In my opinion, the APA is an organization which has earned our support. Its accomplishments over the past year have been impressive. One also has the sense of better things yet to come. Progress has been made legislatively on issues of parity, at the state and federal level.

In New York State, the APA joined a broad coalition of other mental health organizations that helped convince the state assembly in its passage of a parity bill. Hopefully, their organization will be equally effective in convincing the State Senate to pass its version this year.

At the federal level, the efforts of the APA were instrumental in achieving private group health insurance parity for lifetime limits and annual caps through passage of the Domenici/Wellstone Amendment.

Economic issues which directly affect the practice of psychiatry have also been addressed. The APA was influential in the development of the new CPT codes, which are to be instituted this year. Those codes more accurately reflect the work that psychiatrists do in terms of medical management and make a distinction between ourselves and other non-medical mental health professionals.

After a period of falling reimbursement rates, Medicare fees have significantly risen this year, again through APA efforts. "Private contracting" under Medicare has also been achieved.

APA is now trying to get its own financial house in orr of meetings for its employees, consolidation of departments and possible elimination of some salaried personnel. Hopefully, this mode of "downsizing" will not include pressure to consolidate small district branches (i.e. WHPS) into larger ones. The cost savings to the APA would be slight, and an important vehicle for "grassroot" participation of the membership at the local level would be lost.

Finally, the area where APA has had its least success is with Managed Care. Unfortunately, it has fared no better than any other medical organization on the state or national level.

There has been no group, either governmental, consumer-based, or professional, which has made any significant progress in "rolling back" or even effectively controlling Managed Care.

APA has had some small successes. For example, it had a role in the passage of the Managed Care Bill in New York State in 1996, but a coherent strategy has not yet been developed.

Should APA chart a course of fighting Managed Care at every opportunity or should it be accommodating to the present reality and helping its membership to do so as well?

These are difficult questions. But APA should not be held responsible for failing to remedy what is a national problem: the vast changes brought on by Managed Care.

Certainly, the APA's inability to have a major impact on this issue, should not be taken as a reason for its membership to see it as a less credible, less viable organization.

For a number of years, we have observed numerous corporations cutting back on costs (possibly due to prior overexpansions) in various ways, including laying off of employees and reducing sizes of their product lines. This and other strategies have been effective, since the economy is more sound today than in many years.

At the same time, we have observed an increasing concern by our own American Psychiatric Association regarding its fiscal health, in part due to loss of membership, in part to increasing costs of running the organization. Some of these increased costs may well be due to the expenses associated with fighting the Managed Care onslaught, while others are produced by a significant increase in the costs of dealing with ethics violations.

The APA Ethics Appeals Board has recently described a number of significant cost increases in litigation against the APA and DB?s by members accused of  violations, during the investigation of that complaint, trying to stop the investigation, or at least to slow it down, possibly for years.

This then allows the accused member to avoid final disposition of the complaint and if unfavorable, reporting to the licensing authority (in New York, the NYS Education Dept. and Office of Professional Medical Conduct), which might then earlier complete it own investigation and cancel the member's license to practice medicine.

As a recent APA memo (from the Ethics Committee) stated: "The current system with all its problems is a very good one, from the perspective of quality ... the changes herein are suggested not in order to improve a system that is not working, but in order to achieve other ends ... likely to have some negative impact on functioning of the system ... (but) in the hopes of achieving the savings ... cost savings/ streamlining/expedition ... the greatest costs seem to be associated with two aspects of the (Ethics) process: 1. The Ethics Appeals Board and 2. Litigation initiated by members who "are under investigation or have been sanctioned", as well as costs associated with bringing Appeals Board members to Washington and its other expenses."

Thus, the APA is recommending a number of cost-saving moves including:

a. Reduce the number of Ethics Appeals Board members.

b. Forward selected complaints to the State Licensing Board during the Ethics investigation, thus allowing the Licensing Board to "take over" the investigation and probably resolve the Ethics complaint much earlier.

c. Allow the Ethics Appeals Board to increase sanctions imposed by the DB (not previously an option) and to pressure members to avoid an appeal for fear of an increase in sanctions.

d. Prohibiting or dramatically reducing postponements of the Ethics Appeals Board hearing, which is costly. Accused members do this to delay final disposition, referral to State Licensing Boards, and potential loss of income.

e. Requiring any accused member who ini-tiates an appeal of the DB Ethics decision and sanction to deposit a substantial fee with the APA, which would be returned if the appeal went forward but be lost if the accused member dropped the appeal before it was processed.

f. Eliminate remands of cases back to the DB for a rehearing, since the DB's often refuse to rehear the case and petition the APA to handle it on its own, again increasing APA costs.

