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									                                          COALITION REPORT
                                                    The National Coalition Of Mental Health
                                                       Professionals & Consumers, Inc.
                                          Committed to Preserving Choice, Confidentiality and Quality
                                             and to Building a Pro-Consumer Health Care System
                                                                                                   June 2004

BOARD REPORT TO OUR MEMBERS                                               DAVID BYROM, PHD & PAT DOWDS, PHD
I   n the last column, we asked you to support the Coalition
    and the goal of medical privacy through your financial
contributions to the Privacy Legal Defense Fund. At that
                                                                          In any event, this fundraising effort, called for with
                                                                 little notice, continues to bring home the central fact that
                                                                 the few can act for the good of the many.
time, we were still uncertain concerning the status of the                 And the result? The National Coalition met the
lawsuit, Citizens for Health, et al, v. Thompson. Also in that   $5,000 commitment, and our networking and conscious-
issue, the lead attorney for our group of co-plaintiffs, Jim     ness-raising has brought in pledges of more funds. The
Pyles, laid out his case that we had a good chance to over-      collective work of all has raised enough money, for Jim
turn the Bush administration changes to the HIPAA privacy        Pyles to go forward—the Notice of Appeal was filed on
regulations if we went ahead with an appeal of US District       May 27th with the United States Court of Appeals for the
Court Judge Mary McLaughlin’s ruling in the case.                Third Circuit.
          We are convinced that if this appeal does not go                 On our commitment to meet the rest of our pledge,
forward privacy rulings will then continue to shrink per-        the appeal is going forward. Thanks to the generous efforts
sonal rights, with no time in the foreseeable future that will   of our members, we were able to begin our share of the com-
be more opportune for a restoration of our health care pri-      mitment and contribute money to the fund the lawsuit appeal.
vacy rights (e.g., particularly the likelihood of the appoint-             Obviously this is not the end of our fight, of our
ment of more pro-corporation federal judges).                    need for support, OR of our need for your money, and
          At the same time, no appeal could go further unless    your involvement in all ways possible for you! The law-
the co-plaintiff groups, and anyone understanding and            suit appeal is only one part of the broader agenda of the
caring about this grievous loss of privacy, would sign on to     National Coalition and we need your ideas, support, effort
raise additional funds—$85,000 by May 24th. The Coali-           and financial contributions on a regular basis.
tion pledged to raise and deliver $5,000 by this deadline,                 The National Coalition is approaching its 14th year
and to raise, as is necessary, up to an additional $15,000,      in operation. We continue to be the only organization of
during the Appeals process.                                      public interest citizens, consumers and professionals work-
          Over the last month, we have written and called        ing collectively that speaks clearly and strongly for choice,
our members, and myriad other organizational leaders, and        privacy and quality of mental health and substance abuse
asked our members to write and call friends and colleagues,      care for all who need help. We have had successes along
to support our efforts and raise the money to fund this          the way. We have forged common ground with other health
appeal. We have done educational, consciousness-raising          care groups. We have had support from mental health orga-
work with our presentations and disseminated explanations.       nizations, both professional and grassroots.
Some good community organizing and network-building is                   But we find that the forces arrayed against us
ongoing.                                                         remain viable and strong, armed not with ideas and values,
         It is worth noting, by the way, that this request for   but with money and political influence. As Harold Eist
funding by Jim Pyles and his law firm is modest in the           reminded us so many years ago, at our first conference,
extreme. (Jim Pyles himself, is a quiet model of a profes-       being surrounded by your enemies means that you can
sional who works for a higher good.) Jim remains willing         fire in any direction with the hope that you will at least hit
to proceed on this modest sum, since he has been stand-          one of them. We will continue to fight this fight, as long
ing with us and with quality mental health treatment for         as our members stand with us. At our June Board Meeting
many years, as readers of this newsletter may recall. The        we will once again develop goals and an agenda for the
two Philadelphia firms who are co-counsels in the federal        coming year. Let us hear from you. Contact the officers,
3rd Circuit are similarly working with Jim for a nominal         board and committee chairs by e-mailing our president at
fee—nearly pro bono.                                             DaveByrom@optonline.net.

        The final strong pitch again! The National Coali-            c/o NCMHP&C, P.O. Box 438, Commack, New
tion volunteered to initiate this further appeal for funds to        York 11725.
finance the extensive legal work and representation, the         •   When donating as business expenses: to NCMHPC:
amicus brief organizing, and the essential media/publicity           P.O. Box 438, Commack, New York 11725, or on
work, and to be the receiving organization for donations.            our website to be payable to NCMHPC with memo
Please:                                                              “Privacy Legal Defense Fund.”

 •   When donating as charitable contributions to the           Our organization is grateful to you, our nation’s people
     non-profit, 501(c)3: Please make checks payable            are grateful, as the future generations can have health care
     to: Foundation for the Coalition of Mental Health          privacy protection rights established by the highest federal
     Professionals & Consumers, with the memo nota-             courts! Together we are continuing to make an invaluable
     tion of “Citizens Lawsuit” and send to: Foundation,        difference!

                                                                                             BILL MACGILLIVRAY, PHD

F    orget about the search for weapons of mass destruc-
     tion; what we really need is a search for a health care
policy that will work for all Americans. A not very exhaus-
                                                                     a health care plan that meets their needs at a price
                                                                     they can afford. When people have good choices,
                                                                     health plans have to compete for their business
tive survey of the Internet had yielded information about            – which means higher quality and better care.
what the candidates are proposing, although decoding what
these propositions really mean is another undertaking alto-     Ralph Nader’s health care proposals are more straightfor-
gether. John Kerry’s website touts Affordable Health Care       ward, since he favors development of a universal health care
for Every American:                                             system roughly based upon Canada’s, which he would finance
                                                                through a payroll tax as well as corporate profits taxes. He
     John Kerry believes that your family’s health is           would also set strict limits on drug company profits and
     just as important as any politician’s in Washington.       include prescription drug coverage for all in his health plan.
     That’s why he will give every American access to                    Of course, the National Coalition does not endorse
     the health care plan that the President and Mem-           any of the candidates and does not endorse any specific
     bers of Congress already have. John Kerry has the          health care plan. We have endorsed HCAR, the resolution
     courage to take on special interests to get health         before Congress that calls for development of universal
     care costs under control. He will stand up to big          healthcare plan. We have also endorsed or at least encour-
     insurance and drug companies that impede prog-             aged other broad proposals that advance our core agenda of
     ress. John Kerry’s health care plan takes care of our      promoting mental health care that is determined by quality,
     most vulnerable citizens by covering every child           access and privacy. By this standard, none of the major can-
     and preserving and strengthening Medicare.                 didates for president are strongly on our side. Both Bush and
                                                                Kerry propose incremental changes in the health care deliv-
His stated goal is to enroll 27 million currently uninsured     ery system that will allow for-profit insurance companies,
American into health care plans, concluding that 95% of         HMOs, drug companies and others to determine access and
adults and 99% of children would be covered by health care      quality and continue to limit patient choice. While Bush’s
if his plans are enacted.                                       policies are more alarming in threatening dismantling Med-
         President Bush also has a health care plan and         icaid and favoring the wealthy by an almost exclusive reli-
agrees the affordable health care is an important goal:         ance upon tax credits to direct health care spending, Kerry’s
                                                                plan is largely an expansion of existing programs with a
     President Bush’s comprehensive health care agenda          funding scheme that will face considerable opposition in
     improves health security for all Americans by build-       Congress, with Republicans strongly opposed to allowing a
     ing on the best features of American health care. Our      rollback of tax cuts for the most wealthy individuals.
     health care system can provide the best care in the                 Our task, during this election year, is to continue to
     world, but rising costs and loss of control to govern-     promote the core values of the Coalition, while at the same
     ment and health plan bureaucrats threaten to keep          time taking opportunities to engage others in a dialogue
     patients from getting state-of-the-art care. The Presi-    about healthcare initiatives. While we will not endorse a
     dent believes that everyone should be able to choose       specific candidate, we can and will support policies that
                                              COALITION REPORT, JUNE 2004                                                         3.

advance our agenda, oppose policies that limit access, pri-         Later this month, the Coalition Board will hold an in-person
vacy and choice, and support initiatives, such as the Well-         weekend meeting to review our efforts and to identify new
stone Parity Bill, which are not central to our agenda, but         goals and objectives for the coming year. Please be a part
help us build alliances with, and educate, others, both politi-     of this effort by writing to me (DrMacG@bellsouth.net), or
cians and advocacy groups. If we do not have a seat at the          our president, Dave Byrom (davebyrom@optonline.net), to
table, we will never be heard. But I do not think George will       express your ideas, volunteer your efforts, and to help the
be inviting Pat and Dave to the White House any time soon!          Coalition continue its mission.
          There was a recent dust-up on the listserv concern-                 In this current issue, we have an important contri-
ing the posting of a fundraising event for John Kerry. Some         bution from Russ Holstein, who, in addition to his member-
members took exception to what was seen as a partisan               ship in the Coalition, has been involved in the Interdivi-
advertisement. Now, the fact is that anyone can post to the         sional Task Force on Managed Care and Health Care Policy
listserv, and the notice was not placed there by a current          of the American Psychological Association (APA). More
board member, and, in any event, could not be construed             importantly, Russ has been a thorn in the side of managed
as anything other than what it was, an announcement, not            care companies for many years. If all mental health profes-
an endorsement. The National Coalition wants the Bush               sionals had the tenacity of Russ in confronting managed
administration to reinstate the privacy guarantees that were        care abuses, the system would have surrendered a long time
stripped from HIPAA in August 2002. We want it so much              ago. He is at it again, as you will read. In another article,
we are suing HHS and Tommy Thompson (well, we are                   incoming APA president, Ron Levant, addresses the issue
really supporting the Medical Privacy Coalition’s efforts to        of empirically-validated treatment, and the potential misuse
do this, to be precise), but this does not mean we are against      of the very real need to demonstrate efficacy and effective-
all the Bush administration proposals.                              ness in saddling the mental health profession with an overly
          I also have been referring to “we” quite a bit            narrow view of how treatment works and what is effective.
throughout this column; but I will also note that the “we”                    There is a reprise of the Privacy Form, developed by
of the Coalition is, and continues to be, diverse. Medical          Pat Dowds, and the Privacy Petition, developed by American
Savings Accounts? National Health Insurance? Managed                Mental Health Alliance. These forms should serve as potent
Cooperation? Single Payer? There are members (and board             weapons in the fight against privacy inroads sanctioned by
members) of the Coalition who strongly support one or               the Bush administration. This brings us to the roundups of
more of these proposals, and there are members (and board           news items, featuring a number of articles that compare and
members) who just as vehemently oppose these options.               contrast the Bush and Kerry positions on health care. There
We are held together by our determination to support any            rest of the issue is the usual grab bag of items, although one
plan that advances access, privacy and choice in mental             deserves further mention. Kathie Rudy sent me the Scotsman
health care. That is our sole mission as an organization.           joke that you will find on page 18. Personally, I find it offen-
                                                                    sive and an affront to my forebears, but what can you do?

