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Considering the Place of Mental Health in the Re-structuring of Health Care in the U.S. A Position Paper The Consortium for Psychotherapy Brookline, Massachusetts THE CONSORTIUM FOR PSYCHOTHERAPY is a growing multi-disciplinary associ- ation of experienced psychotherapists--psychiatrists, psychiatric nurses, psychologists and social workers--from the greater Boston area. Though members come from differ- ing educational and philosophical backgrounds, we have joined together for the common goal of promoting mental health services of the highest quality--services that place primary emphasis on the best interests of the client. This goal is central to the reasons that our members entered their professions. Consortium members are deeply concerned that some of the health care alternatives being promoted for our country today will create an atmosphere in which the best interests of clients will not be met, and in which many providers will be unable to work effectively. The purpose of this document is to communicate our concerns and proposed alterna- tives to Congress and the White House. We will focus our attention on out-patient mental health benefits as we see this as a seriously neglected area in the overall debate. Specifically, we want the Administration to be aware of (1) why out-patient benefits need to be fully included as a priority in the re-structuring of the nation's overall health care; and (2) why the micro-management of outpatient benefits by for- profit managed care companies is economically wasteful, counter-productive from a consumer perspective, and fundamentally flawed from a clinical perspective. Considering the Place of Mental Health in the Re-structuring of Health Care in the U.S. Overhauling our health care system so that quality care is treated as a basic right of our citizens may be the most politically challenging task that faces the nation today. The task of providing quality care at a reasonable cost can be done--as has been demon- strated in various nations in Europe, and in Canada. Our nation's task has become so difficult primarily because of the political need to take into account the entrenched finan- cial interests that have entered the health care industry over the past two decades--and that have imposed powerful constraints on the kinds of solutions seen as viable. We are aware of the political difficulties involved, and our reading of media reports over the past few years makes us wary about whether a good solution can be found. But we would be seriously remiss in our duty as citizens and as professionals if we did not raise our voices about what we believe will work in the long run, and about what we believe cannot work--and why. Briefly summarized, the positions we support are: I. We advocate for the full inclusion of outpatient mental health and substance abuse benefits; these benefits should be part of the primary health care delivery system in the U.S.. II. The manner in which mental health services are delivered and benefits are assigned needs to take into account what is unique about the provision of mental health care. We advocate the position that the most clinically effective and cost efficient way to provide these services is without the use of micro-management by external third parties. III. We advocate a different system of health care and a different method of controlling costs than the one that has emerged in the U.S. We believe that a uniquely American single payer health insurance system can be designed which will eliminate the wastes inherent in the current system. The arguments developed below include a number of ideas. First, outpatient mental health care saves money for the overall health care system by (1) reducing primary medical costs; (2) reducing psychiatric in-patient costs; (3) contributing to prevention of intergenerational transmission of mental health problems; and (4) enhancing the capacity of workers to function effectively. Second, mental health care delivery, perhaps more strongly than other health care services, depends on the relationship between the provider and the client. This generates special requirements for delivery: freedom of choice of provider; continuity of care regardless of insurer; preservation of privacy; and freedom from intrusion by third parties who cannot know the needs of the individual client. We argue that there are critical lessons to be learned from the total failure of industrial "inspec- tion" systems to control quality. Instead, we argue, only delivery methods that educate and empower both consumers and providers will have the desired results. Third, we present briefly the outlines of a system that controls costs by negotiating nationwide fees with providers, emphasizing primary care, and holding providers accountable for delivering prevention programs to the communities they serve. DEVELOPMENT OF THE POSITIONS I. We advocate for the full inclusion of outpatient mental health and sub- stance abuse benefits; these benefits should be part of the primary health care delivery system in the U.S. We take this position because we are convinced that mental health care saves both lives and money--in the short run and in the long run. Evidence is accumulating that the overall quality of health care is improved when mental health is taken into account. Evidence also suggests that when people make effective use of out-patient mental health services, financial savings can be realized in at least four ways: (1) by reducing more expensive and often unnecessary medical services; (2) by reducing the over-utilization of expensive crisis-related psychiatric inpatient hospitalizations; (3) by helping to reduce the inter-generational transmission of serious social and health problems; and (4) by increas- ing productivity, satisfaction and stability in the work place. Our