Director’s Blog – NIMHBy Thomas InselMay 30, 2014… The paradox of parity is that even with the new laws, in the absence of such a framework, some treatments might not be covered even to the extent that they were covered in the past. To address this concern, NIMH and other stakeholders have asked the Institute of Medicine [IOM] to develop a framework by which standards for psychotherapeutics can be established to help guide both payers and providers. The IOM has set up an expert panel to review the issues and recommend a way forward. At a meeting last week, the IOM panel heard how other providers like surgeons have established guidelines for rigor and quality that ensured parity for their interventions, many of which have less evidence than what we have for cognitive behavioral therapy.
In the world of parity, psychosocial treatments may need to be accompanied by measures of quality and fidelity [e.g., evidence of homework if the treatment is cognitive behavior therapy], measures of dose and duration [e.g., a predetermined length of intervention], and measures of outcome [e.g., improvements on a standardized rating scale]. And electronic records may become as essential to psychotherapy as the rest of medicine for ensuring that treatments meet established standards and are reimbursed.
Of course, many providers may look for reimbursement outside of the insurance or Medicaid systems. A recent report from Bishop et al found that only 43 percent of psychiatrists accepted Medicaid and only 55 percent accepted private non-capitated insurance. These figures are much lower than rates for other medical specialties [73 percent for Medicaid and 89 percent for private insurance]. And the rates for psychiatrists accepting private insurance are going down, decreasing 17 percent from 2005–2006 to 2009-2010 when these data were collected.
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. The IOM study can help by providing some guidelines, but true parity may require that the mental health community take steps to demonstrate that they provide the most evidence-based treatments with measures of both rigor and fidelity. We will need standardized reporting systems. And we will need a detailed definition for each evidence-based intervention, including not only dose and duration but indication…
I don’t even know where to start. And since I didn’t want to rant, I took a break and made coffee [it seemed to have helped]. They created a reimbursement system that essentially directed psychiatrists to do pharmacotherapy, and backed it up with an academy obsessed with Clinical Neuroscience, a disease-model Diagnostic System, psychopharmacology, and a not-so-subterranean alliance with the pharmaceutical industry. Insel mentions CBT [Cognitive Behavior Therapy] as his example of an evidence-based psychosocial intervention because it and its variants are essentially the only ones that have earned the EBM moniker. I was certainly influenced by the principles of CBT, incorporating them into my everyday approach to people, but I’ve never personally been or worked with a psychiatrist who does formal time-limited CBT with homework for very long beyond training – though it’s listed on most résumés. And if there were or will be such psychiatrists, they will need either lots of free time or an expensive support staff to manage the system described in the highlighted paragraph above [to handle the paperwork/electronic records involved]. Being independently wealthy would also be an adjunct.
I see nothing in this vision of mental health parity that will change the practice of psychiatry represented even by the insurance-accepting psychiatrists in those graphs, or do anything to halt their dwindling numbers. I see nothing in this vision of mental health parity that reflects anything but Dr. Insel’s disconnect with the specialty of psychiatry and its practice. He and his colleagues in academic psychiatry and the American Psychiatric Association created a vision of the future that lead us to where we are now based on an as-yet-undiscovered neuroscience with a reliance on some not-so-very-effective drugs based on a not-so-very-helpful diagnostic system and a not-so-very-enduring-or-healthy relationship with industry. Their hope for a breakthrough neuroscience pharmacologic future has now tanked, and they’re scrambling to find some new directions with things like collaborative care and whatever-you-call-the-thinking in this post. Were I to allow my suppressed rant unrestricted access, I would speak heatedly about the role the non-practicing psychiatrists like Dr. Insel and his cronies in academia and organized psychiatry had in creating this un-holy-hell-of-a-mess, and their unwillingness to accept responsibility for the impact of their short-sightedness-and-monocular-ideology on the fate of both psychiatrists and our patients.
The scales fell from my eyes on issues of reimbursement during a visit to Montreal in the late 1970s. Over drinks with a group of Canadian psychiatrists, the topic turned to the new Quebec provincial health plan and the going rate for psychiatric services. I asked about supportive psychotherapy and they fell about laughing. For supportive psychotherapy, they said, they were reimbursed $50 per session whereas for psychoanalytic psychotherapy the rate was $65 per session. How, I asked, did they document which form of psychotherapy they were delivering? They fell about laughing again, and when they recovered they explained that one interpretation per session was sufficient to qualify the encounter as psychoanalytic. Apparently, with one stroke Quebec eliminated the practice of supportive psychotherapy in the entire province.