N     ow, to change gears a bit and talk about the Coali-
      tion Report. This issue marks the completion of my
fourth year as editor of the newsletter. The Coalition has
                                                                    Given the fiscal prodigality in my own lineage, I have never
                                                                    really understood Scotsman jokes anyway, and, besides, we
                                                                    really dinna’ talk thot way, mon.
gone through a great many changes in the last four years, not
the least of which has been the change in leadership from
                                                                      The Coalition Report is published 6 times
Karen Shore, to Deborah Peel, to our current president, Dave
Byrom. Probably more central has been our ongoing search              per year by the National Coalition Of Mental
to find ways and opportunities to highlight our central mis-          Health Professionals & Consumers, Inc.
sion and to grow the Coalition in membership and resources            Deadline for submission of articles is the 1st
to the point that we can make a significant contribution to           of January, March, May, July, September and
the national debate on health care and mental health care             November. All articles must be sent as a disc
specifically. I do not think it is too much of a shocker to point     or attached file in Word or “text only” format.
out that we have yet to find a way to make our influence felt         All announcements and advertising must be
in the ways we would wish. We have continued to depend                sent as camera ready copy. For additional
upon the energy of a few members to carry on the work of              information, contact the editor, Bill MacGil-
the Coalition and to rely upon the financial support of our
                                                                      livray, 7 Forest Court, Knoxville, TN 37919,
members to fund these efforts. We have had, and will con-
                                                                      Phone and Fax: (865) 584-8400, E-mail:
tinue to have successes, primarily in developing contacts and
support among professional and grassroots advocacy groups.            DrMacG@Bellsouth.net

This article was originally published in the Spring 2004         ity went nowhere. I was referred “upstairs” to administra-
issue of the Independent Practitioner, the official publica-     tors, some of whom asked that I submit my questions in
tion of Psychologists in Independent Practice, a Division of     advance. When I did, they did not get back to me. Along
the American Psychological Association, and is reprinted         the way, I did speak to a psychiatrist in the regional admin-
with permission.                                                 istrative office. He advised that the survey would reveal
                                                                 that like any HMO, Kaiser was an “overburdened system.”

T      he American Psychological Association Practice
       Directorate’s managed care legal strategy has cul-
minated with a lawsuit involving the Virginia Academy
                                                                          My third effort was far more successful. I was able
                                                                 to complete the questionnaire with a Northern California
                                                                 facility with three very cooperative individuals, all of who
of Clinical Psychologists against Care First and Value           happen to be psychologists.
Options (Holloway, 2003). In this legal case, which has                   Efforts at virtually every other facility I called were
been partially resolved, it is alleged that Care First and its   routinely met with resistance and/or referral to administra-
mental health subcontractor failed to provide the services       tors who did not respond to my efforts to be allowed to
it promised to consumers. This was accomplished, the law-        contact potential respondents.
suit alleges, via the lowering of fees paid to providers with
subsequent provider resignation resulting in a “phantom          SURVEY RESULTS
network.” Holloway indicates that the lawsuit holds “the         In spite of the small response rate, there was some con-
companies accountable for essentially putting profits ahead      sistency in the answers provided and suggestions that the
of patients--by not providing the services it provided to        quality of care and accessibility problems that led to the
consumers or providers….”                                        strike in Colorado a few years ago still existed. To summa-
          The allegation that the push for profits resulted in   rize the results, new patients are seen very quickly, usually
the failure to provide mental health services to patients,       the same day or immediately in an emergency. A two-week
brought to my mind a strike that took place at a Kaiser          wait for an appointment is unusually long, based upon
Permanente facility in Colorado (Herz, 1998). At this facil-     the five respondents. Regarding concerns that the length
ity, treating clinicians were expected to integrate ten new      or frequency of individual treatment was restricted, some
patients a week into their caseloads. The question arose as to   respondents mentioned this was a concern. Most clearly,
the adequacy of care that resulted from this policy. A group     at a Northern California facility, it was mentioned that the
of clinicians staged a job action to protest what they felt      ubiquitous use of group psychotherapy compensated for
were requirements that interfered with adequacy of services.     limited access to individual treatment. The two Colorado
          With that in mind, I decided to attempt to design      respondents also emphasized the almost universal reliance
a simple study that would look at the services Kaiser was        on group psychotherapy. In this part of my research and in
offering and evaluate these services in regard to access and     the subsequent investigations, there was a feeling that indi-
availability. A seven-item questionnaire was prepared (see       vidual, weekly psychotherapy is, as one Northern Califor-
Table 1). My intention was to call 3 or 4 random Kaiser          nia respondent put it, “not a covered benefit.”
facilities and speak to three clinicians: an intake clinician             There was disagreement as to whether patients are
and two treating psychologists.                                  informed of practices or circumstances that limit access to
                                                                 individual treatment and the frequency with which such
RESPONSE RATE                                                    treatment can be obtained (e.g. less than weekly individual
My first call began auspiciously enough with an intake           therapy, even when weekly would be optimal). The ques-
worker at a Kaiser mental health facility in Colorado offer-     tion regarding the requirement of a certain number of
ing to answer the questions freely. After that, things became    intakes per week resulted in consistent answers. In the
difficult. I was able to get only one other psychologist to      Colorado facility the number was eight and in the Northern
answer the questions and finally I was referred to people at     California facility the number was seven.
the facility who identified themselves as “administrators,”               The answer to question five suggested that, in fact,
who asked that I cease and desist my efforts to pursue the       because of the large number of new patients, patients are
study. Reluctantly I did at this facility.                       not free to choose their own treatment modality. To the
         Phone calls to a Southern California Kaiser facil-      extent that they would like to have weekly individual (or
                                             COALITION REPORT, JUNE 2004                                                        5.

conjoint and/or family) visits, this is not an available treat-   Hawaii and Southern California. In all cases I called indi-
ment modality. Weekly sessions are a luxury afforded to           cating that I had a patient being transferred by his employer
very few. If one compares the seven or eight new patients         who needed to choose quickly between a fairly generous
to be integrated per week, subtracting out the fact that          Kaiser mental health benefit and a somewhat less generous
Kaiser utilizes a model that emphasizes group psychother-         Blue Cross /Blue Shield plan. I indicated that I had con-
apy, no more than 24 hours per week are available in the          tacted a colleague who worked at a Kaiser facility but not
schedule to provide individual psychotherapy. This was the        the one within proximity to where my patient was being
highest number offered by any of the respondents to the last      transferred. I indicated I had been instructed to call the
question; others indicated as few as 16 hours/wk available        closest Kaiser mental health facility to my patient’s new
for individual therapy.                                           location and ask about the requirement of treating clinicians
                                                                  having to integrate a quota of new patients each week.
DISCUSSION—TREATING CLINICIANS ARE MORE LIKE                      Accordingly, my colleague suggested that this would give
GREETERS THAN TREATERS                                            me a clear indication as to the adequacy of the services pro-
Despite a small number of responders, the answers raise           vided under the proposed Kaiser benefit.
questions about what is going on in Kaiser facilities. I pro-              Of the facilities I contacted, only one facility in
pose Kaiser attempts to look good by offering virtually no        Georgia indicated that there was no limitation on treatment
waiting list for new appointments. However, Kaiser comes          and weekly psychotherapy. The person at the facility was of
off exceptionally badly, even as compared to other man-           the opinion that a quota of new patients was not a require-
aged care plans, in the way they overburden the treating          ment of treating clinicians. In Southern California, the
clinicians with new cases. The requirement that therapists        respondent indicated that they did not know of a quota but
have to handle seven or more new intakes per week makes           added that weekly psychotherapy was not available except
weekly psychotherapy, other than group, a virtual impossi-        in a crisis. In all the other locations, there were quotas. In
bility. As each treating psychologist is expected to integrate    Northern Ohio, the new patient quota was ten and indi-
seven or eight new patients into their case loads, the state-     vidual psychotherapy was something that they “don’t
ment by one of the Northern California respondents that,          traditionally do.” In Oregon the number of new patients
“Kaiser treating clinicians are more like greeters than treat-    seen per week was seven but it was indicated that weekly
ers” makes sense.                                                 psychotherapy was available. It was mentioned that outside
                                                                  treatment with specially contracted therapists was avail-
FROM INVESTIGATIONAL SURVEY TO INVESTIGATIVE                      able for those with better benefits and those patients were
JOURNALISM                                                        more likely to have weekly, individual psychotherapy. This
The effort to do a clean survey was sabotaged. Administra-        apparently was also true in the greater Washington, DC
tors did not provide access to intake or treating clinicians      area. In the greater Washington, DC area, the person indi-
so the survey could be done. The clinicians who did answer        cated the number of new patients seen per week was chang-
the questions raised serious concerns about under treating        ing from six to seven but had previously been four. That
and poor accessibility to individual psychotherapy. Because       person indicated it was rare for someone to be seen weekly
of this, it is reasonable to assume that Kaiser is withhold-      due to the large volume of patients. In Hawaii, the quota
ing information about its policies. This assumption is given      was for seven to eight new patients to be integrated weekly.
more credibility in light of the report by union officials
following the Colorado job action in 1998 that clinicians         FURTHER DISCUSSION – TRIAGE AS TREATMENT:
were gagged to talk about certain Kaiser policies (Miller,        It should come as no surprise that at many of the Kaiser
personal communication). As it became clear the only way          facilities I contacted, the initial patient evaluation is called
to do this survey at most Kaiser facilities would be with a       “triage,” not “intake.”
Court Order requiring clinicians to answer truthfully and a                According to the individual I spoke to in the DC
Gag Order on administrative and public relations person-          area, Kaiser has a philosophy of wanting their clinicians to
nel, I decided to pursue only the fourth survey question to       relate to patients in a way that generates the greatest sat-
create discussion in other Kaiser facilities.                     isfaction with services, rather than the greatest benefit to
          This question seemed to provide the greatest indi-      the patient. This leads to the cynical conclusion that Kaiser
cation as to whether or not Kaiser is providing for the range     Permanente is committed to providing less than the stan-
of services necessary to provide adequate mental health           dard of care but in a way that “cools the mark out.” (Goff-
care. A facility at each of the following locations was con-      man, 1952) This phrase has to do with con artistry. It relates
tacted: Georgia, suburban Washington, D.C., Ohio, Oregon,         to how to deal with a person who has been the victim of

a con so as to calm them and make them less incendiary,            ing the quality and cohesion of group. At Kaiser, group psy-
perhaps even appreciative. This is a notion that should chill      chotherapy is the way to pretend that patients are not kept
any clinician who has concern about providing adequate             on a waiting list. In sum, at Kaiser, mental health problems
services to patients. And with this, there is one significant      are, in my opinion, frequently under-treated, and I have
question that needs clarification. How is it that a large facil-   concluded that attempts at member satisfaction are substi-
ity such as Kaiser does not create significant clinician out-      tuted for appropriate mental health treatment. Sitting just
rage at their being required to offer phantom services?            beneath the surface appears to be an attempt to save money.
         As noted above, the settlement of the Colorado                      To the point, a look at a Kaiser master contract
Kaiser job action involved “gagging” the clinicians. The           indicates that outpatient visits/psychotherapy are provided
appearance is of a company that causes clinicians to fear          for up to 20 individual and/or group psychotherapy visits
speaking out against conditions that might be considered           per calendar year. However, many Kaiser benefits do not
sub-standard.                                                      offer these limitations. In the contract I reviewed, beyond
         While it is my opinion that there are a number of         the limit of 20 visits, an additional 20 may be offered so
clinicians who are very fearful that their deliberate or inad-     long as they are for group psychotherapy if they “meet
vertent critical comments could get them in trouble, it was        medical group criteria”. Severe mental illness and serious
also my impression there were a number of clinicians who           emotional disturbance are given unlimited coverage. But
bought the notion of patient satisfaction as the most impor-       in actual fact there is no way an individual could obtain up
tant product and who genuinely felt by providing a pleasant        to 20 individual, psychotherapy visits/year at most Kaiser
demeanor, they would obtain better results than providing          facilities due to the requirement for large numbers of new
adequate treatment. The problem with Kaiser’s emphasis             intakes each week. This discrepancy should be investigated.
on group psychotherapy is that there is little evidence that
group psychotherapy fits most patients with some evidence          DOES KAISER VIOLATE THE LAW?
clearly against such a primary modality. My experience             Kaiser Permanente walks a very fine line with regard to
and the experience of others is that many clients will forgo       violation of law. While there is a clear violation of morality
treatment rather than attend group psychotherapy. Success-         by not offering services Kaiser patients need, the question
ful group psychotherapy requires a strong commitment and           as to whether they violate the law probably will not get
those patients who are not committed drop out, deteriorat-         addressed by regulators. This is despite the fact Kaiser indi-

