Am J Psychiatry
135:/i,
Private BY
November
Practice
ZIGMOND
M.
/978
ZIGMOND
of Psychiatry:
LEBENSOHN,
Future
Roles
appointed a task force to study the problem. After 5 years, 2 chairmen, and various consultants, a report was finally published in June 1973 on ‘The Pnesent and Future Importance of Patterns of Private Psychiatric Practice in the Delivery of Mental Health Senvices” (1). This report, in spite of certain statistical weaknesses, is well worth reading. The data in it are derived primarily from the American Hospital Association, the 1972 survey of mental health needs in Kentucky, and various other National Institute of Mental Health, American Medical Association, and APA sources. This report concluded that ‘
the
private
most services
for
those
that
never
all their
-Oliver
Wendell
in them! Holmes,
‘
‘The
Voiceless”
fidential,
in private practice have had a singular ineptitude for telling their story. In spite oftheir major contributions to the efficient delivery of mental health cane to a substantial segment of the population, their achievements have gone largely unsung. The reasons fon this are multiple and complex. Most psychiatrists in the private sector are so swamped by their clinical responsibilities to their patients that they have little time or energy to compile statistics, write about what they are doing, or mount a campaign to quantify their results. They are characteristically a hand-working, dedicated group who devote 90% of their time to treating their patients, a task that is often exceedingly demanding. Thus they tend to be ineffective spokesmen for their cause. Possibly as a result of all these factors, psychiatrists in private practice have been called “an endangered species” by critics from both within and outside the profession, and they well may “die with all their music in them.” It was not until 1968 that the American Psychiatric Association finally recognized the need for a study of private psychiatric practice in the United States and
Revised
version
2-6,
presented
at the
130th
annual
Association,
Toronto,
Ont.,
practice,
2015 R St.,
NW.,
meeting
Canada,
system
is in private
not
.
one
which
comprises
a
of mental cannot
be
health replaced
.
the doctor
that
.
.
all
.
.
for
continuity
Admittedly
ofthe
be available
to him
in a crisis,
range
.
provides .
will
will have access to a wide adding up to a comprehensive the
health
and
our
present
velopment of a single health services. (1, p.
needs
of treatment
private
practice
ofthe
American
and
of care
man-
model
will
people.
It
day
unitary
culture
model
contraindicate
for
the
the
delivery
de-
of
vi)
It is quite probable that the imminence of some form ofnational health insurance inspired the Joint Information Service in 1973 to launch a national survey of private office practice. This study, prepared by uS staff with a text by Dr. Judd Manmor, was published in 1975 with commentaries by experts in various fields (2). In general, the methods used in this study were more sophisticated and comprehensive than those used by the APA task force but still depended largely on responses to a lengthy questionnaire. Psychiatrists as a group are notoniously loath to answer questionnaires, particularly the lengthy ones needed in this kind of a survey. Hence, the extraordinarily high response rate (73%) is not only an eloquent testimony to the good design of the questionnaire but also suggests that psychiatrists in private practice have finally become sufficiently concerned about their own future as an endangered species to take the time to answer such questionnaires.
of May
©
meet
system
Washington,
1-1359$0.50
and
psychiatry
delivery
must be supplemented by a wide range of public services. But the end product should he a balanced ,nix of both, each reinforcing the other. Our political and economic
20009.
0002-953X/78/001
of
in the
country, .
that
agement.
1977.
Dr. Lebensohn D.C.
of a paper
Psychiatric
in our
time.
and that the doctor hospital facilities
PSYCHIATRISTS
the American
sector
element
In general, the average American, when he is sick prefers to see a physician of his choice and is willing to pay for his services in the knowledge that once chosen, the physician is his doctor, that anything that is revealed in their relationship will be private and con-
sing
music
practice
essential
at this Alas
LEBENSOHN
M.D.
Psychiatrists in private practice have contributed more to treating the mentally ill in America than is generally known. The private practice sector may be viewed as a massive national outpatient and inpatient seri’ice for the mentally ill. The impact of national health insurance on the future character of the private practice ofpsychiatrv and the thorny problems to be resolved are discussed and compared svith the experiences ofEngland, the Soviet Union, and China. Future trends will most likely include increased emphasis on adjuvant techniques, greater emphasis on resident training in generalpsychiatrv, briefer forms oftherapy, andpsvchiatry’s return to the medical model.
But die with
M.
1978
American
Psychiatric
Association
1359
PRIVATE
Am
PRACTICE
HIGHLIGHTS
OF
THE
KENTUCKY
SURVEY
J Psychiatry
135:11,
tients was 140. Although Senator mentary said he was personally therapy (psychoanalysis) is the can offer to many patients who treatment,’ he made the shrewd
The private practice segment tucky is the largest component
of the profession in Kenofthe state’s mental health delivery system. This finding quite possibly may be applicable to the nation as a whole. It is useful to picture the private practice sector of psychiatry as a massive national outpatient and inpatient service for the mentally ill, and one that meets the service needs of about half of all emotionally disturbed persons who seek professional .
.
.
help. (I, pp. 15, 27)
Sharfstein and associates (3) point to ‘the statistical hazards inherent in projecting findings from a single state to the nation as a whole and show that more modest claims regarding the role of the private practice sector of psychiatry might be more appnopriate even in the state of Kentucky Statements in the report and the critical rejoinder by Sharfstein and coworkers point out the futility of such comparisons between the private and public sector: the situation is not an ‘either-or’ one, and it seems clean that we must end with a viable mix ofthe best ofboth systems. ‘
.
.
