Now that we are engaged and having an impact beyond our numbers in protecting the privacy and confidentiality fundamental to psychoanalysis, we need to work toward insuring that patients have access to psychoanalytic treatment. Privacy and confidentiality are essential to quality health care, but they do not accomplish it alone.
The fact that the number of psychoanalytic patients drops 1 percent per year nationally does not mean that the need has gone away. It means that fewer people in need have access to our services, and it illustrates the effect of managing mental health care as a restrictive “carve-out” within health plans.
It is time we helped in an organized way. This article takes up the industrialization of mental health care, the rationale for it, and what to do about it, including approaches to medical necessity, practice guidelines, effectiveness vs. efficacy, coalition building, education, and information — and showing up (as we'll discuss further below).
In terms of access, psychoanalysis enjoyed broad inclusion in health plans until about fifteen years ago. At that point, as outlined by Bob Pyles in his plenary address last May, business and government interests evolved a strategy to contain costs and, not incidentally, to maximize profits. The business concept was put into operation by organizing purchasing power so that clinicians would be treated contractually just like other suppliers of services — in a word, as “providers.” Further steps in making a profession into a business included threatening organized clinician opposition with anti-trust prosecution, pushing the use of panels and other forms of large-scale contracting, inducing competition for contract dollars, shifting cost risks to providers, and securing liability-free control over services under the 1974 Employee Retirement Income Security Act (ERISA).
The effect was to curtail the patient's (“consumer's”) right to opt for high-quality care and the clinician's (“provider's”) options to provide it. As Karen Shore, a recent honorary member and founder of the National Coalition of Mental Health Professionals and Consumers, observed [seepage 25], the Orwellian parallels are remarkable.
Various clinical sectors responded to the economic incentives of health care industrialization. There are profits in managed care if contractual payments exceed costs. Profitability has been pursued through limiting benefits, “medical necessity” screening, utilization review, and employing lowest-cost providers and methods. Economic incentives are rationalized through the following assumptions:
Illnesses are collections of symptoms.
Treatment is the relief of target symptoms.
Target symptoms generally represent brain chemical imbalances to be treated with psychopharmacologic agents.
Non-biological symptoms represent errors in thinking or behavior to be treated cognitively or behaviorally by evidence-validated therapies with laboratory efficacy.
Prime tools used by those who want to rationalize curtailment of care include the DSM IV and the managed care suitable treatment guidelines of the American Psychiatric Association. In other words, there is a pharmacological-behavioral view, which serves as both rationale and lever to support the industrialization of mental health care.
How can these problems be addressed? First we must realize that we are not alone. This process has affected all of health care. Mental health, however, was viewed as an especially vulnerable sector, subject to being carved out of the rest of coverage and given notably more stringent capitation or utilization limits. The assumption seemed to be that there would be relatively little patient, public, or professional protest because of the stigma of mental health conditions and treatment. While there was little protest initially, the public has begun to look for relief in such concrete forms as the Patients' Bill of Rights, sponsored by Reps. Charles Norwood (R-Ga.) and John Dingell (D-Mich.), including the right to sue managed care companies. It may be time to harness that general energy toward a specific quest for better mental health coverage, including benefits covering psychodynamic psychotherapy and psychoanalysis as the highest quality treatment.
We cannot stop fighting for privacy and confidentiality because they remain under threat. However, it is important to take a page from what we are learning in the continuing effort to assure privacy and confidentiality, both fundamental quality issues. To go forward means:
To address our deficiencies in developing responses to our critics.
To move broadly on public education fronts.
To forge alliances and engage with employee and business interests.
Most importantly, we need to convey to our members that we can go forward and that our own disheartenment is a formidable foe.
Specifically, we need to do the following for both psychoanalysis and psychodynamic psychotherapy:
Address the question of “medical necessity.”
Develop our own procedure-based guidelines.
Disseminate the research already available on effectiveness.
Encourage the funding of solid effectiveness research.
Work together with partners, public and professional, in the fight for psychoanalysis and psychodynamic psychotherapy as the essential services in any high-quality mental health care plan.
Use our accumulated educational, lobbying, and public information experience and contacts to work with Congress, the White House, and the state and federal regulators, including the Health Care Financing Administration, which is responsible for Medicare.
Learn to engage with employee groups, employers, and the insurance industry.
Most important of all, we need to show up.
“Medical necessity” is subject to various legitimate definitions, but it has become a catch-phrase for justifying denial of care. As the experience of the North Carolina Psychoanalytic Society illustrates, it cannot be ignored. The Milwaukee plan deals with medical necessity, as follows:
By way of determination of medical necessity, we look for evidence of chronic long-term suffering, prior unsuccessful or only partially helpful experience with briefer or less in-depth treatments, unsuccessful or only partially helpful trials of medical management, evidence of impairment in the capacity for personal intimacy, evidence of impairment in the capacity to fully use creative abilities, career stagnation, marital or other difficulties, problems with children, and a symptom complex — hysterical, obsessional, depressive, anxious, or narcissistic — usually considered appropriate for analytic intervention.
