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Every Psychiatrist Needs To Be an Advocate

For more than 30 years, I have happily paid my APA dues. My membership in the national APA and my local district branch has been part of my identity as a psychiatrist and my commitment to professional standards and ethics that transcend economic self-interest. It is one way of giving back. I believe my membership in APA has served as a means to express my views in the political marketplace and to develop an advocacy agenda that puts my patients and access to quality care first. Now, as president of this wonderful organization, I plan to make advocacy the central theme of my year in office.

The Oxford English Dictionary states that "to advocate is to publicly defend, maintain, recommend, stand up for, or raise one's voice on behalf of a proposal...." As psychiatric physicians, I believe we are the natural advocates for our patients because of our special, hard-earned knowledge and expertise and our sacrifice and commitment to putting patients first. Medicine needs a strong APA today more than ever.

The American health care system is in crisis. Americans are the least satisfied health care consumers in the English-speaking world. Despite the fact that we spend more than any other country on health care (approaching 15 percent of the gross domestic product), we are doing worse. According to the World Health Organization, life expectancy in the United States measured in healthy years ranks 29th in the world, between that of Slovenia and Portugal. With the number of uninsured Americans now at 45 million and growing, and the number of underinsured at many millions more, especially for mental health care, one can see the dimensions of the crisis that led President Bush's New Freedom Commission on Mental Health to declare "the mental health system is in shambles."

Since 1980 American health care has radically changed. Before then we were a system that was largely not for profit, driven by the doctor-patient relationship and in the public interest. Over the last quarter century, we have succumbed to market-driven strategies—for-profit, corporatized, managed health care. Publicly held corporations accountable to Wall Street and stockholders ration care in America where the for-profit health maintenance organizations (or managed behavioral health care companies) decide who receives care, how much care one can receive, whether one can see a specialist, how long one stays in the hospital, how many therapy sessions one receives, and what medications one may take—and these decisions apply to the lucky individuals, those with health insurance. Those without insurance are out luck.

We have the world's largest, costliest health care bureaucracies, estimated to cost in the tens of billions of dollars. There is colossal administrative waste in our system today, which includes countless hours spent by the average American health care consumer on the telephone correcting billing mistakes, arranging medical appointments, obtaining tests, and getting referrals. It also includes the time and expense of dozens of billing specialists at hospitals and doctors' offices trying to collect from the more than 1,000 insurance plans that people have and hope will actually cover their expenses, not to mention the hours spent on the phone or filling out forms justifying "medical necessity."

There is basic anxiety among Americans about access to health care. If they have health insurance, they worry they will lose it. If they don't have health insurance, they know they are close to financial ruin. The most common cause of personal bankruptcy in America today is medical expenses.

APA's agenda for advocacy must be to fight for the integrity of the medical system and the public health. Advocating for universal access to health care and parity of benefits along with utilization-review methods for psychiatric and other medical conditions is not only just, it is a moral imperative that also makes sense clinically and financially.

At the national level, APA has one of the finest government relations teams among medical specialty organizations, but APA's advocacy also depends on our district branches as more and more health decisions are made in state capitals, and that means we need you, as individual physicians and members, to step out of your office and get into the political arena for the good of our patients and our profession.

Articulating the case for access to quality psychiatric care is the advocacy leadership I ask of each of you. Today, to paraphrase President John Kennedy, it's not enough to just pay your dues and ask APA to do the advocacy for you. What can you do for APA and our patients? Being a member of APA is a calling to always do more. If you are interested in getting involved, please contact me at SSharfstein{at}sheppardpratt.org.

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