positions are based, therefore, on considerations of the quality of care provided to citizens, access to care, and cost containment. A. Immediate cost of medical services is reduced. Research has shown dramatic decreases in the utilization of medical services (i.e., fewer visits to the doctor, fewer extensive and expensive tests, and fewer high-tech medical procedures) following out-patient psychotherapy (Massad, West, and Friedman, 1990; Inman, 1981; Cummings and Follette, 1968). In fact, it has been reported that at least 60% of doctor office visits are made by patients who have no medical problem whatsoever (Bak, Weiner, and Jackson, 1992). It would seem that many people who go to the doctor because they "hurt" may, indeed, be hurting psychologically, and successful efforts to alleviate psychological distress will sharply curtail the utilization of more expensive medical treatments. This may be particularly true among the elderly, where studies find that elderly patients receiving mental health care averaged 12 fewer hospital days per year than those not receiving such care (Mumford, 1984). This medical offset (i.e., the decrease in medical utilization as a result of mental health care) has also been shown to be present for up to at least two years following psychological treatment (Kessler et al., 1982; Borus et al., 1985). Additionally, there is evidence that patients with physical limitations and mild to serious medical conditions will realize considerable medical cost offsets if treated in outpatient psychotherapy (Fiedler and Wight, 1989). Helping people deal with the psychological distress associated with their medical condition and helping them develop alternative coping strategies can sharply reduce the number of physician visits and medical hospitalizations over a three-year period (Schlesinger et al. 1983, Cummings et al., 1990). Similar findings apply to the treatment of alcohol and drug-related conditions. The evidence suggests that as much as 85% of medical expenditures could be reduced through the use of psychological interventions directed toward the root (rather than merely the symptom) of the problem (Jones, et al., 1979; Cummings, 1990). Many apparently physical disorders are rooted in stress and in misunderstandings of psychological distress. In fact, given a culture that continues to see psychological distress as a sign of "weakness," the likelihood that individuals will translate their emotional vulnerability into physical vulnerability continues to be high. One wonders, for example, whether the administration of expensive MRI's for neck and back pain might be reduced considerably if people were encouraged, first, to deal with the stressors that might be exacerbating their physiological symptoms. Given the continuing and consistent evidence that people's physiological well-being is intimately tied to their psychological well-being, we advocate that outpatient mental health benefits be linked to the primary health care delivery system rather than being treated as a "specialty" service. With primary care physician and psychotherapist working together to identify and treat stress-related medical conditions, we believe that enormous savings can be realized in terms of frequency and cost of medical usage. B. Out-patient mental health care prevents more expensive in-patient care. Perhaps one of the most convincing arguments for generously supporting outpatient psychotherapy is the considerable evidence that good outpatient care can significantly reduce the need for more expensive psychiatric and substance abuse inpatient care. It is rare to find a patient who chooses psychiatric hospitalization over less restrictive treatment. And it is rare that people are hospitalized because we do not have the skills to treat them in less expensive outpatient settings. More often, people are hospitalized either because their medical coverage does not provide for the intensity of out-patient service that they need in the midst of a crisis or because their outpatient coverage was insufficient to cover them prior to the onset of crisis. Frequent outpatient therapy, day treatment programs, psychological supports for family care-takers and therapists who can be available to travel to patients' homes, particularly when patients in crisis are children or adolescents, are all less expensive than hospitalization. While the data are limited, findings strongly suggest that in the treatment of alcoholism there is absolutely no difference in outcome for patients who are treated in the hospital (at far greater cost) as compared to those treated in non-residential settings (German, 1990). While there will always need to be a provision for inpatient services for the most severely suicidal, homicidal, or acutely psychotic patients, we believe that funding mechanisms have indirectly supported the over-utilization of hospital services. When outpatient psychotherapy coverage is limited to twenty visits a year (and far less in some states or under some insurance plans), and when there is no funding mechanism to provide for in-home treatment of patients in acute psychological distress and to assist their caretakers, then the incentive is to hospitalize highly vulnerable patients for their own protection. Unfortunately, such hospitalizations are often stop-gap, revolving-door measures. They may stabilize a patient in crisis and may alleviate some disturbing symp- toms, but they rarely lead to enduring change. This may be particularly true among our most dependent populations--children and adolescents and the elderly--for all of whom in-patient mental health costs have sky-rocketed in the past five years. Thus we support the thoughtful use of inpatient services primarily as a backup for intensive out-patient care. We urge that provision be made for assistance to family members and others who serve as caretakers of our dependent