As the general public becomes increasingly dependent on health insurance to finance medical care, the structuring of insurance benefits for psychiatric care becomes, in turn, a major factor in determining for most the choice of psychiatric treatments.
Psychoanalysis is increasingly subject to question as a most expensive treatment for only a few individuals, whose illness may not be so obvious to others and whose treatment thus seems purely elective. When the demand for treatment exceeded the available supply, analysts could afford to dismiss such questioning as “resistance”. However, as alternative treatments multiply and people increasingly depend on health insurance to help finance treatment, analysts must re-evaluate their reserve about more direct public education and political activity.
The terms for such undertakings — “marketing” or “public relations” or “consumer education” — make many of us uncomfortable. They seem to imply gimmicks and distortions — anything to sell, regardless of the truth. However, the effective use of such approaches by other mental health professionals and by dentists has been a factor in displacing health insurance coverage for psychiatric illness. Finally, organized psychiatry has begun to respond.
The Virginia Psychoanalytic Society developed the first such program, when in 1979 they hired a consultant to help them go to the decision-makers (the buyers of health insurance) to stave off a threat of drastic Blue Cross cutbacks in the state. With the help of materials focusing on the potential costs of poor psychiatric coverage, the analysts visited about 100 employers in the state. Alerted to the value of coverage for psychiatric treatment, so many employers protested the cuts and proposed the alternative of peer review that the coverage (which gave very significant help toward analysis) was maintained.
The remarkable success of this effort has stimulated similar undertakings by psychiatric societies in Ohio, Washington, D.C., North Carolina, California, Michigan, and Houston, Texas, while the State Society in Virginia has taken over what the Analytic Society there began. Now the American Psychiatric Association has designated $134,250 for the first year of a two-year Psychiatric Benefits Marketing Project (PBMP) to gather information, develop and coordinate strategy, take action on a national level, and evaluate results in the effort to increase acceptance of insurance coverage for psychiatric disorders.
The APA Competition-Legislation Work Group which launched the PBMP has cogently analyzed the problems. Currently, most health insurance provides less coverage for mental illness than for other conditions, especially for nonhospitalized patients. Though 92% of plans in a 1981 survey had coverage for outpatient psychiatric care, most had very significant and discriminatory “inside” limitations for psychiatric care.
The Work Group also summarized the typical attempts to justify limited or no mental health coverage. Insurers cite disagreements on diagnosis, disagreements on the specific treatment for a specific disorder, and the difficulty in assessing outcome or efficacy. They question whether people are really suffering from an illness or merely seeking self-improvement. They complain about obstacles to adequate review posed by requirements of confidentiality.
Peer review panels have addressed themselves to those issues fairly effectively and have blunted some of these criticisms. Moreover, recent research has affirmed the effectiveness of psychotherapy, though not differentiating clearly between different modalities.
However, although there is allegedly substantial public demand for increased coverage for Optometric and dental services, there is said to be little demand for psychiatric coverage. When the new supposedly popular coverages are added, coverage for mental illness is readily cut to avoid increased premiums. It is this situation that has impelled the various local psychiatric societies and the APA to embark on consumer education and marketing projects.
The targets of these efforts are those who make decisions on health insurance: employers, employees, legislators, unions, government agencies, insurance carriers, and employee benefit plan consultants. The psychiatric societies in Virginia, Ohio, Washington, D.C., and North Carolina, with the help of their public relations and communications consultants, have already undertaken many direct presentations to corporate personnel and insurance benefit administrators, as well as to some legislators, government officials, and union leaders.
The consultants have prepared summaries of information and arguments that they believe will address the concerns of these decision-makers. They cite studies
from industry, itself, that show increased productivity, reduced absenteeism, reduced injuries and accidents, and reduced utilization of other medical services to be correlated with mental health coverage. They point out that inadequate coverage for psychiatric treatment may be costing many times more than the premium increase for better care. The consultants then help pick out the decision-makers, arrange the meetings, and prepare the psychiatrists.
The results, so far, are not systematically tabulated but seem promising from personal reports. In Ohio, for example, 150 employers have been visited in two years. One analyst, who has met with 10 employers, reported three of them have already definitely increased coverage, and two others are considering doing so. The Cleveland Academy of Medicine increased outpatient coverage from a maximum of $1,500 yearly to $5,000 per year; whereas the last $1,000 had been paid out at 50 percent of a $30-per-hour maximum fee, the new plan calls for payment of 80 percent of the usual fee. In North Carolina, the legislature was convinced to give better psychiatric coverage for its employees.
In Washington, D.C., one of the largest employers, after one analyst's visit, was convinced of the need to change employee practices and invited the presenter to speak to a large meeting of company officers. In Virginia several administrators stated that they had intended to allow reduced coverage but now would not.
While improving benefits is a desirable and observable goal, perhaps more important is the long-term goal of clearing up prejudices and misconceptions. For this, the presence of the psychiatrist, himself, is vital. Psychiatrists who have made such visits felt it was most important that they could be experienced as serious physicians, concerned about patient care, who could understand the apprehension of the administrators, counter negative impressions from particular care reports, and give information on the need for treatment, its rationale, and its overall controllable and reasonable costs.
What should be the role of psychoanalysts and the position of psychoanalytic organizations in this activity? Many of the leaders in the current efforts are analysts, and some societies have made specific contributions. However, some would point out that psychoanalysis is so infrequently and scantily covered by insurance that such efforts are not worth the diversion of resources and energy. Third-party payment may be seen by some as an unanalyzable parameter or as an unacceptably damaging breach of confidentiality.
Insurance, nevertheless, has increasingly become the standard and necessary mode for financing expensive medical care. Furthermore, it even threatens to become an arbiter of what is reasonable care. Given all the other resistances to analysis, exclusion from insured health care could drive away most people for whom analysis could be by far the best treatment for their psychiatric disorder.
The APA and other psychiatric organizations have, so far, endorsed the principle of medical necessity, as determined by peer review, as the appropriate criterion of insurance coverage. However, insurance companies, eager to limit their risks, now tend to view analysis as an expensive procedure involving only a few individuals and one that is, therefore, especially easy to exclude from coverage. To forestall this eventuality, it may be time for psychoanalytic organizations to become actively involved in these public information projects.
L. David Levi, M.D.
Milwaukee
Pritnary Process by Dr. Norman Gottreich