. ‘ ‘
‘ ‘
‘
‘
1978
Kennedy in his cornconvinced that this best medical science are in deep need of observation that
‘ ‘
According to the survey of mental health needs in Kentucky conducted in 1970, the private practicing psychiatrists ofthat state treated approximately 12,300 people. The APA task force report concluded that pnivate psychiatrists treated nearly one-halfofall persons who received psychiatric treatment that year. The repont went on to say,
November
‘
the average cost of a year’s analysis (at 140 visits) today would be over $6,000. In face of this very high cost, it is distressing
to
note
the
relatively
limited
given in private psychiatric practice treatment modalities that hold apparent efficient, less lems remain plement
a comprehensive
gram ican pay
costly treatment. with respect to
tomorrow
.
.
.
families whose the lion’s share
.
.
.
equity.
National
attention
being
to group and other promises for more Finally, grave probIf we
Health
were
to
im-
Insurance
Prowe would be asking the 80% of Amerearnings are under $20,000 a year to of the cost of a health care service
which whose
is rendered by and large to individuals in families incomes are over $20,000 a year. Moreover, we
would
be asking
black
only 2% of which be asking residents
families
to pay
taxes
for
services
go to blacks. And, of course, we would ofareas ofthe country which have few
psychiatrists
available
of our nation pp. 150-152)
where
to
help
help
pay
the
can be more
bill
for
easily
other
areas
obtained.
(2,
Manmor is quite properly concerned by the doubleedged nature of overfrequent sessions. Most general psychiatrists would agree that most patients treated on the average of once a week do every bit as well as those seen 3 or 4 times per week. He emphasized that it is not the frequency of therapy that is the crucial determinant but rather its duration Franz Alexander’s observation (4) that high frequency of sessions may be antithenapeutic and even lead to excessive dependency on the therapist has been made many times (before and since) by seasoned psychiatrists who sense this danger and take steps to wean the patient from this unrealistic type of support before it is too late. Whether analysts would see their patients more frequently if all visits were covered by a health insurance scheme may be open to question. If they did so it might raise very serious ethical, technical, and fiscal problems. In this connection Manmon refers to some recent data collected by the late Dr. Louis Reed, compiled from the Blue Cross/Blue Shield plan for federal employees, which pays 80% of psychiatric fees above a $100 annual deductible. Reed found that in 1973 in the Washington, D.C., metropolitan area, psychiatric patients with changes of $5,000 or more for that year constituted only 3% of all persons with supplemental mental health changes but incurred 19% of the total changes for mental illness. For the United States as a whole it was found that 2% of persons (all on most of whom were presumably in analysis) accounted for 17% of the charges. .
HIGHLIGHTS
OF
THE
itS
SURVEY
ON
PRIVATE
PRACTICE
It will not come as a surprise that the JIS survey reported that therapy is the dominant modality jority of psychiatrists in private substantial number occasionally vant techniques such as group,
to most psychiatrists one-to-one psychoused by the vast mapnactice, although a combine it with adjuconjoint, or family
therapy. The use of these other techniques tends to be more widespread among child psychiatrists and general psychiatrists than it is among psychoanalysts. Manmon, in his commentary, regretted this tendency among analysts and urged greaten flexibility in the psychoanalytic sector for the greater benefit of patients. As might be expected, the added use of small-system modalities, with chemotherapy when indicated, seemed to shorten the course of treatment. With the imminence of some type of national health insurance and its understandable emphasis on the cost-benefit ratio, pressures will be exerted on psychiatry to use these less expensive methods. The number of patient visits per year in the JIS survey appears to be significantly higher than in the Kentucky survey. The JIS survey reported an average number of psychotherapy visits pen year for nonanalytic patients of only 38, and the figure was even lower for those receiving adjunctive chemotherapy. The average number of visits per year for analytic paI 360
COST
OF
PRIVATE
Because therapy,
of the
the
cost
AND
PUBLIC
time-consuming per
unit
SERVICES nature
of
service
of one-to-one is high,
and
the
Am
J Psychiatry
/35:1/,
November
/978
ZIGMOND
patient faces a serious financial burden, especially if he is not covered by some fonm of insurance. This gives rise to much loose talk about high fees and fat incomes enjoyed by psychiatrists. However, the AMA reported that psychiatry ranks next to last among 8 specialties in yearly net income. Only pediatrics ranks lower. The difficulties of making a meaningful comparison between costs of one hour’s therapy by a private psychiatnist and by a psychiatrist in a CMHC were cleanly presented by Sharfstein and associates (5). The JIS median cost figure for therapy by a psychiatrist was $35 an hour in 1973. Data from 53 CMHCs in 1974 indicated that the cost ofone hour’s psychotherapy by a psychiatrist in a CMHC ‘could be approximated at $45 pen hour’ (5). The CMHC estimates ranged from $20 to $70 an hour. Again, we see an example of the futility of comparisons between apples and oranges, which benefit no one. ‘
‘
ATTITUDES
OF
TOWARD
PRIVATE
NATIONAL
Amenican
PSYCHIATRISTS HEALTH
psychiatrists
have
INSURANCE traditionally
been
more
liberal politically than doctors in most other branches of medicine. Although no individual poll can be cited, it is my impression that most psychiatrists feel that some form of national health insurance is inevitable; most of them hope, as does their parent organization, the APA, that mental illness will have equal coverage with other illnesses under any form ofNHI. Most psychiatrists of my acquaintance in private practice have a rather fatalistic attitude toward the possible advent ofnational health insurance. Perhaps they are lulled by the fact that most of them have full practices and their patients seem to be satisfied with their services. This may explain the results of a 1973 Harris poll which showed that even though confidence in all institutions was declining, the American public still had a higher degree of confidence in medicine as a profession than in
such
institutions
as
higher
education
and
the
mili-
All of this suggests that the American public trusts its own doctors and may not be as dissatisfied with the present system of medical care as is so often reported. It is also my impression that most private practitionens would tend to agree with Eli Ginzberg’s observatany.
tion
that the are
shortcomings and defects not likely to be cured by problems of access, availability, not
likely
to
administrative ty
and
the
be
solved
of the national and
through
action
because
distribution
of
health action
of the resources
of care
quality
national
care system alone. The
legislation
tremendous among
are and
variabiliand
within
regions and small areas of the country. The only way a national solution might work is if the entire system were under total government control-doctors, hospitals, patients. Yet even in Yugoslavia and Bulgaria, which have such systems, I have found that access, availability, and quality are a long way from being assured to the entire population. (6, p. 18)
M.
