Human Rights and Managed Care: Part 3

Steven Moffic, M.D.

May 22, 2012

Now, enough about me (and my life in managed care). Let’s look more into the two topics of our presentation, human rights and managed care.

To my chagrin, realizing that even if I had come to know a lot about managed care, I didn’t know much about the evolution of human rights, so I began to investigate. If the upcoming ACOs were to be HMOs on steroids, as many, including myself, have suggested, understanding this association might be central to our future.

Here’s some of what I found, at least as it seems to related to managed care. In the USA, it was FDR (President Roosevelt) who explicitly stated that health care was a human right. In 1944, not long before he died, he called for a second Bill of Rights, which were to include “the right to adequate medical care and the opportunity to achieve and enjoy good health” and “the right to adequate protection from the economic fears of old age, sickness, accident, and unemployment”. Not long after, in 1948, came the Universal Declaration of Human Rights. This came out of World War II, and thereby that Nazi connection again, and the obvious international goal was to avoid similar atrocities in the future. These prior atrocities, which most of us know about, included torture, unethical medical experimentation, concentration camps, and mass killings of those deemed undesirable to the government. As just one example of how hard this would be to put into practical effect, not long after this declaration, the laws that were to begin Apartheid in South Africa were passed, with virtually no international response.

What astonished me about the Universal Declaration, once I read it, is that while it covered the extreme affronts to human rights, it also covered the everyday needs of everyday life in its 30 Articles. Two of the Articles in the Declaration seemed to be especially apropos to healthcare in general, and maybe managed care in particular.

Article 3: “Everyone has a right to life, liberty, and security of person”.

Article 25: “Everyone has the right to a standard of living adequate for the health and well-being of himself and his family, including food, clothing, housing, and medical care . . .” (I assume this sexist language was intended to include “herself”)

Honing in on healthcare, then, we need to examine how managed care may influence one’s life as far as the prevention and treatment of illness (from Article 3) and how it may influence medical care contributing to health and well-being (Article 25).

Historically, managed care actually predates the Universal Declaration. Over a hundred years ago, it was founded as a not-for-profit way to organize cost-effective care for a group of workers. It was viewed as a socialistic kind of development until President Nixon helped pass legislation beneficial to the emergence of for-profit HMOs and modern managed care. Now, managed care was clearly capitalistic.

Of course, there was no managed care per se in Nazi Germany. Or Stalinist Russia. Or Mao’s China. Or in South Africa (though after apartheid ended, the Archbishop Desmond Tutu at one time would come to advocate for the global spread of managed care). In those countries, it would become common to forcibly hospitalize political dissidents and drug them against their will. We in the United States have not gone to that extreme, yet we could be accused of the torture of political detainees post 9/11 and the related psychological harassment to elicit confessions in jails.

As far as psychiatry per se goes, human rights have been obviously violated with long hospital commitments and unnecessary use of physical and chemical restraints. Currently, the worse may be the enforced, for-profit treatment of adolescents in residential settings. Moreover, a startling percentage (1/6) of adolescents are being medicated with antipsychotics in foster homes. Of course, there are situations of much subtler abuses of human rights, which could include misleading diagnoses, overuse of medication, subtle coercion through the power of the clinician, and lack of adequate informed consent. If we reflect back to Article 3 and “Life” and “Liberty”, maybe the unifying principle, which we we’ll see played out in managed mental healthcare, is the loss of freedom of choice, not only for the patient, but for the clinician.

At its essence, managed care is part of a system of healthcare where some organization is given the authority to manage what healthcare is available, paid for, and delivered. In the USA, the decision to use managed care companies is made by governments or businesses and put into operation via contracts. And, by now, it can be any system that adapts managed care principles without calling itself managed care, due to the Hawthorne effect and need to control costs.

Translating such examples into Article 3 of the Universal Declaration of Human Rights, does managed care help prevent illness? Well, at the beginning, HMOs, aka Health Maintenance Organizations, actually did emphasize prevention. Then, for some time, hardly at all as most companies concluded that the higher initial costs of prevention were not worth the long-range perspective in saving costs, since what could be prevented over many years would likely not still be under the same managed system. More recently, as it became more commonly accepted that behavior was at the root of many chronic illnesses, the trend has shifted back a little as inexpensive wellness programs have emerged.

As to treatment which helps extend and save lives, the conclusion must be inconclusive. There is data and research that unnecessary treatment has been reduced and poor treatment curtailed, but whether better quality of care has also increased seems dubious.

Turning to Article 25, does managed care contribute to health and well-being? The answer remains uncertain, even after 25 years of managed care dominance. Some think managed care companies use the business concept of “trade secrets” to hide whatever data they have that they don’t want to get out. That is similar to what we have found out with many pharmaceutical companies.

