LAZAR AND YEOMANS GUEST EDITORS’ INTRODUCTION
Guest Editors’ Introduction Susan G. Lazar and Frank E. Yeomans This Special Issue* of Psychodynamic Psychiatry, “Psychotherapy, the Affordable Care Act and Mental Health Parity: Obstacles to Implementation,” is written to address a moment of both crisis and opportunity with respect to the health of the nation. The ongoing crisis lies in the psychiatric illness that affects one half of the population during some point in their lifetimes; illness which is stigmatized, undiagnosed, and more often than not, treated inadequately if treated at all. Untreated psychiatric patients fill our jails and the ranks of the homeless. Undertreated psychiatric illness leads to enormous losses in the form of increased healthcare costs, disability, morbidity, mortality, diminished productivity, and human suffering. Opportunity lies in the 2008 Mental Health Parity and Addiction Equity Act (MHPAEA) mandating the provision of mental health care at parity with all other medical care and the fact that the 2010 Affordable Care Act (ACA) mandates mental health care including psychotherapy as one of the 10 Essential Health Benefits. But significant obstacles to this breakthrough legislation remain, particularly in protocols used by insurance companies to rationalize limitations on treatment consistent with immediate cost considerations but not with clinical needs. In the May 3, 2014 Director’s Blog: The Paradox of Parity from The National Institute of Mental Health, Director Thomas Insel raises the concern about coverage for efficacious psychosocial treatments and states that “we care deeply that those non-pharmacological treatments that have been shown to be helpful are disseminated and reimbursed broadly . . . It would be a sad irony if in the era of parity only those who could afford to pay out of pocket could get access to effective psychosocial treatments.” We would like to acknowledge our gratitude to Julianne Dorset, Research Assistant to William Sledge, M.D., Department of Psychiatry, Yale School of Medicine, for her meticulous care in editing the majority of the articles in this special issue. *The articles in this Special Issue were written by The Committee on Psychotherapy of the Group for the Advancement of Psychiatry.
Psychodynamic Psychiatry, 42(3) 347–352, 2014 © 2014 The American Academy of Psychoanalysis and Dynamic Psychiatry
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Perhaps the largest group of psychiatric patients at risk of undertreatment is those with chronic, severe, and complex illness, including personality disorders (up to 10% of the population), chronic anxiety and/or depression, and multiple diagnoses. Given proper treatment, often including a more extended and at times also intensive psychotherapy, many, and perhaps most of these patients can improve significantly. In fact, years after treatment ends with extended psychodynamic psychotherapy, these patients, in addition to other diagnostic groups of patients, continue to improve in mental health, productivity, and overall health status with lowered health care expenses. This long-term ongoing consolidation of health improvement, even years after extended psychodynamic psychotherapy, is sometimes referred to as “the sleeper effect” which is noted only with careful long-term follow-up. This effect compares favorably with the fading effects of briefer treatments, including cognitive-behavior treatment. Research suggests that the sleeper effect is correlated with the improvement in interpersonal relationships and self-image that can be traced to psychodynamic approaches. The takeaway is that chronically ill patients need more extensive psychotherapy which yields health gains and is often cost-saving over the long run. Unfortunately, in the current insurance and practice environment, these patients are all too frequently unable to access this care. This Special Issue includes seven articles relevant to the provision of psychotherapy including the pertinent legal and regulatory issues and current insurance practices that too often severely limit reimbursement. Two articles address the research data on the efficacy and cost-effectiveness of psychotherapy for the major psychiatric diagnoses with particular emphasis on those who are most negatively affected by arbitrary limitations on its provision. Other articles address the enormous challenge of the mental health needs of military service members and veterans, the current practice environment which confronts providers of psychotherapy, the impact on workers’ productivity of untreated psychiatric illness, and obstacles to the training of psychotherapy to residents in psychiatry. “In Name Only? Mental Health Parity or Illusory Reform” by Meiram Bendat, J.D., M.F.T., healthcare attorney and psychotherapist, explains the historic need for mental health parity legislation and analyzes the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) in conjunction with the Affordable Care Act (ACA). Despite the mandates for parity, insurers continue to circumvent the law with intrusive “peer reviews” based on proprietary clinical protocols that are much more stringent than the nuanced and clinically sensitive guidelines adopted by mental health care providers and their professional organizations.
