Evidence-based data, studies of medical-cost offset, and advocacy will be
needed to reverse the managed care industry's skeptical view of dynamic
psychotherapy, according to Paul Appelbaum, M.D.
"Research on the greater efficiency and effectiveness of integrated
therapy will be essential to restoring the provision of psychotherapy by
psychiatrists," said the former president of APA, speaking at the
winter meeting of the American Academy of Psychoanalysis and Dynamic
Psychiatry in Washington, D.C. "Without those efforts, psychotherapy
will die out, and that would be a sad end to a core aspect of psychiatry for
over 100 years."
Psychotherapy was an early target of managed care organizations (MCOs)
during their ascendancy in the 1990s, said Appelbaum, chair of the psychiatry
department at the University of Massachusetts Medical School and director of
its law and psychiatry program.
Psychiatric illness could be dismissed both as "not real" and"
untreatable," so that paying for treatment was deemed not
worthwhile, he said. MCOs slashed mental health spending by 54 percent from
1989 to 1998, helped by an "oversupply" of clinicians, especially
nonphysicians. The overall percentage of payments for mental health treatment
fell in the same time from 7.2 percent to 5.1 percent (not counting
medications) and now hovers around 2 percent, a decline that only confirms to
employers just how unimportant mental health benefits are, he said.
There were hidden burdens to managed care besides reduced payments.
Physicians had to bear added costs of utilization reviews, costs of rebilling
when invoices were rejected for minor clerical errors, or long-delayed
payments even when bills were correct.
Managed care also had disproportionate effects on the practice of
psychotherapy, said Appelbaum. More patients were seen at least once, but the
number of visits per patient dropped, reducing the intensity of therapy. An
increased emphasis on psychopharmacology meant that while expenditure per
patient remained flat (going from $79 to $78 for adults from 1992 to 1999),
the mean number of prescriptions rose from 4.3 to 5.9 per user, and mean
expenditures rose from $166 to $326 per year, he said.
"More money was spent on pills, not on people delivering care,"
The MCOs also made it more financially rewarding for psychiatrists to bill
for short pharmacology visits than for longer psychotherapy. He cited one
study showing that psychiatrists might receive $107.64 for a single 45-50
minute therapy session, but could reap $182.16 for three 15-minute
medication-management visits. Many hospitals and clinics now hire
psychiatrists only to write prescriptions.
Even when authorized, care was often divided among several practitioners,
"This leads to difficulties in coordinating care," said
Appelbaum. "You lose part of the picture of what's going on with the
One difficulty in making the case for psychotherapy coverage lies in its
inherent incompatibility with the idea of health insurance, added APA
President-elect Steven Sharfstein, M.D. For health insurance to work, there
must be some definable treatment for a definable illness, one with measurable
outcomes, he said.
Instead of this clarity, there are more than 400 kinds of psychotherapy
with few data on what works and why.
"What works best? Short- or long-term therapy? Group or individual
treatment?" asked Sharfstein, president and chief executive officer of
the Sheppard Pratt Health System in Maryland. "The effect may be due as
much to the therapist as to the therapy."
This lack of specificity among therapies makes it hard to match patients
with therapists who could treat them best, he said, and the nature of
psychotherapy makes it hard to fit into the mold of managed care.
"Psychotherapy takes time," said Sharfstein. "It does not
follow a smooth curve because each session is not an individual
Meantime, health care costs are still rising, insurance companies too often
offer minimal benefit packages with little or no mental health coverage, and
medical savings accounts will shift the burden of outpatient treatment to
patients and families, said Appelbaum. One comprehensive solution, universal
health coverage, remains "unimaginable," he said. So bringing
mental health treatment back from the brink means making the case for the
effectiveness of psychodynamic therapy and the inefficiencies of split
"We need data on evidence-based treatments, studies of when
psychotherapy works, in what settings, and for which disorders," he
said. "We need cost-offset studies to show when medical expenses are
reduced with increased psychotherapy, and we need to demonstrate to businesses
that `presenteeism' is an enormous drag on the economy." ▪