Daniel B. Borenstein's APA Presidential Address Daniel B. Borenstein's APA Presidential Address
Daniel B. Borenstein's Inaugural Address
Position Statement of Daniel B. Borenstein, MD
Does Managed Care Permit Appropriate Use of Psychotherapy?
Incredible scientific achievements in the last decade, led me to select “Mind Meets Brain” as the theme for the 2001 APA Annual Meeting. Recognize that daily, new discoveries are helping us to understand how our personal interactions influence brain development and function. Psychiatry, psychoanalysis and neuroscience have overlapping areas of interest, such as perception, affect, dreaming and memory, that will help elucidate relationships between mind and brain.
During the first decade of the 21st Century, neuroscience and clinical research, including psychotherapy, neuroimaging and psychopharmacology studies, will lead to scientific explanations for how our minds work. These findings will unify the major branches of knowledge under the banner of science. In particular, biology will explain our highest cognitive functions in terms of genetic programming. This era will be the Decade of the Mind. Now that the Human Genome has been mapped, additional research will disclose how specific genetic expressions lead to psychiatric illnesses. The 2001 Annual Meeting brings together experts from psychiatry, psychoanalysis and neuroscience to teach us about their latest discoveries and how they are beginning to integrate findings from basic neuroscience with clinical research and practice. We are on the frontier of better understanding the treatment and prevention of psychiatric disorders.
My presidential year began with a working Board retreat focused on Maintaining Professional Values in the New Millennium. Two topics were elaborated: our business relations initiative, and fresh developments in the realm of patient privacy and the confidentiality of psychiatric records.
The 52nd Institute on Psychiatric Services in October 2000 addressed “Psychodynamic Psychotherapy.” The meeting had the second highest attendance in the Institute’s history. When attendees were surveyed as to what they would like to hear at the next meeting, the most frequent request was for more psychotherapy presentations.
Psychiatric trainees have been asking for more psychotherapy training and their residency training directors have demonstrated an interest in providing it. Moreover, the Accreditation Council for Graduate Medical Education and its Residency Review Committees recognized the need for additional emphasis on psychotherapy training by adding requirements for five competencies in psychotherapy for psychiatric residents beginning January 1, 2001. Residents must demonstrate competence in brief, cognitive-behavioral, psychodynamic and supportive psychotherapies and in combined psychotherapy and psychopharmacology. This requirement will return balance to training programs that had become excessively biologically oriented. I am gratified by these events since psychotherapy is the centerpiece of our interactions with patients.
APA has undergone a sweeping reorganization. Seven months of my presidency were served in the 20th Century as leader of the Old APA and five months in the 21st Century as President of the New APA. On January 1, 2001 the APA transitioned from a 501 C.3 non-profit tax status common for charitable organizations to the more usual 501 C.6 non-profit tax status for professional organizations. This change took one and a half years to accomplish. The shift permits APA to provide more financial assistance to District Branches and state organizations and to commit more of its resources to legislative and public relations activities, including a new Political Action Committee. APA’s three subsidiary organizations – American Psychiatric Publishing, the American Psychiatric Foundation and the American Psychiatric Institute for Research and Education – retain their 501 C.3 tax status. Publishing activities for books, journals and newsletter were consolidated into the new publishing entity.
In 2001, APA provided $700,000 in revenue-sharing funds to District Branches and state associations through asset reallocation. An additional $150,000 was made available to District Branches to support lowered dues for Early Career Psychiatrists. Upon the recommendation of the Commission on Judicial Action, another $20,000 was provided for amicus briefs supporting successful lawsuits in California and New York.
During its first year, the Commission on Public Policy, Litigation and Advocacy evaluated requests for assistance from District Branches and state associations. In response, the Board approved over $300,000 for assistance with scope of practice issues. When the Commission was formed, I asked that it develop action plans in three areas: psychologist prescribing, parity of mental health benefits in relation to other medical benefits, and psychiatric confidentiality and privacy issues. I also envisioned the development of a $1-2 million “public education fund” from voluntary contributions to support this and other high-priority activities. I am pleased to report that 32 states have enacted some form of parity legislation, that a proactive plan to deal with the efforts of psychologists to obtain prescribing privileges is well underway and we have begun building a sizable fund to support advocacy and litigation.