GUEST EDITORS’ INTRODUCTION
349
Other parity violations include the use of arbitrary algorithms to flag high-needs patients and ration their care with prospective, predetermined reviews, practices not used in reviewing other medical claims. The author recommends both provider alertness to often subtly rationalized parity violations and also outlines potential legal and legislative remedies. “The Efficacy of Psychotherapy: Focus on Psychodynamic Psychotherapy as an Example” by Kenneth N. Levy, Ph.D., Johannes C. Ehrenthal, Ph.D., Frank E. Yeomans, M.D., Ph.D., and Eve Caligor, M.D., presents a review of empirical data that support the efficacy of psychotherapy in treating mental illness, with a focus on psychodynamic psychotherapy. This article challenges the common misconception that psychotherapy is an imprecise and ineffective treatment, a misconception that has been associated with the current relative decrease in reimbursement for effective psychotherapy. The increasing body of psychotherapy research supports maintaining psychotherapy as a cornerstone of psychiatric education and practice. The current trend to disregard this literature, which is often the position of insurance companies with regard to reimbursement, puts the public at risk of being deprived access to treatments that can provide long-term improvement of both symptoms and productive engagement in life. This research literature should also have a hand in guiding policy makers in the application of the mental health provisions of the ACA. “The Cost-Effectiveness of Psychotherapy for the Major Psychiatric Diagnoses” by Susan G. Lazar, M.D., summarizes a nearly 40-year survey of the medical literature relevant to the cost-effectiveness of all kinds of psychotherapy for the major psychiatric illnesses. Most of the studies found in a systematic search reflect cost-effectiveness and at times cost savings (“cost-offset”) in overall health care costs, increased productivity, and decreased morbidity and mortality. The group of patients focused on primarily are those most in need of a longer and more intensive psychotherapy, namely the more severe and chronically ill with personality disorders, chronic anxiety and/or depression, and comorbid, complex disorders. Such patients are currently at high risk of inadequate care due to inadequate insurance coverage. Undertreated, they remain vulnerable to residual and recurrent illness with all of its associated sequelae in lowered productivity, dysfunctional relationships, higher overall medical costs, and increased morbidity and mortality. “The Mental Health Needs of Military Service Members and Veterans” by Susan G. Lazar, M.D., reviews the high prevalence of psychiatric illness in our active duty military and veterans and their urgent need for greater access to effective treatment. Only 23% to 40% of return-
350
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ing military who met strict criteria for any mental health problem in 2004 received psychiatric care after coming home. One fourth of active duty service members have a psychiatric disorder with the prevalence of all disorders, particularly posttraumatic stress disorder, major depressive disorder, bipolar disorder, generalized anxiety, and intermittent explosive disorders increasing with each deployment, especially three or more. Their untreated psychiatric illnesses are associated with increased substance abuse, medical illnesses, decreased employment, family dysfunction, and suicide, currently occurring at a rate of 22 per day among veterans. In addition to the need for increased access to care, Veterans and Department of Defense treatment guidelines need to include recommendations for the research-documented, more extended psychotherapy needed for service members and veterans with chronic, severe, and complex psychiatric disorders to achieve full recovery. We remain far from the goal of providing full mental illness treatment for all military service members and veterans in need. “Obstacles to Early Career Psychiatrists Practicing Psychotherapy” by Norman A. Clemens, M.D., Eric M. Plakun, M.D., Susan G. Lazar, M.D., and Lisa Mellman, M.D., outlines the difficulties encountered by early career psychiatrists who face a practice environment in which their use of psychotherapy, an essential psychiatric tool, is discouraged by insurance reimbursement practices. In fact, there is a steady decline in the practice of psychotherapy by psychiatrists. The psychiatrist, as a physician, is the only mental health professional capable of providing a differential diagnosis with other medical illness, making fully informed referrals to other physician specialists, prescribing medication, and functioning as a supervisor, consultant, and mental health team leader who can assume full medical responsibility for patient care. The obstacles to coverage of psychiatrist provided psychotherapy pose a serious risk