The health insurance plan available to the employees of the Medical College of Wisconsin proves that third party plans can cover psychoanalysis and be economically viable. The college's plan provides full coverage of psychoanalytic treatment for its faculty and employees and their dependents as part of a mental health plan that enjoys complete parity with covered physical benefits, up to a lifetime maximum of $2,000,000. As a result, eligible persons never have to pay out of pocket for psychoanalytic treatment.
How did this come about at a time when trends are going the opposite way? David Black and Jon Meyer, the former and current directors, respectively, of mental health services at the Medical College, say the situation in Milwaukee looks like that in other parts of the country two decades ago. Federal government employees, for example, once had ready access to psychoanalysis and intensive psychotherapy through their health insurance. Milwaukee is both a throwback to earlier times and a progressive indicator for the future.
There are three major components to this story: the political, the institutional, and the personal. Politically, Wisconsin's early socialist trends led to a highly inclusive provision for social and health services. In the 1970s and early 1980s, most insurance plans in the state covered psychoanalysis, although there was no parity with physical benefits. Nonetheless, these liberal benefits were easy to eliminate, as they were in other parts of the country. With few exceptions, they have disappeared from most plans in Wisconsin. Only at the medical college of Wisconsin have the benefits been upgraded and improved.
Two institutional characteristics were key. The Medical College is self-insured, meaning that the administration is both the provider and the manager of the benefits. Its faculty came to appreciate the value of the potential cost of poor mental health coverage. The faculty had the autonomy to protect what was important to its employees, if it chose to do so.
Moreover, in the mid-1980s, the Medical College, in line with the managed care spirit of the times, had proposed to curtail mental health benefits to match a state-mandated ceiling of 90 percent of $2,000 per year. Meyer went before the faculty welfare committee to explain the proposal and to outline what would be lost.
The faculty reacted. They wanted to maintain the original benefits, even though their fringe benefit rate would be higher under the new plan, and even though the total coverage would be significantly lower — full coverage only up to $3,000, with a 30 percent co-payment for all fees above $3,000 and a lifetime benefit of $100,000.
At this point in the story the personal component comes into focus. In the early 1990s, a faculty dependent incurred mental health expenses that exceeded the lifetime coverage. “I told the dean about this, and he was willing to make an exception,” David Black explained. “I then asked him how he would handle the same situation when it came up for the next person and the next one, as it inevitably would.”
Black's point was well taken by the dean, who became supportive of full parity. Meanwhile, the Faculty Welfare Committee had been educated about the benefit and was “committed to the best medical care they could get,” which included parity for mental health services, including psychoanalysis. “We got parity and eliminated the co-pay provision. Psychoanalysis was covered, period,” Black said.
Under the plan that was ultimately developed, rates are discounted by 20 percent and all co-payments are waived. A group of clinicians (Meyer has specifically banned the word “provider” from the plan's lexicon) has agreed to provide services under the terms of the plan. Most of the psychoanalysts in Milwaukee, both at the medical college and in private practice, are participants. Analysts who are not full-time faculty were specifically included to ensure that off-campus offices were available to preserve privacy. To preserve confidentiality, all payments and other records are coded and are not available to anyone except perhaps the clinician's office staff.
An important part of the parity agreement is a peer review of randomly chosen cases of all types every two years. This is done in accordance with guidelines developed by the American Psychoanalytic Association because they are the best available. “The peer review process helped legitimize analysis and intensive therapies,” Black explained. The very thorough write-ups required by the guidelines provide a reassuring measure of quality control. A few years after parity was achieved, the lifetime mental health benefit was increased from $1 million to the $2 million it is today.
Despite the generous coverage of psychoanalysis, there has not been a significant increase in use of the benefit. In fact, fewer than ten people are in analysis under the plan at any one time. By far the largest expenditure is for once-a-week psychotherapy and medication management. Training analyses are not covered under the plan, although, as Meyer points out, this would affect few people.
As Black and Meyer described the Milwaukee victory, it became clear that none of this could have happened without strong leadership. ‘You can't give up, and you have to show up,“ they asserted. ”We knew the people, we knew where to go, we were well organized, and we didn't take ‘No’ for an answer.“
How could the Milwaukee experience be transferred to other settings? Were all the ingredients that existed in Milwaukee necessary conditions for success? In observing what has been happening in North Carolina, where the political and institutional characteristics are quite different, it does seem that variations on the Milwaukee recipe are possible.
Hinda B. Simon, M.S.W., is a graduate of the Houston-Galveston Psychoanalytic Institute and a member of that institute's faculty. She is also a clinical instructor at the Baylor, Tex., College of Medicine.