It is certainly evident that with the development of the National Practitioner Data Bank, accused psychiatrists are becoming more and more skilled in preventing or delaying sanctions (Ethics, licensing and malpractice cases) from being reported and from losing their licenses. The longer they can stay in practice the longer they can earn a living, the more it costs the APA.

I wonder if there might be other means or cost savings which do not threaten an extremely well-functioning and very serious system of dealing with psychiatrists who commit Ethics infractions. I certainly do not believe that shifting enforcement to State Licensing Boards (often made up of non-psychiatrists) is in our best interests and I do not believe that the other cost saving recommendations in this important area are designed to benefit us either.

Let the APA find a better way to save money, without harming our legal rights.

As a psychiatrist, I spend my days soothing the worries of the anxious and quelling the fears of the paranoid. But, more and more, the stresses of life have begun to take their toll on me. I am more than acutely aware of the health risks, both mental and physical, of too much stress.

Recently I have embarked on a plan of relaxation and stress reduction. Striving to improve the quality of my leisure time, I tried my hand at gardening. Where I live, there is concern that the soil may be contaminated from years of exposure to a local chemical plant. So I hired a gardener to create an organic garden for me, delineating an 8'x 10' area with landscape ties, covering the ground with plastic and filling the box with peat and clean top soil.

Happily I gardened, sowing vegetables for my family and friends. I weeded and watered tomatoes, eggplant, fresh basil, eagerly anticipating reaping the rewards and savoring the fresh- grown flavors. Until I saw a report on television that landscape ties are treated with an arsenic compound that can leach into the soil....

I wanted to spend more quality time with my loved ones, so I planned a barbecue. Hamburgers, however, were off the menu: beef is too high in fat, laden with hormones and antibiotics, possibly tainted with E. coli and, perish the thought, "mad cow" disease.

We tried to limit our time in the yard to after 3:00 PM (when the prime UV danger is passed) and before 7:00 PM when mosquitoes, some possibly carrying encephalitis, were the hungriest. And, of course, we wore long pants in an effort to stave off deer ticks and the possibility of Lyme disease. 

I planned a trip to the seaside, but they closed the beach again due to pollution. Terrorism stems my desire for overseas travel. In my spare moments, I wonder what has become of the missing "nukes" in Russia, then estimate my relative position to ground zero if New York City is chosen as a target. (And, if I should be spared that fate, how long can I continue to dodge those meteors and asteroids all out there gunning for Earth?)

I've tried to take advantage of all the newest conveniences that exist to make my life easier and more enjoyable. Modern appliances have freed me to be out and about but still in touch with important people. Of course, I try not to use my cell phone too often and only on my right ear lest I incur a tumor near my speech center (and, never while driving so I won't risk getting into an accident and deploy a potentially over-aggressive airbag meant to save my life).

I am ever more fascinated with the wonders of cable, satellite, VCR and FAX, answering machines and computer screens. But, as they multiply within my home, I calculate the Gauss and my exposure to EMF (a thought never far from my mind as I drift off each night beside my clock radio and portable phone).

Eating out at restaurants was once a pleasurable activity, but now, that has become too complex. I have been informed about the obscene quantities of fat and calories lurking in my favorite cuisine. And if my server becomes disgruntled, will some of his or her spit find its way into my entree? 

That after dinner movie just doesn't have the same charm when I must forgo the buttered popcorn containing my allotment of fat for an entire week. Instead, I prepare more foods at home, devoid of cholesterol, fat, and taste. I eat five servings of fruit and vegetables daily, being sure to wash off any pesticide residue. I filter my drinking water, take anti-oxidants and whatever is the vitamin or nutritional supplement of the moment. Poring through vitamin catalogs supplants reading for enjoyment. I abstain from smoking, drinking, and use alcohol-free mouthwash.

