“APA and State Associations are Unable to Cope in a 21st Century Healthcare Environment”
“The Need For A National Guild in Psychology” generated a number of emails asking what are the advantages of having a national guild. Others inquired how would it work and others asked about the organizational and strategy aspects of forming a national guild. Because of the interest generated, we are going forward with a SURVEY to gather a wider range of opinions. We encourage everyone to participate and have their opinions known. We will then publish the results in the TCP and on the NAPPP website. In the meantime, I think that some discussion of what a national guild can offer practitioners can be useful.
What A National Guild Would Look Like?
A national guild is like a union. Members of the guild pay a monthly or yearly fee and in return have access to specific benefits relating to practice. Like the current structure of labor unions, a psychology guild also would represent practitioners in a collective bargaining arrangement as is typical in labor unions. A professional guild, however, would have a completely different structure and focus, but would be aligned and affiliated with a national union as nurses and pharmacists do now. Following are some of the benefits and goals that a national psychology guild could encompass.
Dealing with Insurers on National Standards for Reimbursement
Presently, practitioners of psychology have no place at the table and zero to little input on how insurers decide on reimbursement, panels, qualifications or utilization of psychological services. A nationalguild would have the clout to develop a quasi-bargaining structure with insurers, facility chains, and hospitals through their national associations on many of the issues important to practice. With the help of allies in the affiliated labor union, the psychology guild would have the clout that we now lack. No state association or the APA can do this. With academics, student, and others in the membership mix, APA is too diverse to focus their attention solely on practitioners. This is and has been our problem, and is the main reason for the decline in practice. Practitioners need a single entity that is focused solely on practice, patients, and our interests. The biggest hurdle we face is acknowledging that we cannot do this alone and that being a professional does not mean we should remain alone and outside the broader labor market. Whether laborer or professional, what we all have in common is that we sell our labor. As such, we have every right to collaborate and negotiate for consistent and fair working conditions.
The American Medical Association Is a Guild
Why are physicians at the top of the practitioner food chain in the healthcare system? The sole reason is that they are structured and function as a national guild. They focus on issues that are common to all physicians without regard to where they practice. They also have policies that protect every one of their specialties. They do this by ensuring that any changes to the system will not benefit one specialty at the expense of another. In other words, they ensure and practice solidarity. They bargain with hospitals, insurers, and governments, yet they do not label themselves a union. They just function as one and it works.
The AMA has obtained license mobility for physicians. Psychologists have little license mobility and have difficulty in trying to get licensed in most states even though we too are required to take and pass a national exam, and meet strict criteria that is almost identical in every state. Physicians, because of the AMA, develop, control, and own practice reimbursement codes and set their relative value. Psychology input is relatively non-existent. Psychiatry owns the DSM and reimbursement rates depend on their input.
The AMA has a strong lobbying presence. Psychology does not. APA has little clout because mental health is seen in state capitols and in Washington as the realm belonging to the ApA. The AMA and its state affiliates can stop and hinder any legislation that they see as negatively affecting their membership despite that fewer than half of physicians belong to the AMA. Presently, if APA had 100% of psychologists as members, still we would be a no-nothing force in Washington. At the state level, being in the APA is of no consequence, and state associations as APA affiliates means little. So, it is clear that the AMA is doing something right, actually many things, that professional psychology is unable or unwilling to do.
A National Guild and State Boards of Psychology
Most state associations have little power with state BOPs. Contrast that with the power and influence that state medical associations have with their state boards. Things have gotten so bad for practitioners of psychology that it appears those entering the field might have to pass a third examination to get licensed (and they do in some states like Texas). Why? Because practice is now being directed by the Association of State and Provincial Psychology Boards, a meta-entity that is literally taking control over the practice of psychology. Check out their website at http://www. asppb.net/ to see just how much they control practice. Clearly, this is the group that practitioners need to gain influence and we can do this with a national guild. APA and state associations have failed to gain any traction.
Help from Union Allies
Although unions are in decline with lower skilled workers, the one clout that remains is the aid, resources, and help that unions provide to each other. Professionals, on the other hand, have greatly gained from establishing a national guild and affiliating with a national union. Nurses, nurse practitioners and pharmacists, for example, are doing very well since forming their guilds. Nurses, for example, are becoming as powerful and influential as physicians. In some cases even more so. In fact, healthcare workers at all levels have been gaining through their affiliation with national unions. In many cases, these guilds are negotiating not with individual hospitals and facilities, but with the owners of the hospital and facility chains. As local hospitals and facilities increasingly are being consumed by larger chains, these workers are able to negotiate both wages and working conditions with a single entity, irrespective of geography. Clearly, the situation for psychology practitioners is different. Many of us are in solo practice. The benefit for us is with affiiation with other guilds that are rule bound to assist us. The ability to negotiate with insurers, where the market also is restructuring into control by just a few large companies, is analogous to negotiating with large hospital chains. Reimbursement, for example, should be based upon skill level, degree, time and service. Sixty dollars a session is not a living wage for professionals at our level. These insurers need to know that we are not alone.
One of the most significant benefits of having a national psychology guild is having the resources to get a remedy for the unfair and tortuous conduct of the entities that affect our practice. These entities include state BOPs, insurers, facilities, and even other associations such as state medical associations, boards, and others who engage in restraint of trade against psychologists. State associations lack both the resources and motivation to do this. The APA prefers defending and settling lawsuits as opposed to bringing them. A national guild would have the resources, help, motivation, and focus to use the courts to remedy the harms done to psychologists and our patients. The use of legal strategies is perhaps the one way that psychology practitioners can achieve parity with physicians.
Presently, it is difficult and expensive for practitioners to obtain reasonable health insurance. A national guild can provide this insurance on its own or through affiliation with a larger union.
Access to a Wider Patient Population
A national psychology guild that is affiliated with a large union will give members access to a new and wider population of patients. For example, affiliated unions can include in their healthcare packages that our national guild members be included in panels. Reimbursement rates and other important issues can be included in these packages.
There are many more benefits that psychologists and psychology would achieve through a strong national guild. Is a national guild a panacea for all of our problems? Of course it isn’t. There is no panacea. There may also be some disadvantages. Whatever they may be, however, we need to disrupt the way we do business. APA and state associations are unable to cope in a 21st century healthcare environment. They are an outgrowth of academia. Their diversity of members means that they are unable to successfully focus on practice. Look at the APA motto: “APA: SERVING MEMBERS, STUDENTS, TEACHERS, POLICYMAKERS, AND THE PUBLIC.” Despite the average annual budget that exceeds $115 million dollars, without counting real estate holdings and reserves, very little has been focused on issues relevant to practitioners. Subsequently, practice has declined for over two decades. Yes, APA has a practice organization but it has been even more of a problem for practitioners. The PO is controlled by academics or former practitioners who prefer organizational bureaucracy to practice. There is no expectation of help coming from there. Practitioners may be diverse in many ways, but we are singular in our needs, which revolve around maintaining and sustaining a practice and a profession that increasingly seen as irrelevant. We cannot continue to do this with the present structures that restrict psychology. A national guild would go a long way in remedying our situation by bringing a positive disruption to psychological practice.
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