I want to acknowledge the outstanding leadership and commitment of our colleagues who have been in the forefront of our legislative battles being fought state by state with non-physician providers. Adversaries want to prescribe medications through legislative fiat, without the background of medical education and supervised residency training. Our members raised their voices in the legislative arena, protecting patients' quality of medical treatment from assault by self-serving psychologists. Our colleagues deserve not only our recognition but also our gratitude.
Our grass roots leadership, District Branch presidents, Legislative Representatives and lobbyists are striving tirelessly on behalf of our patients to ensure that persons with mental illnesses are not subjected to deeply flawed health care by psychologists who believe prescribing medication, to quote one of their former presidents, is: "no big deal."
The APA Business Relations Initiative to improve employee access to psychiatric treatment began during the second half of 2000. Soon thereafter, it became clear that the Fortune 500 companies we contacted wanted to talk to us and learn what we had to offer. The main contacts have been with Union Pacific Railroad, Hughes Electronics, Delta Airlines, a major financial services organization, the Pacific Business Group on Health, Constellation Energy and General Telephone, which is now Verizon. Additional discussions occurred with representatives from Bank One, Sears, General Electric, American Airlines, AT&T, Dow Corning, Anheuser-Busch, Texaco, Conoco and Pacific Gas and Electric. I am disappointed that we have not yet been able to begin pilot projects with several corporations. The unavoidable delays are attributable to the complexities of the business world. I am most gratified by the work of the Business Relations Committee and its partnership with the Carter Center in presenting “The Business Case for Mental Health Care,” an invitational forum for corporate healthcare decision makers in June.
We have not solved all of our database and electronic communications problems. Mohamoud Jibrell, APA’s new Director of Information Systems, was recently hired to help resolve remaining difficulties. He is working closely with members, staff and District Branch executives to provide what the members, DBs and state organizations need and want. An overarching plan for the development of a comprehensive, integrated system that will meet our needs will be presented in June. APA’s multiple membership categories and differing DB dues structures have contributed to the enormous complexity of our information system. APA’s recently enhanced Web site provides a “Members’ Only” section where members can search for staff, components and other members. Members can also revise their own address data. This is an important step in moving toward a reliable, organization-wide database.
With the guidance of Darrel Regier, M.D., Executive Director of our research activities, APA has received research grants totaling $3.6 million for 2001. Approximately 66 percent of the funds are from government agencies, 26 percent from pharmaceutical companies and 8 percent from other sources. Eighty-five percent of the government grants and all of the pharmaceutical funds support the current 132 research training and educational fellowship awards. One of the current major research projects is an evaluation of the costs and quality of psychiatric care in the Federal Employees Health Benefits Program, covering nine million Federal employees, in which parity is mandated, but the care is managed. Another highly significant research activity is beginning work on the development of DSM-V, which we hope will lead to a uniform international diagnostic nomenclature. Dr. Regier also participates in The Global Burden of Disease studies which predict that depression will be the second leading cause of disability worldwide by 2020.
In an effort to build stronger bridges with allied psychiatric organizations, I initiated a leadership summit meeting with the presidents and executive directors of the 14 groups that are currently represented in the APA Assembly. These leaders represent 20,000 psychiatrists. The meeting demonstrated our common interests. The special concerns of allied organizations were highlighted. Similar meetings with representatives of minority and ethnic organizations were planned, but adequate funding will not be available until next year.
Another initiative I am particularly satisfied with is the appointment of APA’s first Committee on the Prevention of Psychiatric Disorders and the Promotion of Mental Health. The psychiatric profession and our academic institutions have largely ceded promotion of health and prevention efforts to others in the pediatric, mental health and social sciences fields. We have focused successfully on patients who need psychiatric treatment. However, our prevention efforts with vulnerable populations have been meager and we must do more.
Our relationship with pharmaceutical companies has created unease among many members, stimulated by industry activities at APA scientific meetings. I had hoped to work with the companies to help them identify matters that hurt their image with our members and to encourage additional constructive activities. I presented this idea to company representatives on several occasions, but did not receive a response. Subsequently, I appointed a Task Force to develop guidelines for APA’s entire relationship with pharmaceutical companies. It will report its recommendations in June.
