The 1996 Survey of Psychoanalytic Practice was more extensive than other surveys conducted in 1990 and 1993 and took longer to collect. The response rate of 61 percent of the membership was less than the 71 percent collected in 1993, but was still large enough to be taken as representative. Only 12 percent of the membership answered questions about terminated cases that required information about both DSM-IV diagnosis and total number of sessions. Some analysts thought questions about managed care and income were more intrusive than they preferred. However, much valuable information was gathered.
This article will focus on both familiar findings repeatedly found in all surveys since 1976 and some new findings from data not previously collected which are relevant to the current questions about the effects of managed care, the advisability of using government insurance, and whether or not to allow psychoanalysis to remain an insurable procedure for both government insurance and other carriers.
The relatively slow decline in the size of psychoanalytic practice continues. The 7 percent decline in the size of analytic practice since 1990 follows the long-term trend of a decline of 1 percent a year noted since 1976. Forty-nine percent of analysts believe their analytic practice has declined in the past three years, while 20 percent believe it has increased. The current decline is shown in Graph 1.
Size of analytic practice continues to be related to many other aspects of the analyst's life. Training analysts have a mean of two cases more in analysis than do non-training analysts. Satisfaction with the analytic profession and identification as an analyst are strongly related to the size of analytic practice, as shown in Graph 2.
Analysts with larger analytic practices work more hours and have larger incomes from the profession. They are less likely to belong to HMOs and less likely to work for a salary. They are more likely to be child analysts. They see more therapy patients intensely and are less likely to see patients once a week or less than once a week. They are more likely to be satisfied with the American Psychoanalytic Association and their local institute, but size of practice is not related to satisfaction with the local society. When they have had their treatment cases reviewed by managed care, they feel the treatment has been adversely affected by the review. They are much less likely to be familiar with and use the DSM-IV or psychiatric diagnosis. Although women work slightly fewer hours and have smaller incomes, the size of analytic practice is not related to the sex of the analyst.
The size of analytic practice is remarkably affected by the local society. Only the Michigan Society (treated as one group) has a mean practice of 6.5 patients in analysis. Two other societies of moderate size show a mean practice of between five and six patients in analysis; in 12 societies the mean practice is between four and five patients. Marvin Margolis has visited many societies to describe the internal changes and external outreach programs that have proven so successful in Michigan, and Erik Gann has rejuvenated the workshop program of the Committee on Psychoanalytic Practice, to visit local societies and consider how to improve the practice in a given area.
Analysts see most patients in analysis (55 percent) four times a week. Fifteen percent are seen five times a week, and 30 percent are seen three times a week. Analysts see about 14.5 patients in therapy. Almost half of these are seen once a week. More patients see analysts once a week for therapy than in any other treatment modality.
Analysts are highly identified and satisfied with both analysis and the profession. They are moderately satisfied with the APsaA and their institutes and societies, although less with the national organization than with the local organizations. They are remarkably dissatisfied with HMOs. Identification and satisfaction with psychoanalysis has increased in the past six years. Satisfaction with both the local institute and local society has also increased in the past three years, but there is no change in the level of satisfaction with the APsaA.
The median common analytic fee is $110, and the median common fee for therapy is $125. Those with larger analytic practices charge higher fees. The median income from the profession is $120,000, and the median household income is $180,000. Those on salary have only slightly smaller professional incomes than those not receiving a salary, but they work an average of about five hours more per week.
Record keeping and review requirements associated with government insurance (Medicare, Medicaid, or Champus) is particularly intrusive into analytic and psychotherapeutic care. These problems are discussed in detail in a paper by Lee Brauer, Drew Clemens, and, Paul Mosher, “Information for Psychoanalysts about Medicare,” which was distributed to the Executive Council in December 1997 and is being sent to the local societies. Findings in the current survey indicate that only 35 percent of analysts who have graduated from an institute accept government insurance for any of their patients! This indicates that 65 percent of the
Lee D. Brauer, M.D., chairs the Committee on Psychoanalytic Practice.
association could opt out of Medicare using Kyl Amendment procedures affecting none of their clinical cases currently in treatment until these cases became eligible to file for Medicare.
Training analysts are less likely to use government insurance, even though they are older than the other analysts surveyed (and insurance is most likely to be used by those over 65 years of age). However, in this 61 percent sample of our membership's practice, 112 adult patients and two children are in analysis using government insurance. Extrapolating to the entire membership of The American, withdrawing analysis as a procedure from government insurance would affect approximately 187 cases currently in analysis out of a total of 11,700 analytic patients, or 2 percent of the analytic patient population.
At present, 33 percent of our members belong to at least one HMO or other managed care plan. Three years ago the number was 27 percent. Clearly our members who have graduated from institutes are avoiding joining HMOs. As mentioned earlier, most members are very dissatisfied with managed care. However, 53 percent of affiliate members belong to HMOs, so the problem will be of increasing concern. Graduated members in HMOs have one less case in analysis than those who are not providers for managed care.
Analysts reported on 367 analytic cases reviewed by managed care. The analysts thought 11 cases were helped by the review, but they reported 72 cases failed or interrupted due to the review, and 160 of the 367 cases were compromised. Similarly, of an average of five therapy cases reviewed for those who participate in managed care, about 3 percent were helped, but 18 percent were reported interrupted and 47 percent compromised. The clinical problems presented by this change in the financing and review of care are enormous. It would seem that most members find the best strategy is to simply avoid the problem whenever possible.
The present report reconfirms previous findings about the relationship between size of analytic practice and members' satisfaction. Practice is fostered by an analyst's vigorous commitment to a variety of professional activities. Practice improves in regions where local societies have been active in promoting practice.
An anticipated acceleration in the decline in the size of analytic and psychotherapeutic practice did not occur, most likely because most members assiduously avoid participating in HMOs and submitting claims for government insurance. Younger members who are joining HMOs will increasingly face a difficult set of problems generated by the intrusion of these plans into clinical care.