LEBENSOHN
Unless there is a radical and unforeseen change in our democratic form of government, with its emphasis on the free enterprise system, it is unlikely that medical cane will be placed under “total governmental control” in America. However, a quick look at what has happened in other countries may give us some clue as to what the future may hold for those in private practice.
EXPERIENCE
The
IN
OTHER
COUNTRIES
National Health Service has been in cx1948. Although there have been problems from time to time, most Britons would agree that it is there to stay. Under the British system, private practice is not outlawed, and many psychiatrists conduct a part-time private practice in addition to caring for patients assigned to them under the national health plan. Citizens who have the means to consult a private psychiatnist are able to obtain treatment more quickly and have greater latitude in choosing a psychiatrist. Although this practice is periodically attacked by the Laistence
bour
British since
Party
and
unions
on
the
grounds
that
it is mani-
festly unfair and that the right to good health should never be affected by the power of one’s pocketbook, private practice in Britain has continued to exist. In the Soviet Union I expected to find a system of medical cane under total governmental control, as Eli Ginzberg described it. However, I was in for some sunprises. On my last trip to Leningrad, my guide was a schoolteacher in hen 40s who worked for Intourist duning school vacations. Toward the end of our stay and after
visiting
several
psychiatric
institutions,
she
con-
fided to me that she had consulted a psychiatrist and had benefited greatly from his help. I asked if she had seen the psychiatrist at the Dispensan’ in her district. She replied emphatically and rather proudly, “Oh, no! I see him privately at his home!” One is reminded of an episode in Solzhenitsyn’s Cancer Ward. Dr. Lyudmila Dontsova, a radiologist, believed somewhat naively but fanatically in the Soviet medical system oftotal governmental control. But when she developed symptoms of cancer herself, she became terror-stricken at the possible consequences and, instead of consulting her colleagues at the clinic, went as a private patient to her former professor, Dr. Oneshchenkov, an older man, now retired, who was still permitted to conduct a small private practice. The dialogue between Dr. Dontsova, the firm believer in state-controlled medicine, and Dr. Oreshchenkov, the saddened but wise old exponent of private practice and personalized service, brings out the strengths and weaknesses of both systems, with the private practice model emerging as the superior and more humanistic system of ministering to the sick. The few reports available concerning the practice of psychiatry in the People’s Republic of China (7) indicate that their entire health system is under much more rigid and total governmental control than is the ‘ ‘
‘
1361
PRIVATE
Am
PRACTICE
case in the Soviet Union. It is doubtful, for example, that any private practice exists there today. Some observers have commented astutely that the reduction or elimination of prostitution, drug addiction, unemployment, begging, abject poverty, starvation, venereal disease, and crime, and the general improvement in public health that has occurred since the ascendancy of Chairman Mao have done more for the mental health of 800 million Chinese than the efforts of all the world’s psychiatrists and mental hygiene movements put together. Perhaps so, but most of us who live in Western democracies would consider the absolute and total conformity to a monolithic political system too high a price to pay. The example of China, however, points up the truism that shapes the future form of the practice of medicine in any country-namely, that any system ofmedicine exists at the pleasure ofthe society it serves. Society giveth and society taketh away. Political systems such as ours, which permit a diversity of medical practice, may be more inefficient at times, but their great strength lies in the freedom given to the human mind to develop new and better methods to serve the sick. In this freedom lie both the warning and the challenge to the private practice ofany profession, including psychiatry.
Changes
in Psychiatric
stresses,
and
more
psychiatrists
will
be enter-
ing some form ofgroup practice. Third-party coverage for psychiatry will continue to increase both in the numbers of those covered and in the psychiatric benefits provided. This is especially tnue ofoutpatient visits to a psychiatrist’s office. Most health plans, as well as NH! (when it arrives), will have limits on the number of visits per year, which number may well correspond to the average of 46 found in the JIS survey for all patients (analytic and nonanalytic). Whether the limitation is placed on the total number of visits or on the dollar value ofthese visits, such a step is sure to influence mightily the character of psychotherapy in Amenica. My own feeling is that this influence, when it comes, will put psychiatrists on their mettle to develop more efficient and briefer forms of psychotherapy, which will most likely involve the greater use of adjunctive methods such as chemotherapy and group therapy. People with emotional problems will continue to seek out private psychiatrists when that is the most appropriate step to take. Peer review will exert its influence on all aspects of practice, and ways will be found to circumvent one of the serious problems attending such review, namely, the erosion of patientdoctor confidentiality. The second problem that has already emerged from peer review will be more difficult to counter. I refer to the tendency to conformity. This 1362
/978
Medical
schools
Education and
psychiatric
will slowly but surely begin more attention to training residents practice of psychiatry. This means programs
emphasis
on
the
medical
model
residency
training
to pay more and for the general placing a greater
and
the
biological
roots ofpsychiatry. Gerald Klerman (8) recently listed the current hierarchy of psychiatric therapies in descending order as follows: 1) insight therapy, 2) supportive therapy, and 3) pharmacotherapy. He then added that ‘the degree of involvement of the profession in these three therapies is in inverse proportion to the proven evidence of their effectiveness. It is now high time that the profession, and particularly psychi‘
‘
atnic
residency
portant believe
apy
special
November
could well stifle development of innovative methods and encourage mediocrity, to the of the patient’s health. In spite of all these psychiatrists’ schedules will continue to be though their income may be somewhat less; still be able to live comfortably while puntheir chosen field.
