We live in a harsh environment for the practice of medicine. Predictably, what is harsh for medicine will be even worse for people with mental illness, given the anxiety and ancient stigmas that surround these disorders. Third-party payment for psychiatric and psychological treatments has been drastically curtailed. Where it remains in place, it often comes with a draconian utilization review strongly biased toward short-term palliative treatments. Intrusions on confidentiality and on the freedom to set one's own fees further complicate the practice of medicine.
Self-paying patients remain the foundation of psychoanalytic practice, but many cannot afford full-scale psychoanalysis. For some the result is to deny them the only effective treatment for their condition. The American is committed to seeking the restoration of full parity of third-party coverage of psychiatric treatment, including intensive psychotherapy and psychoanalysis.
What is The American doing to deal with the challenge of reversing these trends? In the last four years the Committee on Government Relations and Insurance (CGRI) has engaged in an unprecedented level of activity to address these issues. Although concentrating on economic issues, it is attentive also to concerns about confidentiality and the freedom to practice according to accepted psychoanalytic standards.
The augmenting committee is the Task Force on Research and Information (TFRI), made up of representatives of CGRI, the Committee on Public Information, and the Committee on Scientific Activities. This task force, appointed by the Executive Committee, has the charge of developing informational materials for use in dealing with economic decision makers, and of correlating these with research data on the efficacy and clinical applications of psychoanalysis. Much has been accomplished by a dedicated group of volunteers, yet much remains to be done, not only on the national level but also by affiliate societies and individual members.
All this must go on in addition to the various public information and practice development activities for which other committees are responsible, as well as the time-honored tradition of outreach through education in the larger community. The latter activities are urgently needed to reach self-paying patients as well as those with third-party support; without constant effort, the message that psychoanalysis is alive and well and offers unique advantages will not get out.
Operationally speaking, CGRI and TFRI have three main target areas: government decision makers, private economic decision makers, and professional society decision makers in psychiatry and medicine.
Activities must be directed both to the people who make the laws and those who implement them. As regards the Federal executive branch, The American has recently been very active in protesting the shockingly faulty application of the RBRVS system to the Medicare Fee Schedule, to the great disadvantage of medical psychoanalysis. A campaign conducted with very little time to spare resulted in dozens of letters to HCFA from members and achieved the active support of both the American Psychiatric Association and the AMA. The results will be known this fall.
Information about the conditions under which a patient may request a psychiatrist not to bill Medicare for services rendered will shortly be distributed to the affiliate societies and will be available from local Government Relations and Insurance representatives. (It appears to be illegal to bill any amount in excess of the limiting charge Medicare has established, regardless of whether the patient wishes a claim to be submitted.)
On the legislative side, psychoanalysts must work for equal coverage for psychiatric conditions in whatever system of universal health care might emerge. Suggestions for how to convey the message to Congress have gone out through the Government Relations and Insurance Network to the affiliate societies. Lawmakers should also be encouraged to join the Mental Illness Task Force, the first such caucus representing the mentally ill in Congress.
Laws are now on the books in Texas, Maine, and California, calling for full parity of insurance coverage for specific lists of disorders claimed to be more severe or biological in etiology. Some within organized psychiatry consider this a great victory, a forward step that can be an opening wedge for broader coverage. Others, however, are greatly concerned about the evident pressure to make advocacy of such legislation the national policy of the American Psychiatric Association. The bases of the concern are: (1) that such strategies are untested; (2) that the wedge effect is very unlikely to happen and we will be left with an unsatisfactory division of coverage; (3) that the lists of diagnoses are arbitrary, clinically unrealistic, and unscientific, not to mention discriminatory against children and people with personality disorders; and (4) that the strategy places the burden of humiliating stigma and economic discrimination even more heavily on the patients we treat. The strategy has the potential to be divisive and to leave psychiatrists with a major interest in psychotherapy and psychoanalysis feeling that the national association is no longer concerned about their patients and practices. This situation calls for the membership of The American to communicate urgently with their APA officers and Assembly representatives, as well as with district branch councils, some of whom are considering similar “most favored diagnosis” strategies in their own states.