populations. We believe that services must be directed toward the root of impairment problems, and not solely toward the relief of symptoms. C. Inter-generational prevention is critical. The social and economic cost of such problems as substance abuse and child sexual and physical abuse is incalculably great. We also know these problems are very often inter-generational--passed from parents to children and grandchildren. Given a national mission that targets the reduction of street crime, domestic violence and child abuse, we need to bring to bear more resources than are available in educational programs such as Head Start. If we can create mental health services that explicitly target prevention, we have the potential to address some of these devastating effects. By attend- ing to the psychological needs of individuals, couples and families in meaningful ways, we can help stop the inter-generational cycles of abuse and violence, alcohol and drug addiction, torn relationships, suicide, and homelessness. Psychotherapy, because it works to help children and adults become able to invest in themselves, their families, and their communities, is a long-term investment in the future of our society. For families who see themselves as at risk, one might consider the preventive effects of psychotherapy as analogous to those of childhood inoculation programs; by paying a small sum to strengthen and empower individuals and families now, we avoid paying later the larger sums connected with entitlement programs and the criminal justice system. To achieve this goal, however, requires that we look beyond a short-term "bottom line" orientation to health care. These important goals require concerted attention to prevention in addition to treatment. They require, especially, a much broader view than that inherent in the use of the concept of "medical necessity" as a criterion for providing mental health services. "Medical necessity" is a term based in the traditional medical model, and implies a focus on specific symptoms and unambiguous diagnosis and treatment of a disease entity. If you were abused as a child and are having a difficult time parenting your own children as a result, and if your children need mental health services because of that, do you and they have medically necessary conditions? Will you, after a short term of treatment, be able to return to a "pre-illness level of functioning" (another ill-conceived term used to restrict services)? Probably not. Despite our knowledge that appropriate treatment for such families can save millions of future dollars in legal and welfare costs as well as current dollars in medical expenditures, many families are now being deprived of treat- ment they need because they do not meet "medical necessity" criteria. D. The work place: restoring impaired employees to functioning. The creation of employee assistance plans in the work place has been predicated on the assumption that emotional problems that remain untreated lead to many organi- zational costs: violence in the work place; elevated medical utilization costs; elevated absenteeism and sick leaves; lowered productivity; increased worker turnover and associated training costs; and lowered group morale and effectiveness. These assump- tions have been examined in case studies which suggest that psychotherapeutic interven- tion can have a dramatically positive impact on important variables: job attendance, performance, satisfaction and productivity (Manuso, 1980); absenteeism, sickness/ac- cident costs, and medical/surgical costs (Kennecott Copper Corp., 1970); job perfor- mance, absentee days, disability absences, and employee retention (Gaeta, Lynn and Gray, 1982). The more indirect effects of ignored emotional problems among employees and their families, which may be even more important, need further study. It is highly plausible that employees with emotional problems can directly endanger other employ- ees, and can also adversely affect their performance and job satisfaction. This is likely to be true especially of troubled people in positions of authority and influence, whether they are in management or in unions. Enhancing the capacity to work effectively. The usefulness of psychotherapy for restoring the functioning of workers who become impaired is only part of the story. Therapists have long taken the position that psychotherapy has important positive consequences for the capacity to work in general, as well as for creativity and the capacity to relate effectively to co-workers. Such "non- clinical" outcomes, while subtle, can be assumed to have great social and economic importance. Thus even workers whose functioning would not be seen by the casual observer as impaired or symptomatic can profit enormously from psychotherapy--along with their employers and their families. II. The manner in which mental health services are delivered and benefits are assigned should be fair to all regardless of income, and must take into account what is unique to the provision of mental health care. We advocate the position that the most clinically effective and cost efficient way to provide these services is without the use of micro-management by external third parties. There is in our nation a tendency to view health care as a technology that can be applied by any properly trained person to any consumer. While this perspective is highly questionable in the delivery of all kinds of health care and social services, it is probably fair to say that mental health services do have special characteristics that bear on how they can be delivered effectively. Here is the idea: the tools of the psychotherapist have less to do with the tech- niques that we use and the tests we give than with our capacity to establish a trusting relationship with people who have been psychically injured in the course of their lives. There is much evidence