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                                             COALITION REPORT, JUNE 2004                                                              7.

cates in its plan documents that individual psychotherapy         “HEDIS (Health Plan Employer Data and Information Set)
of up to 20 or more visits a year is something patients are       was developed by NCQA and is a set of standardized per-
entitled to. The failure to actually provide individual psy-      formance measures designed to ensure that consumers have
chotherapy does not get Kaiser within the purview of State        the information they need to reliably compare the perfor-
regulators. The main reason for this is clear. State regula-      mance of health care plans. Our HEDIS scores rank us as
tors receive complaints from health consumers. Yet, mental        one of the top health plans in the nation.”
health consumers are probably the least likely individuals                 I called NCQA and spoke to Barry Scholl of NCQA
to complain about the inadequacies of mental health care,         Marketing and Communication. He indicated that, “what
so these concerns fail to come to the attention of regulators.    is important to NCQA is that health plans are making treat-
         Additionally, in this writer’s experience in New         ment decisions that are based on the best available medical
Jersey, state regulators refuse to listen to the complaints of    evidence and are appropriate to the individual’s particular
health care providers against managed care organizations.         needs.” I shared with him my findings and my concerns that
Their assumption is that health care providers do not like        Kaiser’s one size fits most philosophy goes against NCQA’s
managed care organizations and therefore will make com-           priority that treatment decisions are appropriate to the
plaints. Sadly, this disempowers health care providers whose      patients particular needs. He allowed that NCQA has very
aim is to see more adequate services provided.. It is probably    limited standards to evaluate mental health treatment in the
true in each of the states where Kaiser services are offered      plans they accredit. They are working on them. I offered to
that provider complaints will land on regulator’s deaf ears.      help and gave him my contact number so they can speak to
          It is hoped consumers will be alerted to the inad-      me and am holding my breath waiting.
equacy of services provided at Kaiser by those who read
this article. Affected consumers are urged to make contact        REFERENCES
with state regulators. If consumers confront regulators, they     Goffman, Erving, (1952). On Cooling the Mark Out. Psychiatry:
will be forced to review the issue of phantom mental health         Journal of Interpersonal Relations 15:4, pp 451-463.
services at Kaiser facilities.                                    Herz, Gordon, (1998). Therapists Dodge Bullet – Kaiser Perma-
                                                                    nente Holds Smoking Gun. Retrieved December 8, m 2003,
                                                                    from http://www.drherz.us/ProfessionalResources.htm.
IS THERE ANOTHER WAY TO ADDRESS KAISER’S                            Holloway, Jennifer Daw, (2003). Virginia Managed-Care
DEFICIENCIES?                                                       Finally Heads to Trial: Monitor on Psychology 34:4 p. 24.
While considering this question, I got a letter from Kelli        Kane, Kelli, personal communication.
Kane, LCSW, Manager of Behavioral Health for Kaiser               Miller, Ivan, personal communication.
Permanente-Colorado Region. She writes, “An independent           Scholl, Barry, personal communication.
research company measures patient satisfaction for the
                                                                   TABLE 1: Seven Item Questionnaire
Behavioral Health Department on a quarterly basis. This            1. How soon can somebody be seen?
past quarter 90% of our patients rated their overall satis-                   a. In an emergency
faction with our service as excellent or good. 87% of our                     b. In a non-emergency
patients stated their needs were met extremely or very well.                            i.Adult
93% of our patients were satisfied with the amount of time                              ii. Child
they spent with their therapist.”                                  2. Are there any situations or circumstances that result in
         Once again, Kaiser may be very good at generat-               restricting the length or frequency of individual treatment?
ing patient satisfaction data. I’m sure Kaiser therapists are          What are these situations and/or circumstances?
excellent ambassadors for their employer. They’d better            3. Are patients informed of these practices, if so, how?
                                                                   4. Is there a policy or practice that requires a number of
be if they wish to keep their jobs. Kaiser’s independent
                                                                       intakes per week per treating practitioner?
research pursues patient satisfaction data, not patient out-       5. Are patients free to choose the treatment modality (e.g.,
come. There is a difference. Ms. Kane continues, “Patient              individual, family, couple or group psychotherapy) that
satisfaction with their initial appointment access and                 they will be most comfortable with?
appointment frequency was at a record high of 86%. Our             6. Are weekly individual psychotherapy sessions available to
routine access for a new appointment is 14 calendar days for           those who need it (e.g. a bona fide DSM IV Axis I diag-
a psychiatrist and 8 calendar days for a clinician. This is the        nosis)?
NCQA benchmark and exceeds the community standard.”                7. Putting aside times for ongoing group psychotherapy and
         As mentioned above, Kaiser’s intake abilities are             staff meetings, new intake appointments, administra-
excellent. Patients are seen quickly and triaged (to use               tive functions such as report preparation, etc, how many
                                                                       hours remain per week for ongoing individual, conjoint or
their term) quickly. That is both their strength and their
                                                                       family therapy for the average therapist?
deficiency. Her consideration of NCQA goes on to say that,

This article is adapted from Levant, R. (in press). The             alization. Longer term, more complex approaches (e.g.,
empirically-validated treatments movement: A practitioner-          psychodynamic, systemic, feminist, and narrative) were not
educator perspective. Clinical Psychology: Science and              well represented.
Practice and originally appeared in Psychologist-Psycho-                      The empirically-validated treatments movement
analyst, the newsletter of the Division of Psychoanalysis of        has had quite an impact on practitioners. It provided ammu-
the American Psychological Association, and is reprinted            nition to managed care and insurance companies to use in
here with permission.                                               their efforts to control costs by restricting the practice of
                                                                    psychological health care (Seligman & Levant, 1998). It

I   would like to weigh in on the issue of what has been
    called, sequentially, “empirically-validated treatments”
(APA Division of Clinical Psychology, 1995), “empirically-
                                                                    has also influenced many local, state and federal funding
                                                                    agencies, which now require the use of empirically-vali-
                                                                    dated treatments. Moreover, this movement could have
supported treatments” (Kendall, 1998), and now “evidence-           an even greater impact on practitioners in the future. For
based practice” (Institute of Medicine, 2001).                      example, it could create additional hazards for practitio-
          Empirically-validated treatments is a difficult topic     ners in the courtroom if empirically-validated treatments
for a practitioner to discuss with clinical scientists. In my       are held up as the standard of care in our field. Further,
attempts to discuss this informally, I have found that some         adherence to empirical-validated treatments could become
clinical scientists immediately assume that I am anti-sci-          a major criterion in accreditation decisions and approval
ence, and others emit a guffaw, asking incredulously:               of CE sponsors, as the Task Force urged (APA Division of
“What, are you for empirically unsupported treatments?”             Clinical Psychology, 1995, p. 3). Some clinical scientists
McFall (1991, p. 76) reflects this perspective when he              have gone so far as to call for APA and other professional
divides the world of clinical psychology into “scientific and       organizations “to impose stiff sanctions, including expul-
pseudoscientific clinical psychology,” and rhetorically asks,       sion if necessary,” against practitioners who do not practice
“What is the alternative (to scientific clinical psychology)?       empirically-validated assessments and treatments (Lohr,
Unscientific clinical psychology.” (see also Lilienfeld,            Fowler & Lilienfeld, 2002, p. 8).
Lohr, & Morier, 2001).                                                        Given all of this fallout, it should be no surprise
          There are, thus, some ardent clinical scientists (e.g.,   that the Task Force report was soon steeped in controversy.
McFall and Lilienfeld) who appear to subscribe to “scien-           Critics argued first and foremost that the Task Force used a
tistic faith,” and believe that the superiority of scientific       very narrow definition of empirical research. For example,
approach is so marked that other approaches should be               Koocher (personal communication, 7/20/03), observed that
excluded. Since this is a matter of faith rather than reason,       “ ‘empirical’ is in the eye of the beholder, and sadly many
arguments would seem to be pointless. Nonetheless, clini-           beholders have very narrow lens slits. That is to say, quali-
cal psychologists have argued over it, a lot, for the last          tative research (and) case studies… have long been a valu-
eight years. Punctuating these interactions from the prac-          able part of the empirical foundation for psychotherapy,
titioner perspective, the controversy seems to stem from            but are demeaned or ignored by many for whom ‘empirical
the attempts of some clinical scientists to dominate the            validation’ equates to ‘randomized clinical trial’ (RCT). In
discourse on acceptable practice, and impose very narrow            addition, a randomized clinical trial demands a treatment
views of both science and practice.                                 manual to assure fidelity and integrity of the intervention;
          Let’s start with a brief recapitulation of the events.    however, the real world of patient care demands that the
Division 12, under the leadership of then-President David           therapist (outside of the research arena) constantly modify
Barlow, formed a Task Force “to consider methods to                 approaches to meet the idiopathic needs of the client…
educate clinical psychologists, third party payers, and the         Slavish attention to ‘the manual’ assures empathic failure
public about effective psychotherapies” (APA Division of            and poor outcome for many patients.”
Clinical Psychology, 1995, p. 3). The Task Force came up                      Furthermore, Seligman and Levant (1998) argued
with lists of “Well-Established Treatments” and “Probably           that, efficacy research programs based on RCT’s may have
Efficacious Treatments.” Not surprisingly, the lists them-          high internal validity, but they lack external or ecological
selves emphasized short-term behavioral and cognitive-              validity. On the other hand, effectiveness research, such as
behavioral approaches, which lend themselves to manu-               the Consumer Reports study (Seligman, 1995), has much
                                           COALITION REPORT, JUNE 2004                                                        9.

