Norman A. Clemens, M.D.
The Commission on Psychotherapy by Psychiatrists welcomes you to its fourth American Psychiatric Association (APA) Annual Meeting Forum. I chair the Commission and am Clinical Professor of Psychiatry at Case Western Reserve University in Cleveland. I'm a solo practitioner in a university hospital's multispecialty, full-service medical building. I have several patients in psychoanalysis and many others in varying combinations of psychodynamic psychotherapy and medication management.
I do not participate in any managed care plan. This is a slight problem because the primary care doctors in the building all have to, even though they don't like it. But whether I was in managed care or not, to make a psychiatric referral these doctors would have to give the patient an 800 number, and I'd probably only see those who might need medication after a social worker had evaluated them and started psychotherapy. When my psychiatry department set up its mental health managed care plan, most medical psychoanalysts like me were excluded. Later the department's plan began contracting only with multidisciplinary groups, with no new solo practitioners. Fortunately, my colleagues send me self-paying, indemnity-insured, and traditional Medicare patients, and I do quite well with these new patients and those who recycle intermittently from 37 years of practice.
Personally and professionally, the last thing I want is any contact with managed care. Though my style may differ from Harold Eist's, I am just as angry about what managed care has done to psychiatry. Managed care is perversely influencing the nature of our profession. I believe psychotherapy by psychiatrists in a managed care environment is an oxymoron. I dwell on my situation and feelings because they are like those of many APA members across the country. Disincentives to take part in managed care are severe for psychiatrists who do much psychotherapy.
So why am I here talking about “does it have to be an oxymoron?” Because managed care is big, and it's here for now, and what happens now will influence whatever follows it. According to the industry figures, managed mental health care covers up to 176.8 million Americans, about 78% of those who are insured.1 Managed care fallout lands on public psychiatric facilities: when managed care reviewers deny necessary treatment, state and county services are the safety net. Furthermore, it is profoundly affecting our training programs and our early career psychiatrists, who don't have an accumulated, loyal practice. Psychotherapy is still taught in most residencies, but there is such concern about its survival that the Psychiatry Residency Review Committee is instituting psychotherapy competency requirements to pressure residencies into beefing up their programs.
American medical graduates are selecting psychiatry 40% less often than in the early 1990s. Managed care may contribute to this in two ways. Big fee reductions imposed on a specialty already at the bottom of the income ladder may deter new graduates, who often carry more than $100,000 in educational debts. In addition, applicants see little appeal in a modern psychiatrist's professional life of doing medication checks and no psychotherapy.
The quality of psychiatric care in organized systems must be our concern. This is APA's business. It had better be managed care's business as well.
Mental health managed care has dug itself into a hole. Extreme consolidation has taken place with leveraged money, jeopardizing the financial stability of the industry (and of anyone to whom some firms owe money). Over the past decade vicious price competition has cut outlays for treatment of mental illness by 54%, compared with 7% for medical and surgical illness.2 Capitation rates are ridiculously low. Hospitalized patients are discharged “quicker and sicker,” foisting serious risks on patients and “24/7” urgent care on their psychiatrists. Expensive inpatient services have been cut, but instead of the cuts producing a compensatory rise in outpatient follow-up services, these services too have been slashed. Outpatient fee scales have fallen to absurd levels, often 70% of Medicare. For that, the psychiatrist must listen to elevator music for hours while seeking authorizations from people with much less training and minimal clinical data to go on—or else divulge masses of confidential information. Managed care fee scales and referral policies almost mandate that psychiatrists do brief medication checks instead of integrated psychotherapy and medication management if they are to make a living. Malpractice insurance claims are soaring disproportionately for high-volume psychiatric practices. (Source: Reports to APA Board and Assembly by Alan Levenson, M.D., President, Psychiatrists Purchasing Group, Inc., which manages APA insurance programs.) I don't want to belabor this series of atrocities, because everyone knows what is happening. But let's look at the inevitable results.
For one thing, most managed systems cannot offer quality in psychiatric care. With their low premium rates, 3% to 4% of the health care dollar, they just can't afford to provide comprehensive psychiatric care. Quality psychiatric care includes psychotherapy. For another, they are having a devil of a time getting psychiatrists to work in their systems. Reports now come from psychiatrists all over the country about managed care organizations (MCOs) being unable to recruit or refer to participating psychiatrists and having to refer patients out of network. This is no surprise: psychiatrists have had enough.
But these systems are responsible for funding treatment for most of the populace. And responsible psychiatrists within managed care genuinely want to provide quality care at reasonable cost. How can we ally ourselves—bring the profession together—to meet the needs of patients?
Let us focus on psychotherapy by psychiatrists. There is no doubt that psychotherapy is a vital part of psychiatric care. There is abundant evidence for its efficacy in most psychiatric illnesses—often on a par with medications, sometimes more efficacious, and frequently clinically combined with medication for enhanced effectiveness. The data are there; this is not the time to review them. Studies on cognitive-behavioral therapy (CBT) and interpersonal psychotherapy (IPT) are rigorous enough that MCOs are forced to acknowledge them and authorize some treatment—but often in courses of treatment shorter than the 12 to 20 sessions used in most of the research, and usually administered by social workers and psychologists, not psychiatrists. Psychiatrists just do the medication checks, as a rule.