to the opportunities for the physician mental health specialist to consolidate psychotherapeutic skills. Being an expert and experienced psychotherapist serves both as a crucial treatment tool for the psychiatrist physician and also provides vital skills in differential diagnosis and skillful team management, especially with complex treatment situations. This article calls for vigorous advocacy for the enforcement of mental health parity, appropriate payment levels for psychotherapy provided by psychiatrists, and freedom from insurance companies’ parity violation of intrusive case management protocols not utilized in their management of other medical care. “Workplace Effectiveness and Psychotherapy for Mental, Substance Abuse, and Subsyndromal Conditions” by William H. Sledge, M.D. and Susan G. Lazar, M.D., addresses the underappreciated disabling impact of psychiatric illness and subclinical psychiatric illness on workers’
GUEST EDITORS’ INTRODUCTION
351
productivity. This article discusses the complex variables from the perspectives of the different stakeholders involved in constructing a policy for the recognition and treatment of these disorders. Important variables include understanding the epidemiology and the negative impact of inadequate care for psychiatrically ill workers, identifying cost-effective treatments, and removing barriers to patients’ access to them. While all psychiatric illnesses occur among workers, substance abuse, depression, and especially subsyndromal depression have a profound negative effect on workers’ productivity and increased medical care visits and expenses. Studies on the cost-effectiveness of different psychotherapeutic treatments that improve health and productivity are reviewed. Research supports the value of employee assistance programs, specialized cognitive-behavioral treatments, and brief and longer term psychodynamic interventions for different populations of psychiatrically ill workers. Currently employers are insufficiently aware of which evidence-based treatments can mitigate the negative impact on these workers’ health and productivity and are most appropriate for which diagnoses. Given the relevant data, employers are in a more informed position to negotiate proper worker benefits with insurance companies which have at times been reluctant to approve them. “Current State of Psychotherapy Training: Preparing for the Future” by Jerald Kay, M.D. and Michael F. Myers, M.D., provides an overview of what is currently being taught in psychiatry residency programs about psychotherapy in general and discusses the evolution of changes in the field related to mental health parity and the Affordable Care Act (ACA) in particular. These two latter mandates provide the opportunity to redress a relative degree of neglect that has occurred in many training programs with regard to psychotherapy training. While accrediting bodies support the central role of psychotherapy in psychiatric training and practice, there is talk of a “lost generation” of psychotherapy faculty. Timely attention to this vital issue and vigorous advocacy for implementation of true parity are required to remedy the problem. Future psychiatrists must have a firm grasp of not only the principles of psychotherapy but also the development of increasingly effective and evidence-based psychotherapies if they are to be effective health care leaders. The authors conclude with recommendations to residency training programs and to residents themselves regarding what is considered essential in both the curricular and clinical exposure to psychotherapy training. Tomorrow’s psychiatrists have a fiduciary responsibility of advocating for their complex and chronically ill patients, including their psychotherapy needs. This Special Issue surveys current issues impacting the availability of many kinds of psychotherapy for the diverse populations in need. The
352
LAZAR AND YEOMANS
legal and regulatory landscape has changed in a promising way that opens the possibility for more access to evidence-based appropriate psychotherapeutic treatments. Obstacles in the practice environment and challenges in training psychiatrists to deliver psychotherapy are outlined. Among the impediments to provision of appropriate psychotherapeutic treatments is a widespread lack of appreciation for the robust research base documenting its efficacy and cost-effectiveness for particular psychiatric diagnoses. Perhaps the most daunting obstacle lies in the opposition of insurance entities which are similarly unaware of the research and driven more by concerns regarding their business models and short-term costs. An important goal lies in expanding the dialogue so that these stakeholders also can become more focused on the health, long-term costs, productivity, morbidity, and mortality experienced by patients, their families, their employers, and their communities when proper care is not supported.