suing
TRENDS
It is my firm conviction that the private practice of psychiatry in the United States will not only survive but will continue to flourish. Fewer psychiatrists will be going into solo practice, probably because of its
/35:1/,
tendency treatment detriment problems, filled even they will
training
fact and revise it is inevitable
Group FUTURE
J Psychiatry
programs, the curriculum that they will
‘
recognize
this
im-
accordingly. do so.
I
Therapy
I anticipate a sharp increase in the use ofgroup in private practice. The indications and
traindications
for
this
specialized
approach
thencon-
will
be
sharpened and new techniques will be developed. The group therapy movement will become more solidly entrenched in American psychiatry, and some of the ‘far-out’ methods will fade into oblivion. The reasons for the phenomenal growth of group therapy in the last decade are complex, but certainly the economics of reaching larger numbers with limited personnel is one of them. Aside from that, group therapy will continue to fill a very real need in the lives of thousands of unhappy, lonely people living in our overcrowded urban centers. For these maladjusted people who have had so much difficulty in establishing satisfying interpersonal relationships, group therapy will continue to be the treatment of choice. ‘
‘
Social
Psychiatry
Psychiatry,
Versus
the
frustrated
Medical
by its flirtation
gy,
Model
with
sociolo-
will return firmly to the medical model, from which it should never have strayed. Some will choose to call it the biopsychosocial’ model, a term coined by Engel (9), which includes the biomedical, psychological, and sociological aspects of all illness. Engel points out the dangerous dogmatisms of the biomedical model when it is adhered to with fanatic singlemindedness. However, the medical model, as I use that term, is broad enough to include the psychological, social, and biological factors that may be present in any illness, and the future will see its reemergence not only in the medical school but in the private practice of general ‘ ‘
psychiatry.
‘
Am
J Psychiatry
/35:1/,
November
/978
STEVEN
REFERENCES 1. Task
Force
Patterns
6: The Present and Future Importance of Psychiatric Practice in the Delivery of Men-
Report
of Private
tal Health Association,
Services. 1973
Washington,
2. Marmon I, Scheidemandel Their Patients: A National Washington,
3. Sharfstein
DC,
accountability: practice. Am
4. Alexander
Will BY
loint
SS, Taube response I Psychiatry
F, French
P.
CK:
Psychiatrists
Practice.
psychiatry
to the APA task force 132:43-47, 1975
report
Therapy.
Mental
on private
New
York,
bio-medicine.
Health
1975
8. Klerman G: Ethical issues in pharmacotherapy. sented at the Washington School of Psychiatry, DC, April 9, 1975 9. Engel GL: The need for a new medical model:
and
SHARFSTEIN
NY, Ronald Press, 1946 5. Sharfstein SS, Taube CA, Goldberg ID: Problems in analyzing the comparative costs of private versus public psychiatric care. Am I Psychiatry 134:29-32, 1977 6. Ginzberg E: The young physician-inevitable changes ahead. Pharos of Alpha Omega Alpha 38 (1): 18, 1975 7. Walls PD, Walls LH, Langsley DG: Psychiatric training and practice in the People’s Republic of China. Am I Psychiatry 132:121-128,
1975
ID: Private
T: Psychoanalytic
and
Office
Service,
Goldberg
S. SHARFSTEIN,
Psychiatric
of Private
Information
CA.
American
Kanno
Study
Community STEVEN
DC,
S.
Survive
Science
in the
196:129-136,
Lecture preWashington, a challenge
for
1977
1980s?
M.D.
There are nott’ 675funded community mental health centers (CMHCs), covering almost halfthe country. Many ofthese prograns ss’erefunded in the social optimism ofthe /960s and nowface a crisis of purpose andfunding. Additional requirements imposed by the /975 amendments to the CMHC act are not matched by additionalfiscal resources. Prograns are graduatingfrom thefederal grant tofind that other sources offunds, especially third-party insurance f unds, are not replacing the lostfederal dollars. There is evidence that CMHCs are changingfrom clinical/ medicalprograms to socialprograms: the numbers of persons seeking care who have diagnosable mental illness and ofpsychiatrists and nurses relative to other staffare decreasing. The issue is whether CMHCs as a national program are headedfor extinction or whether there si’ill be new vitality for this program into the /980s.
nity mental health center (CMHC) is in danger of cxtinction. This is the story of that program, conceived and nurtured in the optimism and abundant budgets of the 1960s but coping with a precarious adolescence in the 70s, increasingly burdened by fiscal constraints and multiple levels ofaccountability. The ending of the story is still in doubt. Whether the program will end with a whimper, collapsing under the weight of its own problems and changing times, or whether it will generate a new vitality, producing a second generation of service programs fitted for survival in the l980s, will become evident in the next two years.
