The first part of this study, printed in the last issue of the Newsletter, considered some problems in the practice of psychoanalysis arising from the proliferation of “third party” systems of paying for mental health care. Part 2 considers efforts by individual analysts and committees in which they have been working to educate third parties about the nature of psychoanalysis, the appropriateness of using psychoanalysis as the treatment of choice in selected cases, and the feasibility of including long-term psychotherapy and analysis in all evolving private and public plans for payment for psychiatric treatment.
Psychoanalytic peer review and utilization committees are charged with establishing standards for the selection and treatment of patients by psychoanalysis. With counterpart psychiatric and medical society peer review committees, they serve a liaison function in relation to third party payers.
One such committee has been functioning in the Washington, D.C. metropolitan area since early 1972. Chaired by Dr. Robert Gillman, it was originally established as a joint committee of the Washington and Baltimore-District of Columbia Societies. In addition to providing psychoanalytic consultation on cases referred for peer review by insurers, this committee, working with representatives of the A.Psa.A., succeeded in halting distribution of an A.P.A. pamphlet on health insurance coverage for psychiatric care which contained misleading and discriminatory statements about psychoanalytic treatment. Since the Washington Psychiatric Society (W.P.S.) had simultaneously established a peer review
committee, the joint psychoanalytic committee was eventually discontinued in the interests of solidarity and consistency of functioning in relation to third parties. Several of its senior members became a working psychoanalytic subcommittee within the W.P.S. peer review committee. The latter has maintained close liaison with the District of Columbia Medical Society (D.C.M.S.) peer review and utilization committee. When the insurer refers a case for peer review to the D.C.M.S. committee, it is forwarded to the W.P.S. committee which assigns the case to its psychoanalytic subcommittee. After completing its study, the subcommittee presents its recommendations to the full W.P.S. peer review committee, which, after further review and discussion, forwards the findings to the D.C.M.S. committee. The W.P.S. committee's recommendations are then transmitted to the concerned parties (the insurer and the treating analyst).
The necessity of protecting confidentiality has been partly met in the W.P.S. peer review committee by assuring the anonymity of both the treating analyst and his patient to the reviewing analytic subcommittee. Only the chairman of the W.P.S. committee can identify the treating analyst. The patient is identified by a number assigned by the insurer. Insurance company executives have stated that peer review records are maintained separately from the subscriber's general file, and destroyed following adjudication of the case. Although this procedure has some loopholes, study of the problem within the committee continues, and additional steps to preserve confidentiality are being considered.
Since its inception, the W.P.S. peer review committee has reviewed over forty claims for outpatient psychiatric treatment questioned by the insurer. Some of these were for psychoanalysis. Although no formal statistical study of the cases, including the final adjudication reached by third party payers, is currently available, the committee has the impression that its recommendations have been accepted by insurers in the great majority of cases. The insurers have raised questions in these cases concerning usual and customary charges for services, frequency and duration of treatment, charges for missed appointments, correlation of diagnosis with psychoanalysis as the prescribed treatment, and coverage of treatment when it appears to serve an “educational” purpose for the subscriber.
To provide guidelines for response to these and other questions, a joint committee of the Washington and Baltimore-D.C. Societies has been established to formulate a model set of peer review standards for psychoanalysis. This Committee, chaired by Drs. Robert Gillman, is composed of eight analysts in private practice, six of whom are training and supervising analysts in their respective institutes. The group has formulated a set of standards which has been endorsed by its sponsoring societies.
The following excerpts from the report may provide a perspective of this committee's work for the guidance of similar committees in other Affiliate Societies. From the “Introduction” of the report:
“Psychoanalysis is a long term, active method of treatment indicated for the correction of specific functional impairments resulting from deep-seated psychological conflict which has its origin in early childhood….Mental illness is defined not only by obvious signs and symptoms but may take the form of private suffering….A person may seem to carry normal responsibilities and earn substantial income, yet have a disorder which is causing himself, his family… enormous suffering, and distorting the normal development of his children. Psychoanalysis is the treatment of choice for certain of these conditions. The primary purpose (of psychoanalysis) is the discovery (and correction) of the (underlying) causes of the patient's illness— The treatment requires the continuity of several sessions each week during which application of specialized techniques facilitates the re-experiencing of relationships and affects of early life…. (Its duration) depends on how long it takes to resolve the ways in which the patient's past is still inappropriately active in his current perceptions and behavior. The decision about which form of treatment is ideal, indicated, possible, or contraindicated depends upon the needs of the patient, as determined by the specialist applying established criteria in his field.”
