President’s Column, September 2010
By Seth Warren
In a recent email exchange on our CPPNJ listserv, one of our faculty members, Bob Raymond, raised a controversial and, I think, essential question for all of us as psychoanalysts and psychotherapists to consider. He was responding to the dismay of a list member who was reporting that sex therapy was not covered by a client’s health insurance plan.
I am reproducing Bob’s full email posting, with his permission:
I would ask: why aren't we educating potential clients to understand that not all problems for which they seek help from a therapist can or should be covered by medical insurance? When it comes to relationship problems, and for purposes of this post I will suggest that a good starting place for dealing with sexual problems is to look at the relationship, why should prospective clients have the expectation that their insurance will cover treatment?
And more importantly, why are we not, as therapists who do not want our work to be controlled by insurance companies, assertively taking the position that non-medical disorders should be paid for directly by individuals seeking our services for non-medical problems?
I would like to take this opportunity to explore the question of insurance reimbursement, the medical model, DSM diagnosis, and the future of psychoanalysis. I understand that this subject is complicated and also controversial, and that this present format cannot do it full justice, but my purpose here is to stimulate some thinking and dialogue about these issues, which I believe are very close to the heart of some major contradictions we face as psychoanalytic practitioners.
Most, if not all of us, have encountered the dismaying, demeaning, and alienating impact of insurance companies on the practice of psychotherapy. It has become almost impossible to practice psychotherapy without experiencing the degrading and dehumanizing bureaucratic procedures of “managed care,” the routine violations of patient privacy, disgracefully low in-network psychotherapy fees, and artificially manipulated out of network fees. It seems pretty clear that the situation has worsened significantly in recent years, and given the ongoing crisis in rising health care costs, and the political paralysis our nation apparently faces in relation to any substantial change in the way health care is provided in the US, the situation is likely to deteriorate further.
The implementation of the Federal Mental Health Parity Act during recent and coming months will likely provide some relief for some of the abuses of the health insurance industry. There is some indication now that some insurers may reduce or abandon certain types of outpatient “care management,” and for some people mental health services will be more accessible. And, the passage this year of the federal health care reform bill will also likely increase significantly the number of people covered by health insurance, and hence able to seek at least some mental health services.
But if we are honest about it, we must admit that these changes do relatively little to support psychoanalytic practice. The health insurance industry has made it very clear that it will seek to avoid reimbursement for intensive, depth-oriented psychotherapy, has dismissed diagnostic formulations regarding personality functioning, and continues to demand a kind of empirical research support for the efficacy of mental health treatments that is in many ways contrary to the basic worldview, sophisticated clinical outlook, and philosophical assumptions of psychoanalytic therapists.
I am well aware that psychoanalysts were among those who fought, decades ago, to have psychotherapy included as a covered treatment in health insurance. The inclusion of psychotherapy in health insurance plans led to a great expansion in the US in the accessibility of psychotherapy for a much broader range of patients. It led to increased compensation for skilled psychotherapy practitioners, and opportunities for a much larger pool of mental health workers of all kinds.
However, this inclusion also involved significant compromises. It meant a reliance on a medical framework for diagnosis, which is the only framework recognized by insurance companies. It meant the use of medical descriptions of psychotherapy procedures. It also has led to increased documentation requirements impinging on the confidentiality of patient-therapist relationships. And more recently, with the rise of managed care, it has meant even more unacceptable violations of confidentiality, and administrative methodologies totally alien to the mindset and practices of psychoanalysts, such as “treatment request forms,” telephone reviews of treatments, and behavioral conceptualizations of problems, goals, and treatments.
Finally, third-party reimbursement enters into every affected treatment situation as a complicating clinical element. It affects fee arrangements, alters the financial relationship of patient and therapist, creates difficult transference and countertransference issues around money, dependencies, privacy, autonomy, and greed. I understand that we all deal with these issues as they arise, viewing them as another kind of “grist for the mill,” accepting these various intrusions into our work as ‘just the way things are.’ But, to return to Bob’s questions, I would ask whether we as a practice and a tradition are coming to a crossroads. Or, maybe more accurately, coming to a place where we have to consider the possibility that continued cooperation with the current system of third party insurance reimbursement is really a dead-end for psychoanalytically-oriented psychotherapists (by the way, the dismay of my more CBT-oriented colleagues suggests that we are not alone in reaching this point).
