Dr. Gray is Co-Chairman of the Committee on Peer Review.
Peer review is a collegial process within medicine, whose aim is to maintain and ultimately to improve the standards of medical practice. We learned its principles early in our medical education, often through participation in a “deaths and complications” conference on a clinical teaching service. The opportunity to evaluate one's clinical performance in the context of a secure personal relationship with one's peers and mentors is an essential aspect of this activity. For this reason, peer review has traditionally been a private and confidential undertaking of physicians. As such, it has been protected from intrusion by individuals or agencies outside of medicine under the laws of many states and of the District of Columbia.
Within the psychoanalytic community, we regularly conduct supervision and clinical case conferences according to the principles of peer review. In addition, we recognize two special peer review situations. The certification examination of the Board on Professional Standards requires reports of actual cases. Our institutes may require ongoing supervision of the work of a colleague around the time of achieving training analyst status. These reviews also are traditionally shielded from external scrutiny; they are not thought to be associated with any adverse impact on the treatments under review.
Peer review has in our time also been used in pursuit of a very different goal, to contain the cost of medical care by limiting its delivery. This originated as part of the implementation of the early Blue Shield service benefit plans. Under these contracts, patients paid a fixed fee in exchange for which the providers, participating members of a medical society, promised to give them all necessary medical care. The economic success of many of the early Blue Shield programs depended in considerable part on the help of the utilization and peer review committees of their sponsoring medical societies to assure that only necessary services were provided, and to limit treatments which could be deemed excessive or excessively expensive.
These peer review committees have also been available to commercial insurance carriers and indemnity Blue Shield programs who may need help in determining whether the services for which claims were submitted are reasonable and justifiable. More recently, in response to a perceived fiscal crisis some specialty societies began to market so-called peer review services to third-party payers, insurance companies, and CHAMPUS, with the implied promise that these reviews would lower the utilization, and thus the cost, of health care.
A professional process which had evolved out of a desire to assure and
enhance the quality of medical care was gradually transformed into an economic tool which third parties may use to justify limiting the kind or amount of services which they would be expected to finance under a contract which is expected to provide all medically necessary treatment. This is no longer true peer review, but a significantly different process, cost containment.
Much of the difficulty which has been attributed to the peer review of psychoanalytic treatment has been the consequence of mistaking this new “peer review” for true peer review. An outstanding example of the deleterious impact of this sort of confusion on clinical psychoanalysis was presented by Rudominer in a case report published in the Journal of the American Psychoanalytic Association in 1984.
There are also some reports of cases which were subjected to extensive claims review by or at the behest of insurance carriers or other third parties that are reported to have run into serious difficulty and which may actually have become unanalysable after this intervention. The cause seems to lie in the open reporting process which is inherent in claims review. This creates not only transference reactions, which may prove analysable, but also a basic and unanalysable defect in the therapeutic alliance. The published case material certainly supports this interpretation.
It follows, then, that the guidelines which the American Psychoanalytic Association adopted for reporting cases for peer review (published in the American Psychiatric Association's Manual of Psychiatric Peer Review) cannot be applied to the creation of reports for claims review or for CHAMPUS charts without posing a grave risk to the therapeutic alliance, and hence to the survival of the psychoanalysis.
Because the report must circulate outside the traditional circle of confidentiality, basic trust is impaired even when privacy is maintained. A conscientious psychoanalyst cannot, therefore, submit a full report drafted according to one of these outlines to even the best insurance carrier or to its most conscientious and trustworthy agents.
We are not, however, entirely precluded from helping our patients to gain access to external funding for their treatment. It has been established in three controlled studies that analyses funded by medical insurance in which the contract remains exclusively between patient and analyst do seem to work out about as well as those which are funded directly. I have published some of my own findings in an article in the Bulletin of the Philadelphia Association for Psychoanalysis in 1973. These findings apply, however, only to cases in which the analysts' reports are limited to fairly straightforward diagnostic and administrative information.
It is essential for a psychoanalyst to know the distinctions between peer review, claims review, and cost containment review, and to be certain that the report which is created is appropriate to that process. In practice, you must
verify the actual nature of the review, and determine that the information requested is appropriate to that level of review. Then, obtain assurance that both privacy and confidentiality will be protected.
If there is any ambiguity, obtain legal advice. At this point, armed with facts and assurances, you may discuss and plan a response with the patient; this is also the time to clarify the patient's attitude to the review process. Then, having obtained the patient's valid permission, one may begin writing a report. Do not present material which the patient is unwilling to have communicated outside of the psychoanalytic situation; and avoid statements which might prove traumatic to a patient who reads the report. The patient can often provide material for the report, to illustrate the nature of the complaint or the progress which has been made. In my experience, this substantially mitigates the dangers noted earlier and allows the patient to participate responsibly in the review.
Since the material in these reports can readily be used by the patient as a premature or inexact interpretation, exclude ideas which are not yet in the patient's conscious awareness or which have not been adequately metabolized in the psychoanalytic process. In addition, reports for claims review are best limited to the sorts of information which could also have been gathered through non-analytic methods. These considerations require us to eliminate the traditional “dynamic formulations” from such reports; and they present a challenge to describe our work without speculation or technical jargon.
The Committee on Peer Review of the American Psychoanalytic Association is now developing guidelines for reporting clinical information to the medical director of an insurance company. The new protocols for initial and follow up reports will also be suitable for creating CHAMPUS reports and for use in the APA Peer Review Project and similar claims review programs. These guidelines will suggest methods by which a psychoanalyst may provide third party payers information which they require to make their decisions regarding claims. We hope to make it possible for claims review to be conducted in a fashion which protects the third party, the patient and the psychoanalysis.