I have developed interests related to home improvement and have taken on several small projects. I have installed smoke and carbon monoxide detectors, burglar alarm systems, bars on the windows, and a club for the car. Pets are known to lower the blood pressure of their owners, and owning a cat has brought me great joy over the past twelve years. Playing with her can make me forget the cares of the day.

Lately, however, I have been wondering if she is getting the proper nutrition in her food. Is there enough taurine in her diet? And what about giving her vaccines? The last time she received them, she was lethargic for days. And there is the risk of developing fibrosarcoma at the injection sites...

It seems to me that the old saying 'ignorance is bliss" has taken on new meaning as we approach the dawn of the next millennium. We find ourselves bombarded each day by media reports telling us what is healthy and not healthy and warning us of "dangers" both real and perceived.

We can all recite our relative risk factors for coronary artery disease, accidental death, and various types of cancers. It remains to be seen which, if any, of these new bulletins will really serve us well, but one thing is clear: they add to our ever-increasing stress. And that, we know, will create all manner of ills.

I was fortunate enough to have known several of my great-grandparents. They lived to ripe old ages eating whatever they liked, breathing the air, and drinking the water without concern, blissfully exposed to any number of untold hazards. Yet, they were seemingly unaffected.

My generation, I fear, is destined to literally worry itself to death. No part of a day goes by when we are not faced with some potential disaster. Once simple tasks have become monumental. Even something as basic as throwing out the trash requires thought and effort as we separate, sort, and rinse.

What can be done? Is there hope for the hopeless? Perhaps the best thing to do is to turn off the television, unplug the Internet, recycle the newspaper before it is read, and return to some of life's more basic pleasures like... If only I could remember what they were!

There are innumerable other nonspecific factors, that contribute to the healing phenomenon, by reinforcing the first two factors enumerated above. The support network, the get well cards, the flowers and the comfortable restful atmosphere, are all contributory nonspecific factors in the healing drama. They may all be considered as the placebo' factor in healing. In other words, a placebo may be defined as any component of a therapy that is without specific activity for the condition being treated.

The twentieth century has witnessed the phenomenal sophistication in the surgical and medical management of diseases. To test the efficacy of these measures an elaborate system of double blind placebo controlled research protocol has been developed. Stated simply, the attempt is made to exclude the placebo factor from the specific medication or surgical method under investigation. This is all well and laudable, but in the process the placebo effect has acquired a derogatory connotation, almost equating it to quackery.

Let us consider here, a surgical procedure that had become popular in the early 50s, for the treatment of Angina Pectoris. This involved the ligation of the internal mammary artery. The success rate of this procedure was claimed to be very high.

Edmunds Dimond of the University of Kansas Medical Center, decided to investigate the effectiveness of this surgical measure. He compared 13 patients who underwent this procedure, with another group of patients in whom the chest incision was made and closed without the ligation of the artery. Whereas among the patients who received actual ligation of the artery, the relief from chest pains was achieved in 76% cases, the relief in the control group, where no ligation was done, was 100%! Here obviously the placebo was not an inactive one, in as much as a mock surgical procedure was performed, in a prestigious setting, by a reputable team of doctors. And it produced results!

This powerful effect of the placebo should lead to a rethinking of this mysterious phenomenon. Andrew Weil, MD defines the placebo effect as the power of the mind over body. Over the centuries, physicians have been utilizing the healing power of the placebo. If the placebo is harmless, and in some cases of some tonic effect on the body, is it unethical to mobilize it to bring about healing in a patient? In clinical practice there is no need to introduce the blinding aspect of the research model. The patient is fully advised about what the medicine is and its safety. Consider the following case:

A 41 year old woman went into severe depression during which she made a serious suicide attempt. She had been under treatment for infertility for ten years, which finally resulted in pregnancy, but the baby was born with multiple neurological deficits and was not given the likelihood of survival beyond a few months. Feeling devastated and hopeless the woman saw no purpose in going on living. She was treated with tricyclic antidepressants (the SSRIs were not in the market then) and intensive psychotherapy (there were no HMOs in existence). Her depression became less intense and she talked about the void she felt as one doomed to be childless. She refused to go back to the rigors of the previous ten years of fertility treatment which had resulted, in her mind, with a defective child.

