know it gets discouraging when we face an enemy like MC. But they are not the first ones who tried to stop us from doing good work. First, it was the medical profession.. Then the insurance industry... then it was the public and their fear of the stigma of mental illness.. and it was also our own brothers in experimental psychology who were threatened by the popularity of clinical psychology. We have had to overcome obstacles in our path to creating an autonomous profession from the very beginning. As we became successful, we only discovered there were new obstacles to overcome. APA and its affiliated state associations developed strategies and action plans to further the enhancement of our profession, always keeping in mind that the ultimate beneficiary of our professional work was the public.

It seems that as we have matured as a profession so too have come greater responsibilities and new obstacles. For example, the current ERISA law was not intended to do away with freedom of choice in the states but it is written in such a way that it supersedes insurance laws in the states and exempts self insured companies from following state laws. To amend ERISA takes an act of congress who is not inclined right now to change it the way we want. However, we are chipping away at it by educating legislators to its unintended effects and raising their consciousness that something needs to be done. I am optimistic that eventually we will prevail. We were not recognized in Medicare as independent practitioners for over 20 years as we tried to get the law changed to include us. But we did it! With the help of Senator Inouye and Senator Rockefeller who lobbied their colleagues hard in our interest, we made it into Medicare. Now the elderly have access to our services. Getting the road paved to allow us to travel it is a continuing saga.

Parity of mental health with physical health took some heavy duty work on the part of our Practice Directorate. With Russ Newman and Marilyn Richmond and their staff working on the legislators, and with the help of AAP and its political giving activity, and the grass roots activities of psychologists all over the nation we have built a system that has gained respect in the halls of Congress. This all takes a lot of money, a lot of brainstorming, a lot of activism on the part of individual practitioners. But we never let up and we aren't now as we struggle with the changing health care climate.

MC was the insurance industry's answer to cutting costs. But their answer has created new problems. Costs are cut while the industry makes huge profits. How do we get our message out to the public that what we have to offer them is good for them? That process of public education is not a one shot deal. It must be built into the APA budget as a regular line item. We are able to put $6.5 million into it for the next three years but then what? We better make sure it's a permanent part of our expenses because we need it. I don't think it will be a hard sell with the Council of Representatives. It has already shown good results.

I think the current graduate students may not know the history of how our profession has had to battle its way into existence in law and in the mind of the public. They are attracted to psychology probably the same way we were. It's fascinating. To discover meaning, and change behavior is still the strongest wish of our graduate students. They don't see this as a business but as a helping profession and they want to be there doing just that. What I hope they will also learn is that in order to guarantee their own futures they may have to become activists also. You know the old story of the fellow with the black eye..."Who gave you the black eye?" asks a friend. "Nobody gave it to me. I had to fight for it!", he replied.

Do I believe that we have a future? Absolutely! But it depends on you and the next generation of psychologists. APAGS, our student organization has 60,000 members. They are the future. APAGS has members attending all the major boards and committees of APA and is very involved in securing their own futures. But it isn't guaranteed. Nobody gives it to you. You'll have to fight for it. How can you fight MC? You must support those organizations who are carrying on the fight. You must support your State Association PAC. You must support AAP. You must support them with your money as well as your energy. The other organizations who are actively fighting MC are the National Coalition, that I mentioned before. The American Mental health Alliance is an organization that is springing up in many states. They are a non-profit coalition of mental health professionals who are setting out to contract with industries to provide mental health services without the interference of managed care and without MC profit motive. Support them. Join them.

My message is very simple. All of our gains as a profession came about through hard work and battling other professions and the insurance industry that worked to keep us out. We have been successful. But the beat goes on. We will guarantee our future and the future of our next generation of psychologists by remaining vigilant and of doing what we can to protect our field. This means committing ourselves and our resources to advance our profession in the laws of the land and not to take the current climate for granted but to fight back with all our might. We have come too far to let an uncaring industry dictate what our treatment should be and how to do it. We shall overcome!