Tuesday, March 21, 2017
My Dear Readers,
One of the lovely elements of practicing psychoanalytic psychotherapy in a private practice setting is the clarity in the nature of the professional relationship. Psychotherapists provide distinct services. In some of my scholarly articles, I have identified framing the relationship as one of three basic features. They also bring their presence, meaning their interest, curiosity, and empathy to their patients. Lastly, they engage patients in dialogue in various ways, consciously and unconsciously, verbally and non-verbally. In some settings, the fee is set by an institution. In most private practice settings, a fee is negotiated. After that point, all elements of the basic service unfold in a transparent way.
In contrast, if you get into a serious automobile accident, sustain a head injury and multiple fractures, and are transported by ambulance to the nearest hospital, you will enter a labyrinthine, complex, extremely opaque system. Let’s assume you remain hospitalized for ten days, undergo one orthopedic surgery, and then the hospital discharges you with prescriptions for pain-relieving and anti-inflammatory medications. If you ended up in one of the major US hospitals, you would struggle to understand the billing — if you are even lucky enough to get an itemized bill. Most hospitals are paid based on your diagnosis, and so you’ll have no idea what an x-ray, a lab test, a physical therapy treatment, or possibly even the surgery actually cost. This is a terrific problem. If you think about it, entering the hospital — even though you are preparing to receive a service — is diametrically opposite to entering a grocery store. This seems more than weird. If you are familiar with grocery stores, say the difference between Vons and Whole Foods, you’ll already have a sense of price differences between them. Once inside the store, you’ll see the prices of milk, cheese, bread, dog food, and so on clearly marked. You’ll have no surprises at the time of checkout — an experience not unlike discharge from a hospital.
This bizarre situation has been decades in the making, and results primarily from private, capitalist insurance companies controlling the medical delivery systems. A rather unkind way to view the health insurance companies is to compare them to the Mafia, or to narco-traffickers. Oh so sadly, in many small villages and towns in central America, particularly in places like Honduras, these mobs extort local businesses. In other words, they will make a firm, say a coffee shop or a tire store, pay a fee for protection. If the firms don’t pay the fees, their buildings are burnt or their owners or workers hurt. It’s a “shake-down.” So, when you go to the hospital, or even when you consult your personal doctor, there’s always a third party involved, like the Mafia or the narco-traffickers, skimming off part of your fee. I consider it mostly luck that I ended up in clinical psychology rather than psychiatry or some other branch of medicine. Those “providers” (another insurance company-invented term) receive increasing smaller amounts for their fees, while insurance company executives earn increasingly more. It’s nothing less than an outrage.
In fairness, the insurance companies are not solely to blame. There also exists what has been termed the “medical-industrial complex,” a loose conglomerate of pharmaceutical firms, medical device manufacturers, and other related companies, struggling to provide ever greater profits for their shareholders. When World War II came to an end, most of the major industrialized countries — Canada, Japan, Germany, England, France, the Netherlands, and others — considered the medical care of their citizens a right of citizenship. In other words, these countries treated medical care as a basic right, much like the police or fire departments. The US, and I believe it was President Truman who was responsible, chose to allow “free market forces” to control the health care system. The result is the kind of mob-like operations we all see in our country. Hardly a day goes by when you don’t see headlines proclaiming rising insurance premiums, eliminations of benefits, increased costs for medications. The recent scandal regarding the Epi-Pen provides an excellent if horrible example. The firm making it raised the cost of the life-saving but extremely cheap-to-make drug to nearly $1000. I find it embarrassing, shameful, even frightening that our country has, and continues, to follow this model. It’s about to break, and solving it would be extremely simple. Here’s a proposal that is hardly unique:
1. Extend Medicare coverage to birth for all citizens of the US: The Medicare system seems to be working extremely well. Codes for a wide variety of procedures, and the costs of those items, are well established. I consider myself politically moderate, ok, perhaps somewhat left-leaning, but this talk about “socialized medicine” is nothing less than insane. Why not consider public schools, sanitation departments, and the Federal Aviation Administration (FAA) examples of socialism? In a sense, they are. More accurately, they emerge from social democracy, a fundamentally democratic political system that has decided that certain basic, shared needs, like for education, trash collection, and flying airplanes, are best managed by governmental agencies. How could an argument possibly be made that the health of a citizen is less important than learning, trash colleciton, or flying? It’s unbelievable! Whoever doesn’t understand this argument has been, in my view, brainwashed by the medical-industrial complex. (Perhaps I’ve been brainwashed too because I just had the fantasy of having to look over my shoulder after posting this.) Please note that more than half the health care services currently provided in the US are already government based (Medicare, Medicaid, the VA). Further, whatever increase in taxes would be required to extend Medicare to birth would definitively be less expensive. It would stop the “shake down.” It would remove the middle-man. Since Congress is debating the most expensive, and least amount-of-coverage insurance possibilities as I write this, the timing would be ripe for such a radical but simple change. Again, the system exists. Doctors and hospitals use it daily. The change would require simply extending what is already in place.