The 107th Congress will be considering significant legislation of interest to APA, including:
The APA’s Division of Government Relations, under the sagacious direction of Jay Cutler, J.D., will be working to revise inpatient seclusion and restraint regulations and inappropriate provisions of the Health and Human Services privacy regulations, while endeavoring to preserve the special privacy protections in the regulations applicable to psychiatric records and psychotherapy.
APA must transform itself to maintain psychiatry’s leadership in a rapidly changing world. Organizations that are flexible, nimble and able to change rapidly will survive. Organizations that are slow to recognize needed changes and have difficulty overcoming their own inertia will fail. Tom Peters opines that organizations have to be “lean, linked, electronic and malleable.”
Keeping up is not sufficient. Will Rogers reminds us “Even if you’re on the right track you’ll get run over if you just sit there.” We must devote time to creative thinking. We must recognize the intense appetite our society has for technology and learn from our younger members and employees who are less inhibited by life’s experiences.
Currently, APA has a limited number of revenue sources. Although we may be able to increase our income from these sources, we would be on far more stable ground if we can create new funding streams. Our American Psychiatric Foundation will help to meet this challenge.
The business community is beginning to focus on “Customer Relations Management,” recognizing that success depends upon customer satisfaction and loyalty. This business strategy uses current technology to enable employees to provide optimal, personalized service to its valued customers. Employees recognize that they are in the customer-service business and are evaluated on that basis. The American Marketing Association reports “65% of business comes from existing, satisfied customers and that customer acquisition costs six times the amount of customer retention.” The same principles apply to organizations whose existence depends upon maintaining a satisfied membership. We must redouble our efforts to provide our members with what they need and to give them the service they deserve.
The demands of the APA presidency have been much easier to manage with the wonderful support I received from my family, colleagues, friends and APA staff. My wife, Bonnie, has been my understanding, patient, considerate and loving partner. Her support, encouragement and practical approach to life have been of enormous help to me throughout my career, but especially during the past two years. Our son, Jay, keeps me up to date on the latest e-world developments and has accepted my frequent absences and missed family occasions with equanimity. Thank you Bonnie and Jay.
I am delighted to have my special friends Dr. and Mrs. K.C. Yeh and my medical school classmates, Mel Belding and Ray Betson with us today. K.C. recently retired from his work as an economist for the Rand Corporation. Mel is an internist specializing in infectious diseases. Ray is a plastic surgeon. It is an honor to have you here for this event.
I also want to thank my many psychiatric colleagues and their spouses from the Los Angeles area who have joined us today and the members of the Board of Trustees and Assembly for their hard work this year. In particular, I want to thank Herb Sacks, Marcia Goin and Drew Clemens for their friendship, assistance and thoughtful advice.
Phil Muskin and the program committee put together a remarkable scientific program. Our members, including international members, apparently agree with my assessment. This Annual Meeting has the highest number of pre-meeting registrations in our history. Thanks also to Michelle Riba and the Institute for Psychiatric Services program committee for the highly successful meeting last October. In addition, I want to acknowledge the consistently, highly efficient job Cathy Nash and her staff and the Meeting’s Management staff have done for all of our scientific meetings.
It has been a pleasure to work closely with Richard Harding, President-Elect and Mike Pearce, Speaker of the Assembly. This year, I have enjoyed regular communications and collaboration with Steve Mirin, our talented Medical Director, in addressing a range of projects. Steve’s negotiating skills and ability to analyze complex issues has been extraordinary. I also want to thank Jay Cutler and John Blamphin for keeping APA’s messages before politicians and the public. Finally, I want to thank the staff in the Governance Office for their support and assistance. Margaret Dewar, Yoshie Satake, Laurie McQueen and Carol Lewis have been especially helpful.
Serving as APA President has been a wonderful and exciting experience. I was privileged to have served at a time when there is a growing public and government awareness of the plight of those members of society who suffer from the stigma of mental illness; when the U.S. Surgeon General has recognized for the first time that psychiatric patients have real disorders that are diagnosable and treatable; when psychiatric illnesses are being accepted in the same way as other medical illnesses; when our science reveals profound, new discoveries every day; when psychotherapy is regaining its prominence as an essential component of our treatments; and when special protections for our patients’ private communications are becoming more prevalent.
