An Interview with
Paradigm: In a recent interview on CBS's "60 Minutes," you said you had "declared war" on managed care companies and vowed to fight "the scourge of managed care." What specific action is the APA taking?
Eist: The APA is involved in an extensive public education campaign, informing the public of just exactly what managed care is doing to their health, particularly their mental health.
We have produced a brochure describing managed care and your mental health, advising patients of what to look for in a health plan to assure they will get the coverage their plan says they should get. We advise them of what to do if they don't get the care they need.
We have been very active in extending our strategic alliances. On June 6, 1996, we had an historic meeting at the APA of almost all of the professional organizations that provide care to the mentally ill. I think it was the first time that has ever happened. We now have an alliance of nearly one million strong. We have produced a manifesto, which the organizations have all agreed to as to what constitutes quality care for the mentally ill.
We have been meeting with corporations to educate them as to the importance of adequately treating the mental health of the work force and the benefit to them and to their communities of treating the mentally ill.
We're engaging actively in litigation against managed care depredations. We are working very hard with the AMA to strengthen the house of medicine as we work.
Confidentiality is a key issue for the citizens of America -- privacy is one of the Constitutionally guaranteed rights. We are fighting the managed care industry's intrusion into privacy, confidentiality, which they have run roughshod over. We are battling on behalf of the mentally ill of America to assure that they get the care that they need.
We're also fighting for a larger share of the healthcare dollars. Whereas in most HMOs medical/surgical costs over the last 10 years have gone up about 20 to 25 percent, psychiatric costs have gone down 80 percent. That amount of money being raked out of the system can do nothing but deny people access to care they need. Managed care medical directors and their CEOs, if they're not CEOs, are laughing all the way to the bank, at the expense of the American people.
Paradigm: Do you think managed care should be involved in the decision about what care a patient should receive?
Eist: The doctor and the patient should make the decision. Managed care shouldn't be involved.
Paradigm: They say the reason managed care came about was to manage costs. Haven't they been successful in doing that?
Eist: It really came about to manage price. In the ("60 Minutes") program, I did say "managed cost and mangled care," but I should have said managed price, because the cost of managed care doesn't make the prices they've managed to reduce, the expenditures of corporations, even nearly worth it.
The fact of the matter is they do not reduce cost, they increase cost. They might reduce prices, but the overall costs are much higher with managed care than they ever were before. There is more suffering, there is greater morbidity, greater mortality. In 1993, for the first time since statistics have been kept, the average life expectancy of Americans declined, and there has been a 3 percent increase in mortality rates all across the board.
If you believe in "family values," how can you justify drive-through mental healthcare, drive-through mastectomies, drive-through deliveries, sending people home quicker and sicker to suffer in their households, with families who have to suffer with them. If you believe in "family values," it's a real hypocrisy isn't it?
Families have to take time off work, or hire people to come in and help them care for their relatives while these people are saying they are lowering health costs -- while they are making enormous salaries. Fifteen million, 20 million, a billion -- when did you ever hear of a doctor making money like that? And then these managed care companies have the nerve to say they are protecting the public against greedy doctors?
Paradigm: Are you saying that managed care should be "the dinosaur"?
Eist: It is the dinosaur -- it's always been the dinosaur. Managed care has called everybody else the dinosaur.
I thought it was very telling when (the head of a large managed care company) said, "Well in the old days, people used to go to their doctors and trust them." This guy had the unbelievable nerve to say, "We really have a question about people trusting their doctors." Who are you going to trust when you're sick, your doctor or an insurance agent or some kind of corporate benefits manager?
Paradigm: What do you believe is the solution to the problem?
Eist: For years, we heard that the problem with healthcare was that patients weren't chipping in and paying a piece of it. Under managed care, they pay less, they don't pay more. What happens with managed care, and how they market their plans is, they say we'll give you more for less. That's a lie. The patients get less for less, of course.
In the old fee-for-service system, patients paid a certain percentage of the healthcare bill. Paying that percentage -- at least from the point of view of the economist -- resulted in their being responsible partners in the transaction and not simply going along with anything that unscrupulous workaholic doctors demanded.
The fact of the matter is that the medical system itself was not responsible for high costs. The insurance system is responsible for high costs. In other words, whenever real healthcare costs went up 4 percent, insurance premiums went up 16 percent; whenever real healthcare costs went up 7 percent, insurance premiums went up 28 to 30 percent.
Also, the way the insurance industry "Balkanized," or carved up the community, massively increased costs. If everybody in the community paid a little -- only 13 percent of the people ever use more than $2,000 a year for healthcare -- then when somebody got sick, there would be money there to take care of them, right? That's called community rating -- everybody pays the same, a small amount, and when somebody gets sick you take care of the sick people.
Now, what the insurance industry saw was, hey we can carve out healthy young workers and their families, charge them a significantly lower premium, but never spend a penny in benefits -- that all goes into profit. They began to extract more and more money out of the system. Then they had to charge sick people the actual cost of their healthcare, plus the cost of their profit margin on top of it. By "Balkanizing" the healthcare market, the insurance industry created massively higher costs.
It was astonishing when the "fox" went into the "henhouse" to save money for corporate America. The way they did it was they reduced services, they reduced access, and then they kicked back some of the money they saved to the corporations. The money they kicked back actually was money that belonged to the employee, who has earned his benefits. The employee never saw that money. There has got to be a law against that. The corporation never paid any tax on it -- it is a kickback on a reimbursement. Very clever.
Paradigm: Do you think we should go back to the way it used to be?
Eist: I think that, first of all, there's not going to be one system that's going to work in this country. This is not a nation-state. What's right for one area, is not going to be right for another area. There can't be a global plan.
We are going to have a "cafeteria" type system, I think. There will be some fee-for-service, there may be some HMO -- though the HMO was always a bad concept, from day one. The HMO always discriminated against the mentally ill.
Paradigm: What do you think will happen with the HMOs?
Eist: There was an article in the New England Journal of Medicine, written by a family practitioner from San Francisco, who was complaining that the HMO backlash was going to result in healthy people leaving HMOs and buying MSAs (medical savings accounts), and when they leave the HMOs the only ones left there are the sick people. Then the HMOs won't be able to compete.
I thought to myself, "That's exactly what the HMOs have been doing and how they've been destroying the healthcare system right now!"
I see that MSAs will become more important, that people will control their own health insurance rather than their companies owning it, so they can go to the doctor they want to, when they want to.
I do not take the position, like the managed care companies do, that the people are stupid -- that always offended me. So people can't tell who the good doctors are? They have to be protected by the managed care companies? And yet the managed care companies always use satisfaction surveys. The satisfaction surveys are structured so that if you waited five hours for your appointment and that's as long as you had expected, then you're a "satisfied customer." They folded the mainly healthy people that they have in their network in with the sick so the statistics always look good. If they had taken those people who are sick and who needed care out of their system and then said to those people "How do you feel you've fared in this system," they would have gotten a completely different picture.
Paradigm: How long do you think it will take to evolve back to the idea of "taking care of the patient"?
Eist: Three years ago, when I was the only voice in America saying what I'm saying now -- when I was a very lonely voice -- I kept telling people things change quickly in America, and that as fast as things have gotten bad, they can get good.
© 1997 Targeted Publications Group, Inc. All rights reserved.
Click here for Managed Care's response in the Fall 1997 issue of Paradigm.
