At the December meeting of The American in New York, I presented and discussed a proposal developed by the Southern California Psychoanalytic Society and Institute to preserve the economic and clinical viability of the practice of psychoanalysis. We asked that The American revise the current Action Plan (1) to focus primary effort on preserving the private base of psychoanalytic practice; and (2) to advocate that psychoanalysis be excluded from universal managed care insurance coverage. Here I will outline the thought and experience that led us to this proposal.
Cost containment is a fundamental objective of all proposed federal and state insurance systems that aim to provide universal medical coverage. Psychoanalysis is unlikely to be considered for inclusion as a covered procedure in any of these systems without being subject to managed care utilization review. These assumptions are based on knowledge gained from a decade of experience in California, where we have been extensively subjected to fully developed managed care insurance systems, far in advance of the rest of the country.
If allowed to become a covered procedure, psychoanalytic treatment, even when authorized to begin under managed care, will rarely be authorized to continue beyond an arbitrary number of sessions or beyond the stage of symptom relief—in other words, at the point when symptoms drop away in favor of the emergence of transference to the analyst. Further sessions will be authorized only if it can be substantiated that without them the patient would require hospitalization. Cost containment systems will prevent the rarely authorized cases (including control cases and training analyses) from ever reaching completion through a properly conducted termination phase.
Utilization review by managed care does not meet the standard of independent peer review and confidentiality; the reviewer is usually not a professional peer of the analyst, is not independent, and is not free from conflict of interest in serving the full range of mental health care needs and the desires of the patient. Ethical considerations
and informed consent standards therefore require that the analyst share review documents with the patient for revision and consent before they are released for third-party review. Ongoing activity by analyst and analysand to prepare these reports violates the technical standards of analysis, hinders analytic listening by analysts, and restricts the freedom of analysands to explore their inner life. Over time, this process will profoundly erode the standards and quality of psychoanalysis, and will diminish the opportunity to conduct effective analytic treatments and education. In consequence, the scientific validity of psychoanalysis will be increasingly difficult to substantiate and defend in open scientific discourse. Yet the current Action Plan indicates a willingness to accept “noninvasive managed care”—a phrase we find self-contradictory— as a price for insurance coverage for psychoanalysis.
A successful effort by the Action Plan to gain inclusion for psychoanalysis as a covered service under programs aimed to insure all Americans will encumber private psychoanalytic practice outside the insurance system by drastically restricting fees for all patients in analytic treatment, as is now the case only for the Medicare population. This restriction would stifle the development of our profession, prospective applicants to our institutes, if they are to justify their investment in psychoanalytic education, must be able to anticipate the establishment of a viable practice.
Unrestricted private contracting between patients and doctors is not a legally protected freedom in this country. To gain this freedom, extensive effort will be required to include in the health care legislation a provision for unrestricted private contracting. Otherwise, regulations against such contracting (like those for Medicare) will prevail universally.
But, paradoxically, the first priority of the Action Plan is to obtain nondiscriminatory universal insurance coverage for psychoanalysis, a priority inconsistent with the effort to obtain unrestricted private contracting. This priority in fact encumbers the effort, because the constituencies to which the cost containment agencies must answer will not allow psychoanalysis to be exempted from the cost containment methods and fee restrictions applicable to all covered procedures. Thus, attaining “nondiscriminatory coverage” cuts both ways.
Our Society recommends that we correct these problems with the Action Plan before there is any further erosion of the freedom to conduct psychoanalytic treatment. The time to attend to these matters is now, while we can still influence the terms of our relationship with insurance systems. Our plan has been misinterpreted as advocating that we turn away from all participation in health care planning. To the contrary, we feel that it is vital that we remain actively engaged with government and insurance policy makers in order that psychoanalysis can become respectably independent, but also positively complementary to, mental health care delivery systems and government-regulated insurance programs. At stake is the survival of the private practice base of our field, and with it our ability to maintain sufficient autonomy to influence the course of our profession.
In summary, our Society's proposal aims to preserve freedom for psychoanalysis to maintain its fundamental quality and frame, freedom for analysands to obtain a proper and confidential analysis, freedom to maintain quality psychoanalytic educational programs and their attractiveness to qualified students, and freedom to earn a living from psychoanalytic practice. Our proposal aims to preserve the vitality of psychoanalysis as a respected mental health treatment and not allow it to be eroded into a form that would render it scientifically and therapeutically less defensible.
Dr. Cummings's thesis ignores the significant dangers of excluding psychoanalysis from health care reform: denial of access for middle- and low-income patients; inadvertent exclusion of intensive therapy; damage to the public view of psychoanalysis; alienation from other mental health constituencies; loss of flexibility in adapting our approach to the reform proposal as it evolves; alienating members who believe psychoanalysis should be covered; and jeopardizing psychoanalysis if analysts must choose between practicing entirely inside or outside the system.
The assumptions he makes about the future system are simplistic and faulty. Single payer, fee-for-service systems could emerge in the states, if not nationally. Even if Clinton's managed competition prevails, organized care systems are metamorphosing rapidly, and fee-for-service options would not be an organized, coercive system. Other reform proposals would give us an even more heterogeneous system.
Robert R. Cummings, M.D., is a training and supervising analyst at the Southern California Psychoanalytic Institute and is liaison representative of the Southern California Psychoanalytic Society to The American's Joint Committee on Issues of Psychoanalytic Practice.
Psychoanalysis is successfully covered now under some organized systems without intolerable disruption of the treatment process. Managed systems can, and some do, use procedures appropriate for psychoanalysis, taking into account the need for extensive ongoing work after symptom relief, using true peers as reviewers, asking for second opinions rather than transmitting treatment data, etc. The future accountable health plans might leave wide latitude for providers to devise their own utilization management, operating very differently from current predatory mental health carve-outs. We shouldn't foreclose our options unknowingly.
Reports from IPA colleagues indicate that psychoanalysis can succeed either inside or outside a government-directed health care system. A reformed system could afford a better environment for psychoanalysis than the harsh, profit-driven climate we currently inhabit. Success in our most fundamental objective, the freedom to contract privately at one's own expense outside the system, will allow analysts and analysands to make their own choices about “opting out.”
The Southern California proposal is ill-founded, premature, inflexible, and potentially disastrous in its irrevocable consequences.