Reactions of a Solo Practitioner in Toronto (7/14/98)

    Yes, I fell in love with Toronto. I went there for the Annual Meeting

of the American Psychiatric Association, June 30 to July 4. A very clean

city with nice people and good public transportation. Impressive to see

Metro functioning in an honor system. No gates and no revolving doors.

    The Canadian Single Payer? Was alive and well. I went around asking

Canadians about it. I talked with bus drivers, waiters and waitresses;

workers for airlines and telephone companies; professionals and, why not,

even psychiatrists. Yes, they have complaints, high taxes being one of

them. But they ALL love their health care system, and did not want to have

it changed. A female bus driver spent time telling me about her

tranquility knowing that if she or her children got sick they would have

the care they needed. What did she like the most? Choosing and changing

her doctors. Also, she could change jobs, and could have pre-existing

conditions without losing her coverage.

    Yes, she realized that for some elective conditions she and her

children sometimes had to wait for appointments. She understood that this

was necessary to make the system cost effective. One Canadian psychiatrist

told me how his income was about the same as an American psychiatrist but

without the paper work and harassment from Managed Care Organizations.

    Then, the American Psychiatric Association Annual Meeting.

Disappointment! Oh, my! Very few discussions on health care and yet this

is the biggest issue in America today. Why? I am not clear! Then there

was the deluge of meetings, symposiums, presentations, buffets,

receptions all sponsored by drug manufacturers. The big corporations

it seems to me, took over the Annual Meeting of the American Psychiatric

Association. I was embarrassed and ashamed. Are we, American

psychiatrists, selling ourselves and our independent thinking to these

powerful interests? I came back with this question in my mind...

    I went to Symposium 49: "Single Payer or Competition? Canadian and

United States Views." I thought the place would be packed! Instead,

very few people showed up. Good speakers and good discussion. Two

Canadian doctors talked about their system. The more elegant, better

dressed and articulate (looking like a CEO... yes, why are all these

"privatization" people so well dressed and elegant?...) was in

favor of privatizing the Canadian system. But what he said just did not

fit with what I heard from the people in the streets.

    But what impressed me the most? Fred Goodwin MD, an US psychiatrist

and Rodrigo Munoz MD the president of the APA trying to sell Medical

Savings Accounts to us. Dr. Goodwin is a very smart man. In Brazil we

would say that he take bananas from monkey's hands. He compared Medical

Savings Accounts with Managed Care but he failed to compare them with the

Single Payer. I hope he will do this in the future.

    When he commented on the Single Payer in Canada he came up with the

same old clichés: "Canadian doctors are flocking into the USA" and the

"Single Payer is having 'managed care'". He sounded like an Harry and

Louise TV add. He did not go into the vast difference between managed

care for profit and managing care as an effort to control costs in a

Single Payer.

    You know... in Medical Savings Accounts, once the savings accounts

are spent people will have to fall back on insurance and, again,

managed care for profits!... Is this what the American people wants?

It was nice to see a Canadian psychiatrist stand up in the meeting and

say how much she liked the Canadian Single Payer.

    By the way, here is what Uwe E. Reinhard PhD, an economist at

Princeton University has to say about Medical Savings Accounts when

commenting on the government subsidies for employer sponsored health

insurances in his paper Wanted: A Clearly Articulated Social Ethic

for American Health Care: "This regressive tax preference would only

be enlarged further under the Medical Savings Accounts (MSAs) now

favored by organized American medicine. Under the concept, families

would purchase catastrophic health insurance policies with annual

deductibles of $3000 to $5000 per family, and they would finance their

deductible out of MSAs into which they could deposit $3000 to $5000 per

year out of the family's pre-tax income. In terms of absolute, after-tax

dollars, this construct effectively would make the out-of-pocket cost

of a medical procedure much lower for high-income families (in high

marginal tax brackets) than it would for low-income families. ...

Unwittingly, perhaps, by favoring this regressive scheme to finance

health care, physicians take a distinct stand on the preferred

distributive ethic for American health care. After all, can it be

doubted that the MSA construct would lead to rationing childrens'

health care by income class?"

    In the opening session of the Congress I liked the speakers. Herbert

S. Sacks MD, the past president, stood up against Managed Care. But he

failed to guide us into what kind of health system we should be fighting

for. Rodrigo A. Munoz MD, the new president also stood up for us and our

patients but again did not spell clearly what kind of health system the

American Psychiatric Association believes will be better for the American

people.

    All the computer seminars in the meetings did not address the needs

of Solo Practitioners. Are we a vanishing species? Everyone was trying

to sell computer software for GROUP PRACTICES. Worse yet, nobody seemed

interested in computerizing treatment plans of Managed Care so that we

could fill, file and fax them. Shouldn't someone be working in helping

us put these forms in our computers?

    In Symposium 82: "Psychiatric Ethics: Facing the 21st Century", a

very interesting discussion. Good speakers. Leon Eisenberg MD was quite

vehement about his position against Managed Care. But he also did not

say what kind of health care system Americans should have. Sydney

Block MD took a more balanced view of the ethics of cost containment.

Unfortunately, I missed the first two speakers.

    I loved the Forum 4: "Toward a neurobiology of psychotherapy". The

room was not large enough to accommodate the crowd. It is about time for

psychiatry to bring psychotherapy back into its main stream and this

was the emphasis of the presentations. Solo Psychiatrists should be

allowed to medicate and do psychotherapy with MCO patients. Most Managed

Care Corporations are not "authorizing" psychiatrists to do this. They

only allow us to do "med-checks", that is, 15 minutes sessions to review

the medication.