SURVIVAL
FROM
1963
TO
1977
At the time of its inception in 1963 the community mental health center represented a bold new approach’ toward meeting the mental health needs of the community. The scope of its mission was delibenately writ large-a minimum of 5 essential services to be made readily accessible to all in need, regardless of ability to pay, a commitment to service to the community at large as well as to troubled individuals. At the same time it was assumed that after a 51-month period of declining federal financial support, the centers would generate alternative sources of funding and become self-sufficient. After the first 51 months, when significant nonfederal sources did not materialize, the period of federal support was extended to 8 years. The CMHC prognam continues to nest on the notion that after federal “seed money” initiates a program, it will be replaced over time with increasing amounts of non‘ ‘
‘
IN THE
ices,
GENUS
a species
Revised
version
the American 2-6,
of social programs called human servknown as the federally funded commuof a paper
Psychiatric
presented
Association,
at the
130th
Toronto,
annual
Ont.,
meeting
Canada,
of
May
1977.
Dr. Sharfstein is Director, Division of Mental grams, National Institute of Mental Health, Rockville, Md. 20857.
Health 5600
Service ProFishers Lane,
Views expressed herein are those of the author and do not necessarily reflect the opinions, official policies, or positions of the Alcohol, Drug Abuse, and Mental Health Administration or the National Institute
of
Mental
Health.
1363
135:/i,
Private BY
November
Practice
ZIGMOND
M.
/978
ZIGMOND
of Psychiatry:
LEBENSOHN,
Future
Roles
appointed a task force to study the problem. After 5 years, 2 chairmen, and various consultants, a report was finally published in June 1973 on ‘The Pnesent and Future Importance of Patterns of Private Psychiatric Practice in the Delivery of Mental Health Senvices” (1). This report, in spite of certain statistical weaknesses, is well worth reading. The data in it are derived primarily from the American Hospital Association, the 1972 survey of mental health needs in Kentucky, and various other National Institute of Mental Health, American Medical Association, and APA sources. This report concluded that ‘
the
private
most services
for
those
that
never
all their
-Oliver
Wendell
in them! Holmes,
‘
‘The
Voiceless”
fidential,
in private practice have had a singular ineptitude for telling their story. In spite oftheir major contributions to the efficient delivery of mental health cane to a substantial segment of the population, their achievements have gone largely unsung. The reasons fon this are multiple and complex. Most psychiatrists in the private sector are so swamped by their clinical responsibilities to their patients that they have little time or energy to compile statistics, write about what they are doing, or mount a campaign to quantify their results. They are characteristically a hand-working, dedicated group who devote 90% of their time to treating their patients, a task that is often exceedingly demanding. Thus they tend to be ineffective spokesmen for their cause. Possibly as a result of all these factors, psychiatrists in private practice have been called “an endangered species” by critics from both within and outside the profession, and they well may “die with all their music in them.” It was not until 1968 that the American Psychiatric Association finally recognized the need for a study of private psychiatric practice in the United States and
Revised
version
2-6,
presented
at the
130th
annual
Association,
Toronto,
Ont.,
practice,
2015 R St.,
NW.,
meeting
Canada,
system
is in private
not
.
one
which
comprises
a
of mental cannot
be
health replaced
.
the doctor
that
.
.
all
.
.
for
continuity
Admittedly
ofthe
be available
to him
in a crisis,
range
.
provides .
will
will have access to a wide adding up to a comprehensive the
health
and
our
present
velopment of a single health services. (1, p.
needs
of treatment
private
practice
ofthe
American
and
of care
man-
model
will
people.
It
day
unitary
culture
model
contraindicate
for
the
the
delivery
de-
of
vi)
It is quite probable that the imminence of some form ofnational health insurance inspired the Joint Information Service in 1973 to launch a national survey of private office practice. This study, prepared by uS staff with a text by Dr. Judd Manmor, was published in 1975 with commentaries by experts in various fields (2). In general, the methods used in this study were more sophisticated and comprehensive than those used by the APA task force but still depended largely on responses to a lengthy questionnaire. Psychiatrists as a group are notoniously loath to answer questionnaires, particularly the lengthy ones needed in this kind of a survey. Hence, the extraordinarily high response rate (73%) is not only an eloquent testimony to the good design of the questionnaire but also suggests that psychiatrists in private practice have finally become sufficiently concerned about their own future as an endangered species to take the time to answer such questionnaires.
of May
©
meet
system
Washington,
1-1359$0.50
and
psychiatry
delivery
must be supplemented by a wide range of public services. But the end product should he a balanced ,nix of both, each reinforcing the other. Our political and economic
20009.
0002-953X/78/001
of
in the
country, .
that
agement.
1977.
Dr. Lebensohn D.C.
of a paper
Psychiatric
in our
time.
and that the doctor hospital facilities
PSYCHIATRISTS
the American
sector
element
In general, the average American, when he is sick prefers to see a physician of his choice and is willing to pay for his services in the knowledge that once chosen, the physician is his doctor, that anything that is revealed in their relationship will be private and con-
sing
music
practice
essential
at this Alas
LEBENSOHN
M.D.
Psychiatrists in private practice have contributed more to treating the mentally ill in America than is generally known. The private practice sector may be viewed as a massive national outpatient and inpatient seri’ice for the mentally ill. The impact of national health insurance on the future character of the private practice ofpsychiatrv and the thorny problems to be resolved are discussed and compared svith the experiences ofEngland, the Soviet Union, and China. Future trends will most likely include increased emphasis on adjuvant techniques, greater emphasis on resident training in generalpsychiatrv, briefer forms oftherapy, andpsvchiatry’s return to the medical model.
But die with
M.
1978
American
Psychiatric
Association
1359
PRIVATE
Am
PRACTICE
HIGHLIGHTS
OF
THE
KENTUCKY
SURVEY
J Psychiatry
135:11,
tients was 140. Although Senator mentary said he was personally therapy (psychoanalysis) is the can offer to many patients who treatment,’ he made the shrewd
The private practice segment tucky is the largest component
of the profession in Kenofthe state’s mental health delivery system. This finding quite possibly may be applicable to the nation as a whole. It is useful to picture the private practice sector of psychiatry as a massive national outpatient and inpatient service for the mentally ill, and one that meets the service needs of about half of all emotionally disturbed persons who seek professional .