higher external validity and fidelity to the actual treatment   20% of the white, middle class, patients who come to us,
situation as it exists in the community. Additional effec-      the average practitioner would have to spend many, many
tiveness studies are needed, and could be conducted by the      hours, perhaps years, in training to learn these manualized
Practice-Research Networks that have recently appeared          treatments. And if we restricted ourselves to use only these
(Borkovec, Echemendia, Ragusea, & Ruiz, 2001). Finally,         manualized treatments, we would be limiting our role to
others have pointed out that many treatments have not           that of a technician. And, in the end, these treatments would
been studied empirically, and that there is a big difference    only account for 15% of the variance in therapy outcomes
between a treatment that has not been tested empirically,       in these patients. One can readily see why few practitioners
and one that has not been supported by the empirical evi-       embrace the empirically-validated treatments movement.
dence.                                                                    In my view, although one of psychology’s strengths
         A few years later, John Norcross, then-President,      is its scientific foundation, the present body of scientific
of Division 29 (Psychotherapy), countered by establishing       evidence is not sufficiently developed to serve as the sole
a Task Force on Empirically Supported Therapy Relation-         foundation for practice. Practitioners must be prepared to
ships, which emphasized the person of the therapist, the        assess and treat those who seek our services. To be sure,
therapy relationship and the non-diagnostic characteristics     we all get referrals of clients that we decide to refer to
of the patient (Norcross, 2001). Lambert and Barley (2001)      others because we don’t think that we are the best clini-
summarized this research literature, pointing out that spe-     cian for that case, but those who are in general practice
cific techniques (namely those that were the focus of the       have to work with the clients that come to us. Whether we
studies underlying the Division 12 Task Force Report)           operate from a single theoretical perspective or are more
accounted for no more than 15% of the variance in therapy       eclectic, we bring to bear all that we know from the empiri-
outcomes. On the other hand, the therapy relationship and       cal literature, the clinical case studies literature, and prior
factors common to different therapies accounted for 30%,        experience, as well as our clinical skills and attitudes, to
patient qualities and extra therapeutic change accounted for    help the client that is sitting in front of us. This is what
40%, and expectancy and the placebo effect accounted for        is often referred to as clinical judgment. Some condemn
the remaining 15%.                                              clinical judgment as subjective. To them I say that clini-
         Westen and Morrison (2001) reported a multidi-         cal judgment is simply the sum total of the empirical and
mensional meta-analysis of treatments for depression, panic     clinical knowledge and practical experience and skill which
disorder, and GAD, in which they found that “the majority       clinicians bring to bear when it is our job to understand and
of patients were excluded from participating in the aver-       treat a particular and very unique person.
age study,” due to the presence of comorbid conditions (p.                Fox (2003) goes even further, pointing out that in
880). Approximately 2/3 of the patients in the studies they     many learned fields science and practice are often separate
reviewed were excluded, which seems like a high percent-        endeavors, and that practice often has to precede science.
age, but is actually a bit lower than national figures for      Physicians were treating cancer long before they had much
comorbidity. Meichenbaum (2003) noted that fewer than           of an idea of what it was, and were using pharmaceutical
20% of mental health patients have only one clearly defin-      agents like aspirin long before the pharmacodynamics were
able Axis I diagnosis. Thus, the vast majority of cases seen    known. To quote Fox (2003):
by practitioners do not meet the exact diagnostic criteria
used in the RCTs that established efficacy for various treat-       The fact of the matter is that if clinicians restrict them-
ments.                                                              selves to applying only narrowly validated or known
         Furthermore, the empirically-validated treatments on       techniques, they will never be of much value to soci-
these lists have typically been studied using homogeneous           ety. Lest you think that statement is an invitation to
samples of white, middle class clients, and therefore have          charlatanism, remember that clinicians do not have the
not often been shown to be efficacious with ethnic minority         luxury to start from what is known. They must start
clients.                                                            with the needs of the people who come to them and
         So what does this all mean? Suppose we had lists           then apply all the knowledge, information and skill
of empirically-validated manualized treatments for all DSM          they have to help resolve those problems.
Axis I diagnoses (which we are actually a long ways away
from). We would then have treatments for only 20% of            On the other hand, we do have a problem of accountabil-
the white, middle class, patients who come to our doors,        ity in health care, one that will surely affect psychology.
namely those who meet the diagnostic criteria used in           For example, the current lag between the discovery of
studies that validated these treatments. That’s bad enough,     more effective forms of treatment in health care and their
but that’s not all. In order to limit services to only these    incorporation into routine patient care is, on the average,

17 years. DeLeon (2003) predicts that health care in the        REFERENCES
21st century, abetted by technology, will be characterized      American Psychological Association Division of Clinical Psy-
by even greater accountability for practitioners, due to the       chology (1995). Training in and dissemination of empirically-
combined effects of the increasingly well-informed health          validated psychological treatments: Report and recommenda-
care consumer, who gathers relevant health care informa-           tions. The Clinical Psychologist, 48, 3-27.
                                                                Borkovec, T. D., Echemendia, R. J., Ragusea, S. A., and Ruiz, M.
tion from the Internet, the increasingly well-informed prac-
                                                                   (2001). The Pennsylvania Practice Research Network and pos-
titioner, who will be able to obtain best practice informa-
                                                                   sibilities for clinically meaningful and scientifically rigorous
tion from a PDA, and increased monitoring of health care           psychotherapy effectiveness research. Clinical Psychology:
practices, to flush out variation in treatment for specific        Science and Practice, 8, 155-167.
diagnoses. In this environment we are going to need better      DeLeon, P.H. (2003). Remembering our fundamental societal
ways to evaluate practice. I would suggest that we consider        mission. Public Service Psychology, 28, 8, 13.
using the broad and inclusive definition of evidence-based      Fox, R. E. (2003, August). Toward creating a real profession
practice adopted by the Institute of Medicine (2001). This         of psychology. Paper presented at the Annual Meeting of
definition consists of three components: best research             the American Psychological Association, Toronto, Ontario,
evidence, clinical expertise, and patient values. The defini-      Canada.
                                                                Gonzales, J.J., Rngeisen, H. L., & Chambers, D. A. (2002). Clini-
tion does not imply that one component is privileged over
                                                                   cal Psychology: Science and Practice, 9, 204-220.
another, and provides a broad perspective that allows the
                                                                Institute of Medicine (2001). Crossing the Quality Chasm: A new
integration of the research (including that on empirically-        health system for the 21st century. (2001). Institute of Medi-
validated treatments and that on empirically supported             cine: Washington, DC.
therapy relationships) with clinical expertise and, finally,    Kendall, P. C. (1998). Empirically supported psychological thera-
brings the topic of patient values into the equation. Such         pies. Journal of Consulting and Clinical Psychology, 66, 3-6.
a model, which values all three components equally, will        Lambert, M. J., & Barley, D. E. (2001). Research summary on the
better advance knowledge related to best treatment, and            therapeutic relationship and psychotherapy outcome. Psycho-
provide better accountability.                                     therapy: Theory/Research/ Practice/Training, 38, 357-361.
                                                                Lilienfeld, S.O., Lohr, J. M., & Morier, D.(2001). The teaching of
                                                                   courses in the science and pseudoscience of psychology: Useful
                                                                   resources. Teaching of Psychology, 28, 182-191
                                                                Lohr, J. M., Fowler, K. A., & Lilienfeld, S. O. (2002). The dis-
                    NATIONAL COALITION                             semination and promotion of pseudoscience in clinical psy-
                     ADVISORY BOARD                                chology: The challenge to legitimate clinical science. The
                                                                   Clinical Psychologist, 55, 4-10
                                                                McFall, R. M. (1996). Manifesto for a science of clinical psy-
      Sandra Bloom, MD               Pennsylvania                  chology. The Clinical Psychologist, 44, 75-88.
      Robert Dobyns, MD              Texas                      Meichenbaum, D. (2003, May). Treating Individuals with Angry
      Joyce Edward, CSW              New York                      and Aggressive Behaviors: A Life-Span Cultural Perspective.
      Harold Eist, MD                Maryland                      Paper presented at the Annual Meeting of the Georgia Psycho-
      Stanley Graham, PhD            New York                      logical Association, Atlanta, GA.
                                                                Norcross, J. C. (2001). Purposes, processes, and products of the Task
      Bertram Karon, PhD             Michigan                      Force on Empirically Supported Therapy Relationships. Psycho-
      Rep. Patrick Kennedy           Rhode Island                  therapy: Theory/Research/ Practice/Training, 38, 345-356
      Mary Kilburn, PhD              North Carolina             Seligman, M.E.P. (1995). The effectiveness of psychotherapy.
      Scott Miller, PhD              Illinois                      American Psychologist, 50, 965-974.
      Stanley Moldawsky, PhD         New Jersey                 Seligman, M. E. P., & Levant, R. (1998). Managed care policies
                                                                   rely on inadequate science. Professional Psychology: Research
      Rodrigo Munoz, MD              California                    and Practice, 29, 211-212.
      Arnold Richards, MD            New York                   Westen, D. and Morrison, K. (2001). A multidimensional meta-
      Elaine Rodino, PhD             California                    analysis of treatments for depression, panic, and generalized
      Rep. Ted Strickland, PhD       Ohio                          anxiety disorder: An empirical examination of the status of
      Bryant Welch, JD PhD           Maryland                      empirically supported therapies. Journal of Consulting and
                                                                   Clinical Psychology, 60, 875-899.
      Charles Zadikow, PsyD          New Jersey
                                                                Ronald F. Levant is Dean, Center for Psychological Studies, Nova
                                                                Southeastern University, Fort Lauderdale, FL, and President-
                                                                elect of APA. Comment on this article can be addressed via email:
                                              COALITION REPORT, JUNE 2004                                                      11.

                                                                                                            GEORGE W. BUSH
Remarks by the President to those attending A Conversa-            See, that’s part of the problem. The medical terminology
tion on the Benefits of Health Care Information Technology,        is really different from English, and is different from one
Department of Veterans Affairs Medical Center, Baltimore,          office to the next. And so when Tommy is talking about
Maryland                                                           standards, I think he’ll help you understand how we can
                                                                   help with standards. At any rate, we’re doing some smart

A     nd the health care industry is missing an opportunity,
      if patients, in order to make sure they get quality care,
have to carry files from one specialist to the next. It’s like
                                                                   things at the federal government, and the federal govern-
                                                                   ment can lead because we’re spending a lot of money in
                                                                   health care. We’re a large consumer on behalf of the Ameri-
IT, Information Technology, hasn’t shown up in health care         can people. Think about it—Medicare, Medicaid, veterans’
yet. But it has in one place, in one department, as you’re         benefits, federal employee health insurance plans, I mean,
about to hear, and that’s the Veterans Department. So here’s       there’s a lot of money going through the federal govern-
what we’re here to talk about. We’re here to talk about how        ment, and therefore it provides a good opportunity for the
to make sure the government helps the health care industry         federal government to be on the leading edge of proper
become modern in order to enhance the quality of service,          reform and change.
in order to reduce the cost of medicine, in order to make
sure the patients, the customer is the center of the health
care decision-making process.
         And we’ve made great progress. There’s a role for
                                                                   I   did not make this up. This was an actual press release
                                                                       from HHS. At least it wasn’t on the benefits of a liberal
                                                                    education. I find the vacuity terribly discouraging and the
the federal government. One thing is the federal govern-            words far more patronizing, for all his feigned Everyman
ment has got to make sure the privacy rules are strong.             simplicity. His words really say that there is nothing to ques-
You’re going to hear us talk about medical—electronic               tion, nothing to oppose. The soporific quality of his remarks
medical records. And that’s exciting. But it’s not so exciting covers the fact that his real goal is to serve corporate inter-
if you’re a patient who thinks somebody could snoop on              ests at every turn. This “dumbing-down” of political debate
your records, to put it bluntly. I’m not interested in having       was not invented by Bush, of course, but he is increasingly
my—well, it’s too late for me. My medical records are               showing his mastery in turning non sequiturs into hammers,
pretty well known. But for those people—there’s a lot of            dulling the national conscience and debasing the function of
people in America who say, good, I want there to be good            political debate and language. The editor.
information technology in the health care field, I
just don’t want somebody looking at my records
unless I give them permission to do so.                      N                      C
                                                                  ATIONAL OALITION OARD                       B
         And I fully understand that. And your
records are private, if that’s the way you want                  &C           OMMITTEE              M     EMBERS
them to be. But there’s a way to address this, the
privacy issue. And there’s a way to make sure that          PRESIDENT:         David Byrom, PhD          Smithtown, New York
the federal government’s role is helpful in expand-         FOUNDER:           Karen Shore, PhD          Westbury, New York
ing information technology. And that’s what we’re           VICE PRESIDENT: Patricia Dowds, PhD          Smithtown, New York
going to talk about. Tommy Thompson is the head             TREASURER:         Roz Gilbert, ACSW         New York, New York
of the -- the Secretary of Health and Human Ser-            SECRETARY:         Bill MacGillivray, PhD     Knoxville, Tennessee
vices -- is a strong advocate about the spread of IT        BOARD MEMBERS
throughout the health care industry. I think he’s got                          Michaele Dunlap, PsyD Portland, Oregon
-- I know he’s got the proper perspective of the role                          David Goldman, MD         New York, New York
of the federal government in encouraging not only                              Peter Gumpert, PhD        Boston, Massachusetts
the federal agencies, but the private sector, to adopt                         Kathie Rudy, PsyD         Great Neck, New York
these strategies in a way that is positive for the                             Janice Rohlf, CSW         New York, New York
American consumer and cost beneficial for society.          CONSUMER COMMITTEE CHAIR
         You hear him talk about standards. I told                             Sheri Larivee             Austin, Texas
him when he starts talking about standards, make            OFFICE MANAGER
sure it’s the kind of language we all understand.                              Michelle Curiacopoulos Commack, New York

  Taking Back Patient Privacy Rights: Suggested Form
                                  Offer and Addendum to Consent Form of Patient
                                                                  Print your name
                                         Relating to HIPAA ‘privacy regulations’
  I hereby assert my fundamental right to privacy and my reasonable reliance on established ethical standards, by
  expressly forbidding my physician, or any entity under his or her control (collectively, “medical staff”), from releasing
  my medical records, or portion thereof (collectively; “medical data”), to a third party that shall use such medical data
  for marketing purposes without my express consent. Thus, this document is part of the compact between recipients of
  this document and myself.
        In particular, I decline to consent to the release of my medical records for the purpose of entry into a computer
  database that may be accessed by third parties outside of the offices, laboratories, payment processors, accountants or
  hospitals utilized by my physician.
        Furthermore, I forbid the release of my medical data to law enforcement entities unless pursuant to an order of
  court of competent jurisdiction.
        Notwithstanding the above, medical staff may release data contained in my medical records to:
  •      Members of my immediate family, extending to aunts, uncles, cousins, and

  List other entities / individuals you will allow to review your medical records / be advised of your medical condition.