2. Like the USDA does with meat, allow the US government to certify, as it already does with Medicare, what qualifies as a basic medical benefit: To prevent thousands of medical-industrial complex employees from losing their jobs, let’s allow the insurance companies and medically-related firms to stay in business. The latter would retain the government as their customer; the former could compete for policies offering extra benefits. Insurance companies would cover supplemental insurance, as they already do. The wealthier Americans could buy platinum level policies, covering everything from dental implants to cosmetic surgery. Middle-income folks could purchase a less generous supplemental type of insurance. Again, the insurance companies would lose a great deal of business, but do we want to keep a Mafia-like structure at the center of American health care? Please remember we are the ONLY major, industrialized country, in the entire WORLD, that lacks such universal coverage. It is more than a shame; it’s a disaster.
3. Require complete transparency in costs of medical procedures or equipment: As I suggested with the grocery store example above, and benefiting Medicare and consumers, insist that drug companies, laboratories, hospitals, doctors, etc., clearly indicate their price structure. If you’re shopping for an internist, you should be able to find, easily on a website, the cost of an office visit or a hospital consultation. If you choose that internist and she finds you have an infected appendix requiring surgical removal, you should just as easily be able to determine what a night in the hospital costs, the fee for the surgery, the rate for the surgeon and the anesthesiologist, etc. Notice also how the system now allows for fraud, for immense differences between retail and wholesale prices. Even worse, no transparency currently exists, so how can you do comparison shopping? One of the only clear benefits of having insurance coverage is that these firms negotiate their prices with providers and hospitals, and so you get the discount when you need the service. They enjoy the income from your premiums, and pay discount rates when you have a need for help. This is why so many individual medical providers and hospitals are hurting financially. Once again, it’s a Mafia-like problem.
I strayed from my usual primary focus on psychoanalytic psychotherapy for several reasons. First, we are all getting bombarded with news about the failing US health care system and the new bill being debated in Congress. Second, and as I noted at the start of this posting, the perspective of the individual psychotherapy patient provides a useful vehicle for understanding these startlingly simple fixes. (What would not be simple is the unspeakable resistance we will encounter from the lobbying forces of the medical-industrial complex which, many have argued, has grown more powerful than any individual politician or even government.) If the psychotherapist chose to work within the Medicare system, then the fee would be set as would the number of sessions allowed. A universal coverage would not prevent patients from consulting practitioners who work outside of Medicare; it would also not prevent them from seeking help from clinics that cost less, like the Rose City Counseling Center (RCC) in Pasadena, California. RCC offers psychoanalytic psychotherapy by post-doctoral, unlicensed but supervised clinicians, at fees ranging from $35 to $80 per session, and with no limit on number of sessions! Universal coverage would hurt neither the private practitioner nor a non-profit like RCC. It would, however, solve an immense problem, greatly simplify what keeps becoming dazzlingly complex, and — most importantly — immediately end the SHAME that our country, the richest in the world, fails to guarantee the health of its own citizens.
Too bad this isn’t a tweet; if it were, then perhaps Mr. Trump would read it and realize he would ensure himself immortality if he dared to embrace such an eloquent solution.
Submitted with full expectation of my health insurance premium increasing with its benefits decreasing,
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