In my last post I outlined some complexities of third party payment for office psychiatry, and especially for psychotherapy. As my example I used Medicare, the only third party payer I bill. Some of the problems include complex billing (i.e., collecting from multiple parties), partial reimbursement, unrealistic documentation requirements, loss of patient confidentiality, and a misplaced emphasis on medication “evaluation and management” over psychotherapy. There are also challenges specific to dynamic psychotherapy, such as obscuring the transference. But I saved the most fundamental issue for this post: Does third party payment for psychotherapy make sense in general?
This may seem a puzzling question, coming from me. I not only value deeply what psychotherapy offers, I make my living from it. Shouldn’t it go without saying that psychotherapy should be paid for somehow, no matter where the money comes from? My experience with public and private health insurers tells me otherwise.
“Medical necessity” is the linchpin, and frankly the problem. The more a therapeutic encounter fits a medical model and is arguably “necessary” in that framework, the more readily it is covered by health insurance. Psychotherapists of all stripes tiptoe uncomfortably around this issue. Medication management fits the medical model very well, so psychiatrists who incorporate this into their psychotherapy sessions enjoy outsized reimbursement (or their patients do). Talking about anything else, no matter how central to the patient’s presentation, does not fit the medical model nearly as well. Nonetheless, psychotherapists who offer a step-by-step approach aimed concretely at relief of symptoms emulate medical evaluation and treatment much more than those who employ open-ended, exploratory approaches to tackle dysfunctional family dynamics, chronic self-sabotage, and many other concerns for which people seek psychotherapy (and later report benefit; see Consumer Reports, November 1995, Mental health: Does therapy help? pp. 734-739, and this analysis of the Consumer Reports survey by Martin Seligman). Note that the crucial variable for coverage is not what helps more, or relieves more agonizing misery. It’s what seems more “medical.”
Using “medical necessity” as the criterion to treat human misery that often isn’t medical at all leads to much inconsistency and even cruelty. As mentioned in my last post, insurers demand that I code my “procedure” (i.e., the session) depending on what we talked about. If we spend the hour discussing medications, even if this focus can easily be understood as a symbolic, unconscious appeal by the patient for care-taking or some other emotional need, it’s worth far more to the insurer than if we spend the same hour explicitly discussing the patient’s experiences and reactions to actual caretakers. (As added irony, the latter discussion can obviate the former in future sessions, a detail lost on insurers and most everyone else.) Since private insurance partly reimburses many of my non-Medicare patients based on how their sessions are coded, an agitated, marginally employed, chronically suicidal patient with severe personality issues is reimbursed far less over time than a high-functioning, stably-employed patient with a medication obsession. This makes no sense and is blatantly unfair.
The truth is, I’m the same expert — and put bluntly, worth the same amount of money — no matter what I’m discussing with the patient. That is, as long as I have the integrity to focus on the patient’s central issues, not to provide or bill for unneeded services, not to offer hand-waving in lieu of explanation, not to mindlessly prescribe medication after medication, not to casually chat and call it psychotherapy, and so forth. In other words, I need to be a good doctor instead of a sloppy or unethical one. I need to know when to be “medical” and when not to be.
Traditional dynamic psychotherapy fits the medical model especially poorly. It is not primarily focused on symptom relief. The treatment is not tailored to diagnostic categories. It follows no step-by-step sequence. Even expert practitioners often cannot estimate treatment duration. After many decades of published studies the evidence base for treatment efficacy still triggers heated debates. Arguing “medical necessity” for such treatment is at best unnatural, at worst contrived or even misleading. (It’s even more absurd to argue the medical necessity of one specific session in an ongoing treatment; to me, this is like asking whether the 10th note in a piano concerto is “musically necessary.”) Those of us who recognize the value of dynamic work and have seen patients change in important, fundamental ways are kept busy trying to pound this square peg into a round hole. But CBT doesn’t avoid this problem either: it’s more like a square peg with rounded corners.
Faced with the struggle to show medical necessity, it’s tempting to wonder whether psychotherapists should refuse to play this game. However, opting out isn’t easy. Even if I chose not to be a Medicare provider — I admitted my mixed feelings about this last time — self-pay patients with private insurance would still seek maximal reimbursement for seeing me. I can hardly blame them. I see no way out of participating, at least indirectly, in this misapplied standard of medical necessity.
It’s hard enough to assure that all Americans have access to basic health care. Assuring that all have access to mental health care is one step harder, even when that care accrues only to the seriously mentally ill and fits the medical model very well. It will be a very long time indeed before America deems it worthwhile to offer psychotherapy to the so-called worried well: those who have all their faculties but are miserable due to inner conflicts, self-defeating beliefs, or a traumatic past. If that day ever comes, it will be when medical necessity is supplanted by a more fitting standard, one that judges mental distress and its treatment on their own merits, and not by borrowing legitimacy from medicine.