Copyright of Psychodynamic Psychiatry is the property of Guilford Publications Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Guest Editors’ Introduction Susan G. Lazar and Frank E. Yeomans This Special Issue* of Psychodynamic Psychiatry, “Psychotherapy, the Affordable Care Act and Mental Health Parity: Obstacles to Implementation,” is written to address a moment of both crisis and opportunity with respect to the health of the nation. The ongoing crisis lies in the psychiatric illness that affects one half of the population during some point in their lifetimes; illness which is stigmatized, undiagnosed, and more often than not, treated inadequately if treated at all. Untreated psychiatric patients fill our jails and the ranks of the homeless. Undertreated psychiatric illness leads to enormous losses in the form of increased healthcare costs, disability, morbidity, mortality, diminished productivity, and human suffering. Opportunity lies in the 2008 Mental Health Parity and Addiction Equity Act (MHPAEA) mandating the provision of mental health care at parity with all other medical care and the fact that the 2010 Affordable Care Act (ACA) mandates mental health care including psychotherapy as one of the 10 Essential Health Benefits. But significant obstacles to this breakthrough legislation remain, particularly in protocols used by insurance companies to rationalize limitations on treatment consistent with immediate cost considerations but not with clinical needs. In the May 3, 2014 Director’s Blog: The Paradox of Parity from The National Institute of Mental Health, Director Thomas Insel raises the concern about coverage for efficacious psychosocial treatments and states that “we care deeply that those non-pharmacological treatments that have been shown to be helpful are disseminated and reimbursed broadly . . . It would be a sad irony if in the era of parity only those who could afford to pay out of pocket could get access to effective psychosocial treatments.” We would like to acknowledge our gratitude to Julianne Dorset, Research Assistant to William Sledge, M.D., Department of Psychiatry, Yale School of Medicine, for her meticulous care in editing the majority of the articles in this special issue. *The articles in this Special Issue were written by The Committee on Psychotherapy of the Group for the Advancement of Psychiatry.
Psychodynamic Psychiatry, 42(3) 347–352, 2014 © 2014 The American Academy of Psychoanalysis and Dynamic Psychiatry
348
LAZAR AND YEOMANS
Perhaps the largest group of psychiatric patients at risk of undertreatment is those with chronic, severe, and complex illness, including personality disorders (up to 10% of the population), chronic anxiety and/or depression, and multiple diagnoses. Given proper treatment, often including a more extended and at times also intensive psychotherapy, many, and perhaps most of these patients can improve significantly. In fact, years after treatment ends with extended psychodynamic psychotherapy, these patients, in addition to other diagnostic groups of patients, continue to improve in mental health, productivity, and overall health status with lowered health care expenses. This long-term ongoing consolidation of health improvement, even years after extended psychodynamic psychotherapy, is sometimes referred to as “the sleeper effect” which is noted only with careful long-term follow-up. This effect compares favorably with the fading effects of briefer treatments, including cognitive-behavior treatment. Research suggests that the sleeper effect is correlated with the improvement in interpersonal relationships and self-image that can be traced to psychodynamic approaches. The takeaway is that chronically ill patients need more extensive psychotherapy which yields health gains and is often cost-saving over the long run. Unfortunately, in the current insurance and practice environment, these patients are all too frequently unable to access this care. This Special Issue includes seven articles relevant to the provision of psychotherapy including the pertinent legal and regulatory issues and current insurance practices that too often severely limit reimbursement. Two articles address the research data on the efficacy and cost-effectiveness of psychotherapy for the major psychiatric diagnoses with particular emphasis on those who are most negatively affected by arbitrary limitations on its provision. Other articles address the enormous challenge of the mental health needs of military service members and veterans, the current practice environment which confronts providers of psychotherapy, the impact on workers’ productivity of untreated psychiatric illness, and obstacles to the training of psychotherapy to residents in psychiatry. “In Name Only? Mental Health Parity or Illusory Reform” by Meiram Bendat, J.D., M.F.T., healthcare attorney and psychotherapist, explains the historic need for mental health parity legislation and analyzes the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) in conjunction with the Affordable Care Act (ACA). Despite the mandates for parity, insurers continue to circumvent the law with intrusive “peer reviews” based on proprietary clinical protocols that are much more stringent than the nuanced and clinically sensitive guidelines adopted by mental health care providers and their professional organizations.