  •      The following health care entities:

  List doctors, caregivers, medical practices and medical organizations who will be allowed by you to review your medical records.

  • Entities reasonably anticipated to be directly involved in my medical care or my health insurance carrier. (This
  shall not include drug manufacturers seeking to access medical data of those individuals who match certain diagnostic
  It is understood that an entity in possession of my medical data is a gratuitous bailee of such data.
  Failure to adhere to the terms of this Offer and Addendum to Consent Form shall be allowed only with the understand-
  ing by the releasor, that such non-conforming medical data release will be an acceptance of my offer to allow such
  release only in compliance with the following licensing offer:
  •      That releasor shall pay ____________________ of $10,000 for each non-conforming release
                                        Print your name
  •      That releasor shall make such payment within 30-days of such release and mail it to:
        Print your full address

  A copy of this Offer and Addendum to Consent Form shall become part of my medical/patient record file and must
  accompany, or be transmitted collateral to all releases of my medical data. It is understood that any entity in possession
  of my medical data shall be held to the terms of this Offer and Addendum to Consent Form so long as such entity is
  in possession of my medical data.

  ______________________________________                                       ____/____/20___
  Signature of recipient                                                                  Date

  ______________________________________                                       ____/____/20___
  Signature of patient                                                                              Date
                                         COALITION REPORT, JUNE 2004                                                    13.

Client privacy is a fundamental principle in building trust, and a foundation for all our clinical work. Recent
changes in federal privacy rules challenge this fundamental principle. Corporate-medicine’s clinical practice
guidelines, which require that records be kept for third party review, undermine privacy. In order to prevent
further deterioration of patient rights, we offer the Licensed Psychotherapists Petition on Confidentiality – it
supports maintaining strong patient confidentiality guarantees. In Colorado, a similar petition was effective in
blocking erosion of patient rights. In 2000, The Colorado Board of Psychological Examiners proposed that all
licensed psychologists be required to give every client a diagnosis, and keep records for every client in a manner
reviewable by third parties. In response, an ad hoc committee of psychologists in Colorado developed a petition
to object to such requirements. On short notice, 27% of all Licensed Colorado Psychologists supported the peti-
tion and blocked the proposed regulations. We don’t want to wait until the last minute—start now to prevent fur-
ther erosion in patients’ rights. Please join us in protecting psychotherapy clients against all attempts to reduce
traditional guarantees of client confidentiality. Sign the Licensed Psychotherapists’ Petition On Confidentiality.

  To Whom It May Concern: We, the undersigned psychotherapy professionals
  •   Support client confidentiality as a fundamental principle of psychotherapy and as a basic right of our clients
  •   Object to the decline in protections for confidentiality under new federal regulation
  •   Object to unquestioning adoption of corporate medicine’s standards of practice.

  We therefore:
  •   Object to the idea that all records must be kept in a manner to be reviewed by third parties,
  •   Object to any standard requiring psychotherapists to give every client a diagnosis.

  Such requirements provide little consumer protection or service, may stigmatize people, prevent people from
  seeking treatment or obtaining insurance in the future, unnecessarily invade privacy, and compromise patient
  trust. When a psychotherapist and a client both agree, it is appropriate 1) for the therapist to keep no records at
  all of the therapy process or to keep them under a pseudonym and/or 2) for a therapist to forgo giving the client
  a diagnosis. This petition is not intended to circumvent laws that require report of threats to human safety

  Name: ___________________________ Signature:______________________________ Date: ____________
      Supports the Licensed Psychotherapists’ Petition on Confidentiality.

  License (State, Type and Number): __________________________________________

  Complete Address: _______________________________________________________

  E-mail: _________________________________________

  When signed, please return this to:
  Petition On Confidentiality
  PO Box 4075
  Portland, OR 97208-4075

And in the News... Summaries and Commentary
                                                                                             Bill MacGillivray, et. al.
New York Times                                                  Washington Post
May 14, 2004                                                    May 6, 2004
Robin Toner                                                     Ceci Connolly

A      mid all the talk of war and its effects, the two can-
       didates for president are also addressing, more or
less, the problems of health care coverage in this country.
                                                                T    his article compared cost-per-person as a way to look
                                                                     at health care plans of the two candidates for presi-
                                                                dent. And Kerry’s plan spends less! Here are some facts:
Well, Kerry is proposing and Bush is opposing. While the
president and Kerry may not be so far apart on the war as it     •   Bush: his plan will cover fewer than 2.5 million
seems from the papers, in the area of health care, there are         and would cost $90 billion - $3800 per-person.
clear differences, according to this article. Its begins with    •   Kerry: his plan will cover 27 million and will cost
some facts:                                                          $653 billion - $3200 per-person.

 •    Health insurance premiums are up 13.9% in 2003.           I know the math doesn’t work out, but that is what the arti-
 •    This makes the third consecutive year of double-          cle said, probably using unquoted data, since Kerry’s plan
      digit hikes.                                              looks a whole lot cheaper even with a calculator.
 •    43.6 million Americans are without health insur-
      ance                                                      Kerry and Bush’s plans both involve giving refundable
 •    More than 8.8 million of the uninsured are children       tax credits to help people purchase health insurance and
                                                                allowing individuals and small businesses to pool together
“George Bush has had four years to offer America a real         to negotiate discounted health coverage. The information
health care plan, and he hasn’t,” according to Senator          comes from Emory University health economist Kenneth
Kerry; but Republicans claim they are doing some things         Thorpe, who did work for the Clinton administration but
that are stalled in Congress. Bush wants to give tax credits    whose work is independent of either campaign. He con-
to low- and moderate- income families to help them pay          cludes, “[p]art of the reason Bush would put such a small
for insurance: $1,000 for individuals; $3,000 for families.     dent in the number of uninsured—at a comparable or
The plan would benefit 4.5 million families, according          slightly higher cost—is that the people most likely to take
to the administration. ‘’I believe that the best health care    advantage of his proposals already have some insurance,”
policy is one that trusts and empowers consumers and one        In contrast, Kerry’s plans to expand a range of public health
that understands the market,” according to President Bush.      insurance programs such as SCHIP and Medicaid “are more
Other proposals include increasing deductibles and encour-      ambitious and targeted more directly at middle-income
aging use of medical savings accounts.                          workers,” Thorpe said.
         Kerry’s plan call for complete coverage for chil-
dren and most uninsured adults, costing $650 billion over       Bush administration officials dismiss the comparisons.
ten years and paid for by rolling back tax cuts for those       Megan Hauck, deputy policy director for the Bush cam-
making over $200,000 a year. The plan also calls for gov-       paign, “did not dispute Thorpe’s figures but said the
ernment subsidy of catastrophic coverage, and in other          president’s strategy on health care expands beyond Kerry’s
ways provides incentives to businesses to offer health          focus on government and the uninsured. The underlying
insurance. The cost? $177 billion in tax credits over ten       problem is rising health care costs,” which Bush believes
years. Other aspects of the Kerry plan include expansion        can be controlled by reforming the medical malpractice
of the Federal Health Benefit Plan to individuals and busi-     insurance system. So, the problem isn’t lack of health insur-
nesses in addition to federal employees, and expansion of       ance (or adequate health insurance, its…trial lawyers!
Medicaid coverage. By expanding existing plans, Kerry
hopes to avoid the charge of “creating new entitlements”
from the Republicans. Good luck!
                                             COALITION REPORT, JUNE 2004

“DEEP BENCH” ON HEALTHCARE                                        TRIED TO CUT
The Hill                                                          New York Times
April 28, 2004                                                    May 18, 2004
Bob Cusack                                                        Robert Pear

T     he article does not start off very well, noting that Ker-
      ry’s team of advisors has “drawn praise from industry
officials.” Kerry has been talking about health care and
                                                                  WHAT THEY SAID:

                                                                   •   Tommy G. Thompson, the secretary of health
need to address problem of the uninsured throughout the                and human services, announced recently that the
primary season and now into his campaign against Bush.                 administration was awarding $11.7 million in
“Kerry has got a deep bench on healthcare,” a Republican               grants to help 30 states plan and provide coverage
drug-industry official said. “And they’ve got a lot of experi-         for people without health insurance
ence.” “These guys are pros,” said Joseph Antos, a health-         •   The administration also announced recently that it
care expert at the American Enterprise Institute. “They’ve             was providing $11.6 million to the states so they
been doing [healthcare] for a long time.” Are you scared               could buy defibrillators to save the lives of heart
yet? Here is the crew:                                                 attack victims.
                                                                   •   Secretary Thompson announced that the admin-
  • Gene Sperling a lobbyist who used to be Clinton’s                  istration was awarding $3.1 million in grants to
    top healthcare adviser.                                            improve health care in rural areas of Florida, Geor-
  • Chris Jennings, another former Clinton administra-                 gia, Illinois, Iowa, New Mexico and New York.
    tion official.                                                 •   Mr. Thompson announced that the administration
  • Jon Cohen, chief medical officer for the North                     was awarding $16 million to 11 universities to train
    Shore-Long Island Jewish Health System.                            blacks and Hispanic Americans as doctors, dentists
  • Jeffrey Lewis is chief of staff for Teresa Heinz                   and pharmacists.
    Kerry and runs the Heinz Family Philanthropies.
    Previously worked for Senators Pete Domenici and              WHAT THEY DID:
    Bob Packwood.
  • Stuart Altman, a professor at Brandeis University.             •   President Bush has proposed ending state grants
  • David Cutler of Harvard University.                                to assist the uninsured each year for the past three
  • Judy Feder, an adviser on Gore’s 2000 campaign.                    years.
  • Bruce Reed, head of the Democratic Leadership                  •   President Bush has proposed cutting the budget
    Council.                                                           for defibrillators by 82 percent, to $2 million from
  • Sarah Bianchi, who also worked on Al Gore’s 2000                   $10.9 million.
    presidential campaign                                          •   The administration is trying to cut funding for rural
  • Mary Beth Cahill, who used to be Senator Kenne-                    health programs by 72 percent, to $11.1 million
    dy’s chief of staff.                                               next year, from $39.6 million.
  • Heather Mizeur, who previously worked for the
    National Association of Community Health Centers.             The administration is urging Congress to abolish the pro-
                                                                  gram to train minorities in health care professions, on the
The plan Kerry is promoting is “centrist” in focusing on          ground that “private and corporate entities” could pay for
expanding existing programs rather than developing new            training.
programs or initiatives. According to Altman, Kerry’s plan
is “incremental… His long goal is to cover everybody,”
adding that such a prospect cannot be achieved currently:
“Kerry plans on building on the existing system.”
         Pat Dowds comments: If this is true, it sounds like
more of the same dysfunctional insurance managed care
mess. Those of you who are Democrats should start firing
off their letters and calling their local Democratic leaders.

