While the Medical Director of the APA supports nondiscriminatory insurance coverage for outpatient intensive psychotherapy and psychoanalysis, informed sources contend that skepticism about the wisdom of such support abounds among APA staff and the APA's network of decision makers. They are reported as fearing that a vigorous advocacy of this issue would not be supported by a sufficient majority of the APA membership. The apprehension most frequently expressed is that members will fear that determined support for increased outpatient psychotherapy coverage would jeopardize other coverage, i.e. inpatient treatment, which they value more.
Yet little apparent effort, say these sources, has been made to educate and inform the APA membership. They cite as evidence that very few articles have appeared in the APA News issues (an appropriate vehicle for such efforts), setting forth the medical and economic arguments in favor of such psychotherapy coverage.
Critics charge that the APA is consequently moving too slowly and cautiously in any attempts to achieve this goal. There has been an absence of national media coverage to gain public support, such efforts allegedly being spurned as “propaganda”.
Those who believe the APA is dragging its feet on this issue link this diffidence to a relative under-representation of practicing psychotherapists, and psychoanalysts in the APA administration. Psychiatrists who do most of the volunteer work, upon which the APA is dependent, tend to be salaried by institutions and not burdened by heavy psychotherapy or analytic committments.
If such a “built-in” bias exists, it may at least partially account for the recently reported behavior of the Competition/Legislation Work Group of the APA. Consisting of 15 members, one of whom is a practicing psychoanalyst, this group will complete a two year Psychiatric Benefits Marketing Study in December 1983 (at a cost of about $400,000), at which time it is to make definite recommendations to the APA regarding what insurance coverage for psychotherapy should be advocated. Preliminary reports from them suggest the possibility that they will make recommendations placing the APA in opposition to liberal coverage for intensive outpatient psychotherapy.
As a possible portent of final policy recommendations, the minutes of a meeting of this group several months ago noted that “the majority of District branches currently involved in marketing/education programs seem to be primarily focused on protecting long-term outpatient therapy.” The statement is made, “The project… must avoid becoming a vehicle for special interests within the Association potentially seeking to further their own causes …. A concern was expressed that trade-offs might occur between outpatient and inpatient, if too much emphasis was directed toward the outpatient practitioner.”
The summary stated, “It was resolved that the emphasis for the Project should be on the treating of severely mentally ill, regardless of setting, e.g., inpatient or outpatient …. It was decided that a well-balanced approach is in order.”
Moreover, in a critique of District Branches' marketing efforts to industry, the group expressed “serious concerns about the quality and appropriateness of the materials prepared for the District Branches.”
The critique goes on to assert, “The question still remains to be addressed of whether the major psychiatric modality will be useful in decreasing psychiatric symptomatology in the workplace and whether the best modality of treatment is long-term intensive psychotherapy …. There is good data to'show short-term cognitive treatment, behavior therapy, group therapy and counselling are as effective or even more so than extensive psychotherapy.”
Curiously, this report pooh-poohs the statement in the District Branches' presentation that “an alarming trend [exists] on the part of national insurance companies to restrict psychiatric benefits.” According to this group, “there is very little data to support the ‘alarming trend’ referred to.”
Such statements from the group charged with “promoting and encouraging health insurance coverage” dismays those psychoanalysts and dynamically oriented psychiatrists who had hoped the group and thus the APA would be an ally in their efforts to restore the discriminatory insurance cutbacks. With such friends …
Another example cited by concerned observers is the fate of two recent requests for funds from the APA by two District Branches. One District Branch requested funds for legal help to fight a local ban on ECT and was immediately given financial support. The other District Branch, requesting funds to combat FEHBP reduction in psychotherapy coverage through education of legislators and the public, was turned down.
It is true that the APA Legislative Affairs Department has worked with other groups to reverse the Federal Employees Health Benefits Program cutbacks, including the sponsorship of the Oakar Bill. However, according to well-informed sources within the APA, it has not received the priority it deserves, because the APA administration is not convinced that the national membership is sufficiently exercised about it. Were the APA leadership convinced that its membership urgently cared, say these sources, APA activity and focus on this issue would dramatically increase.
Members are again advised to become active in their APA District Branches and to make their views known to the Medical Director, Dr. Melvin Sabshin, urging more vigorous efforts by the APA to combat discriminatory insurance coverage. It is also most important to write or telegram your Representatives and Senators in support of the Oakar Bill (H.R. 656).