Hall of Fame/HallofFameCDROM.cdr/open/living.lzh/HEWETT.TXT

Text File | 1989-01-10 | 12.3 KB | 200 lines

January  10, 1989:

    As  we begin the New Year, there are many projects that all of  us  may
have  in common.  One of those "projects" may be to take a  CLOSE  look  at
our  professional/financial  situations.   In  December,  I  received   the
following letter from a long-time friend.  It is a rather sad commentary on
certain priorities.
    If  you wish to respond to this open letter, please feel free to  write
directly to S. Marie Hewett, Ph.D. at the address given in the letter.

                        Respectfully submitted by:

                        Ann Mark, SysOp
                        Night-Flight 007's BBS
                        [phone]   2400/1200  8-N-1
                        24 Hours / 7 Days
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(Letterhead)
                          S. Marie Hewett, Ph.D.
                             3300 Third Avenue
                       San Diego, California  92103

December 9, 1988

Readers Write
The San Diego Union
Post Office Box 191
San Diego, CA  92112

Gentlemen:

I wish to submit the following for publication on your Editorial page.   If
at all possible, I request that it be published in its entirety and without
editing.

Thank you.
                    __________________________________

I  read  the  front page article in the Union on  November  19th  regarding
medical  costs being "out of control."  I also saw the article a  few  days
prior  to that in the Tribune lauding the merits of the new CHAMPUS   Prime
and  Extra  programs.  These are just two in a plethora of  articles  about
health  care  costs  recently aired in  various  publications,  often  with
explicit  or  implicit  assertions that health care  providers  are  taking
financial advantage of the government, insurers and private payers.   While
I  cannot speak for the medical profession, as a mental health  provider  I
find myself reading such articles with a rising sense of indignation, and I
now feel I must speak out and present another side of the overall  picture,
namely, the professional and personal reality that I see and experience  on
a  daily  basis.  Some of my colleagues might feel I  am  overstepping  the
bounds of professional propriety by doing so, but so be it.  I really don't
care.   And  while I would prefer to talk about my profession in  terms  of
humanistic considerations, the language of the day seems to be dollars  and
cents, so that is the language I will use.

First  of all, some facts and figures.  In the past six or seven  years  my
billing  rates  have increased by a mere 20 to 25%.  In the  meantime,  the
cost  of  my  office premises (rent, utilities,  and  phone  services)  has
increased  by about 350%, malpractice insurance premiums have escalated  by
more  than 600%, and federally-imposed self-employment taxes have  gone  up
approximately 30% and are steadily rising.  Other business-related expenses
have  likewise increased.  In addition, in the personal sector of my  life,
housing  costs have increased 275%, auto insurance premiums have  at  least
doubled and perhaps even tripled, and, if the price of a loaf of bread is a
valid  indicator, grocery costs have gone up by about 50%.   Like  everyone
else,  I  also face increased prices for auto repairs,  utilities,  medical
insurance premiums, etc. ad infinitum.

More  facts and figures.  In 1985 I undertook a very  thorough  time/income
study  of my private practice over a period of a few months and  discovered
some rather astounding things.  On the surface, the $60.00 per hour that  I
averaged  in  face  to face patient contact looked quite  good  (with  this
figure  being  less than my then current billing rate of $85.00  per  hour,
since I choose to take a certain number of reduced-fee patients who perhaps
could  not otherwise obtain needed services).  However, the time-sector  of
my  study  showed me that only about 60% of my  business-related  time  was
spent in face-to-face patient contact, with the other 40% going to business
activities  for  which  I was NOT reimbursed, such  as  utilization  review
reports   for  insurers,  keeping  abreast  of  professional  advances   in
treatment, assorted record-keeping procedures, time spent on the  telephone
with patients, physicians, insurance companies, attorneys, teachers,  etc.,
and numerous lesser but nonetheless vital business that, like pennies in  a
piggy  bank, ultimately add up to substantial amounts of time.  In face  of
this data, my ACTUAL hourly wage plummeted drastically and, when  operating
expenses  were subtracted from income, ended up being embarrassingly  below
the hourly rate I pay my plumber.  At that time, a minimal fee increase and
a  modest rise in patient volume served to somewhat improve the  situation.
But  I  still had quite a way to go to catch up with my  plumber.   And  he
doesn't  have  to  write  insurance reports, or  maintain  an  office.   Or
continue to pay for more than a decade of higher education and training.

In the face of this data, a few other things are rather obvious.  First  of
all,  if  I went to work within the parameters of a 40  hour  work  week---
which  is  perhaps  wise to do in an occupation that  is  very  emotionally
dragging and has a high burn-out potential--- I would have to limit my case
load  to no more than 24 patients.  This alone imposes very real limits  on
my income.  Second, there is absolutely no way in which fees can be  raised
to  adequately  compensate  for increasing costs in  the  professional  and
personal sectors of my life.  Third, unless I care to expand into a  mental
health center where underpaid staff and interns do much of the work, I will
never  become  wealthy in this profession.  In fact, I do not know  of  any
solitary  mental  health  practioners that are affluent  unless  they  have
supplemental income from other sources.