So, if you’ve stuck with me so far, and not been worn down (as managed care seems to try to do in practice!), you may anticipate that one can make a case that managed care in the USA has violated some essential human rights. And, in one respect, it has. But, not so fast! Perhaps in another respect, it has not. Due to our unique capitalistic system of healthcare, where those who work are often covered for healthcare by their workplace, complemented by Medicaid and Medicare for many of those not working, there have been increasing numbers of uninsured without any coverage, up recently to more than 50 million, which seems at its best, could be cut in half if healthcare reform completes its gradual emergence. Without health insurance, morbidity and mortality (illness and deaths) increase, along with such social problems as homelessness.

Now, one of the reasons managed care gained such a foothold is that healthcare costs for USA businesses was adversely effecting their competitiveness around the world. That could be controlled if costs were controlled, and drastic increases in healthcare costs were indeed contained for many years, though eventually the backlash against managed care put the brakes on that. Therefore, a reasonable assumption might be that without managed care, the numbers of the uninsured would have been well over the embarrassing 50 million, as companies would refuse to provide healthcare coverage. The most recent complication in all of this, which parenthetically probably could have been addressed by a universal single payer system, is the economic recession in the USA. That has had a ripple effect on obtaining adequate healthcare and insurance, and most dramatically on our stigmatized mental healthcare, where downsizing and closings of clinical and hospitals, from Louisiana to LA (where jails and prisons are the largest mental healthcare “system”) seems unprecedented in my lifetime.

(To be continued in Part 4, where I hone in on psychiatry in particular).

Steven Moffic, M.D.

Sad in Psychiatry: Affectionately called a “gadfly,” and  known as “da man in psychiatric ethics,” Steven Moffic writes about what makes him sad about modern day psychiatry, and how to “treat” that condition so that we will become glad about what psychiatrists can do to help.

 

 

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14 thoughts on “Human Rights and Managed Care: Part 3

  1. Dr. Moffic, this is high praise coming from me, what I’m about to say to you:

    It is clear you are at least make a cursory effort to understand your profession’s human rights record and current human rights state. You deserve at least some credit for this.

    You have a long, long way to go though. Stick around this site for a couple of years, maybe there is hope for you yet.

    I’m not even going to ‘bite’ when it comes to the paragraph about you believing psychiatric political retribution doesn’t happen to political dissidents in America, but just in Stalinist Russia, Mao’s China etc… you’re incorrect.

    I’m just going to point out that wikileaks whistleblower Bradley Manning is being forcibly drugged as we speak and I am going to copy and paste the United Section on the wikipedia article on ‘psychiatric reprisal’:

    “Drapetomania was a supposed mental illness described by American physician Samuel A. Cartwright in 1851 that caused black slaves to flee captivity.[28]:41 In addition to identifying drapetomania, Cartwright prescribed a remedy. His feeling was that with “proper medical advice, strictly followed, this troublesome practice that many Negroes have of running away can be almost entirely prevented.”[29] In the case of slaves “sulky and dissatisfied without cause” — a warning sign of imminent flight — Cartwright prescribed “whipping the devil out of them” as a “preventative measure”.[30][31][32] As a remedy for this disease, doctors also made running a physical impossibility by prescribing the removal of both big toes.[28]:42

    In the United States, political dissenters have been involuntarily committed. For example, in 1927 a demonstrator named Aurora D’Angelo was sent to a mental health facility for psychiatric evaluation after she participated in a rally in support of Sacco and Vanzetti.[33]

    In the 1970s, Martha Beall Mitchell, wife of U.S. Attorney General John Mitchell, was diagnosed with a paranoid mental disorder for claiming that the administration of President Richard M. Nixon was engaged in illegal activities. Many of her claims were later proved correct, and the term “Martha Mitchell effect” was coined to describe mental health misdiagnoses when accurate claims are dismissed as delusional.

    In 2006, Canadian psychiatrist Colin A. Ross’s book was published, titled The C.I.A. Doctors: Human Rights Violations by American Psychiatrists.[34] The book presents evidence based on 15,000 pages of documents received from the CIA via the Freedom of Information Act that there have been systematic, pervasive violations of human rights by American psychiatrists during the recent 65 years.[34]

    In 2010, the book The Protest Psychosis: How Schizophrenia Became a Black Disease by psychiatrist Jonathan Metzl (who also has a Ph.D. in American studies) was published.[5] The book covers the history of the 1960s Ionia State Hospital located in Ionia, Michigan and now converted to a prison and focuses on exposing the trend of this hospital to diagnose African Americans with schizophrenia because of their civil rights ideas.[5] The book suggests that in part the sudden influx of such diagnoses could traced to a change in wording in the DSM-II, which compared to the previous edition added “hostility” and “aggression” as signs of the disorder.[5]
    Psychiatric reprisals

    Whistle-blowers who part ranks with a government agency or major corporation can expect to be depicted as unhinged; it’s in the agency’s best interests. For example, Russ Tice was punished in 2005 with psychiatric evaluations that labeled him as “mentally unbalanced” after persisting in his investigations of potentially illegal spying activity at the NSA.[35] As another example, an NYPD veteran who alleged falsified crime statistics in his department was forcibly committed to a mental institution.[36]”

    At least Dr. Moffic is trying. Maybe one day he will come to the conclusion that forced psychiatry itself is incompatible with respect for human rights. In a couple of years, I may ask him. For the time being, I’m not going to really waste my time.