I know that this is controversial. I know that almost all of us are at least partially involved in the system of insurance reimbursement, and the thought of giving up any part of our livelihoods is frightening and disturbing. I understand very well the dismay we all may have at living in a world where it is much harder to make a living as a dedicated, well-trained, and well-intentioned psychotherapist seeking to ameliorate human suffering and encourage growth, efficacy, and aliveness in our fellow humans, than it is to make a living as a banker or corporate lawyer or insurance company executive. But – political action aside – we do not choose or control the world we live in, only the choices we ourselves make.
I also understand that the distinction between “medical” conditions and “psychological” conditions is a misleading one. I believe effective psychotherapy has a significant positive impact on our patients’ overall health. There is a large body of research to support this contention. Research suggests that people with free access to psychotherapy use significantly fewer medical health care resources. I think in many ways we psychotherapists have become among the most effective primary care practitioners, spending time with patients, listening to them, establishing meaningful relationships with them, helping them deal with their physical health issues, making constructive choices around behavioral health issues such as smoking and substance use, food and eating issues, dealing with stress, anxiety, and other factors that adversely effect overall health and functioning. It does not seem unreasonable to me to consider psychotherapy as a cost-effective treatment modality that promotes overall health and well-being, and that in a perfect world, our work to this effect would be properly compensated by a health care system. Yet again, this is not the world we live in.
But to follow Bob’s logic and push things a bit further, is it really a good thing – for us and our patients – to be as dependent on third-party reimbursement as we have become? What are we doing to challenge the “$10 copay” mentality an increasing number of our referrals come with? How are we challenging the logic of the health insurance system, which is shaping and encouraging attitudes about how to choose health care providers by funneling patients into networks? How often do we hear now about people looking for an in-network therapist? The majority of referral requests I see on email lists I subscribe to are in-network requests – and that is including psychoanalytic lists. How are we challenging potential patients’ views about using in-network benefits, or relying on third-party reimbursements? Often I see posts that say something like, “needs to use in-network benefits.” But how are we assessing that? How are we defining what we do in relation to those perceived needs? While I am certain there are many patients who cannot pay for psychotherapy on their own, there are also many patients who may be able to afford treatment but are making choices about how they use their money based on priorities, in part, structured by our health care system.
In short, what has become of true fee-for-service psychotherapy? Real private practice? How hostile to the interests of psychotherapists does the health insurance context have to become before we reject that framework entirely? If we really believe, as I do think we do, that managed care is fundamentally contrary to best clinical practices as we understand them, at what point do we say so publicly, and reject that model as a violation of our basic principles, ethics, and understanding – forgoing the reimbursements cooperation with that system brings.
I think that Bob is pointing toward an essential function of our institute and our field: namely, the education of consumers of mental health services about what we really know and believe about psychotherapeutic treatments; about the essential inadequacy of DSM diagnoses; about the importance of true privacy and confidentiality in psychotherapy; about the serious limitations of the insurance-driven health care model; and about our own value as experts working with one (disparaged) foot in the health care system and one foot in a very different model that values real privacy, respect for individuals, appreciation of the complexity and multi-dimensionality of the clinical problems we address, and belief in the social, cultural, developmental, and moral (i.e., non-medical) contexts of our clinical theories and work.
We are not likely to convince the insurance companies, but I think we’re going to have to make our case to the public. And we might have to reconfigure our practices, our fees, and policies, and our identities, to become more congruent with our beliefs and clinical worldview. We will need to assert the value of what we do and our particular contribution, especially in a culture that seems to be less and less hospitable to psychoanalytic thinking and practice.
Your comments to Seth's article are welcome. Please send letters to the editor at email@example.com.