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Presidential Paper   |    
Response to the Presidential Address: APA Enters the Twenty-First Century
Daniel B. Borenstein, M.D.
Am J Psychiatry 2000;157:1769-1770. doi:10.1176/appi.ajp.157.11.1769
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It is exhilarating to become the first APA President to serve in the twenty-first century. I am the 129th President elected but only the 127th President to assume office 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 member of 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! However, I am eager to meet the challenges that accompany this position, knowing that I have the support and assistance of my extremely talented colleagues on the Board of Trustees, the many other members who volunteer countless hours to our organization, and 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 in this position 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, and my closest psychiatric colleagues from Los Angeles have been particularly helpful.

I will focus on some of the actions planned for 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 the way in restoring our patients’ access to high-quality care in both the public and private sectors. Patients must be able to choose their doctors. 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 toward high priorities and a new corporate structure in January 2001 will help us reach our goals.

I will begin 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 health maintenance organization (HMO) executive received $29 million in compensation and held $83 million in stock options. The top 25 HMO executives averaged over $6 million in salary and $13.5 million 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 consolidations of managed behavioral health care organizations. At the end of 1999 the two largest companies had about 86.3 million enrollees, close to a 50% 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 6% in 1988 to 3% in 1998. One managed care executive forecasts a further reduction to 1%–2% of total health care funding. While overall health benefits dropped 7.4%, our patients’ benefits decreased by over 50%. 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 U.S. Surgeon General are on our side. Some employers are becoming more aware of the cost of not providing adequate mental health care to their employees. A recent study of major corporations revealed that 3 years of aggressive managed care led to a 44% decrease in total mental health costs. During the same period there was a 37% increase in general health care costs, a 22% increase in absenteeism, and a decrease in work performance, resulting in zero 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 a 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 proactive 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 levels. 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 $1 million "litigation fund." With our corporate reorganization we will have a $1–$2 million "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 grassroots 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 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 redundancy. 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 ICD.

We must all be excited about the fantastic scientific developments in our field. Even Rip Van Winkle could not 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 have 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.

Presented at the 153rd annual meeting of the American Psychiatric Association, Chicago, May 13–18, 2000. Dr. Borenstein, 129th President of the American Psychiatric Association, is Clinical Professor in the Department of Psychiatry and Biobehavioral Sciences at the University of California in Los Angeles and is in full-time private practice. Address reprint requests to Dr. Borenstein, 151 North Canyon View Dr., Los Angeles, CA 90049-2721.

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