to suggest that it is a therapist's ability to establish a trusting alliance, and to convey a sense of hope and purpose about the outcome of the thera- peutic process that determines treatment success, regardless of what techniques are reported to have been used (Grencavage and Norcross, 1990). Furthermore, what works relationally for one patient does not work for another; relationships cannot be prescribed, or micro-managed. This idea about the importance of doctor-patient relationships probably applies to most other forms of primary health care as well (Roter & Hall, 1992) --but our present concern is with mental health. This apparently simple idea--that trustworthy relationships between skilled providers and their clients are essential for successful treatment, and are not substitutable one for the other--has many important implications. It leads to our advocacy of the following principles, principles which we hope to see adopted as national standards for the provision of out-patient mental health care: A. First, it implies the necessity for freedom of choice: clients must be allowed to make the decision about which trained and licensed provider they feel most comfortable with, with- out constraint. We believe that restriction of trade via preferred provider panels serves insurance companies and perhaps self-insurers in the business community in the short run. It does not serve either consumers or the professional community. Our sense is that, by using provider panels, insurance companies are forced to deal with, (i.e., to externally regulate) fewer providers than if clients had full freedom of choice of provider. Because regulation of providers is expensive, keeping the provider panels small saves the insurer money. Small panels also make providers dependent on the payer and thus more responsive to the payer than to the customer--and skews the choice of treatments toward modes that please the provider rather than considering the best interests of the client. Furthermore, limiting the size of panels makes it more difficult for clients to find compatible clinicians in reasonable locations who have available time; many clients then get discouraged and cease their efforts to seek treatment. Our first concern here is that professionals should be regulated by state licensing boards, not by a for-profit industry. Further, we point to reports that in states with "freedom of choice" legislation, fees for psychologists and psychiatrists are approximately 9% lower than in states without such legislation (Frank, 1982). In addition, the use of restricted panels creates unnecessary discontinuity in treat- ment relationships, when, for example, a person changes jobs or her employer changes insurance plans, and a trusted therapist is no longer on the allowable panel--or, when, years after a successful psychotherapy, a person wants to return to do another piece of work, only to find that access to the former therapist is blocked because she or he is not in the panel. In our experience, restricted panels appear to be saving money because so many clients, after being jostled by the system, drop their efforts to find the services they need. B. Second, it implies that mental health treatment must be considered strictly private, save where the law and profes- sional ethical codes make clear exceptions for the safety of the client or others. Preservation of privacy and trust are inextricably intertwined. The public is gradually becoming aware that health insurance records have, in effect, become part of the public domain, and that other insurers and employers can easily gain access to them (through, for example, the Medical Information Bureau in Cambridge, MA.) Since adverse decisions about health insurance and life insurance are often made on the basis of the prior health care claims--including use of mental health services--this loss of privacy has a chilling effect on patients' willingness to use insurance to pay for mental health care, and often leads to the decision not to seek such care. C. Third, it implies that decisions regarding the type and length of therapy be negotiated between a client and his or her provider, that is, within the context of a trustworthy relationship, rather than by an unknown, geographically distant reviewer. Currently, for clients whose mental health benefits are being "managed," therapists are expected to call managed care company reviewers to receive authorization to treat the client. The therapist and the reviewer generally "negotiate" the kind and length of treatment that will be approved and what the treatment goals may be, based on the client's diagnosis and level of functioning. Therapists must then also agree to frequent reviews of their treatment, via what may be extensive paper work and lengthy phone conversations, often with reviewers who have limited clinical training and who cannot know the patient no matter how much training they have. We believe that such monitor- ing of confidential material, in addition to being expensive and time-consuming for therapists, also serves to disempower clients when the ultimate goal of therapy is to empower them, to help them define what they need from treatment and from life. Perhaps it is useful to consider what happened when the courts began to bring perpetrators of sexual abuse to trial. We found that when child victims were brought to court to testify against those who had molested them, the court process itself, especially cross-examination by the lawyers for the accused, tended to re-traumatize the child victims. Thus what was created to protect became, instead, something that injured. In the same way, many clients who have been shamed, manipulated, violated, and devalued in the course of their lives experience the intrusion of third party managed care review by unknown and often unqualified strangers as a devaluing repetition of past