Guided by distorted or unfounded claims that full coverage of treatment for psychiatric disorders will cause runaway costs in health insurance plans, employers have been persuaded to ratchet down their mental health coverage and institute an aggressive utilization review that clearly depreciates long-term psychotherapies. The American has contracted with a major actuarial firm, the Hay/Huggins Company, to study the cost allegations. The result has been figures based on a large employer data base that demonstrate that excellent coverage of psychiatric treatment is economically feasible, particularly when applied in large-scale plans that cannot be subjected to the pressures of adverse selection. In addition, The American's Committee on Peer Review has shown that responsible utilization review of psychoanalysis can be done without measures disruptive of treatment.
Major threats to confidentiality remain a serious concern, however. The procedure that best avoids these is a second opinion by an analyst, both before an analysis begins and at reasonable intervals during its course, with only the bottom-line assessment by the consultant being forwarded to the insurance companies and their data banks.
How can we get the word out? The task force has developed an array of materials that affiliate societies and individual members can use for communication with employers and benefits managers. These range from an attention-getting introductory brochure to actuarial studies of the cost of good coverage, and from a primer on marketing to a background paper with succinct discussions of key
questions that may arise. All are available from the Central Office. Use of these materials calls for initiative, organization, and careful follow-through by the affiliate societies—not an easy assignment, but one that no local group of analysts can afford to neglect.
On the national level, TFRI has distributed a press release on managed care that has resulted in a number of articles in the employer and employee benefits press. We have responded to negative articles in major newspapers and magazines. A press release will soon present the review of efficacy studies. We are now developing a long-range plan for outreach to economic decision makers in the private sector. CGRI is looking for the opportunity to exert influence directly on the more clinically responsible managed care operations to support psychoanalysis and intensive psychoanalytic psychotherapy for patients who will get the best results with these modalities. However, work with national managed care entities is of limited impact, compared with what can be achieved by direct contact with employers and third-party payers at the local level. In the private sector, the employers ultimately call the shots.
The American is a relatively small organization, with limited financial resources, and it traditionally places a much higher value on scientific and educational activities than on political, economic, and public relations concerns. We do not have an employed staff with specialized training in these areas. Since the changing environment is now affecting the availability and financial viability of trainees in psychoanalysis, interest in outreach activities has fortunately increased greatly. Most members and consultants of the Committee on Government Relations and Insurance have been highly active in either the APA or the AMA (or both) and their state and local affiliates; three are past APA presidents, one is an APA Trustee, and one is now Recorder of the Assembly. The concerns of psychoanalysts are heard when expressed by individuals who have earned the respect of the leadership of these larger and more powerful organizations, and the APA and AMA have been helpful to us and to our patients.
To have a voice, analysts need to be active members of their psychiatric and medical societies. They may get a surprisingly warm welcome from psychiatrists and physicians who are themselves alarmed at the present erosion of support for the doctor-patient relationship. Similar outreach to psychological associations is equally important. The work is not easy, and it distracts us from our cherished work with patients, but satisfaction comes from seeing results that preserve or widen the access of suffering patients to psychoanalysis.
The growing tendency to develop formal guidelines for medically necessary treatment has begun to assert itself in the field of mental health. In keeping with the rest of organized medicine, the American Psychiatric Association (APA) is developing practice guidelines. The first of these, on eating disorders, was recently approved by the Assembly, and another on major depression is nearing completion.
Far beyond their effect on eligibility for monetary payments, these guidelines will have an impact on defining what is common and accepted practice in the treatment of various disorders. This means that they will creep into liability litigation and influence what is taught in residency training programs and tested on examinations. It is vital that psychoanalysis be considered a mainstream standard treatment, either medical or psychological, depending on the discipline of the analyst.
The APA submits the drafts of practice guidelines to organizations like The American for comment and input. For the two guideline sets developed to date, the comment period has been very brief. The eating disorders guidelines were reviewed mostly by selected analysts who had published papers or conducted studies in the field. The major depression guidelines were more systematically critiqued by the American's Committee on Peer Review and this will be the procedure for future guidelines. Members of The American's Committee on Government Relations and Insurance have also contributed to the review process in the Assembly. The American has requested that the APA give more time for outside organizations to develop their input, so that a broader representation of analysts' views can be included in the process.
Although the APA guidelines are based on clinical consensus as well as research data, systematic research clearly has the greatest influence on what is recommended. It is imperative that psychoanalysts begin now to build on the foundation laid by Bachrach, Galatzer-Levy, Skolnikoff, and Waldron in their review of existing efficacy studies (Journal of the American Psychoanalytic Association, 1991). We must do a much better job of defining the conditions for which analysis is the treatment of choice and designing outcome studies that capture the essence of psychoanalytic effectiveness.