.
.
help. (I, pp. 15, 27)
Sharfstein and associates (3) point to ‘the statistical hazards inherent in projecting findings from a single state to the nation as a whole and show that more modest claims regarding the role of the private practice sector of psychiatry might be more appnopriate even in the state of Kentucky Statements in the report and the critical rejoinder by Sharfstein and coworkers point out the futility of such comparisons between the private and public sector: the situation is not an ‘either-or’ one, and it seems clean that we must end with a viable mix ofthe best ofboth systems. ‘
.
.
. ‘ ‘
‘ ‘
‘
‘
1978
Kennedy in his cornconvinced that this best medical science are in deep need of observation that
‘ ‘
According to the survey of mental health needs in Kentucky conducted in 1970, the private practicing psychiatrists ofthat state treated approximately 12,300 people. The APA task force report concluded that pnivate psychiatrists treated nearly one-halfofall persons who received psychiatric treatment that year. The repont went on to say,
November
‘
the average cost of a year’s analysis (at 140 visits) today would be over $6,000. In face of this very high cost, it is distressing
to
note
the
relatively
limited
given in private psychiatric practice treatment modalities that hold apparent efficient, less lems remain plement
a comprehensive
gram ican pay
costly treatment. with respect to
tomorrow
.
.
.
families whose the lion’s share
.
.
.
equity.
National
attention
being
to group and other promises for more Finally, grave probIf we
Health
were
to
im-
Insurance
Prowe would be asking the 80% of Amerearnings are under $20,000 a year to of the cost of a health care service
which whose
is rendered by and large to individuals in families incomes are over $20,000 a year. Moreover, we
would
be asking
black
only 2% of which be asking residents
families
to pay
taxes
for
services
go to blacks. And, of course, we would ofareas ofthe country which have few
psychiatrists
available
of our nation pp. 150-152)
where
to
help
help
pay
the
can be more
bill
for
easily
other
areas
obtained.
(2,
Manmor is quite properly concerned by the doubleedged nature of overfrequent sessions. Most general psychiatrists would agree that most patients treated on the average of once a week do every bit as well as those seen 3 or 4 times per week. He emphasized that it is not the frequency of therapy that is the crucial determinant but rather its duration Franz Alexander’s observation (4) that high frequency of sessions may be antithenapeutic and even lead to excessive dependency on the therapist has been made many times (before and since) by seasoned psychiatrists who sense this danger and take steps to wean the patient from this unrealistic type of support before it is too late. Whether analysts would see their patients more frequently if all visits were covered by a health insurance scheme may be open to question. If they did so it might raise very serious ethical, technical, and fiscal problems. In this connection Manmon refers to some recent data collected by the late Dr. Louis Reed, compiled from the Blue Cross/Blue Shield plan for federal employees, which pays 80% of psychiatric fees above a $100 annual deductible. Reed found that in 1973 in the Washington, D.C., metropolitan area, psychiatric patients with changes of $5,000 or more for that year constituted only 3% of all persons with supplemental mental health changes but incurred 19% of the total changes for mental illness. For the United States as a whole it was found that 2% of persons (all on most of whom were presumably in analysis) accounted for 17% of the charges. .
HIGHLIGHTS
OF
THE
itS
SURVEY
ON
PRIVATE
PRACTICE
It will not come as a surprise that the JIS survey reported that therapy is the dominant modality jority of psychiatrists in private substantial number occasionally vant techniques such as group,
to most psychiatrists one-to-one psychoused by the vast mapnactice, although a combine it with adjuconjoint, or family
therapy. The use of these other techniques tends to be more widespread among child psychiatrists and general psychiatrists than it is among psychoanalysts. Manmon, in his commentary, regretted this tendency among analysts and urged greaten flexibility in the psychoanalytic sector for the greater benefit of patients. As might be expected, the added use of small-system modalities, with chemotherapy when indicated, seemed to shorten the course of treatment. With the imminence of some type of national health insurance and its understandable emphasis on the cost-benefit ratio, pressures will be exerted on psychiatry to use these less expensive methods. The number of patient visits per year in the JIS survey appears to be significantly higher than in the Kentucky survey. The JIS survey reported an average number of psychotherapy visits pen year for nonanalytic patients of only 38, and the figure was even lower for those receiving adjunctive chemotherapy. The average number of visits per year for analytic paI 360
COST
OF
PRIVATE
Because therapy,
of the
the
cost
AND
PUBLIC
time-consuming per
unit
SERVICES nature
of
service
of one-to-one is high,
and
the
Am
J Psychiatry
/35:1/,
November
/978
ZIGMOND
patient faces a serious financial burden, especially if he is not covered by some fonm of insurance. This gives rise to much loose talk about high fees and fat incomes enjoyed by psychiatrists. However, the AMA reported that psychiatry ranks next to last among 8 specialties in yearly net income. Only pediatrics ranks lower. The difficulties of making a meaningful comparison between costs of one hour’s therapy by a private psychiatnist and by a psychiatrist in a CMHC were cleanly presented by Sharfstein and associates (5). The JIS median cost figure for therapy by a psychiatrist was $35 an hour in 1973. Data from 53 CMHCs in 1974 indicated that the cost ofone hour’s psychotherapy by a psychiatrist in a CMHC ‘could be approximated at $45 pen hour’ (5). The CMHC estimates ranged from $20 to $70 an hour. Again, we see an example of the futility of comparisons between apples and oranges, which benefit no one. ‘
‘
ATTITUDES
OF
TOWARD
PRIVATE
NATIONAL
Amenican
PSYCHIATRISTS HEALTH
psychiatrists
have
INSURANCE traditionally
been
more
liberal politically than doctors in most other branches of medicine. Although no individual poll can be cited, it is my impression that most psychiatrists feel that some form of national health insurance is inevitable; most of them hope, as does their parent organization, the APA, that mental illness will have equal coverage with other illnesses under any form ofNHI. Most psychiatrists of my acquaintance in private practice have a rather fatalistic attitude toward the possible advent ofnational health insurance. Perhaps they are lulled by the fact that most of them have full practices and their patients seem to be satisfied with their services. This may explain the results of a 1973 Harris poll which showed that even though confidence in all institutions was declining, the American public still had a higher degree of confidence in medicine as a profession than in
such
institutions
as
higher
education
and
the
mili-
All of this suggests that the American public trusts its own doctors and may not be as dissatisfied with the present system of medical care as is so often reported. It is also my impression that most private practitionens would tend to agree with Eli Ginzberg’s observatany.
