Sunday, October 27, 2013

Stigltiz Commentary and The Implications for the Politics of Psychiatry

Nobel prize winning economist Joseph Stiglitz came out with a recent commentary of the economic recovery and why things are not a rosy as they seem.  He points out that many of the structural problems with the economy including predatory lending and credit, abuses by the credit card industry and abuses by the credit reporting industry are still in place.  In addition there are inadequate capital reserves and no real limits on the kind of low risk speculation by certain parts of the financial services industry - the basic problem that started everything 5 years ago.  I have been posting in political forums for the past 15 years that the American economy at times seems to be based on a fantasy rather than the way a real economy should work.

We have taken an alleged retirement system (401K, 403B) and turned it into a windfall for the financial services industry.  Instead of an actual retirement system, we find that the average American is not able to put away nearly enough to retire and in the process ends up paying significant fees to financial services companies.  In return for these fees they receive the standard boilerplate about no guarantee against losses and frequently have very poor investment choices since they are determined by their employer.  At the same time, low risk retirement vehicles like money market funds are paying negligible amount of interest.  Rather than being a reliable retirement system this is essentially another tax on the American people to fund the financial services industry.  Retirees are left with the option of accumulating cash only or putting their retirement funds at significant risk all of the time in order to accumulate enough capital to retire.

We are in the process of starting a huge health care mandate know as the PPACA or more popularly as Obamacare.  It will create a large influx of capital into the healthcare system based on coverage mandates.  The American health care system is currently the most expensive system of health care in the world.  The standard model used by the federal and state government has been to use managed care companies as intermediaries to contain costs.  There should be no doubt that model is a near total failure.  Recent data for example suggest that a couple nearing retirement should have an additional quarter of a million dollars saved for health care expenses during retirement beyond the cost of Medicare.  The health care system in this country can be viewed as a second tax on the American people.

How do Americans end up with two additional taxes being levied on them in addition to the usual income, Medicare, Social Security, sales, and property taxes?  How does it happen when we have a supposed radical element of one of the major parties working on fiscal responsibility?  I think it comes down to one American institution and that is the US Senate.  The Senate is full of aging, wealthy politicians who have worked for years to develop a power base in Washington and keep it.  They are completely out of touch with what the American people need and pass laws that will largely benefit the businesses that they are heavily lobbied by.  In some cases, they wrote the laws to invent the industry.  The disconnect of this group from the public was evident during the recent stand off to shut down the government and nearly default on our creditors.  In other words they risked the world economy to make a point instead of fairly representing what the average American wanted at that time.

How does all of this apply to the politics of psychiatry?  I can illustrate by looking at a few seminal events that apply to all front line psychiatrists and how their professional organization - the American Psychiatric Association (APA) responded:

1.  Managed care and the disproportionate rationing of psychiatric services:  Apart from Harold Eist, MD and a recent lawsuit against a managed care company there has generally been silence on this issue.  Some literature was generated regarding how to work with meager rationed resources but nothing about how to fight back as managed care became a government institution.  The APA's support of collaborative care means we have come full circle and the APA is explicitly backing a managed care model that involves treating patients without actually seeing them.

2.  The response to accusations of conflicts of interest related to the pharmaceutical industry:  There was a well known initiative against some prominent psychiatrists, the motivations for that initiative are still unknown.  It is well known that many academics in many university departments have contracting arrangements with industries in order to supplement their salaries.  It is well know that some professions charged with determining industry standards insist on industry representation in meetings where those standards are written.  It is known that many professional organizations got more support from the pharmaceutical industry than the APA.  The response to the attack from a Senator was to basically acknowledge that his attack was accurate and proceed with an appeasement approach that allowed critics of psychiatry to use this as additional rhetoric against the profession and any psychiatrist with a contracting arrangement.

3.  The Maintenance of Certification (MOC) issue:  This issue was forced by the American Board of Medical Specialties (ABMS) based on limited research.  The APA immediately aligned themselves with the ABMS despite considerable complaints and a petition by the membership.

The three examples given about are some of the main political issues for psychiatry, particularly the average working psychiatrist and the APA.  To say that the interests of most psychiatrists are not represented by the APA is a massive understatement.   Like the U.S. Senate, the APA seems almost totally disconnected from the people it is there to represent.  I have heard many reasons over the years about how the actual structure of the APA is the problem.  But nobody seems to want to remedy that problem.  I attended a seminar at one point where an APA official explained the MOC issue and how it would actually create a financial burden for the American Board of Psychiatry and Neurology (ABNP), despite the obvious fee generation to take a commercially monitored and administered test.  If it really is that burdensome -  why do it in the first place?  The initial rationale was that the public demanded it.  It seems that there is now solicitation for public support.  Who would not support an initiative to improve the competency of doctors - even if there is absolutely no evidence that a multiple choice exam with a high pass rate does that?

I think it is highly likely that the political structure of the APA is very similar to the political structure of the Senate.  While there is no lobbying there are ideas and affiliations based on those ideas.  Any political structure that is so far removed from what its constituents want it driven by cluelessness, conflicts of interest, or a divine mandate.  It is only logical to conclude that like the Senate, the issue is conflicts of interest.  In the 21st century, patriotism is no longer the last refuge of a scoundrel - accountability is.  The APA would do well not to follow the Senate on that course.

George Dawson, MD, DFAPA

Joseph Stiglitz.  5 Years In Limbo.  Project Syndicate, October 27, 2013.

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