AMNEWS                                                           NEW YORK TIMES
MAY 24/31, 2004                                                  MAY 12, 2004
JOEL B. FINKELSTEIN                                              ROBERT PEAR

T     his article reviewed events associated with Cover the
      Uninsured Week, beginning with the statistic that 44
million Americans do not have health insurance, and the
                                                                 T    his article reviewed the proposals developed by the
                                                                      Senate Republicans to both improve health care and
                                                                 provide help for uninsured Americans. The proposals are
number is increasing on average of 2 million each year.          meant to be gradual and incremental and the panel propos-
Four out of five of those uninsured are working adults,          ing the reforms emphasized their determination to avoid
or their spouses or children. Not having health insurance        “nationalizing the health care system,” according to Senator
means that people delay or avoid seeking health care: The        Judd Gregg of New Hampshire, “The uninsured are not a
result is that people live sicker and die younger, and are       monolithic group. They are diverse.” The House Democrats
financially strapped by high medical costs when they do          have proposed the following:
finally seek treatment.
         According to Uwe Reinhardt, PhD, professor of             • $50 billion to states to cover parents of children in
economics and public affairs at Princeton University, “If            Medicaid or the Children’s Health Insurance Pro-
we had to do it all over again, we’d never have this system;         gram.
but the employment-based system is like diabetes. Once             • Allow people ages 55 to 64 to buy Medicare cover-
you have it, you can’t get rid of it, and you just have to           age, with the government paying up to 3/4 the cost.
learn to control it and live with it.” It comes as no great        • Offer tax credits to help defray the cost of insurance
surprise, given that Cover the Insured Week was sponsored            for small businesses and self-employed individuals.
by such powerhouse organizations such as the Robert Wood
Johnson Foundation, that no earth-shaking proposals were         Senate Republicans endorsed the following proposals:
offered and the buzz word was “incremental: in describ-
ing new initiatives to address problems of the uninsured. “I       • Provide tax credits to help low-income workers buy
would not discourage piecemeal approaches,” said Louis               insurance on their own if coverage is not available
Sullivan, MD, a former secretary of the Health and Human             from their employers.
Services Department, “There is no dearth of strategies on          • Make it easier for clinics run by religious groups to
the table.” Here were the brilliant ideas from the House and         qualify as community health
House Republicans:                                                   centers and therefore eligible for federal grants.
                                                                   • A tax deduction for medical specialists who pro-
 •    Limit liability awards                                         vide charity care to patients referred by community
 •    Deregulate association health plans                            health centers and nonprofit clinics. The maximum
 •    Allow rollover from flexible spending accounts.                deduction would be $20,000 a year.
                                                                   • Government-negotiated discounts for low-income
There were some who did speak out against incremental                people and the uninsured to buy prescription drugs.
approaches: “Incremental programs are extraordinarily                The discounts are already available to federal agen-
expensive, and they are by nature temporary and don’t                cies and some clinics that receive federal grants.
really contribute to the health security of people individu-       • Aid to colleges and universities that make health
ally or the population at large,” said Georganne Chapin,             insurance available to full-time students.
president of Hudson Health Plan, a nonprofit managed care          • Government forgiveness of student loans or defer-
organization based in Tarrytown, NY. A survey from Kaiser            ral of interest payments for college graduates who
and Harvard School of Public Health found one-third of               establish health savings accounts.
respondents “very worried” about losing health care cover-         • Deferral of interest payments on student loans for
age, and one-half worried about having to pay more for               health professionals who work in nonprofit clinics
health care.                                                         serving the uninsured
         The fact that limiting liability awards tops the list     • Provide malpractice insurance for doctors volun-
of Republican proposals for dealing with the problems of             teering in community health centers.
the uninsured suggests either bankruptcy of ideas, or the          • Support small business to band together to buy
paucity of interest in addressing these problems.                    health insurance through trade associations.
                                             COALITION REPORT, JUNE 2004                                                   17.

The “Cost” Of Medical Care                                       of its benefit. So far, so good.
                                                                          Then comes a really good observation: “All the
Creators Syndicate                                               existing efforts to control the rising expenses of medical
May 4, 2004                                                      care—whether by government, insurance companies, or
Thomas Sowell                                                    health maintenance organizations—are about holding down
                                                                 the amount of money they have to pay out, not about reduc-

I  should have known better, but this column by a well-
   known henchman for the radical right started off rather
well. He pointed out that we tend to think of “cost” in a
                                                                 ing any of the real costs.” But get ready for the conclusion:
                                                                 “stop frivolous lawsuits against doctors, hospitals or drug
                                                                 companies, “which are huge costs.” Even more remarkable
narrow way, i.e., how much we had to pay for the goods           is his conclusion that the FDA, by adhering to an approval
acquired. In contrast, he observes, “But these are not the       process for new medications, ends up, “costing millions of
costs…[t]hese are the prices paid. The difference between        dollars, and also costing the lives of those who die while
prices and costs is not just a fine distinction made by econ-    waiting for the drug to be approved by bureaucrats.”
omists. Prices are what pay for costs.” Applying this logic               One of the great things about being a right wing
to medical care, he points out that physicians incur average     ideologue is that these startling conclusions can be advanced
debt of $100,000 during medical school and face costs of         without even a shred of evidence. He feels no need to cite
$100 per hour to run a medical office. If these costs cannot     even one example of a “frivolous lawsuit.” Presumably all
be recouped in some way, physicians will be driven out of        are. He sees no need to even consider that government test-
health care. Similarly, a drug company spends $800 mil-          ing might actually keep terrible medications from the public
lion, on average, in developing a new medication. If they        (although how Oxycontin got through the process may not
cannot recoup these costs, and then make a profit, there will    be good evidence of oversight!). Well, I overstate. He has
be no incentive to develop the new medication, regardless        two examples. Using Britain as an example, he laments that,
                                                                 due to the fact that the medical system in government-run,
 WHERE ARE THEY NOW? THE TRUE                                    over 50% of the physicians come from “Third World coun-
 BENEFICIARIES OF THE MEDICARE DRUG BILL                         tries.” Presumable that’s a bad thing. Presumably he has not
                                                                 perused the Yellow Pages under “Physicians” for awhile.
    • Tom Scully, Administrator, CMMS (The guy that              One more example? In 1959, he witnessed an example of
        threatened to fire the accountant who wanted to tell     bureaucratic mismanagement, when a man, suffering from a
        the true price of the bill to Congress). Within 10       heart attack, was refused care at the US Public Service Hos-
        days of passage of the bill, he took a job as lobbyist   pital because he was not a federal employee, and died on the
        for a firm handling Johnson & Johnson, Nat. Assoc.       ambulance trip to another hospital. And Laura Peeno has the
        for Home Care & Hospice, Vitas Health, Health-           nerve to complain about managed care!
        South, WebMD, & the Georgia Hospital Assoc.                       Sowell is right that health care cost money, a lot
    • Colin Roskey, Health Policy Adviser to Senate Finance      of money. Politicians do not want to say that because the
        Committee. Within 3 days joined the same firm.           public does not want to think about that. Health care pro-
    • Thomas Grissom, Director of Center for Managed             fessionals, including mental health care professionals, do
        Management (managing Medicare’s $240 Billion             not want to say that, because it makes us looks greedy.
        HMO budget). Within ONE day became vice presi-           That’s why employer-paid health insurance with physicians
        dent for government affairs at Boston Scientific (a      accepting assignment of benefits was such a great scam,
        medical supply company)                                  hiding the real costs of care from everyone. The really curi-
    • Sarah Walter, Legis. Director to Sen. Breaux, one          ous thing is that the “left” is readily subject to the mocking
        of the 2 democrats involved in negotiations on the       scorn of the so-called conservatives for promising every-
        bill. Within 28 days joined a firm which lobbies for     thing and hiding the cost in higher taxes and has been dead
        Eli Lilly.                                               in the water as a result, since they have to lie and promise
    • John McManus, Staff Director for Health Subcom-            “no new taxes.” The “right,” on the other hand, can spout
        mittee of House W&M Committee, one of the chief          off nonsense like malpractice is the only problem we have
        bill negotiators. Within 60 days set up his own          with health care, or drug companies need to be paid for
        health care consulting company.                          their (government-subsidized) discoveries, or corporations
 Of course, it’s not surprising. 4 of the 5 had been lobby-      only have a responsibility to their stockholders, despite the
 ists for big healthcare companies BEFORE they’d been            fact that their government-authorized charters include that
 hired by Bush! Now you know where bureaucrats come              they are formed for the public good, without anyone calling
 from!. Excerpted from Mother Jones by Harvey Frey               them to an account. Well… I guess I have.

AGENCY TO ALLOW INSURANCE CUTS FOR THE                          removal of this provision overcame a prime objection of
RETIRED                                                         American Association of Retired Persons (AARP) and
                                                                paved the way for AARP to support the bill. So much for
NEW YORK TIMES                                                  the benefits of horse-trading with this administration.
APRIL 22, 2004                                                           Dave Byrom adds: This is a solution? Clearly more
ROBERT PEAR                                                     is being added as part of the problem. Take away what is
                                                                hard earned from those over 65 to help those under 65?

T     he Equal Employment Opportunity Commission
      (EEOC), voting along party lines, ruled that it was
permissible for employers to lower health benefits of retir-
                                                                With employers under such increasing pressures, this of
                                                                course is an incentive to cut costs. And, just as on so many
                                                                other fronts of the onslaught, divide and conquer - set up a
ees after they become eligible for Medicare. Perhaps more       no-win for under 65, over 65, employers... “The new rule
astonishing, not only employers but also some union groups      creates a potentially explosive political issue, because it
favored the rule change. The rationale was to hold the line     will create anxiety for many of the 12 million Medicare
for younger retirees. Cari M. Dominguez, chairwoman of          beneficiaries who also receive health benefits from their
the commission, observed, “We are aware of the anxieties        former employers.” As for the claim that the rule, “is not
and misperceptions that have taken root.” There are 12 mil-     intended to encourage employers to eliminate any retiree
lion people, currently on Medicare, but covered by other        health benefits they may currently provide,” watch care-
policies, that may be affected by the rule. These retirees      fully the sell here, the 180-degree spin is underway. And we
typically rely upon these insurance policies to fill in the     are supposed to take this on faith just like the HIPAA Pri-
coverage gap left by Medicare restrictions on care, as well     vacy Rule was first sold to all as the best ever protections,
as help cover deductibles and co-pays. The reason the issue     while actually taking the privacy of our Personal Health
ended up before was that EEOC is responsible for over-          Information—the right to consent and protect ourselves—
sight of the Age Discrimination Employment Act of 1967,         away from us all.
which forbids age-based discrimination. No problem, rules
the commission, the rule can be set aside as a “reasonable
exemption.” The commissioners nicely added an encour-
                                                                 HOW MANAGED CARE GOT STARTED
aging proviso that the rule “is not intended to encourage        A Scotsman goes to the dentist and asks how much it is
employers to eliminate any retiree health benefits they may        for an extraction.
currently provide.” Now, what can that possibly mean. Of         “$85 for an extraction, sir,” was the dentists reply.
course the Republican argument is that without the exemp-        “Och, huv ye no got anything cheaper,” replies the
tion, employers may simply eliminate all health care cover-        Scotsman, getting agitated.
age for retirees, so the argument is that they have somehow      “But that’s the normal charge for an extraction, sir,” said
“saved” retiree benefits. Here’s a good quote from the vice        the dentist.
president of the American Benefits Council (how do they          “What about if you didn’t use any anesthetic?” asked the
think up names like this?), Paul Dennett, “It removes a            Scotsman, hopefully.
cloud that has been hanging over retiree health coverage         “Well it’s highly unusual sir, but if that’s what you want,
since the court decision in 2000.” That was the year the           I suppose I can do it for $70,” said the dentist.
court ruled that age discrimination was illegal. And what        “Hmm, what about if you used one of your dentist train-
unions supported the rule? For one, the American Federa-           ees and still without anesthetic?” said the Scotsman.
tion Of Teachers and the National Education Association.         “Well it’s possible but they are only training and I can’t
         In practice this means that employers can now pro-        guarantee their level of professionalism and it’ll be
ceed to reduce or even eliminate health care coverage to           a lot more painful, but I suppose in that case we can
retirees once they are on Medicare. According to the Com-          bring the price down to say $40,” said the dentist.
mission, “in order to ensure that all retirees have access to    “Och, that’s still a bit much, how about if you make it a
some health care coverage, employers and unions may pro-           training session and have your student do the extrac-
vide retiree health coverage to only those retirees who are        tion and the other students watching and learning,”
not yet eligible for Medicare. They also may supplement            said the Scotsman hopefully.
a retiree’s Medicare coverage without having to demon-           “Hmm, well OK it’ll be good for the students I suppose;
strate that the coverage is identical to that of non-Medicare      I’ll charge you only $5 in that case,” said the dentist.
eligible retirees.” Curiously, this rule was included in the     “Wonderful, it’s a deal,” said the Scotsman,” Can you
original Medicare bill before Congress this year, and the          book the wife in for next Tuesday”
                                             COALITION REPORT, JUNE 2004                                                    19.

