Psychoanalytic professional organizations need to adopt a strategy to establish a respected independent status for the profession that complements private and government insurance systems. The strategy must allow an analyst the options to work with these systems and to contract separately with patients for confidential, private psychoanalysis. This would strengthen psychoanalytic practice, psychoanalytic education, and the availability of confidential psychoanalytic treatment to the widest socioeconomic range of patients.
The initial strategic action requires consensus among psychoanalytic professional organizations to arrange for the procedure code for psychoanalysis (CPT: 90845) to be selectively excluded from the list of covered procedures in specific managed care insurance plans whose accountability requirements do not allow psychoanalytic treatment to be conducted in accord with psychoanalysts' recognized professional practice guidelines, legal mandates, and ethical traditions. Exclusion would be selective, not applying to the few insurance plans that allow modified psychoanalytic treatment and psychoanalysis to be conducted, on a pre-authorized basis, with no ongoing review, thus permitting adequate privacy, confidentiality and integrity of treatment.
After CPT: 90845 was no longer listed as a covered procedure in certain plans, psychoanalysts would be able to approach these insurance systems from an independent status. They would offer to develop referral options for patients who do not meet managed care criteria for treatment authorization (usually limited to crisis intervention and management) and who can benefit from psychoanalytic treatment on a private, confidential, self-paying basis.
Psychotherapy (CPT: 90844) would remain a covered procedure and would be subject to accountability requirements (e.g. session-by-session progress notes for external review and audit). This compromises privacy and confidentiality of treatment in exchange for insurance subsidy. Exclusion of CPT: 90845 from insurance coverage creates a treatment option for intensive psychoanalytic psychotherapy. The patient and analyst could then make the choice between confidential modified psychoanalytic treatment (90845) or subsidized, but not confidential, psychotherapy (90844). Modified psychoanalytic treatment may be conducted according to practice guidelines for psychoanalysis wherein psychoanalysts are advised to refrain from session-by-session charting of psychoanalytic treatment.
Many thoughtful colleagues will argue that it is wishful thinking to imagine that managed care organizations might refer their patients to psychoanalysts if analysts were to give up their subsidies under these programs. While no longer a financial concern to managed care systems, psychoanalysis might still represent a moral reproach, motivating the managed care providers to continue to depict it as a luxury bordering on indulgence. Some may not cooperate, but others are likely to do so if exclusion to protect the integrity of treatment is achieved during the existing window of opportunity.
Exclusion of CPT: 90845 on a favorable basis (rather than on the basis of default, which invites continued intrusive regulation) is unlikely to be available to psychoanalytic organizations after managed care regulations move more completely from policy created by private insurers into the jurisdiction of law and Medicare-style government regulations, enforceable by severe criminal penalties. This process is already apparent in the “administrative simplification” amendment to the Kennedy-Kassenbaum bill (passed by Congress in 1996) and in legislation pending at both state and federal levels (e.g., the 1997 version of the Bennett Bill). The window of opportunity for psychoanalysts is closing.
To date, no American professional organization representing psychoanalysis has pursued a respected independent status for psychoanalysis. Such organizations are functionally split by divided loyalties to psychoanalysis and to the disciplines of psychiatry, psychology, and social work. They are further internally divided by clinical, academic, research, and business interests. They are governed by well-meaning part-timers who usually lack expertise in politics and public relations. As a result, these organizations have not adopted a truly strategic approach. Instead they pursue multiple contradictory efforts to satisfy competing interest groups. They seek coverage under as many insurance plans as possible; at the same time, they propose to wage a frontal assault on the health insurance complex, aiming to champion the integrity of confidential treatment by overturning the “prudent insurance ideal” that is fundamental to managed care systems.
The prudent insurance ideal posits that certain expensive forms of treatment increase health-care costs and insurance premiums. These include elective forms of treatment that extend beyond the restoration of health to enhance the patient's quality of life and to bring the patient better and better health. Rather than pay higher premiums and taxes to guarantee coverage for these procedures, the prudent insurance ideal assumes that most citizens will forego such coverage in order to pay lower premiums and taxes and will apply the resources saved to other measures that they expect will increase their quality of life.