The short version is, follow the money. Human nature doesn’t change – only the actors are different.
As for Dr. Insel, the less said the better.
Drs. Carroll and Nardo,
With the 2013 changes in CPT coding for psychiatrists, I now know of multiple psychiatrists who do weekly supportive or dynamic therapy, but bill the visit both with a medical evaluation & management (E&M) code and an add-on psychotherapy code. Thus, a 45-minute E&M+therapy visit can reimburse anywhere from $100-200 depending on the insurance carrier (with the therapy portion contributing to maybe a quarter of the reimbursement).
Now, the E&M code is supposed to reflect “medical thinking” in addition to psychotherapy, but I’ve heard it said that as long as one is doing a mental status exam and then considering a range of treatments, then the E&M portion is being fulfilled. I don’t know how proper & correct this is, but it does seem that these days the opportunity is there for psychiatrists to accept insurance, do therapy, and get decent reimbursement for their work.
… “an-unholy-hell-of-a mess” is an apt description of what drs insels & cronies & industrial companies created and struggle to uphold..
The “unholy-hell-of-a-mess” has been spread far and low, with the best of intensions of saving the poor souls, while serving pope and bishops, emperors and kings and their own kind, clerks of an inquisitorial, buraucratic church.
Insel is busy modelling the thinking he and the clerks and their masters depend on to stay in power and wealth. The definitiions in their dsm-bible are as selfserving as those of an Inquisition that created the heretics and whitches they needed, the procedures, the thinking, the fear and the domination. Insel’s church is rotten and will fall down, like its mighty predecessors – some day
Psycritic,
Thanks for the comment. I’m glad to hear it. I can’t be only critical of the restrictions on billing for psychotherapy, because I was alive when that privilege was badly abused. For some, the major indication for long term therapy or analysis was insurance that would cover it. In the day, I hated that being true, because it validated the tremendous back-lash that came in 1980 with the DSM-III. It was a case where the sins of the fathers came down on the children like fire and brimstone on Sodom and Gomorrah. And I actually have some sympathy for the plight of those who have to decide whether or not to cover a psychotherapy.
It’s unfortunate that the backlash was so intense, that the opposite situation resulted – the psychotherapy indication became, in part, the ability to pay. I’ve mused about that over the years but haven’t gotten anywhere much. There’s no integrity meter to attach to clinicians’ ankle to deal with the human nature factor Dr. Carroll mentions above. It’s a problem all over medicine. The number of MRIs ordered just to keep the MRI machine running is staggering.
Common theme here involving NIMH, APA, pharma seems to be that people drop about 30 IQ points and several layers of superego when they live inside a groupthink bubble. But we all know that from studies of group psychology (Asch, Milgram), don’t we?
I agree with Mickey on parity problem. I just feel lucky that I was able to get twice weekly psychotherapy as a resident back in the day when insurance was willing to pay for it. I knew it wouldn’t last. Silver lining: my own experience jibes with that of the analysts who say you get more out of it if it hurts at least a little in the pocketbook.
“And electronic records may become as essential to psychotherapy as the rest of medicine for ensuring that treatments meet established standards…”
At least he admits that information technology is to be used as a governor of care (according to the “established standards” arrived at by a self-appointed elite).
That you, Dr. Insel.
my searches have not found any announcement of this request or meeting
“to address this concern, NIMH and other stakeholders have asked the Institute of Medicine (IOM) to develop a framework by which standards for psychotherapeutics can be established to help guide both payers and providers. The IOM has set up an expert panel to review the issues and recommend a way forward. At a meeting last week, the IOM panel heard how other providers like surgeons have established guidelines for rigor and quality that ensured parity for their interventions, many of which have less evidence than what we have for cognitive behavioral therapy. In the world of parity, psychosocial treatments may need to be accompanied by measures of quality and fidelity (e.g., evidence of homework if the treatment is cognitive behavior therapy), measures of dose and duration (e.g., a predetermined length of intervention), and measures of outcome (e.g., improvements on a standardized rating scale). And electronic records may become as essential to psychotherapy as the rest of medicine for ensuring that treatments meet established standards and are reimbursed. -”
i would also like to know if the other stakeholders include Health Insurers as well as social workers, psychologists, counselors
past history suggests the manner in which the mavens of clinical trials and “medicine” will approach this task
does the authority for this come from the obama administration kicking the issue down the road….final details on coverage of mental health?
another question came to mind after posting last comment
who are the members of the expert panel?
Here is a link for the IOM Committee.
http://tinyurl.com/k5vq76j