by Gerald D. Klee, M.D. , Editor
[Spring/Summer 1998; Vol. 25 No. 1]
Robert W. Gibson, M.D., in this issue "Predicting the Future of Psychotherapy" laments the fact that under various pressures such as managed care, psychiatrists are doing less and less psychotherapy. Despite the many advances in psychiatric theory and treatment, such as those from neuroscience and psychopharmacology, Gibson believes that psychotherapy is vital. He states: "We must retain psychotherapy, but weµll have to fight for it." Most psychiatrists with whom I have spoken, in Maryland and elsewhere, agree with Gibson's assertions. Marianne Benkert, M.D., also in this issue in "Resisting the Attack on Professionalism" strikes a similar note, as she emphasizes the importance of the therapeutic relationship and the ways it is being undermined as control of medical care has shifted from physicians to administrators interested only in the bottom line. Benkert states "Now is not the time for compliance," and she goes on to give examples of how we can overcome our sense of powerlessness by taking political action.
Not everyone agrees with this view. In addition to HMOs and other forms of managed care, some governmental agencies see things differently and are armed with statistics to back up their arguments. If we are going to fight for psychotherapy, this is one of the areas where we must engage our opponents. Our fight is not so much with people as with information that is misleading, at best, and often falsely interpreted. Our feeling of powerlessness is not entirely an illusion.
As every dictator knows, information control is an essential key to power. Much of health care information is now in the hands of those who are frequently motivated to limit access to health care. In addition to for-profit HMOs, this, unfortunately includes certain agencies at various levels of government. It was not always this way. The present author in "Riots and Mental Illness" in this issue, cites a time when the Maryland Psychiatric Society played an active role in monitoring mental health statistics in collaboration with state and federal agencies.
Things have changed since then, as efforts have grown to "reform" and regulate medical care. "In 1993, the Maryland General Assembly enacted health care reform legislation that has as one of its most important elements the creation of the Maryland Health Care Data Base."1 On the same page the report also states "In establishing a statewide Medical Care Data Base the legislature envisioned information that would support the development of cost containment strategies..." (italics ours) This report includes data from a wide variety of sources, including data submitted by all the major payers. This information is available to policy makers.
As we shall see, the report does more than report data; it also makes interpretations and suggestions. Since this is a regulatory agency, their words should not be taken lightly. For example, last year's report (1997) makes the following statements: "Conditions associated with mental health services have long been a target for control,"2 "The substitution of lower cost treatment includes relying more on physician office services relative to hospitals and substituting pharmaceuticals for some physician services, particularly psychotherapy." (italics ours) This theme is continued in the 1998 report, which states "Individual psychotherapy sessions are among the most expensive in aggregate expenditures for HMO and non-HMO population." 1 Table 20A, page 59, supports this statement, showing Individual Medical Psychotherapy with a Physician (CPT CODE 90844) as first among the top twenty payment procedures, accounting for 2.9 percent of total payments for private, non-HMO services. These figures are based on data from 1996. Subsequent tables show similar figures for HMO and Medicare populations.
Are these figures accurate? If they are, does it mean that psychiatrists are doing too much psychotherapy? Most psychiatrists and their patients are likely to view these figures with profound skepticism. The 1997 report also states: "Mental health, overall, constitutes only 3 percent of all care." In 1998, only a year later, the percentage of medical psychotherapy alone is nearly this high according to HCACC. (See above) How can this be? But who can tell without access to the raw data and information on how they were collected and tabulated? The data were drawn from a wide variety of sources. It seems highly improbable that all the sources used identical methods of data collection and tabulation, or that their computer systems were equally reliable.
In a recent story in the Baltimore Sun, May 18, a Baltimore City Councilman is reported to have accused the Baltimore City Police Department of under reporting shootings in Baltimore to make it appear that they had dropped by 60 percent in recent years. Such a drop would reflect well on the Police Commissioner. The police denied any inaccuracies until the Sun found discrepancies during a review of police statistics on shooting. When confronted with this, the Police blamed the errors on their computer systems. Is theirs the only faulty computer system?
The 1998 HCACC report also contains some interesting statistics on fatal accidents by jurisdiction. HCACC offers no interpretations. It comes as a surprise that the highest rates seem to occur where one would least expect them. If the statistics are correct, your chances of dying from a fatal accident (at 69 per 100,000 population) in Kent County, a sparsely populated rural area on the Eastern Shore, are four times higher than if you lived in Howard County, (17 per 100,000), in the bustling Baltimore-Washington suburban corridor. With fair consistency, the rural areas from the Eastern Shore to Garrett County in the west, seem to be the most dangerous for fatal accidents. Before sounding the alarm, it would be prudent to reexamine the data from each source for reliability and validity.
It should be clear from these examples that data can be very misleading. MPS has argued the point with legislators and HCACC itself that the HCACC data base has serious shortcomings even before interpretation of data begins. There is no compelling reason to compromise patients' right to medical privacy for such dubious results. MPS must continue its fight for the requirement of patients' consent before their individual medical data is submitted to HCACC. We must also continue to point out the problems with HCACC's data reporting and analyses.
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