Insurance coverage for psychoanalysis and intensive psychotherapy is compatible with the formerly established “rescue principle” that assumed that insurance claims should receive nearly unlimited approval in the service of maximizing the patient's health and life expectancy. But under the prudent insurance ideal, claims for psychoanalysis and intensive psychotherapy invite close, ongoing scrutiny to be sure that the treatment does not extend beyond health maintenance.
Those who developed managed care philosophies into health care delivery systems in the mid-1980s seized on a change in public attitude to favor the prudent insurance ideal.
Robert R. Cummings, M.D., Ph.D. coordinated the Southern California Position on managed care, psychoanalytic practice guidelines, and the APsaA health care reform plan from 1992 until joining forces with the Coalition fot Patient Rights in 1994. He is now secretary of BOPS and co-chair of the committee on Peer Review. He also is a training and supervising analyst or the Southern California Psychoanalytic Institute.
Since then, a struggle has ensued to determine which health-care procedures will be denied significant insurance support and which will receive reliable subsidy. This struggle has become a political and economic process rather than a medical and scientific process. Public opinion indirectly determines the coverage on a continuum. Near one pole are procedures that are popular and deemed worthy of automatic approval. Near the other pole are procedures that are deemed suspect and will be held to account if any insurance subsidy is provided. Legitimate medical and scientific influence on this process competes with well-funded pseudoscientific marketing. A significant cut of expenditures for insufficiently popular mental health services has proven a key to profitability for managed care systems.
It is possible to describe and critique three fairly distinct interest groups within psychoanalytic organizations in the United States that do not want to establish a respected independent status for psychoanalysis.
The first group is composed of psychoanalysts who are zealous to thoroughly pursue all avenues of insurance support for psychoanalytic treatment. Some believe they cannot survive in practice without subsidies. Some work mainly in non-psychoanalytic areas of care and treat few psychoanalytic cases. They identify mainly with their speciality of origin (psychiatry, psychology, or social work). They claim that insurance coverage can enable psychoanalysts to treat socioeconomic groups not previously served by psychoanalysis. They hope to create increased economic opportunity for psychoanalytic academics to do “scientific” managed care outcome studies.
This group views privacy and confidentiality of treatment in fluid, relative terms. They believe that standards fundamental to the psychoanalytic frame of treatment must bend to the accountability prerequisites for insurance subsidy. They regard proponents of an independent status as psychoanalytic purists who would exclude psychoanalysis from insurance subsidies and encumber colleagues' efforts to make a living. They falsely claim that proponents of independence advocate psychoanalysis only for the rich.
Proponents of an independent status may reply that psychoanalytic treatment under managed care introduces third-party interests into the standard two-party treatment. Managed care insurance programs rarely allow psychoanalysis to be authorized, conducted, and continued beyond an arbitrary number of sessions or beyond the stage where symptoms drop away and transference emerges. Further sessions are authorized only if it can be substantiated that the patient would require hospitalization without them. As managed care systems evolve to replace case managers with capitated arrangements, cost-containment incentives will continue to prevent the rarely authorized case from ever reaching completion comparable to that achieved in a standard private analysis. Once psychoanalysts agree to establish psychoanalytic treatment under these conditions, they lose any negotiating leverage to obtain exemption from the accountability procedures generally required of other medical procedures.
Utilization review by managed care does not meet peer review standards for privacy or confidentiality; therefore ethical considerations and legal informed consent standards require analysts to share review documents with patients for consent and revision before releasing them to third parties. Preparing these reports and records intrudes upon and violates basic standards of psychoanalytic technique, distorts the listening skills of the analyst, and restricts patients' freedom to speak freely and explore their inner life. How can the patient give unconscious informed consent? Creating records for external review has unconscious ramifications that will remain unclear to the patient and the analyst for an extended period of time, degrading the quality of the treatment and the therapeutic alliance and risking a stalemated analysis.
The charge that proponents of independence advocate psychoanalysis only for the rich is scurrilous. Psychoanalytic clinics affiliated with our institutes have traditionally and successfully assisted patients of limited economic means to obtain psychoanalysis at reduced fee. If CPT: 90845 remains a covered procedure and is regulated by laws that do not allow confidentiality, this will effectively regulate the clinics out of existence and shrink the availability of confidential psychoanalysis for all socioeconomic groups. If CPT: 90845 is excluded, psychoanalytic clinics can be freed from mandatory compliance with managed care accountability regulations and will be able to expand and serve a greater number of psychoanalytic cases at reduced fees. This result from respected independent status is far from ideal, because it restricts the availability of psychoanalysis for those whose earnings would not meet upper-middle-class levels, but psychoanalysts may have to pay this price in order for the profession to survive and continue to provide quality care through clinics.