GUEST EDITORS’ INTRODUCTION
349
Other parity violations include the use of arbitrary algorithms to flag high-needs patients and ration their care with prospective, predetermined reviews, practices not used in reviewing other medical claims. The author recommends both provider alertness to often subtly rationalized parity violations and also outlines potential legal and legislative remedies. “The Efficacy of Psychotherapy: Focus on Psychodynamic Psychotherapy as an Example” by Kenneth N. Levy, Ph.D., Johannes C. Ehrenthal, Ph.D., Frank E. Yeomans, M.D., Ph.D., and Eve Caligor, M.D., presents a review of empirical data that support the efficacy of psychotherapy in treating mental illness, with a focus on psychodynamic psychotherapy. This article challenges the common misconception that psychotherapy is an imprecise and ineffective treatment, a misconception that has been associated with the current relative decrease in reimbursement for effective psychotherapy. The increasing body of psychotherapy research supports maintaining psychotherapy as a cornerstone of psychiatric education and practice. The current trend to disregard this literature, which is often the position of insurance companies with regard to reimbursement, puts the public at risk of being deprived access to treatments that can provide long-term improvement of both symptoms and productive engagement in life. This research literature should also have a hand in guiding policy makers in the application of the mental health provisions of the ACA. “The Cost-Effectiveness of Psychotherapy for the Major Psychiatric Diagnoses” by Susan G. Lazar, M.D., summarizes a nearly 40-year survey of the medical literature relevant to the cost-effectiveness of all kinds of psychotherapy for the major psychiatric illnesses. Most of the studies found in a systematic search reflect cost-effectiveness and at times cost savings (“cost-offset”) in overall health care costs, increased productivity, and decreased morbidity and mortality. The group of patients focused on primarily are those most in need of a longer and more intensive psychotherapy, namely the more severe and chronically ill with personality disorders, chronic anxiety and/or depression, and comorbid, complex disorders. Such patients are currently at high risk of inadequate care due to inadequate insurance coverage. Undertreated, they remain vulnerable to residual and recurrent illness with all of its associated sequelae in lowered productivity, dysfunctional relationships, higher overall medical costs, and increased morbidity and mortality. “The Mental Health Needs of Military Service Members and Veterans” by Susan G. Lazar, M.D., reviews the high prevalence of psychiatric illness in our active duty military and veterans and their urgent need for greater access to effective treatment. Only 23% to 40% of return-
350
LAZAR AND YEOMANS
ing military who met strict criteria for any mental health problem in 2004 received psychiatric care after coming home. One fourth of active duty service members have a psychiatric disorder with the prevalence of all disorders, particularly posttraumatic stress disorder, major depressive disorder, bipolar disorder, generalized anxiety, and intermittent explosive disorders increasing with each deployment, especially three or more. Their untreated psychiatric illnesses are associated with increased substance abuse, medical illnesses, decreased employment, family dysfunction, and suicide, currently occurring at a rate of 22 per day among veterans. In addition to the need for increased access to care, Veterans and Department of Defense treatment guidelines need to include recommendations for the research-documented, more extended psychotherapy needed for service members and veterans with chronic, severe, and complex psychiatric disorders to achieve full recovery. We remain far from the goal of providing full mental illness treatment for all military service members and veterans in need. “Obstacles to Early Career Psychiatrists Practicing Psychotherapy” by Norman A. Clemens, M.D., Eric M. Plakun, M.D., Susan G. Lazar, M.D., and Lisa Mellman, M.D., outlines the difficulties encountered by early career psychiatrists who face a practice environment in which their use of psychotherapy, an essential psychiatric tool, is discouraged by insurance reimbursement practices. In fact, there is a steady decline in the practice of psychotherapy by psychiatrists. The psychiatrist, as a physician, is the only mental health professional capable of providing a differential diagnosis with other medical illness, making fully informed referrals to other physician specialists, prescribing medication, and functioning as a supervisor, consultant, and mental health team leader who can assume full medical responsibility for patient care. The obstacles to coverage of psychiatrist provided psychotherapy pose a serious risk to the opportunities for the physician mental health specialist to consolidate