Sometimes, our country leads the world in ways that we wish it didn't. For some 20 years, healthcare practitioners, particularly psychoanalysts and psychodynamic psychotherapists, here have been struggling with increasing threats to our patients and our profession in the form of intrusive third-party payers, increasing government regulation, and threats from lesser-trained therapists purporting to be psychoanalysts. Interestingly, Europe and Latin America have both begun to come under the same kind of pressure. Country after country is reporting increasing difficulties with these same challenges.
While we do not have a single-payer system in this country, many have argued that this would save our badly broken health-care system. Single-payer is the system of choice in a number of countries in Latin America and Europe. In this system, the government, rather than private companies, is the primary payer (as with Medicare). Germany is one such country and we can learn a great deal from their experience. What has happened in Germany is an object lesson in both the benefits and hazards posed to psychoanalysis when the government is the main health-care supplier and payer.
I am greatly indebted to Ekkehard Gattig of the German Psychoanalytical Association for supplying much of the information that follows. It is clear from his report that when the government controls the delivery of health care, the problem of corporate entities maximizing their profit margin by continually reducing the cost and amount of health care delivered is avoided. However, inevitably, the government begins to do the same thing, and begins to behave precisely like HMOs behave in this country. The government starts to cut costs by reducing the amount of health care that is delivered.
In Germany 90 percent of the citizens are insured under public health insurance schemes. Since 1967, Germany has had legislative guidelines for psychotherapy, which detail the kind and extent of psychotherapeutic services which may be offered. Psychoanalysis is included under the rubric of “psychotherapy” for purposes of management by the government. In order to embark upon treatment, a psychotherapist or psychoanalyst has to submit an application and an extensive report to prove that the proposed treatment is medically necessary (yes, they have that, too) and that the treatment is “necessary, appropriate, and sufficiently promising as to outcome.”
Initially, the government insurance would only reimburse for symptom relief and not for a treatment aimed at relieving unconscious conflict or creating structural character change. However, the German Psychoanalytical Society argued that structural change was indeed a legitimate goal, and from 1976 on this was included within the scope of treatment guidelines.
Treatment could only be done, however, by medical doctors and qualified psychologists. The total number of sessions was limited to 300 for analytic psychotherapy. The assumption was that a proper analytic therapy would be finished within that number, and the patient was assumed to be cured either before or when that number had been reached. Apparently, the German regulators operate in the same way as the U.S. Congress, i.e., “in a data-free environment.”
In December of 1992, the board responsible for the regulation of psychotherapy guidelines, the Federal Committee of Medical Doctors and Health Insurances, decreed that psychoanalytic treatment of more than three sessions per week would not be covered by public health insurance. The following rationale was offered: “Analytic psychotherapy as a long-term therapy with a frequency of four or more hours per week cannot be applied in accordance with psychotherapy guidelines because no scientific proof exists of any specific indication for it or of its greater therapeutic efficacy.”
While Gattig and his group suspected that this decision had been made for financial reasons, they were subjected to further arguments that high frequency psychoanalysis, and the so-called Kleinian turning-point, endangered the whole system of guideline psychotherapy by inducing a deeper regression, which caused it to systematically exceed the number of allowed sessions. The problem became even more serious when so-called analysts of other groups, and even some traditionally trained IPA analysts, joined in the government's argument. The German association was also concerned that private insurers might follow the lead of the Federal Committee.
The German Psychoanalytical Association found themselves, as we often have, fighting a lonely battle. They are the only group in Germany that feels strongly about “high-frequency treatment.” Apparently, they are the only group that teaches or practices in this way. To further complicate this situation, the limitation on frequency was applied to the training of candidates as well, thus endangering the German association's educational system for candidates.
In their efforts to fight back, interestingly, the German association followed a similar path to that which our own Association has followed. When dealing with the regulating governmental agencies failed, they turned to a legal solution. The German association then
Bob Pyles, M.D., is chair of the Committee on Government Relations and Insurance and a past president of APsaA.
focused on a two-pronged attack: (a) seeking legal clarification of the legality of exclusion of high-frequency treatment and (b) gathering scientific proof that this treatment is medically necessary, appropriate and economical.
The analysts felt strongly that the actions of the regulating committee constituted an unconscionable interference and that the “rights of a psychoanalyst could be violated” if forced to practice in accordance with the guidelines. Their opinion was confirmed by lawyers, who felt that this was a “clear violation of the basic right of every medical doctor to be free and to practice his profession.”
They retained counsel and confronted the committee with their judgment that the rights of the therapists and the patients were being illegally interfered with. Faced with the possibility of a lawsuit that they might well lose, the Federal Committee backed down and re-opened talks.
In their effort to prove that the analytic method is not only necessary but effective, and cheaper than other methods of psychotherapy, the German association prepared a manual describing the psychoanalytic method and its application to the insurance system. The manual, entitled The Indication for High-frequency Analytic Psychotherapy within the Public Health Insurance System, substantiates the need for high-frequency treatment by two lines of argument. The first describes the greater emotional intensity of the therapeutic relationship and the resultant handling of transference, countertransference, and resistance. The second deals with the reasons why high-frequency treatment should be included in the psychotherapy guidelines. The manual enabled the association for the first time to clearly demonstrate how psychoanalysts work. In addition, clinical data gathered from many individual papers were collated and put together in a single powerful argument.
The resultant negotiations with the public authorities have been concluded with something of a compromise but certainly a kind of victory. The assertion that psychoanalytic treatment involving four or more sessions per week is unscientific has been deleted. The new guidelines state that psychotherapy should be carried out within the frequency limits of two to three sessions a week. However, if the analyst deems it necessary, he may for a certain length of time analyze his patient for five sessions a week by filing an additional application. The public health reimbursement is capped at 300 sessions in total. The new guidelines also apply to candidates. Patients and candidates retain the right to pay privately for additional weekly sessions, and they can extend the analysis at their own expense once the 300 session cap is reached.
In summarizing their experience, Gattig ruefully notes that the term “psychoanalysis” cannot be protected and, therefore, it is inevitable that it will be misused. He underlines that the German experience illustrates the importance for analysts to present their case and exert an influence on the system to insure that psychoanalysis retains a respected place in society and a base from which we can describe our method and illustrate its advantages over other treatment methods.