She was informed by a friend about t he effectiveness of vitamin E in improving infertility in some obscure animal research. She discussed this with her psychiatrist who, instead of dismissing it as hocus pocus, listened to her intently and agreed to go along with the use of this harmless placebo - 400 IU of vitamin E daily. He made one comment that proved to be crucial: "Stop taking the antidepressant at the first sign of pregnancy." The patient took this to mean that the psychiatrist was as positive about its success as she was. She wasted no time, in a spirit of great expectation, went off the antidepressant and started taking the vitamin in right earnest.

In about three months, she became pregnant again, and in due time gave birth to a healthy baby girl! After three years the psychiatrist received a card from her, informing that two years after the birth of her daughter, she decided to get pregnant again. She went on the same dose of vitamin E, and at age 45, was blessed with a healthy baby boy! Twenty years later this woman, now in her 60s, is a proud mother of two college going children.

Today there are many untested remedies going around in the market place. It is important for the physicians to familiarize themselves with these, and to listen to the testimonials' and anecdotes that the patients present to them. The judicious use of these can sometimes result in gratifying outcomes.

Is it ethical to deny the patient the benefit of these, when other remedies have failed? We should perhaps not speak of a placebo effect when we speak of an individual patient who benefits from a nonspecific, unproven, method of treatment. According to H. Benson, M.D, three components bring forth the placebo effect:

a. Positive beliefs and expectations on the part of the patient;

b. Positive beliefs and expectations on the part of the physician; and a good relationship between the two. In the case presented above all these three components were operative and may have contributed to the outcome.

It goes without saying that in the use of placebo in an individual patient, the following provisos should be kept in mind:

a. No adequate therapy for the condition is available or, if available, produces serious side effects;

b. Placebo treatment should not inflict unacceptable risks, and

c. The patient is adequately informed and gives informed consent for the use of the particular treatment.

It is imperative that you know the documentation required for the use of all of the codes, especially the MB/E/M Codes. Even if you don't see Medicare patients, these new codes and documentation requirements will probably become industry standard.

You should have received the useful memorandum from NYSPA in January listing all the codes germane to Psychiatry and their associated fees. This will save you having to calculate all the numbers for yourself.

If you are in Rockland County you may have received the wrong chart and are billing for less than you are entitled to. If the chart you are using does not say Rockland on it, please call the New York State Psychiatric Association at 516-542-0077 and ask them to send you the correct memorandum which also includes a discussion of private contracting and the new fee coding.

Calling it "the worst of all possible worlds," APA wants Congress to amend the law so that psychiatrists and other physicians can elect to sign private contracts with patients at any time if those individuals choose to do so in lieu of filing a claim with Medicare.

To comply with the current law, which was enacted as part of the Balanced Budget Act of 1997, physicians will have to ask all of their Medicare patients to agree to private contracting-an extremely unlikely prospect-if they go along with the request of even one patient to enter into such an agreement (Psychiatric News, November 7, 1997). Once a physician or health care professional signs a private payment contract, he or she must forward an affidavit to the Health Care Financing Administration in Washington, D.C., acknowledging the start of the two-year ban on Medicare participation.

This requirement to leave Medicare entirely for two years is "draconian" and "undercuts a basic foundation of the therapeutic relationship between psychiatrist and patient, namely continuity of care," APA argued in its Senate testimony. "A psychiatrist would be forced to decide whether to give precedence to the request of a single Medicare patient to guarantee absolute preservation of confidentiality via private contract, or to other Medicare patients who wish to have claims filed on their behalf."

APA also pointed out that under yet another of the compromises implemented to bridge the chasm between advocates and opponents of private contracting, even opting out of Medicare does not guarantee a patient that his or her medical records will remain confidential. The law's wording permits the Secretary of the Department of Health and Human Services, who retains authority over the agency that administers Medicare, to gather data on "the fiscal impact" private contracting has on total federal expenditures for the Medicare program as well as on out-of-pocket expenditures by beneficiaries who choose to go the private contracting route. The Secretary can also use the data to evaluate the impact, if any, that private contracting has on the quality of care older Americans receive.

The need to restore unbreachable confidentiality protections was underscored in the U.S. Supreme Court's decision in Jaffee v. Redmond in which the justices ruled, "Effective psychotherapy depends upon an atmosphere of confidence and trust, and therefore the mere possibility of disclosure of confidential communications may impede development of the relationship necessary for successful treatment..."