psychotherapeutic skills. Being an expert and experienced psychotherapist serves both as a crucial treatment tool for the psychiatrist physician and also provides vital skills in differential diagnosis and skillful team management, especially with complex treatment situations. This article calls for vigorous advocacy for the enforcement of mental health parity, appropriate payment levels for psychotherapy provided by psychiatrists, and freedom from insurance companies’ parity violation of intrusive case management protocols not utilized in their management of other medical care. “Workplace Effectiveness and Psychotherapy for Mental, Substance Abuse, and Subsyndromal Conditions” by William H. Sledge, M.D. and Susan G. Lazar, M.D., addresses the underappreciated disabling impact of psychiatric illness and subclinical psychiatric illness on workers’
GUEST EDITORS’ INTRODUCTION
351
productivity. This article discusses the complex variables from the perspectives of the different stakeholders involved in constructing a policy for the recognition and treatment of these disorders. Important variables include understanding the epidemiology and the negative impact of inadequate care for psychiatrically ill workers, identifying cost-effective treatments, and removing barriers to patients’ access to them. While all psychiatric illnesses occur among workers, substance abuse, depression, and especially subsyndromal depression have a profound negative effect on workers’ productivity and increased medical care visits and expenses. Studies on the cost-effectiveness of different psychotherapeutic treatments that improve health and productivity are reviewed. Research supports the value of employee assistance programs, specialized cognitive-behavioral treatments, and brief and longer term psychodynamic interventions for different populations of psychiatrically ill workers. Currently employers are insufficiently aware of which evidence-based treatments can mitigate the negative impact on these workers’ health and productivity and are most appropriate for which diagnoses. Given the relevant data, employers are in a more informed position to negotiate proper worker benefits with insurance companies which have at times been reluctant to approve them. “Current State of Psychotherapy Training: Preparing for the Future” by Jerald Kay, M.D. and Michael F. Myers, M.D., provides an overview of what is currently being taught in psychiatry residency programs about psychotherapy in general and discusses the evolution of changes in the field related to mental health parity and the Affordable Care Act (ACA) in particular. These two latter mandates provide the opportunity to redress a relative degree of neglect that has occurred in many training programs with regard to psychotherapy training. While accrediting bodies support the central role of psychotherapy in psychiatric training and practice, there is talk of a “lost generation” of psychotherapy faculty. Timely attention to this vital issue and vigorous advocacy for implementation of true parity are required to remedy the problem. Future psychiatrists must have a firm grasp of not only the principles of psychotherapy but also the development of increasingly effective and evidence-based psychotherapies if they are to be effective health care leaders. The authors conclude with recommendations to residency training programs and to residents themselves regarding what is considered essential in both the curricular and clinical exposure to psychotherapy training. Tomorrow’s psychiatrists have a fiduciary responsibility of advocating for their complex and chronically ill patients, including their psychotherapy needs. This Special Issue surveys current issues impacting the availability of many kinds of psychotherapy for the diverse populations in need. The
352
LAZAR AND YEOMANS
legal and regulatory landscape has changed in a promising way that opens the possibility for more access to evidence-based appropriate psychotherapeutic treatments. Obstacles in the practice environment and challenges in training psychiatrists to deliver psychotherapy are outlined. Among the impediments to provision of appropriate psychotherapeutic treatments is a widespread lack of appreciation for the robust research base documenting its efficacy and cost-effectiveness for particular psychiatric diagnoses. Perhaps the most daunting obstacle lies in the opposition of insurance entities which are similarly unaware of the research and driven more by concerns regarding their business models and short-term costs. An important goal lies in expanding the dialogue so that these stakeholders also can become more focused on the health, long-term costs, productivity, morbidity, and mortality experienced by patients, their families, their employers, and their communities when proper care is not supported.
Copyright of Psychodynamic Psychiatry is the property of Guilford Publications Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