trauma. It leads patients to question whether they are "sick enough" to be worthy of care. We are also concerned that, in an effort to save insurers money on out-patient mental health benefits, managed care companies have essentially fixed on the notion that the only good or reasonable care is short term, issue-focused care, generally defined as ranging from 3 to 20 sessions (with approval for 20 being considered generous in most instances). We have nothing against the use of short-term therapy where it is indicated. We recognize that it can be the treatment of choice for many problems and is certainly the one that most clients choose. There are people, however, for whom short-term therapy will have the same effect as applying a band-aid to a hemorrhage. It will be totally ineffective and, essentially, wasted effort. People who have been severely de- prived or traumatized as children, or those who have grown up without a sustaining bond to a caring adult, do not present for therapy with clear "symptoms" to be cured; rather, they present with a wide variety of complaints and a poorly-defined sense of themselves as capable human beings, without the inner resources to define or achieve what they need. We understand that it may not be practical at this time to provide unlimited coverage for psychotherapy for adults who can afford to defray part of the cost. We assert nevertheless that decisions regarding treatment must be made on the basis of the client's need, not on the basis of what seems best for the insurer. D. Fourth and foremost, we believe that except in extraordinary circumstances, third parties should not intervene in treatment decisions made between client and provider. From this fol- lows our belief that the use of managed health care micro- management in the delivery of out-patient mental health services does not reduce costs-- it adds cost, and reduces both access to care and quality of care. Ironically, the evidence in the literature about the use of mental health services is very clear. The vast majority of users of services use only a few sessions, even where many more sessions are available. Many studies suggest that nationwide the modal number of psychotherapy sessions used by clients is 4; 50% of outpatient psychotherapy ends by the 10th session, and 75% ends before the 20th session (e.g. Ackley, 1993; Pollak, et al., 1992). A large field experiment done by the Rand Corporation, furthermore, indicates that the use of extended services depends not on their availability, but on the degree of client need, even when insurance will fund more sessions (Ware, Manning, Duan et al., 1984). Thus, "mandating" short-term work via expensive regulating proce- dures creates a counter-productive burden for both clients and providers, with very little benefit. Why mandate something that is already happening, and exhaust financial resources that should be devoted to care rather than administration? Just as the inflated prices charged by drug companies continue to inflate the prices we all pay for medical care, do the excesses of the managed care industry similarly inflate our overall expendi- tures? We now turn to a discussion of the problems that managed care presents for the delivery of health services in general, and mental health services in particular. 1. Lessons to be learned about "managed health care" from the experience of manufacturing and service industries. Over the last 20 years automotive manufacturers have completely scrapped the idea of separating manufacturing and inspection processes, with the exception of a very few government-mandated items related to safety. In their search for high quality and customer satisfaction, other manufacturing and service industries have followed suit. The story of this dramatic change is well known to quality assurance experts, but it is worth repeating in the current context. Manufacturers adopted inspection work forces in their processes because they were convinced that their workers were inherently self-interested, careless and lazy, and would cut corners whenever it suited them to do so: they "had to be watched." (Note that the health insurance industry is now promoting the idea that health care providers are greedy, careless, self-serving and unscrupulous people who must be watched.) The introduction of inspectors created serious intrinsic problems. First, inspectors proved to be a very expensive addition, even though the expense was considered necessary to achieve even marginal quality improvement. This expense was passed on to consumers. Second, an adversarial relationship grew between inspectors and the people whose work they inspected. Inspectors became an interest group, and unions worked hard to insure that inspection jobs would continue to be seen as indispensable. Manufac- turing workers, for their part, felt treated like children by the practice of having someone look over their shoulders as they did their work, and resented being punished for the errors that were identified by the inspectors. Thus they refined the game of trying to fool the inspectors and "get away with" defective work, and lost any commitment they might have had to the task of producing a defect-free product at an effective cost. The original prophecy of the manufacturers about the workers was, therefore, completely fulfilled. The solution, well known to quality management experts, was to eliminate inspec- tion, and to place accountability for quality and cost-reduction in the hands of the primary workers. Management became a resource to workers as they pursued efforts to improve quality and streamline their work. Workers were recognized both for quality improvements and for cost savings that did not sacrifice quality. It became clear to all that the people who know most about manufacturing processes and who have the most valuable ideas about improving them are the workers