Our future is bright. Your American Psychiatric Association is here to represent your interests in research, education and clinical advances, which together, safeguard our work with patients in need. My year as President ends at the close of the 2001 APA Annual Meeting. I offer Richard Harding, our incoming President, and Paul Appelbaum, our new President-Elect, my best wishes and support in furthering APA’s goals. The APA is in good hands. I am honored to have served as your President. It was a great year.
It is exhilarating to become the first APA President to serve in the 21st Century. I am the 129th President elected, but only the 127th President to assume the position because two of our respected colleagues expired before taking office. I am not surprised, considering the stresses of APA elections. My odyssey from a small New Mexico city where I was clearly a minority, through military school, engineering school, medical school, residency, and psychoanalytic training to the leadership of the largest, most prestigious psychiatric organization in the world is beyond my wildest imagination. What an honor and an awesome responsibility! Yet, I am eager to meet the challenges that accompany this position, knowing that I have the support and assistance of the extremely talented colleagues sitting here with me today, of the many other members who volunteer countless hours to our organization and of the dedicated, hard-working staff.
The understanding, encouragement and loving support of my spouse, Bonnie, for the past 33 years and our son, Jay, made it possible for me to be standing here today. We are very proud of Jay. Aside from being a great person, he is Vice President of Engineering in charge of technical development for an Internet start-up company. Our relatives, Skip and Dede Priest and special friends like Dan Belin, a brilliant attorney, have been particularly helpful.
Today I will focus on some of the actions planned for the next year. Many of these initiatives began through the pioneering efforts of previous Presidents.
Through our business and industry initiative, through legislation and through litigation if necessary, we will lead in restoring our patients' access to high quality care in both the public and private sectors. Patients must be able to choose their doctor. Treating physicians must be able to make unfettered, medical decisions for their patients. Peter Drucker tells us, "The best way to predict the future is to create it." That is our aim. Reallocating 2.4 million dollars toward high priorities and a new corporate structure in January 2001 will help us to reach our goals.
I will start with APA's Business and Industry Initiative. During the 1990s, profit-driven managed care shaped and, in many cases, determined the amount and quality of care delivered to our patients while milking enormous profits out of dollars intended for health care. In 1996, the highest paid HMO executive received 29 million dollars in compensation and had 83 million dollars in stock options. The top 25 HMO executives averaged over six million dollars in salary and 13.5 million dollars worth of stock options. John Kenneth Galbraith noted, "The salary of the chief executive of a large corporation is not a market award for achievement. It is frequently in the nature of a warm personal gesture by the individual to himself."
This trend has continued with managed behavioral health care organization consolidations. At the end of 1999, the two largest companies had about 86.3 million enrollees, close to a 50 percent market share. Concomitantly, we have seen the proportion of total health care dollars devoted to mental illness and substance abuse treatments drop precipitously from about six percent in 1988 to three percent in 1998. One managed care executive forecast a further reduction to one to two percent of total health care funding. While overall health benefits dropped 7.4 percent, our patients' benefits decreased by over 50 percent. Most of you are aware of these trends and the degree to which patients are being deprived of high quality care. Dr. Martin Luther King, Jr. emphasized, "Of all the forms of injustice, inequality in health care is the most shocking and inhumane."
Public opinion, state and federal legislatures and the United States Surgeon General are on our side. Some employers are becoming more aware of the costs of not providing adequate mental health care to their employees. A recent study of major corporations revealed that three years of aggressive managed care led to a 44 percent decrease in total mental health costs. During the same period, there was a 37 percent increase in general health care costs, a 22 percent increase in absenteeism and a decrease in work performance, resulting in no net cost savings. Moreover, this study did not include the well documented, significant increase in employee disabilities and disability payments that has occurred under managed care.
An executive from a major corporation, who studied the impact of depression in the workplace, stated that improving employee mental health benefits yields the quickest return of any investment an employer can make. We anticipate working directly with major employers to help them evaluate their costs of restrictive behavioral managed care and the benefit to their bottom line of providing high quality psychiatric care to their employees.
