I welcome the opportunity to reply to the comments of Dr. Michels et al. on my recent TAP article on confidentiality. Clearly, from the tone of their letter one can see that the strong feelings and intense disagreement that accompanied The American's actions of almost a generation ago are still alive today.
My Webster's Unabridged offers one definition of “blunder” as simply “a gross error,” and it's in that sense that I used the term to describe the action of The American in putting its endorsement on a reporting format for utilization management. I was not referring to any individuals, since the responsibility was ultimately attributable to a vote of the Executive Council. On the other hand, I consider the charge of misrepresentation to be a bit rough and somewhat out of bounds.
None of us has a monopoly on the truth, and that is why, not having been present myself during the events of the mid-seventies, I asked both Dr. Sheila Hafter Gray, chair of the Committee on Peer Review, and Dr. Jerome Beigler, former chair of the Joint Committee on Confidentiality, to review my article for accuracy before I submitted it to TAP. However, I take full responsibility for the article's content, which I believe to be correct. The criticisms of Michels et al. are based on an imprecise reading of what I actually wrote and on a very selective use of the literature. I will respond point by point.
The writers claim that the form they developed was simply a routine answer to a “need” of “fiscal intermediaries,” as if any similar request would mobilize such a major and controversial effort in The American. In fact, my article addressed the issue of why the organization responded to the “need” of insurers in the way that it did; that is, by devising, approving, and promulgating the reporting format. I don't think that there is any doubt that the concerns I described were the actual reason for The American's actions—i.e., the fear that insurance coverage for psychoanalytic treatment would otherwise be curtailed or dropped. While it may be true, as the writers themselves proudly admit, that “dozens” of our members collected payments from insurers as a result of this reporting format, any pride they may take in that fact must be tempered by a recognition of the countless other treatments that were carried out with no coverage at all because of analysts' or patients' unwillingness to participate in the kind of review demanded by insurers after the reporting format was promulgated. Even worse, serious difficulties have been noted in intensively reviewed cases. For documentation, see Dr. Gray's chapter in the 1992 American Psychiatric Association “Manual of Psychiatric Quality Assurance,” references 9 and 13–15.
The writers innocently claim that the form was developed “from scratch” and only later adopted by institutes for training purposes. However, this claim is contradicted by the published literature on the subject. In the 1992 chapter cited above, Dr. Gray wrote, “The guidelines that the American Psychoanalytic Association submitted for inclusion in the Manual of Psychiatric Peer Review, had been devised for teaching and research in a closed clinical setting. Offenkrantz (as cited in Pulver) believed that one would be able to use virtually identical reporting protocols in the APA's peer review projects.”
The writers haul out the old chestnut about confusing “claims review” with “peer review,” alleging that I have fallen into that pothole. Actually, neither term appears directly anywhere in my article. Instead, I deliberately chose to use the term “utilization management,” because that is what we are really talking about. Most ironically, the very sentence that the writers chose to criticize (citing Dr. Gray as a reference), in which I state that the old third-party reporting method was “implicitly superseded” in 1991, was written by me using the very wording Dr. Gray herself employed in her December 16, 1993, report to the Executive Council.
It must be obvious to anyone that, if periodic detailed case reports are to be used to determine whether reimbursement of a particular case should continue, somewhere in the process the report and the identity of the patient must be connected in order for payment to be made. Unless the report never enters the possession of the insurer, there is no way that confidentiality can be guaranteed, no matter how much the report is “sanitized” to remove identifying data. The only way that such a process could be carried out, with confidentiality protected, would be for reports to be sent by the analyst directly to the private office of an independent analyst-reviewer, one trusted by all three parties, and then destroyed once that
reviewer makes a determination. As far as I know, no such mechanism was insisted on or established. In fact, as late as 1985 a plea by Daniel B. Borenstein for the establishment of such a mechanism appears in a publication of the American Psychiatric Association. Many doubt that such a plan could ever be established.
Finally, I am well aware of the Confidentiality Committee's past statements in this area, having carried out a detailed review of this subject at the request of Dr. Judith Schachter. The committee's first statement, appearing in its April 1977 report, said “it is the consensus of the committee that most of the insurance coverage problems of psychoanalytic patients can be reasonably managed by a system of prior authorization and concurrent review carried out on non-identifiable data by a peer-review panel completely independent of the insurance carriers” (emphasis added). This position was restated in December 1989.
I believe that whatever good intentions may have accompanied the promulgation of the reporting format, it was naive to assume that the process would remain within the control of the treating professions. Instead, I believe that wide publication of that format, whether described as “peer review” or as something else, was one major link in the chain leading to the present sorry state of affairs in which the content of psychotherapy sessions is considered available data for utilization managers. This was simply an unthinkable idea prior to the 1970s. I am appalled that the writers seem unwilling to share our collective responsibility in this regard. I am reminded of the words of a Tom Lehrer song: “‘Once the rockets are up, who cares where they come down; that's not my department,‘ says Wernher von Braun.”
Paul W. Mosher, M.D.
Chair, Joint Committee on Confidentiality