The second opposition group expects exclusion of CPT: 90845 to have negative consequences for their professional identity, the ability of the field to participate in the advancement of medical science, and the status of psychoanalysis as a respected health care profession. However, they recognize that psychoanalysis will lose respect as a mental health profession if psychoanalysts dilute psychoanalytic efficacy by conducting treatment under managed care, allow patients' vulnerabilities in treatment to be exploited by breaking the two-party psychoanalytic frame, and allow the eventual transformation of psychoanalysis into a compromised treatment, less defensible within the community of scientific discourse. They worry that independence might abandon severely mentally ill patients, some of whom can benefit from modified forms of psychoanalytic treatment. This interest group includes many analysts who have worked successfully for years to maintain harmony between a busy psychoanalytic practice and broader clinical work. It also includes medical psychoanalysts who apply a psychoanalytic approach to all types of clinical work with patients. This group often promotes cooperation and opposes the trend within psychiatry toward a self-defeating split between the psychobiological and behavioral schools (short-term, low-frequency care models) versus the psychodynamic and interactional schools of thought (intensive, sustained care models).
Psychoanalysis is unique in its need to maintain high levels of privacy and confidentiality as technical essentials for effective treatment. In general medicine and surgery today, privacy and confidentiality are considered ethical ideals, not essential technical elements of the treatment. The trend in the mental health fields is to compromise privacy and confidentiality in order to provide accountability for insurance subsidy. Bollas and Sundelson believe that such actions tend to promote the creation of subsidized forms of “social treatment,” which aim to serve divergent interests of the patient, the subsidizing third party, and society as a whole. If enough clinicians can maintain independence, a distinction will develop in the public mind between “social therapists” who are subsidized and accountable to various outside parties and “confidential therapists” who offer patients the only venue in which to talk freely to a mental health professional without fear of being reported externally.
There is too great a risk that private, confidential practice will become extinct when psychoanalysis must maintain unity with other mental health specialties. In contrast, a respected independent status puts psychoanalysis on a path that diverges from other mental health specialties but complements them as well. It aims to preserve optimal levels of privacy and confidentiality for psychoanalytic treatment within a strong private base of practice and education. This strategy encourages psychoanalysts and psychoanalytic organizations to remain actively engaged with government and private insurance policymakers and the other mental health specialties; this will facilitate referral between the two systems and continuity of care across the broad spectrum of mental health and medical services.
The third opposition group energetically supports the effort to preserve the integrity of privately contracted confidential psychoanalytic treatment, but it does not support a strategy of independence. Members of this group want psychoanalysts to champion the preservation of confidentiality for all of medicine. They assume that the general public will naturally agree with them and force managed care to kneel on the issue of confidentiality when attacked in the media and legislature. But managed care's war chest for propaganda and lobbying is huge. Public opinion favors accountability over confidentiality within insurance systems. The rest of medicine has already adjusted and is too dependent for economic survival on insurance subsidy. Organized medicine will not support efforts to preserve confidentiality at the high levels that psychoanalysis requires.
If psychoanalysts seek confidentiality on any basis other than independent status, psychoanalysis will be denied confidentiality and clubbed with accusations that psychoanalysts use high-minded rhetoric to hide their misdeeds in the attempt to secure a greater share of insurance money. Insurance systems see psychoanalysts as primarily interested in money, and dismiss pleadings for privacy, confidentiality, and integrity of treatment as self-serving political rhetoric.
Psychoanalytic organizations may assume that independence for psychoanalytic practice will always be readily available. But unrestricted private contracting between patients and doctors is not a legally protected freedom in this country. Extensive effort will be required to include this freedom in health care legislation. This cannot be accomplished if psychoanalysts concurrently seek insurance reimbursement. Constituencies to which the cost containment agencies must answer will not allow psychoanalysis to be reimbursed by insurance and also exempted from the accountability and cost containment regulations applicable to all procedures.