In fairness, most psychiatrists aren't trained in CBT and IPT, which exacerbates the problem. But most of us are trained in psychodynamic psychotherapy and experienced in tailoring it to the needs of the individual patient, often providing therapy that is short-term and focused on specific problems. Luborsky and colleagues'3 meta-analysis of a limited number of studies comparing short-term psychodynamic treatment with other treatments found equal efficacy. Long-term, usually psychodynamic, treatment is the recognized approach for most personality disorders and other persistent conditions.4 What managed care finds hard to tolerate is a nondirective, listening environment, where the patient's flow of thoughts sets the agenda and opens surprising new vistas of understanding the roots of the problem. Managed care organizations can't systematize and manage that, even though the basic method overall is well established. So they discourage psychiatrists from doing psychodynamic psychotherapy. One managed care executive reportedly asked, “Can't you listen faster?”
We believe, though we can't now prove it, that psychotherapy and medication management integrated in the hands of one person, the psychiatrist, are more effective than split treatment where other clinicians do the psychotherapy and the psychiatrist (or internist) does medication checks. Integrated treatment increases efficiency of data collection, avoids communication breakdowns, and, most important, deals with the transference issues and distorted thought patterns that often disrupt medication compliance. Studies by Dewan5 and Goldman et al.6 suggest that integrated treatment doesn't cost more. The Goldman study was conducted by a major MCO, but it did not look at clinical outcome. Nonetheless, MCOs generally haven't gotten the message yet. Even if they have gotten it, they have driven away psychiatrists who have strong training and experience in conducting psychotherapy and can't find many psychiatrists to do this work. They have “phantom networks” in many areas. The result is a tremendous loss of value in what managed care can offer its clients.
How can we work together to achieve value in managed psychiatry? How can we bring about a working alliance? Inevitably, this will involve change and enhanced understanding on both sides. Here is my prescription to increase the involvement in managed care of psychiatrists expert in psychotherapy:
- Managed care must restore respect for psychiatrists' expertise in conducting psychotherapy.
- Actively recruit psychiatrists trained and experienced in psychotherapy.
- Avoid economic profiling that discriminates against psychiatrists with high psychotherapy case mixes, particularly long-term treatment of serious problems.
- Contract with solo practitioners, not just multidisciplinary groups.
- Establish a decent fee schedule for psychotherapy by psychiatrists.
- We must insist on systemic changes, the scope of which would require that APA and MCOs work together to achieve them.
- Advocate for significantly increased health plan outlays for mental health care to restore their previous levels proportionate to general health care.
- End discrimination against the mentally ill. Here's a real challenge: Eliminate mental health carve-out companies and integrate psychiatric evaluation and treatment with the rest of primary and specialty medical care. Failing that, make mental health management no more stringent than for other services.
- Allow all patients direct access to psychiatrists for evaluation and treatment….
- Or at least maintain point-of-service plans— with reasonable copayments—that allow patients the choice of clinician.
- Advocate truth in advertising that divulges actual limitations on available psychiatric care.
- Fire the management consulting companies that sell widely used patient review criteria based on economic rather than clinical considerations, and instead use APA Practice Guidelines that meet the needs of both acutely and chronically ill patients.
- There must be sweeping changes in review and oversight procedures, based on recognizing that effective psychotherapy requires continuity, confidentiality, and trust in the doctor–patient relationship.
- Eliminate case management of outpatient evaluation and therapies of fewer than 20 sessions, and authorize treatment in clinically realistic blocks thereafter.
- Recognize that some people need long- term psychotherapy.
- Permit denial of care only by comparably trained professionals, who identify themselves and accept responsibility for consequences.
- Eliminate MCO access to confidential psychotherapy records. The process and personal content of psychotherapy should be a black box to the MCO (in keeping with the principles stated in the 1996 Supreme Court decision Jaffee v. Redmond).
- Conduct prospective review of intensive or long-term psychotherapy with a consulting psychiatrist, who reports only “yes” or “no.”
- Stop wasting our time! Improve the mechanics of review procedures.
- Facilitate clearly accessible appeals to an independent panel.
- There must be appropriate fee scales.
- Make psychiatric fees commensurate with those of other specialist physicians.
- Make mental health care fees directly proportional to time and administrative work involved.
- End the fee structure that drastically favors medication checks over psychotherapy.
- Managed care organizations must support psychotherapy training in residencies and Continuing Medical Education for practicing psychiatrists to assure the future supply of well-trained, well-rounded psychiatrists with psychotherapy skills. Experience in intensive, long-term psychotherapy is fundamental to build the skills and the knowledge base for diagnosis, effective management of the psychiatrist-patient relationship, and facility with short-term psychotherapy.
- We as psychiatrists have to make this work. We need to show flexibility and creativity while still preserving the essentials of our craft.
- Respect managed care systems that understand the value of psychotherapy by psychiatrists and genuinely want to provide quality psychiatric care.
- Understand the management system, including the potential (currently unrealized) benefits of increasing broad access to quality care and gathering valuable data about psychiatric care.
- Improve skills in conducting short-term psychotherapy where clinically appropriate— knowing that this modality is not for everyone.
- Improve skills in prescribing specific psychotherapy modalities, including the option of intensive or long-term treatment, based on diagnosis, individual circumstances, motivation, and personality structure.
- Improve skills in communicating appropriate administrative and clinical data without divulging personal details or the content of psychotherapy. We need to clearly express our reasoning about clinical decisions.
- Develop APA Quality Indicators for psychotherapy in organized systems.
- Participate in residency training in psychotherapy skills so that future psychiatrists will preserve the uniqueness and effectiveness of psychotherapy and the doctor– patient relationship while dealing with administrative systems.
- Promote research to validate longer-term psychotherapies, especially psychodynamic, since research studies have already given time-limited psychotherapy some credibility with MCOs.
Can we do it? I don't know. We are talking about enormous changes to deal with an enormous problem. But we have to start somewhere with a message and a plan, and the Commission on Psychotherapy by Psychiatrists is committed to accomplishing this.