Insight Matters
Spring 2005

We Must Be Vigilant - And Vocal

David Bienenfeld, M.D., President

It's the first shrink joke I remember hearing:

A young psychiatrist gets into the elevator at the end of the day with a senior colleague. The young fellow is exhausted and bedraggled, while the older one is fresh and bright-eyed. "I don't get it," says the novice. "How can you listen to people's troubles all day and not tire out."

Says the elder, "So who listens?"

We know better. We know that what we do best is to listen, and further to understand and explain. That's what we do as individuals in practice. But what about this organization of 1000-plus psychiatrists? What is our collective purpose? I'd propose that our function, too, is communication - listening and speaking. As a state level organization we communicate outward and inward, and these directions represent the two prongs of my agenda as your next president. Outward, we speak to the APA, to the general public and to governments. Inward, we communicate with our membership, to listen to their needs and implement what we can, and to provide messages and information our members might not get without us.

On the outward side, I'm going to limit my attention here to those issues we must address at the level of government. We are not only positioned to announce ourselves with regard to matters before the legislature and administration in the state of Ohio, we are the only ones who can and will do so.

Psychologists continue to press for prescribing privileges, and have mounted a large, well-funded lobbying campaign to advance their cause. They cite the continuing shortage of psychiatric services to large parts of the state as evidence favoring their stance. Of course, their logic is flawed, but term limits force us to re-educate new cohorts of legislators in Columbus in order to protect the safety of our patients and the integrity of our mental health system. Other matters arise from time to time related to the same scope of practice issue, covering such domains as family therapy and alternative treatments. Most of these are more subtle than the prescribing privileges matter, and require more nuanced responses. The OPA is obliged to monitor each of these efforts in turn and to craft responses serving our membership.

In the state budget, Medicaid is the monster that the governor and the legislative houses fear most. Unchecked, it will devour the budget. Thus far, mental health has retained its funding levels without cuts, but inflation and particularly the rising costs of personnel and medications mean that a level budget translates to a loss of resources available to our patients. Simple knee-jerk objections to budget threats, and relieved wiping of brows when we get cut less than another group, are no fix for the problem. We must work together with ODMH and press the legislative and executive branches of the state government ourselves, to create a more sane Medicaid program for Ohio.

Inadequate and prejudicially restricted coverage for adults and children, even under current regulations, have mobilized some of us, particularly the Cleveland chapter working through the Psychiatric Practice Committee, to petition the insurance commissioner for fair treatment under existing law. We must continue this pressure, even as we advocate for better laws.

At the national level there are a number of matters on APA's radar to which we must also pay attention and flex our muscle. Mental health parity in insurance has been written into the law since 1996 but boldly ignored in practice. A review by the General Accounting Office in 2000 revealed that 87% of insurers who were technically in compliance were violating the spirit of the law by limiting mental health services. This finding, of course, is no surprise to us who treat patients. This toothless law sunsets in 2005 and will escape the attention of Senators and representatives unless we open their eyes.

Similarly, Medicare copayments, a fair 20% for somatic services, are an unjust 50% for mental health services. This inequity is not a matter of regulation, but is written into the law. It places an undue burden on the shoulders of our aged and disabled patients and must be rectified. The Medicare Mental Health Co-payment Equity Act is before Congress and APA is pressing the issue.

I've presented just a brief list of legislation up for debate in Columbus and in Washington. It represents not just interesting stuff to read over our morning coffee and cluck at, it's our patients' welfare and the integrity of our practices that is at stake. OPA has no choice but to be both vigilant and vocal. We must pay attention ourselves and direct the attention of our state and federal representatives. Effective advocacy is not just lobbying done by a small group in the respective Capitols, it is the concerted voice of our collective membership making our views known persuasively and consistently.

While such advocacy is a vital function of the state organization, that organization is only an abstract entity without the active participation of its more than 1000 members. And that's where we run into the other major challenge.

Most OPA members, frankly, do not identify themselves in any powerful way with the Ohio Psychiatric Association. When they think about their role in organized psychiatry, they are most likely to think about their local chapters, and about the APA. In my opinion, there's nothing terribly wrong with that model. It just forces us to think about what the role of OPA ought to be. In my year as President Elect, I've realized that the relationship between this organization and our constituent chapters is at best loosely defined. I am making it the second prong of my agenda of communication to contribute some definition of that link so that, through the chapters, we at OPA can better serve our members.

The way to start is to listen to the chapters to find out how we can best be of use. While I have little faith in surveys, they're not a bad place to begin. A better vehicle is real human contact. I intend to be on the phone with chapter presidents to get their ideas. Janet Shaw and I, independently and together, expect to be on the road over the course of the year to attend chapter meetings. I also plan to add to the agenda of each of our quarterly Council meetings, a report from one or two chapter presidents about issues and activities at the local level.

I hope, by the end of my term, to have organized proposals to put before the Council, to circulate back among the chapters, clarifying the structure and process that will allow OPA to be of effective service to the chapters that are our backbone.

Even as we are listening and proposing, there are things we can do already for the chapters. OPA has lots of materials about state and national issues that we can provide to chapters for distribution to their members. And most chapters operate on a shoestring. Officers volunteer their time and energy for administrative tasks, and pilfer clerical time from their offices to get through the year, only to start scrounging again after the next election cycle. Few if any chapters can justify even part-time support staff with any continuity. OPA can provide much of this service to local chapters, and Janet, Linda Smith and I will be creating a format very soon to make such assistance available to our chapters.

Our organization is under undeniable pressure to do much with little. We face challenges in the budget and in membership at a time when society and government threaten the shape of our profession. If we can turn to our membership at the chapter level, forge a link with our grass roots, and inform our members of the tasks we face, I am confident we can arouse our collective passion. And when we do so, I am certain we can speak with a voice that will make a difference for our practices, for our patients, and for the society in which we live.

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