In 1993 the insurance industry skillfully defeated the government's efforts to reform health care. Since then, it seems that an implicit deal has been struck between insurance and government. In order to reform the health care system under the prudent insurance ideal, the government is letting the insurance industry gain windfall profits as insurors preside over the politically unpopular process of getting the American people to accept new, selectively rationed health insurance coverage.
The government will begin to create legislation to encode the managed care philosophy and accountability regulations into law. Such laws will include patients and clinicians who behave in accord with “the rescue principle” among those who commit insurance fraud. As competition among insurers tightens, and the profit-driven denials of needed care make the private health insurance industry increasingly unpopular, the government will intervene: first with regulations that curb both the egregious excesses and the industry's profitability, and later with sanctions and fines at levels that serve predominantly political rather than punitive purposes. Malpractice lawsuits may become a further threat to profitability, particularly if medical responsibility is legally assigned to those within managed care systems who make determinations of “medical necessity” and denial of care.
Eventually, this more evolved managed care insurance system may become sufficiently unprofitable and unpopular that the government can enter as a white knight, unopposed by insurance companies, and offer to regulate some form of single payer state or federal system, using the managed care structure of the insurance industry as the foundation for the new programs. The insurance industry may not oppose this, being content to retire after having thoroughly exhausted the profit opportunity. Thus managed care in one form or another may be with us for the foreseeable future.
For psychoanalysts, definitive action requires a disciplined stand; we must decline third-party financial subsidies in order to preserve the essential technical integrity of treatment. Psychoanalysts will lose their chance at respected independent status if they delay action until the managed care entities have their practices and policies encoded into law and then reject psychoanalysis and intensive psychotherapy from coverage because it is “unscientific” and “not medically necessary.” CPT: 90845 may be excluded on this basis if psychoanalytic organizations fail to make the necessary sacrifice of treatment subsidy and act while the window of opportunity for a principled stand still exists.
The initial exclusion effort should focus on Medicare, where CPT: 90845 is currently listed as a covered procedure in most regions of the country. As legislatures respond to the current anti-fraud campaign by passing managed care accountability policies into law, Medicare is likely to be the model for such laws and enforceable penalties. Medicare's legally binding regulations require that confidentiality and privacy be sacrificed to provide accountability for every subsidized treatment session. In 1998, the Kyl private contracting statute will begin to allow the 9 percent of “providers” who do not receive subsidy for Medicare patients to form private contracts to treat Medicare-eligible patients outside the Medicare regulated system. If psychoanalytic organizations rely on the Kyl statute (which is to be reviewed/revised in 2001) and delay seeking exclusion of CPT: 90845 beyond the point when Medicare-style managed care regulations become law, their effort may be dismissed as opportunistic instead of principled. At that late date, attempts to gain exclusion will pit psychoanalysts against a bureaucratic system that is invested in maintaining jurisdiction and authority. Then psychoanalysts' options may be reduced to lengthy, expensive legal battles to regain their ability to practice privately.
If psychoanalytic organizations ignore the window of opportunity for independence and instead make a series of accommodations to accountability and oversight demands, treatment effectiveness will be irreparably diluted and psychoanalysis in the United States will become a treatment in name only, a pale ghost of its former self.
Many American medical institutions and organizations have faced the challenge of managed care encumbered by their members' dependence on insurance subsidies. Since most psychoanalysts have been restricted from high levels of insurance subsidy for years, they are less dependent on it and more able to seek a respected independent status to preserve the fundamentals of the doctor-patient relationship for psychoanalysis and modified psychoanalytic treatment. Ironically, the profession of psychoanalysis has an opportunity for resurgence. Clinicians and prospective patients interested in education and treatment may be attracted to psychoanalysis as the mental health profession that has most thoroughly preserved and protected the ability of doctors and patients to speak freely and openly to one another without conflict of interest on the doctor's part and without fear on the patient's part that what is said will be charted, revealed to outsiders, and used to deprive the patient of employment advancement, social reputation and other opportunities and freedoms in life. Creating a respected independent status for psychoanalysis can lead to a stronger base of practice and education than American psychoanalysts have experienced in recent years.
This article is derived from a larger paper pre sented by the aut hor at the Annual Sprin g Meeting of the American Psychoanalytic Association in May 1997. The full paper, with extensive references, is available from the author at 23422 MillCreek Drive, Suite 210, Laguna Hi lls, CA 92653 or .