DOCTORS GROUP TO SUE UNITED HEALTHCARE                           know how.”
                                                                          One unfortunate quote that perpetuates the very
PIEDMONT NEWS & RECORD                                           notion of managed care is Dr. Seligson’s observation that
4-23-04                                                          insurance should be a cooperative effort among insurance
ELLICA CHURCH                                                    providers, patients and doctors. This keeps the insurance
                                                                 company in the consulting room, when it should only be

T     he North Carolina Medical Society is spearheading a
      lawsuit against United Healthcare of North Carolina,
demanding an end to, “business practices that disrupt the
                                                                 between the patient, who pays for it, and the insurance
                                                                 company. The article goes on to address the data collec-
                                                                 tion that physicians are doing to document the worst cases
care doctors are able to provide to their patients,” accord-     of mismanagement by United Healthcare, including: poor
ing to Medical Society CEO Robert Seligson, “This is a           follow-up from insurance staff, lengthy contract negotia-
last resort, but it’s time to make a change.” The lawsuit is     tions, nonpayment for medical procedures and
intended to force changes in the way United Healthcare           poor management of claim documents.
does business in the state. “The goal of the United Health-               The unpleasant fact is that health care profession-
care lawsuit is to make the company more responsive to           als welcomed insurance providers into the consulting room
answering questions, improve the handling of insurance           since it relieved them of the burden of having to actually
claims and letting doctors deal directly with those involved     ask patients to pay for their care. If they, we, had refused to
in the decision-making process,” according to the article.       accept assignment of benefits, and only completed insur-
More bluntly, a Greenboro physician, Peter Blomgren,             ance forms, for a fee, to allow the patient to be reimbursed,
observed, “We want to hold their feet to the fire and make       managed care would not have had inroads into patient care.
them do what they should be doing anyway,” Problems              Patients would have had to deal directly with the conse-
include: unanswered phone calls and letters, submitting          quences of restrictions of benefits. This would also have
claims forms multiple times and lengthy contract negotia-        meant that health care professionals would not have had the
tions. “Physicians can’t give the care we want to give,”         apparent guarantee of income flow without the worry that
Blomgren said. “As a physician the most frustrating thing        a patient might refuse to pay, be unable to pay, or want to
is to not be able to take care of the patient the best way you   negotiate a smaller fee. A corrupt bargain all around.

AP/THE CHARLOTTE OBSERVER                                        USA TODAY
GARY D. ROBERTSON                                                APRIL 25, 2004
MAY 26, 2004                                                     JULIE APPLEBY

N     orth Carolina Rep. Verla Insko (D) on Tuesday intro-
      duced legislation proposing a constitutional amend-
ment that would make universal health care a “fundamental
                                                                 T     he use of Health Savings Accounts (HSA) is likely
                                                                       leading to a steep rise in out-of-pocket costs, as
                                                                 employers will shift increasing percentage of health care
right” and would instruct lawmakers to pass a bill by 2006       costs away from employers. This article noted the unprec-
that would provide “access to appropriate health care on         edented interest in HSAs in the last year among employers.
a regular basis” to all state residents by 2010. Insko has       Since health care premiums continue to sock double-digit
sponsored similar legislation every year since 1999 in what      increases year after year, employers want to shift these
has become an “annual tradition” in the state. The bill does     costs to employees. The HSAs rules mandate that taxpayers
not provide details on funding, and Insko said that financ-      much have insurance policies with high deductibles, i.e., a
ing should not be decided before lawmakers debate the            minimum of $1,000 for individuals and $3,000 for families.
measure. In 2002, North Carolina experienced the largest         That is more than three times the industry average, accord-
percentage point increase in uninsured residents since 2000      ing to Kaiser Family Foundation data. The article also
among all states except Mississippi, which tied for the larg-    notes that many employers plan to increase this minimum
est growth, according to the North Carolina Committee to         amount by as much as 100%. In addition, few employers
Defend Health Care. In 2002, an estimated 1.4 million state      are interested in contributing to the employees HSAs: 39%
residents lacked health coverage. Insko said, “The United        would contribute nothing and 24% would contribute $500.
States has the best health care in the world, but among          This scheme is an extension of the use of 401(k) savings
industrialized nations we have one of the worst health care      accounts to eliminate pension benefits, and the result is that
systems. (Kaiser Daily Health Report, www.kaisewrnetwork.org)    the employee will end up paying most or all their health

ATTACKS ON KNOWLEDGE ABOUT WOMEN                                evidence of possible harm or misuse. Finally, Ashcroft has
                                                                yet to order and complete a study ordered in 2000 under the
REUTERS NEW SERVICE                                             2000 Violence Against Women Act that was to investigate
APRIL 28                                                        discrimination against domestic violence victims in getting
DEBORAH ZABARENKO                                               insurance.
                                                                         The report concludes with a call for action and

A     ccording to Linda Basch, president of the National
      Council for Research on Women, “Vital informa-
tion is being deleted, buried, distorted and has otherwise

                                                                     The combined effect of the decisions and actions
gone missing from government Web sites and publications.             outlined in this report are deeply troubling for
Taken cumulatively, this has an enormously negative effect           American women - and for their families and com-
on women and girls.” This report identified four main cat-           munities. The pattern is unfortunately all too clear:
egories:                                                             cutting vital information, stacking scientific panels,
                                                                     defunding agencies, withholding data, raising
  • Accurate and science-based information on women’s                doubts, spreading misinformation, holding back
    health                                                           studies, silencing voices for women, spinning data,
  • Accurate and reliable information on women’s eco-                abandoning information resources, privileging
    nomic status                                                     ideology over science, inhibiting health providers,
  • Scientific objectivity and expertise                             censoring researchers. The cumulative effect is a
  • Information to help protect and advance women and                devastating loss of reliable, accessible, research-
    girls                                                            based information on at least three critical issues to
                                                                     women’s lives - health, employment, and violence.
The core accusation is that this information has been                   The American public - women and men - has
removed to advance a political agenda. Examples include              good reason to question whether they can trust that
removing information that use of condoms prevents con-               the information and analysis they receive from
traction of sexually transmitted disease. On the National            Washington is complete, accurate, and based on
Cancer Institute’s website, it was reported that there was           solid science. As this report documents, misinfor-
inconsistent information linking abortion with development           mation - or the lack of information - has a direct
of breast cancer (there is no evidence linking the two condi-        and harmful effect on women’s lives.
tions). Health and Human Services website presents mis-                 The National Council for Research on Women
leading information suggesting abstinence-only programs              joins others in the research and science commu-
are more successful at preventing teen pregnancy than they           nity in calling on concerned citizens to protest this
have proven to be.                                                   pattern of loss. Help the Council identify other
         The Labor Department’s Women’s Bureau deleted               instances of information gone missing by send-
25 publications without explanations, publications that              ing them, or sites where good information is still
dealt with issues such as child care, equity in employment,          available, to its Misinformation Clearinghouse at
women business owners and so on. A Department of Labor               www.ncrw.org. We must challenge officials and
publication on women’s rights in the workplace is no longer          elected representatives to confront this issue and
available. the Census Bureau presents women’s earnings               ensure the unimpeded flow of solid, unbiased, and
ratio compared to men as being at an “all-time high,” while          complete information.
neglecting to add that the “high” represents less than a                Accurate, trustworthy, science-based informa-
1% increase over 2000, when this figure was precviously              tion and data matter, and we should be able to
described as reflecting serious lack of pay equity.                  count on our government to provide it.
         The White House has disbanded the Office of
Women’s Initiatives and Outreach in the White House             The full report can be found at the National Council
and the President’s Interagency Council on Women. The           for Research on Women: http://www.ncrw.org/misinfo/
Defense Advisory Committee on Women in the Services             index.htm
was issued a changes mandate to only address servicewom-
en’s’ issues, not women’s issues in general as had been the
previous mandate. The Food and Drug Administration has
blocked approval of sale of contraceptive drug, Plan B, as
an over-the-counter medication, despite lack of scientific
                                            COALITION REPORT, JUNE 2004                                                     21.

WALL STREET JOURNAL                                               CONGRESS DAILY
MAY 6, 2004                                                       MAY 7, 2004
LAURA LANDRO                                                      JULIE ROVNER

T     he Wall Street Journal on Thursday examined the
      increased number of employers, health plans and
government programs that have begun to offer physicians
                                                                  T     his article is about the administration’s plans to have
                                                                        electronic records network established within ten
                                                                  years, with the lure of saving $140 billion a year in reduced
financial incentives to adhere to “evidence-based” guide-         paperwork and administrative costs. According to HHS
lines for care, a “controversial wrinkle in the pay-for-qual-     Secretary Tommy Thompson, the department has made a
ity movement.” A number of medical schools, specialty             critical first step in identifying the operating system that
groups, government agencies and health care companies             will be used to allow health care information to be readily
have developed more than 100 evidence-based guidelines -          transferred from facility to facility. A medical vocabulary
- based on “rigorous clinical studies and scientific research”    program has been developed, licensed from American Col-
-- that range from how to treat common conditions such as         lege of Pathologists that will further help streamline data
asthma and hypertension to how to perform surgeries and           collection and storage.
treat serious diseases such as cancer. However, some health                 Both Republicans and Democrats are “onboard”
care experts have raised concerns that “going strictly by         with this initiative and the article quotes Hillary Clinton
guidelines” to treat patients may “interfere with doctors’        as viewing the authorizing legislation, “a no-brainer. The
own intuition and experience,” and others have questioned         health care system is the least savvy and technologically
“why doctors should get paid extra to follow guidelines           advanced of our sectors.” To give equal time Connecticut
they should be adhering to already”. In addition, some            Republican Nancy Johnson endorsed the cost savings that
health care experts criticize the practice as “thinly disguised   will be realized by suing information technology for “dis-
cost-containment”.                                                ease management.” Having a system that protects privacy,
          Charles Ingoglia, vice president of the National        yet is able to transmit needed information “is the key to
Mental Health Association, said, “A lot of states and other       whether the health care system moves forward or back,”
payers are exploring the idea of using evidence-based             Johnson said. Newt Gingrich trumpeted the suggestion
guidelines to deliver more cost-effective treatment, but          that the administration move far faster than the allotted
that’s just political cover” for the elimination of treatments    ten years and that all Medicare beneficiaries, beginning in
and services for patients. However, according to Kenneth          2005, should have electronic medical records.
Fink, a program director at the Agency for Healthcare                       This was, of course, the main reason for HIPAA
Research and Quality, “Evidence-based medicine is really          legislation—to push for a national electronic database that
a triangle that uses the best available scientific data within    would presumably lead to better data on health care, what
the context of the values of the patient and the experience       works and what doesn’t, and so on. The privacy regula-
and knowledge of the provider” (Harvey Frey posted on             tions were ordered out of concern that the database could
www.Harp.org.)                                                    be misused; but no one seems willing to question the effi-
                                                                  cacy of collecting the data. It seems very odd that America
                                                                  is swiftly moving toward the kind of cradle-to-grave data
                                                                  collection that we would have sniffed at a “European” only
                                                                  a few years ago. What we would deny to the government,
                                                                  we have gladly handed over to the corporations that now
                                                                  govern our lives: drug companies, insurance companies,
                                                                  and so on. And no one seems to feel the death chill in the
                                                                  phrase “disease management.”