tion
that the are
shortcomings and defects not likely to be cured by problems of access, availability, not
likely
to
administrative ty
and
the
be
solved
of the national and
through
action
because
distribution
of
health action
of the resources
of care
quality
national
care system alone. The
legislation
tremendous among
are and
variabiliand
within
regions and small areas of the country. The only way a national solution might work is if the entire system were under total government control-doctors, hospitals, patients. Yet even in Yugoslavia and Bulgaria, which have such systems, I have found that access, availability, and quality are a long way from being assured to the entire population. (6, p. 18)
M.
LEBENSOHN
Unless there is a radical and unforeseen change in our democratic form of government, with its emphasis on the free enterprise system, it is unlikely that medical cane will be placed under “total governmental control” in America. However, a quick look at what has happened in other countries may give us some clue as to what the future may hold for those in private practice.
EXPERIENCE
The
IN
OTHER
COUNTRIES
National Health Service has been in cx1948. Although there have been problems from time to time, most Britons would agree that it is there to stay. Under the British system, private practice is not outlawed, and many psychiatrists conduct a part-time private practice in addition to caring for patients assigned to them under the national health plan. Citizens who have the means to consult a private psychiatnist are able to obtain treatment more quickly and have greater latitude in choosing a psychiatrist. Although this practice is periodically attacked by the Laistence
bour
British since
Party
and
unions
on
the
grounds
that
it is mani-
festly unfair and that the right to good health should never be affected by the power of one’s pocketbook, private practice in Britain has continued to exist. In the Soviet Union I expected to find a system of medical cane under total governmental control, as Eli Ginzberg described it. However, I was in for some sunprises. On my last trip to Leningrad, my guide was a schoolteacher in hen 40s who worked for Intourist duning school vacations. Toward the end of our stay and after
visiting
several
psychiatric
institutions,
she
con-
fided to me that she had consulted a psychiatrist and had benefited greatly from his help. I asked if she had seen the psychiatrist at the Dispensan’ in her district. She replied emphatically and rather proudly, “Oh, no! I see him privately at his home!” One is reminded of an episode in Solzhenitsyn’s Cancer Ward. Dr. Lyudmila Dontsova, a radiologist, believed somewhat naively but fanatically in the Soviet medical system oftotal governmental control. But when she developed symptoms of cancer herself, she became terror-stricken at the possible consequences and, instead of consulting her colleagues at the clinic, went as a private patient to her former professor, Dr. Oneshchenkov, an older man, now retired, who was still permitted to conduct a small private practice. The dialogue between Dr. Dontsova, the firm believer in state-controlled medicine, and Dr. Oreshchenkov, the saddened but wise old exponent of private practice and personalized service, brings out the strengths and weaknesses of both systems, with the private practice model emerging as the superior and more humanistic system of ministering to the sick. The few reports available concerning the practice of psychiatry in the People’s Republic of China (7) indicate that their entire health system is under much more rigid and total governmental control than is the ‘ ‘
‘
1361
PRIVATE
Am
PRACTICE
case in the Soviet Union. It is doubtful, for example, that any private practice exists there today. Some observers have commented astutely that the reduction or elimination of prostitution, drug addiction, unemployment, begging, abject poverty, starvation, venereal disease, and crime, and the general improvement in public health that has occurred since the ascendancy of Chairman Mao have done more for the mental health of 800 million Chinese than the efforts of all the world’s psychiatrists and mental hygiene movements put together. Perhaps so, but most of us who live in Western democracies would consider the absolute and total conformity to a monolithic political system too high a price to pay. The example of China, however, points up the truism that shapes the future form of the practice of medicine in any country-namely, that any system ofmedicine exists at the pleasure ofthe society it serves. Society giveth and society taketh away. Political systems such as ours, which permit a diversity of medical practice, may be more inefficient at times, but their great strength lies in the freedom given to the human mind to develop new and better methods to serve the sick. In this freedom lie both the warning and the challenge to the private practice ofany profession, including psychiatry.
