Legislation passed by the 92nd Congress in October 1972, and implemented at the beginning of this calendar year, has brought forth a new organizational entity which is likely to be with the practice of medicine and consequently of psychiatry and psychoanalysis for years to come. The PSRO, Professional Standards Review Organization, consisting of physicians from a given geographical area, is currently charged with the specific task of monitoring the medical care rendered to Medicare and Medicaid patient on in-hospital treatment status. Seen by many as the wave of the future, the PSRO may herald the eventual establishment of peer review of all areas of medical practice, out-patient as well as in-patient. This is especially likely in view of the growing trend toward third party coverage of medical care and the expected eventuality of National Health Insurance.
The PSRO must answer questions which are likely to have a significant impact upon the practice of psychoanalysis. These are:
Is the procedure medically necessary?
Is the treatment up to recognized standards for the diagnostic entity in question?
Are the services delivered by the most economical institution or format of care?
Current legislation provides for application procedures by various groups of physicians to HEW to become the designated Peer Review group in the 203 geographical review areas recently established throughout the U.S. and its territories. Criteria for defining a PSRO area include size (300-2500 physicians), existing medical service areas,
diversity of specialists included, and existing boundaries of local review organizations and health planning areas. State, County, and specialty medical societies may not themselves function as PSRO's, but they may establish a “Foundation for Medical Care” (FMC) or a PSRO corporation. There are a few FMC's already functioning on a private contractual arrangement with certain insurance groups and government programs. New FMC's are currently recruiting physician members throughout the country.
Sanctions now available to PSRO's (in their current limited jurisdiction) include refusal to reimburse a physician for treatment judged improper or potentially dangerous to in-hospital Medicaid and Medicare patients, or a fine up to a maximum of $5,000.00.
In the wake of these developments, our Council formed an Ad Hoc Committee on Peer Review and PSRO Formations, chaired by Dr. Donald C. Burnham. The Committee has initiated a study of the impact of these new self-evaluative procedures upon psychoanalysis as a treatment modality. In the Committee's report to the Executive Council at the Mid-Winter Meeting in December, 1973, Dr. Burnham outlined some of the specific pressures which may be felt in the practice of psychoanalysis in the near future. Psychoanalysts will be pressed to provide evidence that the frequency and duration of psychoanalytic treatment produces results which are the equal to, or better than, those produced by other (probably briefer and more economical) treatment methods for given clinical syndromes. Dr. Burnham pointed out that medical planners hold in high esteem such statistical evaluations as the cost/benefit ratios which would lead to specific pressures to abbreviate treatment. The AMA and APA are drawing up models to be used as guidelines for treatment of specific diagnostic entities, and these models will probably be used, with regional variations, by local PSRO's. A major concern of both the AMA and APA is that PSRO control remain in the hands of medical groups rather than outside non-medical agencies. A parallel concern is appropriate for the APsaA. Each specialty group must become active in the design of peer review systems, if standards of practice are to be fairly outlined and applied to each discipline.
The Committee made several specific recommendations to the Board and to members in general:
First, each constituent psychoanalytic society should initiate a committee to plan positions and means of making our field felt in peer review practices. Stronger links to psychiatric and medical societies are necessary, not only by organizations, but through personal participation in these related bodies by individual analysts and candidates in training.
Second, “prompt and active membership” in the newly established Foundations for Medical Care is advised as the only way analysts will be assured that our particular therapy will be judged by bona fide peers.
Third, Dr. Burness Moore has charged the Ad Hoc Committee to begin work on defining criteria for psychoanalytic treatment of those disorders for which analysis is indicated. These criteria must specify diagnosis, prognosis, progress indicators and estimates of the duration of treatment.
Dr. Burnham emphasized the need for collaboration and help from analysts throughout the country, and invites communications from the membership in this regard. He concludes that we must gather evidence which will be convincing in the face of great pressure from physicians who may think only in terms of masses of patients and cost/benefit statistics.
Frederick M. Lane, M.D.