The next topic I want to emphasize is APA's enhanced advocacy activities. I have appointed a new Commission on Public Policy, Litigation and Advocacy. This group has the ability to formulate topical action plans using the desired combination of approaches – legislative, public relations and/or litigation – to address identified problems. I anticipate a frequent combination of legislative actions supported by focused public relations efforts around specific issues. Three identified priorities around which pro-active action plans will be developed are psychologist prescribing, parity of mental health benefits in relation to other medical benefits and psychiatric confidentiality and privacy issues. The action plans will be implemented at both the state and federal level. We anticipate that many crucial legislative battles will be fought at the state level. APA will be there to help. When our District Branches are engaged in litigation with significant national implications, APA will be there, standing shoulder to shoulder with our members.
In the past APA had a one million dollar "litigation fund." With our corporate reorganization, we will have a one to two million dollar "public education fund," much of which will come from voluntary contributions, to support our advocacy activities. We will also have an expanded and more effective "political action" or PAC entity.
Another important topic on which I will continue to focus this year is improving our communications with each other. Members must know what APA is doing and APA must learn what members are concerned about. An expanded, interactive Web site will help. Eventually, I want every member to receive periodic electronic e-mail or fax updates detailing APA's recent activities. Involvement of current District Branch leaders at the Board of Trustees meetings, in the Assembly and on components is extremely beneficial. In turn, District Branch leaders must develop methods to communicate with members at the grass roots level. APA's Chief Information Officer plans to launch wide area, electronic communications networks or WANs to help facilitate better communications.
The final topic I want to emphasize today is my desire to integrate our organization, our members and our science. The APA central office is responsible for implementing our policies and for providing support to members in their APA work. Our talented medical director is completing his third year on the job. Significant employees have left and new ones have arrived. Reporting relationships and staff assignments have been altered. Working together over a relatively calm period of time, in a mutually supportive environment will improve internal integration.
I have already noted the importance of bringing our members into closer relationships through enhanced communications and inclusion in local, state and national APA activities. We must also develop closer working relationships with psychiatric specialty societies to maximize our effectiveness and limit redundancies. Currently, the major societies are represented in the Assembly and inconsistently on our committees. I have planned an allied society leadership summit in early June as a step toward further integration.
All segments of our membership have a place in our organization. All perspectives must be heard and considered. Member and interest groups deserve our support. But we must be careful to avoid disintegrating into factions within our organization. We must place our common purposes above personal or chauvinistic interests. Coming together is a beginning. Keeping together is progress. Working together ensures success.
I also anticipate more extensive and closer alliances with our international colleagues. We plan to work with the World Psychiatric Association on a number of projects, including an effort to develop a uniform international diagnostic nomenclature, eliminating the differences between DSM-V and psychiatric aspects of the International Classification of Diseases.
We must all be excited about the fantastic scientific developments in our field. Even Rip Van Winkle couldn't sleep through the remarkable discoveries during the 1990's "Decade of the Brain." I am optimistic that Freud's 1895 "Project for a Scientific Psychology" will be realized in the not too distant future, as the fields of cognitive psychology and neuroscience converge. In light of these scientific developments, the theme I selected for the annual meeting next year is "Mind Meets Brain: Integrating Psychiatry, Psychoanalysis and Neuroscience."
Our future is bright. Your American Psychiatric Association is here to represent your interests, safeguarding our work with patients in need. I look forward to working with you in the coming year. With your help we can meet any challenge.
In my former roles as Vice President and Secretary, I was a leading figure in recasting APA into an organization which truly reflects your hopes for our future. Steady information flows from District Branches, Assembly, and fellow Trustees sharpened my views. My actions on the Board during the past ten years established APA accountability, openness, dues reduction, fiscal stability and assistance to members in dealing with managed care.
It is exciting working with Steve Mirin, our dynamic Medical Director, a friend for many years.
The New APA will be flexible and streamlined, reacting nimbly to swiftly changing developments. As a membership organization, our leadership, policies and actions reflect the interests and needs of members and our patients. When elected your President, my extensive experience, creativity and close collegial relationships will ensure that APA will lead American psychiatry into the 21st century.