Jon Meyer, M.D., is secretary of the American, a member of the Wisconsin Psychoanalytic Society, and a training and supervising analyst at the Chicago Institute for Psychoanalysis/Wisconsin New Training Facility. He has been an executive councilor and was chair of the Ad Hoc Committee on Executive Council Structure and Function. He is currently chair of the Committee on Community Clinics.
The American needs to put together a joint task force to review medical necessity and draft a set of necessity indicators we can all endorse. An APsaA-endorsed set of standards of necessity for psychoanalytic or psychodynamic treatment would be useful, both to our members in responding to challenges and to potential purchasers reviewing health care plans.
The Peer Review Committee and the Joint Committee on Confidentiality have defined (1) a psychoanalytic note, (2) the parameters that protect patient and analyst from intrusion, and (3) the guidelines under which psychoanalysis may be reviewed. Their expertise, and that of others, is needed to address the reductionism of the DSM IV and the psychiatric practice guidelines. Beyond formulating our standards of necessity for treatment, we need our own diagnostic statements and our own practice guidelines. The difficulty in agreeing on diagnostic or practice guidelines for psychoanalysis is not to be underestimated, but it is in the interest of our present and future patients to begin the task. The DSM IV and the American Psychiatric Association Practice Guidelines have achieved the status of textbooks, not only in psychiatry but also in other mental health fields, and we must respond. It is an axiom of politics that a statement left unchallenged is no longer seen as a point of view but rather as the truth. We need substantive, well-reasoned, effective responses.
The American's science initiative is another significant development, valuable not only for its intrinsic importance but also for what it can contribute to the effort for high-quality care. While evidence-validated therapies have assumed the mantle of science, the emperor may not have very many clothes. When psychoanalysis is challenged on the basis of efficacy by comparison to evidence-validated therapies, it may be that the wrong questions are being asked.
Robert Galatzer-Levy, science advisor of the Executive Committee, noted that effectiveness studies are better than most efficacy studies, since the latter have questionable “ecological validity.” In other words, what works reductionistically with subjects in the laboratory may not work with the complexity of patients in the office. Effectiveness studies are available to us (for example, see the Open Door Review on the IPA Web site, ). We need to make more use of them. Although not at the same level of rigor, we also have reports from consumers, as reflected in Consumer Reports and in the Mellon grant to the Baltimore-Washington Society and Institute out of gratitude for a life-changing psychoanalytic experience. Research and public testimony are not comparable in scientific merit, but we learned in lobbying Congress for privacy and confidentiality that reports about and from individuals, particularly constituents, carry formidable weight. We need and should use both.
If we develop our standards of medical necessity and guidelines for psychoanalytic and psychodynamic treatment, we can then build on some of the coalitions that supported privacy and confidentiality to work further for higher-quality mental health care. As goals change, coalitions shift; nonetheless, there are powerful forces within psychiatry, psychology, social work, academia, and the public that support an improvement in quality. In Milwaukee, those who were going to have to pay for high quality mental health care through their fringe benefit rate believed that quality and access made the cost worthwhile. The administration also viewed the plan as a positive benefit to recruitment, productivity, and retention. The Milwaukee experience has also shown that analytic benefits were not abused or overused. People do not go into psychoanalysis because it is there, but because they need to.
As analysts, our strength is to enlighten and inform. We should undertake a long-term policy of educating the public, their representatives in Congress and the Bush Administration, the purchasers of insurance plans, and the insurance industry about the benefits of high quality mental health care. We have never really dealt with employers on behalf of our patients, but our members who are experienced in business consultations can help us find a strategy. Is this pie in the sky? If so, then so was the idea that a small organization could influence patient-therapist privilege and sway powerful interests toward privacy and confidentiality. We are not large in number or in funds, but we do have a focused, compelling message of privacy and quality.
Finally, the last and most important point: We have to show up. If the North Carolina Psychoanalytic Society had not organized to respond (see page 11), or if the faculty in Milwaukee had not been addressed about the threat to their benefits (see page 12), psychoanalysis and psychodynamic psychotherapy coverage would have been lost. To protect the benefits that are there, to remove the blocks to their utilization, and to restore what has been lost are difficult tasks, but we can begin. The absence of any voice speaking for quality from a broad, humanistic perspective is the worst situation of all. We have to do our homework, we need to be prepared, we need to learn new and different ropes — but first of all, we must show up.