themselves. Thus American manufacturers are finally catching up with their foreign competitors in terms of high- quality, lower-cost production processes. Successful service industries have adopted highly similar strategies. The managed health care business is, in effect, an inspection system, with all the ills of inspection systems. It is an anachronism that presents very serious problems for health care, both immediately and in the long run. 2. There is an inherent conflict of interest between the health insurance/managed health care businesses and the community. Commercial health insurers discovered in the 1970s and 1980s that they could maximize their profits by (1) picking carefully the people they were willing to insure and (2) withholding services from their subscribers. They encouraged the growth of managed care firms with whom they contracted to inspect and micro-manage the decisions of individual health-care providers and their patients, and to introduce a variety of proce- dures to "manage" (reduce) the care delivered. The monetary cost of this "management" to the nation is not directly visible, since it is partially disguised in the indemnifier's cost of doing business. But the hidden, indirect costs to the nation are very great indeed. The cost of micro-management is added to the administrative costs of health insurers and health care providers, and these costs are passed on to the consumer--while the providers are blamed. More people who could formerly afford commercial health care insurance lose their coverage, and become part of the larger and larger uninsured group, or are cared for in some way through government programs. The escalating amount of crisis care for the uninsured is paid for indirectly, but it is surely paid for, both through taxes and through higher premiums for employers and policy holders. At the same time, we believe, overall quality of care has been compromised. We know this from our experience in mental health care, and believe it is likely to be true elsewhere as well. Many victims are blamed in this system: the consumer, the provider and the so- called "inefficiencies" of the public sector.1 We note that even some state governments have begun to use managed health care companies to "reduce their costs" (withhold services). Like the manufacturing workers described above, health care providers are not only being blamed for the high cost of health care delivery, but are infantilized, inter- fered with and, particularly in mental health care, even rendered ineffective. Consumers are experiencing a similar fate, and both groups are losing heart; no one really represents them. Mitchel J. Rabkin, M.D., President of the Beth Israel Hospital in Boston, was quoted recently as saying that "we used to think of the patient as our prime custom- er...Now the payer is our customer too."(Boston Globe, 2/7/93). We note that the insurer's reviewer becomes the more important customer, since the insurer is the source of funds needed to survive. Mental health providers tell us that their capacity for empathy with their own clients is sometimes undermined as a consequence of their conversations about the client with managed care gatekeepers. Clearly, the patient suffers from this arrange- ment; s/he has been placed in a structurally adversarial relationship both with the provider and the indemnifier. This is a ticket to disaster. ____________________________________ 1In 1991 the average administrative cost of health care under the current commercial system was 13.7% of premiums, as compared with the 3.6% of premiums for public programs such as Medicaid and Medicare (Shields et al., 1992). Administrative costs under the Canadian single- payer system are estimated at 0.9% (Woolhandler & Himmelstein, 1991). We believe the appropriate solution involves empowering both consumers and health care providers, and making them responsible for the quality and cost-effectiveness of the health care that is delivered. This requires education for consumers and assistance to providers as the patient and the provider collaborate toward the end of providing high quality care at an effective cost. The evidence is mounting that patients who are educated about health care and take responsibility for their own care respond better to treatment than non-educated patients (e.g. Kaplan, Greenfield & Ware, 1989). Likewise medical providers who communicate effectively with their patients create dramatically improved outcomes for patients and have fewer malpractice claims (Roter and Hall, 1992). Solu- tions that devalue and infantilize the consumer and the provider simply cannot work. Health care should not exist for the benefit of commercial indemnifiers and their management systems. It must exist for the benefit of the nation's citizens. III. We advocate a different system of health care and a different method of controlling costs than the one that has emerged in the U.S. We believe that a uniquely American single payer health insurance system can be designed which will eliminate the wastes inherent in the current system. We take the position that health care is a basic right of citizens, much like education and the protection of the law. It is clear to us that for-profit commercial insur- ers and their shareholders are in an inherent conflict of interest with the community and its citizens, because they must try to minimize care delivery to maximize profit. Thus we take the position that if commercial health insurance is used in the nation's revamped health care system it must be administered by non-profit corporations acting in the public interest rather than in the interest of shareholders. These insurers must not be allowed to choose whom they will and will not insure in the communities they serve, and must charge standard rates--the risk must, we believe, spread as widely as possible throughout the nation. If