I was a major contributor to
 | Formation of a new Psychiatric Institute for Research and Education, assisting academic institutions obtain grants and offering more opportunities to young psychiatrists and minorities. |
| Creation of caucuses within APA to reach members who have felt under-represented. The initial groups included community psychiatrists and colleagues working in rural areas, the Veterans Administration, and correctional and state hospital settings. |
| Initiation of a mentorship program for women psychiatrists, and |
| Executive leadership training for Early Career Psychiatrists. |
Our profession remains under siege by economically-driven health care systems, but I am upbeat about our future. In crisscrossing the country, I am exhilarated by the drive and enthusiasm of our members. Public opinion, state and national legislative bodies and the courts have joined us in moving toward ending egregious managed care practices. Managed care medical directors are being held accountable for denials of essential medical care. Employers and HMOs will no longer be able to hide behind the ERISA preemption. Nineteen states have passed parity laws with more to come. My leadership in APA, in concert with dedicated partners, brought about these gains.
I am a strong advocate for
| Patient privacy and the confidentiality of psychiatric records. |
| Private contracting, a fundamental right. |
| An array of health care options including indemnity insurance, PPOs with affordable Point of Service premiums and Medical Savings Accounts. |
| Putting patients in charge of their health care, including health plan selection and choice of physician. |
| Returning clinical decision-making to physicians. |
| Universal access to health care. |
| Availability of the full range of high-quality, biopsychosocial treatments in all settings, including psychotherapy by psychiatrists and substance abuse treatments. |
| Increasing the psychiatric workforce to cope with shortages in Forensic, Child, Geriatric and Substance Abuse fields and the public sector which relies heavily on International Medical Graduates. |
| Dues reduction. |
| Litigation in support of patient care. |
| Accountability of local and national leadership and staff. |
I adamantly oppose managed care's "gag" and "hold harmless" clauses, terminations without cause and financial incentives in physicians' contracts. The efforts of allied health care professionals to expand their scope of practice demands our constant vigilance.
During my presidency, fresh initiatives will be launched to reach the grass roots by involving DB leadership. Government Relations and Public Affairs will work synergistically in legislation and other critical national issues. Legislative activities will be greatly expanded with a marked increase in assistance at the state level where most near-term battles will be fought. Stronger linkages with medical and psychiatric specialty organizations will be forged. Employers will be engaged in a major educational effort to improve the psychiatric care of their employees.
My professional life is centered in my private practice, which is gratifying, truly private and cost-effective. It is my sole source of income. I am also active in teaching and community service. I volunteer 70 to 90 days a year away from my office in my commitment to APA. I serve in the AMA House of Delegates and on the California Medical Association Board of Trustees where I forcefully advocate for psychiatry.
My deep APA experience has taught me how to work our system, to inspire colleagues and to generate rapid staff responses to emergent problems. In these days of crisis, the Presidency is not an office for on-the-job training. I am known for my tenacity, integrity, teamwork, record of achievements and ability to identify and solve problems. Together, we can safeguard the future for our patients and our profession.
We look to the 21st century with optimism, proud of our remarkable research and clinical achievements, heartened by young leaders committed to advancing our mission.
I appreciate your confidence in electing me to serve as the APA President from 2000-2001, as we move into the next millennium.
(abstract)The author reviews the history of the development of managed care, the restrictions it has placedon psychiatric treatments, including psychotherapy, and the concerns it has raised about accessto and quality of care. He discusses research studies documenting that psychotherapy is afundamental component of psychiatric treatment and that it must be included in all health plansand organized systems of care. Several false beliefs about the use and cost of psychotherapy areconsidered, such as that dyadic psychotherapy is based on abreaction, a technique that Freudabandoned, and that costs for psychotherapy will skyrocket if it becomes universally accessible. Research has indicated that inappropriate limitations on psychotherapy in prepaid settings leadsto poor mental health outcomes. The author emphasizes that cost-based constraints onestablished psychiatric treatments are not acceptable until carefully constructed scientificoutcome studies demonstrate that the use of such constraints does not lead to adverse consequenses. (Psychiatric Services 47:971-974, 1996)
Return to top of page 
or 
Return to Home Page
All information, text and images, accessible on the 'borenstein' website is copyright © 1996, 1997 or D.B. Borenstein has authorization from the copyright holder.Technical problems with this site may be sent to Webmaster