The supercharged atmosphere of change pervades the mental health care system. Long battered by coverage cutbacks and the excesses of managed care, the mentally ill and those who treat them now have hopes for real improvement, fueled by the interest of Hillary Rodham Clinton, Tipper Gore, and Rosalyn Carter.
Yet there are pitfalls here that could make things even more difficult for psychoanalysts and their patients. The drive toward competitive managed systems using closed provider networks could prove highly adverse to long-term intensive psychiatric care of any kind. The trend within influential segments of the American Psychiatric Association, in concert with the powerful National Alliance for the Mentally Ill, to emphasize selective coverage for narrowly defined “severe” mental illness threatens all those, especially children, whose illness lies in the middle range of severity.
How is The American responding to this crisis in health care? At its December 17, 1992, meeting the Executive Council endorsed a set of objectives, developed by the Committee on Government Relations and Insurance, pertaining to work both with legislated health insurance reform (state and national) and with private third-party payment systems. The objectives, which apply equally to current benefit packages and future benefits under a nationally mandated managed competition or single-payer system, pledge The American to seek (1) full equality of health insurance benefits for mental illness with all other diseases; (2) the best possible outpatient coverage for psychiatric disorders, if limited benefits packages are being designed for all medical illnesses; (3) the inclusion of psychoanalysis as a covered service under whatever psychiatric benefits are available; (4) a change of attitude toward psychoanalysis and intensive or long-term treatments in general (employers, mental health managed care systems, government officials, and health care planners need help in looking beyond the appearance of short-term cost savings to the long-term consequences of failing to provide high-quality, definitive treatment); (5) prevention of the exclusion of psychoanalysts from provider panels simply because they know that some patients need open-ended, long-term, confidential, and secure treatment environments; (6) institution of appropriate, noninvasive utilization review mechanisms for psychoanalysis and psychodynamic psychotherapy by managed care firms, with special attention to CHAMPUS and Medicare; and (7) heightened awareness on the part of managed firms and the planners of health care systems of their responsibility for the future, not only of psychotherapy and psychoanalysis, but also of psychiatry and psychology as professions (short-sighted economic measures are jeopardizing the supply of competent professionals).
The Executive Council voted to authorize up to $250,000 to hire staff with expertise in government relations, public relations, economic affairs, and practice development to support the work of committees addressing these concerns.
The Government Relations and Insurance Network has been gearing up to meet the challenge. At its meeting last December 17, a study conducted in Ontario by Norman Doidge, M.D., was reported which demonstrated that psychoanalytic patients present with far more serious psychopathology than health planners commonly assume. Doidge's findings, coupled with a persuasive review of available efficacy data, helped to maintain the status of psychoanalysis as an insured service under the Ontario universal health coverage. A similar study of psychoanalysis conducted by members of The American is in the planning stages.
After the meeting on December 17, many Network members stayed to attend a Discussion Group on communication with employer benefits managers. Shelly Fischel, Senior Vice President of Human Resources and Administration and Labor Counsel of the HBO division of Time-Warner, led a lively discussion provoked by her experiences, as an employer sympathetic to providing coverage for psychoanalysis, in coping with a world of rising health care costs and managed care.
Much effort has gone into communicating the concerns of psychoanalysts to the Clinton Administration's health care task forces. Yet much of the decision making will take place in Congress. Members of The American and others concerned about the future of psychoanalysis are urged by the Network to influence the process by communicating with their senators and representatives.
Those concerned with mental illness would achieve the greatest effect if they spoke with one voice. The American therefore works closely on many levels with the American Psychiatric Association. The American endorses the position of the Mental Health Liaison Group, a coalition of major organizations that seeks full parity of coverage for mental illness in health care reform. In addition, The American is developing a consortium with other psychoanalytic organizations. Several members of The American are trustees of the American Association of Private Practice Psychiatrists.
Well-directed action can bring results for psychoanalysis. An example is the considerable improvement in 1993 Medicare fee schedule rates for Medical Psychoanalysis (CPT 90844). The work relative value unit of 90845 was
Norman A. Clemens chairs The American's Committee on Government Relations and Insurance.
restored to its position 3.4% higher than Individual Medical Psychotherapy (90845), about what was originally determined in the Harvard Resource-Based Relative Value Scale, on which the Medicare fee schedule was based. Lower practice overhead and malpractice insurance costs brought 90845 relative fees to a net of 95.4% of 90844. The improvement for psychoanalysis was greater than for any other psychiatric service. The American Psychiatric Association and the American Medical Association were of great help in achieving this result.
Network News: Special Transition Edition, a recent publication carrying a wealth of information on national health care reform issues and managed care, has been widely distributed. Additional copies are available from the Central Office or from affiliate societies and institutes. Those wishing to be on the Government Relations and Insurance Network mailing list may contact the Central Office.