APA views the private contracting option as especially crucial now that the federal government is in the midst of a campaign to convince Medicare beneficiaries to enroll in HMO's and other managed care plans. In these treatment settings there is even more opportunity than in fee-for-service plans for third parties to gain access to treatment information that patients wantheld strictly confidential. This same government initiative also affects the continuity-of-care issue, since a patient may wake up one day to find that his or her longtime and trusted clinician is no longer on the Medicare HMO's provider panel. Private contracting supplies a valuable route for that patient to continue care without having to start over and build a relationship with a new psychiatrist.

Opponents of private contracting in Medicare have focused their arguments on issues far removed from confidentiality needs, however. Some are worried that should private contracting catch on, the U.S. will end up with a two-tiered health care system for its senior citizens defined by the financial ability of these individuals to pay for care that will be more expensive once they leave the Medicare program. The chair of APA's Joint Commission on Government Relations, Miami psychiatrist Ronald Shellow, M.D., maintains, however, that it is, in fact, the two-year mandatory ban that will foster a two-tiered system.

Psychiatric district branches from all 50 states applied for this coveted award. The West Hudson Psychiatric Society was one of only five winners. "In the area of small district branches, Rockland County has one of the most active coalitions in the country", according to Walter Hill, Manager Network Communications of the Division of Public Affairs of the APA.

Within a few days of the conference, the coalition and district branch members were busy in their March 5, 1998 meeting implementing new ideas from the Joint Institute Conference.

Here is a list of some of the upcoming projects:

1. May 5, 1998: Dr. Ducker will speak to the clergy at the Pomona Jewish Center on "Stresses of the Clergy  '

2. May 11, 1998: all psychiatrists from our district branch and coalition members are invited to attend a clergy lunch at St. John's Episcopal Church in New City. Please let me know if you are interested in attending: 914-364-2428.

3. The coalition is having 5 college programs at St. Thomas Aquinas College and Dominican College. At these programs, a coalition or district branch member, a patient, and a family member will speak about understanding mental illness. This is anticipated to be a program the students will remember forever when they hear first hand stories about how mental illness has affected parents and families.

4. Finally, on May 17, 1998, at Rockland Lake State Park in Congers, the mental health coalition and district branch will participate in a "Picnic for Parity."   Currently, 15 states have various forms of parity laws. Data from these states prove that equitable insurance coverage for mental illness is affordable.

This year, the New York State Assembly passed a bill in support of parity   legislation. In June, it will be voted on in the State Senate. This bill requires all managed health care and indemnity plans to do so on the same basis terms and conditions as they do any other illness. At the Joint Institute, the issue of Parity was discussed in many lectures.

Some supporting points for parity include:

1. Mental Illnesses affect 25% of Americans during any one year period (up to 50,000,000 Americans)

2. Individuals with mental ill-ness face blatant mental health discrimination

3. The high cost to society of un-treated and under treated mental illnesses are well documented

4. Parity in mental health cove-rage will help states save money

5. Advances in medical science have yielded successful and cost effective treatments for mental disorders in the past two decades

6. A 1997 Rand Study demonstrates that mental health parity is affordable- Removing the typical average annual dollar limit of $25,000 will increase in surance payments $1 per enrollee per year.

An APA letter stated it best: "The time has come to stop treating people who suffer from mental illness like second class citizens. As psychiatrists, we can not afford to be silent as long as the health insurance industry discriminates against our patients by denying them equal coverage for treatment of mental illness. Parity is right and fair. This is the time for acting."

Dr. Neumann was born in Central, Valley New York at Green Acres on June 27, 1922, the son of Dr. Theodore William Neumann, Sr. and Florence Pilgrim Neumann. He wasthe director of Falkirk Hospital in Central Valley from 1956 until 1988. Dr. Neumann's grandfather, Dr. Charles Pilgrim, purchased Falkirk Hospital in 1920. His father Dr. T.W. Neumann, Sr. operated the hospital from 1934 until l958. Falkirk Hospital was an historically important institution for the treatment of mental illness. Founded in 1889 as Dr. McDonald's House, it pioneered new approaches for the treatment of mental illness until it closed when Dr. Neumann retired in 1988.