In July 2000, members of the North Carolina Psychoanalytic Society learned that the Mental Health Advisory Panel for the North Carolina State Employee's Health Plan (SHP) — an otherwise generous mental health program — had voted to propose eliminating psychoanalysis as a covered benefit. The SHP's board of trustees would decide the proposal in two weeks.
The SHP insures most employees of the state government, more than 500,000 lives. The SHP has contracted with ValueOptions Corp. to manage mental health care. Most reviews by ValueOptions are done at its local office in Research Triangle Park, N.C., where no psychoanalysts are employed. As a result ValueOptions has approved only seven analytic cases in the last ten years, for sessions four or five times per week, although it often approves psychotherapy at once or twice per week.
We learned from colleagues on the advisory panel that ValueOptions' medical director had presented an argument to the advisory panel to eliminate psychoanalysis, with no analysts present and no opposing views. His rationale was that very few reviewed cases met the criteria for “medical necessity” and that these denials generated many complaints.
Contacted later by phone, the medical director explained further that in his opinion, psychoanalysis is the preferred treatment for “neurosis,” and to be neurotic — and able to withstand the rigors of psychoanalysis — generally implies sufficient ego strength to fail to meet the criteria for medical necessity! We objected, and asked what the psychoanalytic society could do from that point. He said that the SHP board of trustees' meeting was “a public meeting, and anyone can ask to speak before the board. You can write a letter, and it will be distributed, but I will be there to say what I think and answer questions.”
Members of the psychoanalytic society arranged to attend the board meeting. Unrelated to our efforts, the board of trustees fortuitously postponed its meeting for six weeks, allowing us more time to mount a defense for psychoanalysis.
Society members were motivated to take up this issue for several reasons. We wished to promote the awareness of psychoanalysis in our state, to draw attention to how rarely the SHP finds psychoanalysis medically necessary, and we thought the society should try to protect the few patients whose analyses were being covered. Perhaps, most important, the SHP is regarded as a model insurance plan in our state; to allow psychoanalysis to be excluded would set an ominous precedent for other insurance carriers.
Our first and most effective response was to seek the support of the other major professional organizations in our state. Society members who were psychologists or social workers garnered the support of their professional associations in these disciplines.
In August, Landrum Tucker, president of the North Carolina Psychoanalytic Society, wrote a letter to the board of trustees of the SHP. He asserted that several members of his and other major professional societies would like to speak to the board against the proposal to eliminate psychoanalysis. He requested a postponement of discussion so the group could prepare further.
The director of the advisory panel withdrew the proposal and put it back into special committee for further consideration with input from the psychoanalytic community.
With this success came more work. Value-Options gave us a list of questions to answer about whether other managed care companies covered psychoanalysis, how they review it, and how “medical necessity” is determined.
Jon Meyer wrote a letter from Wisconsin explaining how psychoanalysis is managed there. We called a psychiatrist administrator from a competing managed care company who told us he knew of no mental health program that had eliminated psychoanalysis as a covered procedure, although many plans limit the amount of coverage for that benefit.
Next we researched the term “medical necessity,” finding a definition in a North Carolina statute as well as in ValueOptions' provider manual. The manual was vague, but it did cite an interesting reference as justification for ValueOptions' approach: the 1985 APA Manual of Peer Review (third edition). Here we found an explicit recommendation for a peer review procedure for psychoanalysis. We have since found others, but since Value-Options' provider manual had an explicit citation, we decided to bring the peer review approach to the attention of the SHP and ValueOptions.
In preparing for discussions with the advisory panel, we were ready to clarify what makes psychoanalysis a unique form of treatment, the types of patients for whom analysis is the ideal treatment, the rates of utilization of psychoanalytic treatment, and the efficacy of analysis. (Especially helpful were “Characteristics of Psychoanalytic Patients” by
Rex Moody, M.D., Heather Craige, M.S.W., and Landrum S. Tucker, Jr., M.D., are members of the North Carolina Psychoanalytic Society who served as the ad hoc committee to fight the exclusion of psychoanalysis as a covered procedure under the State Health Plan. They practice psychoanalysis in Chapel Hill and Raleigh, N.C.
Norman Doidge et al.; “An Open Door Review of Outcome Studies in Psychoanalysis,” edited by Peter Fonagy and available on the Web site of the International Journal of Psycho-Analysis at ; and “Varieties of Long-Term Outcome Among Patients in Psychoanalysis,” by Sandall et al.)
After several delays, the meeting with the subcommittee of the mental health advisory panel was held in late November 2000. The authors of this article represented psychoanalysis.
During the meeting, ValueOptions' medical director's discussion of medical necessity emphasized a combination of symptoms and cost. We argued that inserting cost into a determination of medical necessity is not justified in North Carolina statues or in Value-Options' provider manual. State law, we claimed, states that cost can be a consideration only if there are several equally effective treatments.
The group seemed persuaded by the idea that analysis was the treatment of choice for some patients with serious, long-standing character pathology, most certainly when other, less intensive treatments have not been or will not likely be successful. We argued that these illnesses interfere significantly with functioning. The ValueOptions presentation emphasized treating symptoms and ending treatment when symptoms are relieved. We emphasized not only symptom relief, but also treatment of disease until cure is attained, whenever possible.
The committee decided against eliminating psychoanalysis as a covered treatment. We were able to improve matters further by discussing how to make the review process for psychoanalysis smoother and more effective. ValueOptions' medical director agreed to have future cases reviewed by a psychoanalyst, if requested by the treating analyst.
We believe our diligent preparation contributed to the success of this meeting, but our victory rested most securely on the realization by ValueOptions and the advisory panel that negating psychoanalysis as a recognized procedure faced a major threat of opposition by the mental health community and encouraged destructive divisiveness.
The experience taught us how insurance companies operate on both a policy basis and a day-to-day basis. We learned how to mobilize our society to maintain the interests of our profession. We have seen the importance of analysts' remaining connected to their professional organizations.