    • Physician critics of psychiatry who are not as genial as Dr. Moffic are certainly marginalized by their profession.

      David Healy, a worldwide psychopharmacology expert and prolific author of foundational texts in the field, has presented a particularly thorny problem for psychiatry’s powers-that-be.

      See http://www.pharmapolitics.com/cbcnational.html , where a threatening encounter is described between Healy and Charles Nemeroff, then Chair of Psychiatry at Emory but later disgraced by conflict-of-interest scandals:

      “….HEALY: Dr. Nemeroff came up to me in the course of the meeting in what was a very scary meeting between him and me and told me that my career would be destroyed if I kept on showing results like the ones that I’d just shown, that I had no right to bring out hazards of the pills like these….”

      (Please don’t start on Healy and ECT, we know he does not meet all standards of orthodoxy.)

    • You really are pretty damned amazing when it comes to knowing so much about all of this. I was just explaining good old drapetomania to the staff of Admissions where I work.

      I think the good doctor is trying, but he’s still having some trouble removing the “psychiatric blinders” he has on. If he takes your advice and hangs around MIA I think there may be some hope for him. I thought his post had some good points, until he made the statement about how we don’t do what the horrible Communists did, and lock dissidents up and drug them by force. I was waiting to see how long it would take before you posted. By the way; in the 1960′s, angry, young African American men who dared demonstrate against the inequalities between African Americans and Whites in this country were often arrested and eventually carted off to the state hospitals, where they were kept indefinitely. Detroit experienced a large number of its young African American male population disappearing mysteriously into mental institutions after the riots that took place there in the sixties.

  2. To me, the most important paragraph in this article begins

    “As far as psychiatry per se goes, human rights have been obviously violated…. If we reflect back to Article 3 and “Life” and “Liberty”, maybe the unifying principle, which we we’ll see played out in managed mental healthcare, is the loss of freedom of choice, not only for the patient, but for the clinician.”

    I look forward to the demonstration in part 4 that under managed care, the clinician has no choice in diagnosis and treatment.

    I remain extremely skeptical that managed care forces the clinician to diagnose sloppily, medicate arbitrarily, and attribute adverse effects of treatment to character flaws in the patient.

  3. Well, what do you know, some damning with faint praise, as the saying goes. But I’ll take it gratefully. Also appreciate the elaboration of human rights violations in the USA; I basically was trying to say they don’t compare with what went on in some other countries. My other main intent was to expand the view of human rights violations from these more obvious and horrendous ones to more subtle, everyday ones. That is where managed care comes in; no question they influence what diagnosis is made to receive payment and what treatment is chosen for the same reason. Managed care, in my perspective and insider/outsider status, has influenced psychiatrists becoming 15 minute med checkers as much, or more, than the pharmaceutical companies pr and payouts. Deny that at the costs of all, because managed care is going to get even more powerfu. (Again, see my book, as unfortunately it is not out of date since published in 1997).

    • I tend to finally agree with you on something. I think you’ve pointed out an important point. It’s very subtle but has had tremendous and devastating impact on how things are done. And rather than fight the system, most psychiatrists have succumbed to the pressure because to do otherwise would mean financial suicide. I don’t think managed care wants psychiatrists to do any kind of real therapy, and perhaps has, in a since, forced people into giving out the pills. Thanks for hanging in here with us, even though we sometimes seem to smack you around a little bit.

    • You’re trying to imply that conditions being worse elsewhere somehow makes it not really so bad. (There’s no other reason for making that statement.)

      You blame managed care, but the fact is that psychiatrists themselves brought in the short visits to prescribe drugs, to raise their status in the medical profession, and frankly, most likely to increase their income. Managed care couldn’t include such an approach without psychiatry first bringing the concept into place.

  4. Glad you’ve stayed interested, Altostrata! The editorial goal was to not dominate the blogs with this series, and that hopefully each would stand on its own. Hopefully, the next will be posted the end of this week, then just one more!

    • I put part 3 up briefly, then realized I wanted to give Bob’s latest piece a chance to stay up longer on the front page, and wait until Dr. Moffic’s previous post had moved off the front page. So I asked Dr. Moffic’s permission to do that. Other bloggers put theirs up by themselves, and we have not asked them to hold to having one up on the front page at a time, though we might.

  5. My public thanks to Kermit and Bob for helping me out with these blog postings, as I have much technical limitations and very little time to learn more right now. I also definitely do not want to hog up the blog postings, as all seem quite valuable to me.

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