The report includes a section on Criteria for Selection of Patients by Diagnosis: Suitable for Psychoanalysis— (all diagnoses from APA's Diagnostic and Statistical Manual [DSM II])—All neuroses; Personality disorders (most cases of obsessive-compulsive, hysterical, and selected cases of other types such as narcissistic and borderline personality); Sexual deviations (where such are judged to be symptomatic of neurosis or certain personality disorders); Psychophysiological disorders (in selected cases); in selected cases of psychosis not attributed to organic brain syndromes, application of modified psychoanalytic techniques at certain times in the course of treatment is justifiable.
A section on Duration and Frequency of Treatment states that 33% of analyses are completed in four or fewer years; 50% of analyses are completed in five to six years; and 17% of analyses completed in more than six years. 50% of patients are seen four times weekly; 25% are seen five times weekly; 25% of patients seen less than four times weekly. (Statistics are taken from a 1968 Pilot Survey of active members of the A.Psa.A.).
From General Considerations for Peer Review: “Peer Review (is)… indicated after three years through a brief summary of the case (by the treating analyst)… to the peer review committee (which will) determine the continuing applicability of psychoanalytic treatment. (If doubt arises) …further information from the treating analyst may be necessary … (and) at five to six years and at appropriate intervals thereafter….”
From Questions for Peer Review: “The psychoanalytic training and professional affiliations of the treating analyst; (an estimate of)… the expected duration of treatment; a brief formulation of the criteria for selection of psychoanalysis as the treatment method…; the analyst will …demonstrate that (analysis) has been and continues to be medically indicated…”
Outcome Studies evaluating the effectiveness of psychoanalysis for differing patient populations in specific settings are also of educational value for third party payers. Reports of such studies have begun to appear with greater frequency in the scientific literature. However, follow-up studies have been subject to criticism in terms of the techniques employed in the selection and collection of data, methodological difficulties in establishing valid “control” groups, the replicability of findings, and the
interpretation of results. By now many institute psychoanalytic clinics have accumulated years of experience and a wealth of clinical data on the screening and referral of patients for psychoanalytic treatment. Outcome research originating in such settings promises to provide an unusually rich opportunity for a nationwide effort to compare and collate results of such research and to formulate conclusions which will permit a “position” on this question to be presented to third party payers by appropriate committees of the American.
What is the current outlook for inclusion of coverage for intensive long term outpatient psychotherapies under future National Health Insurance? The position of the A.Psa.A. taken in December, 1972, endorses the principles approved by the Executive Committee of the Board of Trustees of the A.P.A. formulated in a position statement entitled: National Health Insurance—A Statement of Principles. In brief, our Association affirmed that all persons should have access to medically necessary services; that NHI should provide for outpatient psychotherapy, including psychoanalysis, with benefits on an equal coverage basis. We supported the principle of peer review, and asserted the fiscal feasibility of services. A complete survey of the issues bearing on NHI may be found in the A.P.A.'s 1974 Discussion Guide on National Health Insurance.
Until this year, prospects for inclusion of more than minimal coverage of outpatient psychotherapy in pending NHI bills; seemed slim indeed. However, thanks largely to the diligent and tireless efforts of our Association's Committee on Insurance Programs, chaired by Dr. Robert W. Gibson, the A.P.A.'s Commission on Standards of Practice and Third Party Payers (chaired by Dr. Gibson), the W.P.S. Federal Affairs Representative (Mr. Stanley Bregman), and the individual efforts of psychoanalysts and psychiatrists in personal contacts with concerned Congressmen, the tide may be turning. Two bills are of particular significance. HR. 1 submitted by Congressmen Ullman, Chairman of the House Ways and Means Committee, provides for coverage of psychoanalysis under a catastrophic expense benefit “in those cases in which it is utilized for the treatment of severe functional disability for which no feasible alternative modes of therapy exist.”
The second bill, S.l, was introduced by Senators Kennedy and Javits in January, 1975. Although the bill as originally written would limit outpatient psychiatric treatment by private practitioners to twenty consultations per benefit period, a proposed amendment to the bill would add coverage for continuing outpatient services on a sliding scale ranging from 95% of reasonable costs for such services to individuals whose taxable income is less than $5,000;/year, to 75% of costs to individuals whose taxable income is more than $20,000/year, not to exceed 25 % of such income. Although this amendment would seem to provide for coverage of the long term psychotherapies, its inclusion in the final form of the bill is by no means guaranteed. When public hearings are held on any NHI bill, the contributions of informed and concerned analysts, both as individuals and as members of our committees, may be vital in determining the content of legislation eventually passed.
In this connection, the action taken at the recent Beverly Hills meeting by the Executive Council of the A.Psa.A. in approving the formation of a Commission on Judicial and Legislative Review, and in agreeing to submit for referendum to the membership the question of whether or not to establish a position in the Central Office of a Communications and Liaison Coordinator, reflect the concern and far-sightedness of our leadership.