they "compete" to reduce costs, such competition must not be permitted to create an adversarial relationship between the provider and the client. The sensible competition is competition to reduce administrative costs, not to reduce services. A. The quality of health care provided by professionals should be continuously improved through education of providers and consumers, and through the creation of better relationships between the two. The work of providers should be audited if their patterns of delivery are anoma- lous, or show a pattern of deviation from accepted practice. Such anomalies are easy to detect, just as the IRS detects problems in anomalous tax returns. Internal peer review procedures by provider professional organizations will have to be used to identify fraudulent or dangerous practices. Micro-management of the relationship between providers and consumers must be eliminated, on the other hand, since it is both counter- productive and expensive. B. Prevention programs and pro bono services to the community must be asked of providers. We are of the opinion that providers should be asked to design and contribute to a variety of preventive services. Psychotherapists, for example, should make available effective education for parents and couples, and consultative assistance with the manage- ment of difficult classrooms, the resolution of community conflict, the effective supervi- sion of "difficult" workers, debriefing of witnesses and juries after difficult trials, and so on. There are good reasons to believe that psychotherapists will respond if asked to donate some time each year to such community services, consistent with a national service ethos. C. Control of costs is best done through negotiation of standard fees with providers. As a primary method of cost control, fees should be negotiated with every category of provider, perhaps through professional organizations, so that fees for covered services are standard nationwide. As Bak and Weiner (1992) have put it, we urge the use of "fences" instead of "leashes" to control provider costs. In this context, it is important to note that, despite the "greed" that the insurance industry sometimes ascribes to health care providers, the majority of mental health professionals are willing to keep their fees within an accessible range, and to lower fees for clients who are in need of services but are without financial resources or good health care benefits. In both agencies and private practices, reduced fee plans for some patients are the norm rather than the exception. D. Primary and preventive care should be the centerpiece of a system of providing health care. As a secondary method of cost control, much emphasis should be placed on primary and preventive care, so that crisis medicine may be avoided where possible. As stated above, we believe that psychotherapy is an effective component of a primary care system. Mental health care it is relatively cheap to deliver, and independent of hardware technology. E. The cost of malpractice insurance is reduced automatically when comprehensive health care is introduced. A comprehensive health care system would also markedly reduce the cost of malpractice insurance, since some 40% of malpractice awards made by the courts are for future medical care, which would be covered by universal insurance. Additional savings could be realized by requiring arbitration to settle malpractice claims (Himmelstein & Woolhandler, 1992). F. Single payer systems and their alternatives. Our preference is for a single-payer system, because of the potential for adminis- trative cost savings in such a system (Letsch, Levitt & Waldo, 1988). If a single-payer system is deemed politically impossible to implement at this time, a system based on a combination of national and non-profit commercial insurers (as used in Germany, for example) could be an acceptable alternative. A more complete argument for a single payer system is well detailed in the accompanying paper by Bak & Weiner (1992). G. "Managed competition" plans seem to contain the worst features of the current system. The so-called "managed competition" plans that are being described in the public media contain some of the worst features of the current system. They rely on commercial insurers, and encourage attempts at cost-cutting by third-party management of care and associated withholding of services. They restrain trade and limit freedom of choice of providers by encouraging the establishment of preferred provider panels. They jeopar- dize both quality and innovation in the delivery of care. We are profoundly opposed to such solutions. IV. Members of the Consortium are willing to assist in the process of devel- oping and evaluating solutions. Please call on us at (617) 739-7083 or write to us if we can be of service in the policy-making venture you face. We are willing to put out serious effort toward devising sensible solutions to the health care problems our nation faces. NOTE: We have attached hereto documents that may be of interest, including a copy of the full paper by Joseph Bak and Robert Weiner referenced above. Their paper is being published in installments, and only the first third is currently in print. REFERENCES Ackley, D.C.(1993). Employee health insurance benefits. A comparison of managed care with traditional mental health care: Costs and results. The Independent Practitioner, 13 (1),159-164. Bak, J.S. Weiner, R.H., & Jackson, L.J. (1992). Managed health care: Should independent practitioners capitulate or mobilize. The Independent Practitioner, 12 (4), 159-164. Bak, J.S. & Weiner, R.H. (1993) Issues affecting psychologists as health care service providers in the national health insurance debate (Part I). The Independent Practitio- ner, 13 (1) 30-38. Borus, J.F., Olendzki, M.C. et al. (1985). 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