DON’T FORGET THE PATIENTS                                         ISSUE OF THE UNINSURED
LOS ANGELES TIMES                                                 CONGRESS DAILY
MAY 26, 2004                                                      MAY 17, 2004

T     his unsigned editorial begins with the familiar lament:
      when Paul Ellwood and Alain Enthoven pioneered
managed care in the 1970s, their idea was that a free market
                                                                  T     he handful of bills proposed by Congress during Cover
                                                                        the Uninsured Week were notable mostly for their mod-
                                                                  esty and were not real solutions, despite claims by politicians
would drive down health care costs. The government’s role         from both parties that reducing the number of uninsured is
was to set in place ground rules to ensure competition. The       a top priority Cover the Uninsured Week, is a campaign led
result: healthcare costs rise 15% a year. Rules are unenforced    by the Robert Wood Johnson Foundation to raise awareness
or nonexistent. The editorial goes on to praise efforts of a      about uninsured people in the United States. A Senate Repub-
California legislator to address implications of the merger of    lican task force presented “a grab bag of mostly previously
health industry giants WellPoint and Anthem, a move that          proposed policy recommendations,” while Senate Democrats
will provide them with 26 million “covered lives” nation-         introduced a bill that would allow all U.S. residents to pur-
wide, suggesting some questions for industry executives:          chase plans similar to those available to lawmakers.
                                                                           Harvard University’s Robert Blendon said that
  • Will CEO Leonard Schaeffer $194 million buyout                Democrats likely sought to avoid offering any plan that
    affect insurance premiums?                                    might conflict with the health care strategy of presumptive
  • When Anthem takes over WellPoint, what happens                Democratic nominee Sen. John Kerry. According to Drew
    to pre-existing healthcare arrangements?                      Altman, president and CEO of the Kaiser Family Founda-
  • Why is the federal government raising questions               tion, Republican attention to the issue was noteworthy
    concerning Anthem’s uncompetitive practices in                because the uninsured “used to be an issue that Democrats
    Indiana?                                                      talked about and Republicans denied existed.” Altman
  • What are implications for healthcare now that ten             added, “This is an issue that is not played to win, but to
    companies “cover” half the insured in this country?           neutralize the other side.” (Harvey Frey, www.Harp.org)

Kathie Rudy comments: The editorial implies that the                     TEN TOP INDICATORS THAT THE NEW
pioneers of managed care believed it would ruled by the                    MEDICARE BILL ISN’T ALL IT’S
free market. Today there is no free market in health care
                                                                               CRACKED UP TO BE...
and managed care companies often run amok and forget
the patients.In a free market the consumer of a product is           10. Your annual breast exam is done at Hooters.
its purchaser. Today the vast majority of individuals who            9. Directions to your Doctor’s office include “Take
have health care do not purchase it—they get it from their               a left when you enter the trailer park.”
employer and have little say about their coverage. The               8. The tongue depressors taste faintly of Fudg-
employer is rightly concerned about cost. So health care                 esicles.
companies sell a seemingly cost efficient policy that might          7. The only proctologist in the plan is “Gus” from
look good to a benefits manager while all they are often sell-           Rotor-Rooter®.
ing is the illusion of coverage.                                     6. The only item listed under Preventative Care
          Deadly delays and denials abound, medical neces-               coverage is “ An apple a day.”
sity is often determined by paraprofessionals who have               5. Your primary care physician is wearing the pants
never seen the patient and phantom networks—where                        you gave to Goodwill last month.
multitudes of professionals who have resigned from the               4. “The patient is responsible for 200% of out of
network, sometimes years earlier, yet are still listed in                network charges,” is not a typographical error.
the provider directory—are a dirty little secret that often          3. The only expense covered 100% is “embalming.”
leaves very ill patients desperately searching for a profes-         2. Your Prozac comes in different colors with little
sioal. In a free market the employee could freely change                 M’s on them.
plans. But when there is little if any choice, the free market
has disappeared. Until our tax structure changes and the                 AND THE NUMBER ONE SIGN YOU’VE
employer is out of the picture, a free market in health care is             JOINED A VERY CHEAP HMO:
doomed. Without the checks and balances inherent in a free           1. You ask for Viagra, and they give you a Popsicle
market, health coverage will continue to forget the patient.            stick and duct tape.
                                               COALITION REPORT, JUNE 2004                                                          23.

R      ecently-enacted “reforms” to Medicare radically under-
       mine the program that senior citizens and people with
long-term disabilities have relied on for many years. Not only
                                                                     To maintain and protect Medicare as a universal social
                                                                     insurance program, and to safeguard the health of the
                                                                     nation’s elderly and disabled:
does the new law strip away protections that Medicare benefi-
                                                                     Eliminate the subsidies to private insurance companies.
ciaries will continue to need, it also eliminates one particularly
                                                                     These subsidies are purportedly designed to enable insurance
promising platform on which many have been hoping to build
                                                                     companies to compete with traditional Medicare, but actually
a system of health care for all. We, the 55 sponsoring organi-
                                                                     give them special advantages. Subsidized private insurers will
zations of Rekindling Reform, urge support for the following
                                                                     work to attract primarily healthier beneficiaries. This “cherry
changes in to the new Medicare law, changes that are sought by
                                                                     picking” will leave a disproportionate number of sicker
many and—as evidenced by the attached list of Congressional
                                                                     beneficiaries and older seniors in traditional Medicare thus
bills—by Members of Congress and Senators as well.To make
                                                                     substantially driving up its costs. This will result in higher pre-
the drug benefit more helpful to beneficiaries while containing
                                                                     miums for the traditional Medicare program and its ultimate
cost to the government:
          Provide a comprehensive drug benefit available
to all Medicare recipients through the Medicare program              Repeal the Medicare spending cap. The law will trigger a
itself. Given Medicare’s low administrative costs, the prices        fast-track, filibuster-proof response when federal dollar obli-
paid by individuals should be lower than those of private            gations to Medicare are projected to hit an arbitrary cap, a cap
insurance companies.                                                 that neither has been justified nor exists in other federal pro-
          Eliminate the “doughnut hole” gap in coverage that         grams. It risks rash, harmful cuts in the Medicare entitlement,
will prove a real hardship to millions of beneficiaries. Eliminat-   and/or increased costs to beneficiaries. Moreover, the statute
ing it will be affordable if pharmaceutical prices are reined in.    has an ironic twist, in that, at the same time that it purports to
          Direct the Federal government, and authorize state         achieve cost control, it provides huge giveaways to the insur-
governments, to bargain for lower drug prices. One of the most       ance and pharmaceutical industries.
unseemly provisions of the Medicare bill is that it allows private   Eliminate the new means testing that will make beneficiaries
insurance companies, but not the Medicare program, to negotiate      with higher incomes pay higher Part B premiums to partici-
with the drug companies for lower prices This provision deprives     pate in Medicare. This means testing undermines the univer-
millions of seniors and disabled people of the lower prices they     sality of the Medicare program. If policy is to be introduced
need, and gives yet another unfair advantage to private insurers,    to tax individuals with higher incomes at a higher rate, this
making the entire Medicare program less sustainable.                 should be done through the general income tax program.
          Open up the importation of prescription drugs
provided that they are produced in FDA-approved facilities           Repeal Health Savings Accounts (HSAs), which have noth-
and are packaged and shipped with the use of counterfeit-            ing to do with Medicare but which, by tapping off richer,
resistant technologies.                                              healthier beneficiaries through self-selection, will make cover-
End the incentive in the law to employers to shift rising            age costlier for all who continue to rely entirely on Medicare.
drug program costs onto retirees. The subsidies in the law for       (This is comparable to the effect of the “cherry-picking” that
employers with retiree plans are based on combined employer          is encouraged in the Medicare privatization.) HSAs will erode
and retiree expenditures.                                            Medicare’s base of political support. The tax write-offs given
          Eliminate the ban on purchasing private supple-            to these accounts will deprive the government of revenue
mental coverage for prescription drugs that are not provided         sorely needed to fund the Medicare program. These write-offs,
by Medicare.                                                         which will deprive others of health protection, are a major
          Allow qualifying state pharmaceutical assistance           departure from existing tax policy. They will dramatically shift
programs (such as New York’s EPIC and New Jersey’s                   risks back onto individuals and families.
PAAD) to receive subsidies in a manner similar to qualified          Eliminate the “experiment” in “premium support.” In
retiree plans. This step will safeguard these programs and           the name of choice, its radical objective is to transform
provide recipients with continuity of drug coverage and pro-         Medicare’s character fundamentally, from an entitlement to a
tection against the pressure of rising drug prices.                  “defined benefit”, into a “defined contribution” voucher that
          Allow state Medicaid programs to provide “wrap-            helps purchase unreliable private insurance in an uncertain
around” prescription drug coverage for dually-eligible               market.
Medicare/Medicaid beneficiaries, just as they do now with
Part A and Part B hospital and medical benefits.
          Eliminate the assets test for low-income recipients,       For more informationi about Rekindling Reform, go to their web-
which will otherwise exclude many people from coverage.              site: www.rekindlingreform.org, or email@rekindlingreform.org
President’s Column
Dave Byrom.....................................................................1
                                                                                     T     HE FOCUS OF       AMHA-USA

                                                                                     is on direct marketing of professional prac-
Editor’s Column
Bill MacGillivray.............................................................3      tice to preserve the highest standards of
                                                                                     treatment and client privacy.
Triage as Treatment
Russ Holstein...................................................................4    WWW.AMERICANMENTALHEALTH.COM

The Empirically-Validated Treatments Movement

                                                                                     T                       THE NATIONAL
Ron Levant.......................................................................8         HE FOCUS OF
Benefits of Health Care Information Technology                                             COALITION
George Bush...................................................................11

Privacy Form..................................................................12
                                                                                     is on political and legal action to preserve
                                                                                     the highest standards of treatment and client
Privacy Petition..............................................................13     privacy

And in the News: Summaries and Commentary                                            WWW.THENATIONALCOALITION.ORG
Bill MacGillivray...........................................................14

Undue the Damage to Health Care: Reclaim Medicare
Rekindling Reform Coalition.........................................23               J   OIN   BOTH ORGANIZATIONS TODAY!

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                                                  June 2004 Issue

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