Something  is dreadfully wrong with this overall picture.  So very many  of
the  players out there, see me as one of the "bad guys" who is  financially
"gouging"  the  public.  Yet I know that isn't so.  I have data  that  says
otherwise.   If anything, I find myself feeling increasingly victimized  by
the system, and I am more inclined to believe that in psychotherapy, as  in
other  caring  professions such as teaching and nursing  and  social  work,
there  is a societal tendency to use--- and even abuse--- the altrusism  of
involved professionals by undervaluing their services and, consequently not
adequately reimbursing them.  Sadly, this is always done with the  explicit
or  implicit  consent of the providers of such services,  and  many  of  my
colleagues  could, in Alanon terms, be classified as "enablers"  who  allow
their  caring  motives  to  be financially used  by  health  care  delivery
systems.  Physicians, wisely, have not allowed themselves to fall into this
trap,  but  even then it is known that psychiatrists most often  earn  less
than  do  doctors in other areas of medicine.  Perhaps this is due  to  the
relatedly  low  societal  value placed upon mental health as  a  bona  fide
medical specialty, a view which is also reflected in the often ridiculously
low  reimbursement rates of insurers in general for mental health  services
except   for   when   conditions  become   critical   enough   to   require
hospitalization.

I chose my profession because I care about people and over the years I have
deeply  cared about the well-being of every individual who has  entered  my
office.  I also expected to made a decent living via just recompense for my
services.  The caring goes on, but, in the face of increasing reluctance of
insurers to pay for services rendered, the ability to make a living in this
area  becomes  increasingly questionable.  By way of  example  the  Tribune
article  that appeared in mid-November regarding the new CHAMPUS Prime  and
Extra  programs,  coupled  with the above figures,  clearly  points  to  an
impossible financial position for myself and many other providers of mental
health services.


The new CHAMPUS Prime and Extra programs were implemented to save money for
the  government.   First  of  all, pure common  sense  tells  me  that  the
insertion  of two or three layers of middlemen into a system, all  of  whom
expect  to make a profit, cannot possible save the government money  except
by  reducing  necessary  services  to  beneficiaries  while  simultaneously
underpaying the providers of such services.  The Tribune article noted that
psychiatrists who participated in the programs where required to take a 30%
cut  in fees.  What was not stated was that other mental  health  providers
who  chose to participate faced even greater cuts which, in the case of  my
licensure,  amount  to a 57% decrease in reimbursement.  The  article  also
stated  that lowered fees could be offset by increased patient volume.   No
so.  As I indicated above, there are very real time limits to the amount of
patient  volume  I or anyone else can handle and, under  the  reimbursement
rates  of the new CHAMPUS programs, I would have to put in a 60 to 80  hour
work-week  just  to keep body and soul together.   Their  expectations  are
unrealistic and, if I tried to stay in business under those terms, I  might
as well be pushing hamburgers over the counter at McDonald's.

I  ultimately chose not to participate in the new CHAMPUS programs  and  to
stay with the old one, a choice which has since subjected me to a  blinding
barrage  of  increased paperwork that is labeled something  like  "enhanced
utilization   review"  but  which  personally  feels  more  like   punitive
harassment.   Yet  I  know that programs such as CHAMPUS  Prime  and  Extra
represent  an  ever escalating trend in the mental health  marketplace,  as
exemplified  by the increasing number of Health  Maintenance  Organizations
(HMO's),  Preferred Provider Organizations (PPO's) and Employee  Assistance
Programs  (EAP's)  that have sprung up in recent years.  All of  these,  to
providers, mean reduced fees and increased paperwork and, to patients, less
services.

However, even in the face of this trend, I made my choice to avoid the  new
CHAMPUS programs because it was the only choice I could make.  In  addition
to  very  realistic  financial considerations, my  own  sense  of  personal
dignity and self-respect will not allow my altruism, skills and training to
be  financially used in such a manner.  While I have always been a  staunch
advocate  of  caring, kindness and charity, I have never  considered  self-
destructive  sacrifice  to  be a virtue, and I will not consent  to  be  an
externally-mandated sacrificial animal on ANY altar, even that of suffering
humanity.

I  do  not  know where all the health dollars are  going,  or  why  medical
insurance   premiums  are  almost  exponentially  escalating  as   insurers
simultaneously become increasingly reluctant to pay for services---although
I could make some rather interesting speculations.  I also realize I cannot
change  the current trend in the delivery of mental health  care  services,
one  wherein,  very soon, fully comprehensive treatment will  be  the  sole
domain  of the wealthy who can personally afford it, while the rest of  the
people only have financial access to brief "band-aid" therapy to  alleviate
immediate  situational  crises while leaving underlying  causative  factors
untreated.

I cannot change any of this.  But I can change my life.  I can---and will -
--gradually move into other more financially practical vocational endeavors
to  largely remove myself from what is becoming an  increasingly  untenable
professional position.  I don't necessarily want to, but I will.  The  fact
of  the matter is --- I simply don't know how much longer I can  afford  to
care.

                        /s/ S. Marie Hewett, Ph.D.
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NOTE:  To date there has been no reply to Dr. Hewett's request -- not even
       an acknowledgment of receipt, much less a rejection.