Since managed care became the therapy world's version of King Kong, holding clinicians like a mob of little Fay Wrays in its giant, hairy fist, most therapists have been forced to retool their practices, rethink their profession and their own professional identities and reconsider the future of the entire field. Depending on where therapists find themselves in the churning mix master of private practice these days, they have sometimes startlingly different philosophical and practical takes on what clinicians can and can't do, what they should and should not be doing to salvage the future of the profession.
Some therapy consultants and trainers argue that America is a vast, untapped private-pay market for clinicians who eliminate managed care from their practices and become self-defining, self-marketing entrepreneurs. What keeps therapists from reaping the bounty of self-pay markets, suggest the entrepreneurs, is a kind of massive insecurity complex and a lack of marketing savvy. To them, the main problem for many therapists is that they seem to believe they really don't have what it takes to put themselves out in the public arena without the ersatz security blanket of third-party referrals and reimbursements--no matter how few the former, how meager the latter. But for the born-again entrepreneurs, the opportunity to break away from managed care can be a new birth in freedom, allowing them to be true to themselves and make money in the process.
Other therapists doubt that enough Americans are willing or able to pay for enough purely elective fee-for-service therapy to sustain the country's large population of private practitioners. John Riolo, a New England therapist who sees mostly managed care clients, puts it this way: "I don't see the self-pay market as a solution for therapists en masse. There are too many therapists around--some areas are saturated--and the average American is still not ready to pay for any therapy that doesn't deal with an identifiable mental health crisis."
In recent years, however, a third and growing group of practitioners and observers has emerged that doubts that either the self-pay market or managed care will resolve the mental health crisis for therapists or clients. What is more, they believe that the increasing disgust and alienation therapists feel about managed care may actually lead to the decisive step that transforms the mental health marketplace--therapists' taking collective action and finally fighting managed care by forming unions of mental health professionals. "Right now, therapists are disorganized, discouraged and depressed, but if they organize themselves, start thinking in terms of teamwork and consolidate their power, they have a chance at success," says Jim Wrich, president of an accounting firm specializing in the economics of mental health care.
Right now, private practitioners cannot form unions without violating antitrust laws; as "independent contractors," they are considered legally equivalent to giant managed care companies. "It's humorous in a sad sort of way," says Riolo, "that every individual practitioner working with managed care is 'negotiating' his or her contract, as if on an equal basis with the CEO of a billion dollar company." Indeed, clinicians supporting the idea of a union point out that private practitioners working for managed care are "independent contractors" in name only, often without the rights to establish their own fees, choose their own clients, make their own clinical decisions or even set their own schedules. Nor can they legally discuss these issues or take collective action to redress them.
But there are efforts afoot both to change the laws and begin organizing health care professionals, including therapists, into a viable collective entity with the clout to redress the power imbalance between individual health care providers and managed care behemoths. Last June, the U.S. House of Representatives passed H. …