Changes
in Psychiatric
stresses,
and
more
psychiatrists
will
be enter-
ing some form ofgroup practice. Third-party coverage for psychiatry will continue to increase both in the numbers of those covered and in the psychiatric benefits provided. This is especially tnue ofoutpatient visits to a psychiatrist’s office. Most health plans, as well as NH! (when it arrives), will have limits on the number of visits per year, which number may well correspond to the average of 46 found in the JIS survey for all patients (analytic and nonanalytic). Whether the limitation is placed on the total number of visits or on the dollar value ofthese visits, such a step is sure to influence mightily the character of psychotherapy in Amenica. My own feeling is that this influence, when it comes, will put psychiatrists on their mettle to develop more efficient and briefer forms of psychotherapy, which will most likely involve the greater use of adjunctive methods such as chemotherapy and group therapy. People with emotional problems will continue to seek out private psychiatrists when that is the most appropriate step to take. Peer review will exert its influence on all aspects of practice, and ways will be found to circumvent one of the serious problems attending such review, namely, the erosion of patientdoctor confidentiality. The second problem that has already emerged from peer review will be more difficult to counter. I refer to the tendency to conformity. This 1362
/978
Medical
schools
Education and
psychiatric
will slowly but surely begin more attention to training residents practice of psychiatry. This means programs
emphasis
on
the
medical
model
residency
training
to pay more and for the general placing a greater
and
the
biological
roots ofpsychiatry. Gerald Klerman (8) recently listed the current hierarchy of psychiatric therapies in descending order as follows: 1) insight therapy, 2) supportive therapy, and 3) pharmacotherapy. He then added that ‘the degree of involvement of the profession in these three therapies is in inverse proportion to the proven evidence of their effectiveness. It is now high time that the profession, and particularly psychi‘
‘
atnic
residency
portant believe
apy
special
November
could well stifle development of innovative methods and encourage mediocrity, to the of the patient’s health. In spite of all these psychiatrists’ schedules will continue to be though their income may be somewhat less; still be able to live comfortably while puntheir chosen field.
suing
TRENDS
It is my firm conviction that the private practice of psychiatry in the United States will not only survive but will continue to flourish. Fewer psychiatrists will be going into solo practice, probably because of its
/35:1/,
tendency treatment detriment problems, filled even they will
training
fact and revise it is inevitable
Group FUTURE
J Psychiatry
programs, the curriculum that they will
‘
recognize
this
im-
accordingly. do so.
I
Therapy
I anticipate a sharp increase in the use ofgroup in private practice. The indications and
traindications
for
this
specialized
approach
thencon-
will
be
sharpened and new techniques will be developed. The group therapy movement will become more solidly entrenched in American psychiatry, and some of the ‘far-out’ methods will fade into oblivion. The reasons for the phenomenal growth of group therapy in the last decade are complex, but certainly the economics of reaching larger numbers with limited personnel is one of them. Aside from that, group therapy will continue to fill a very real need in the lives of thousands of unhappy, lonely people living in our overcrowded urban centers. For these maladjusted people who have had so much difficulty in establishing satisfying interpersonal relationships, group therapy will continue to be the treatment of choice. ‘
‘
Social
Psychiatry
Psychiatry,
Versus
the
frustrated
Medical
by its flirtation
gy,
Model
with
sociolo-
will return firmly to the medical model, from which it should never have strayed. Some will choose to call it the biopsychosocial’ model, a term coined by Engel (9), which includes the biomedical, psychological, and sociological aspects of all illness. Engel points out the dangerous dogmatisms of the biomedical model when it is adhered to with fanatic singlemindedness. However, the medical model, as I use that term, is broad enough to include the psychological, social, and biological factors that may be present in any illness, and the future will see its reemergence not only in the medical school but in the private practice of general ‘ ‘
psychiatry.
‘
Am
J Psychiatry
/35:1/,
November
/978
STEVEN
REFERENCES 1. Task
Force
Patterns
6: The Present and Future Importance of Psychiatric Practice in the Delivery of Men-
Report
of Private
tal Health Association,
Services. 1973
Washington,
2. Marmon I, Scheidemandel Their Patients: A National Washington,
3. Sharfstein
DC,
accountability: practice. Am
4. Alexander
Will BY
loint
SS, Taube response I Psychiatry
F, French
P.
CK:
Psychiatrists
Practice.
psychiatry
to the APA task force 132:43-47, 1975
report
Therapy.
Mental
on private
New
York,
bio-medicine.
Health
1975
8. Klerman G: Ethical issues in pharmacotherapy. sented at the Washington School of Psychiatry, DC, April 9, 1975 9. Engel GL: The need for a new medical model:
and
SHARFSTEIN
NY, Ronald Press, 1946 5. Sharfstein SS, Taube CA, Goldberg ID: Problems in analyzing the comparative costs of private versus public psychiatric care. Am I Psychiatry 134:29-32, 1977 6. Ginzberg E: The young physician-inevitable changes ahead. Pharos of Alpha Omega Alpha 38 (1): 18, 1975 7. Walls PD, Walls LH, Langsley DG: Psychiatric training and practice in the People’s Republic of China. Am I Psychiatry 132:121-128,
1975
ID: Private
T: Psychoanalytic
and
Office
Service,
Goldberg
S. SHARFSTEIN,
Psychiatric
of Private
Information
CA.
American
Kanno
Study
Community STEVEN
DC,
S.
Survive
Science
in the
196:129-136,
Lecture preWashington, a challenge
for
1977
1980s?
M.D.
There are nott’ 675funded community mental health centers (CMHCs), covering almost halfthe country. Many ofthese prograns ss’erefunded in the social optimism ofthe /960s and nowface a crisis of purpose andfunding. Additional requirements imposed by the /975 amendments to the CMHC act are not matched by additionalfiscal resources. Prograns are graduatingfrom thefederal grant tofind that other sources offunds, especially third-party insurance f unds, are not replacing the lostfederal dollars. There is evidence that CMHCs are changingfrom clinical/ medicalprograms to socialprograms: the numbers of persons seeking care who have diagnosable mental illness and ofpsychiatrists and nurses relative to other staffare decreasing. The issue is whether CMHCs as a national program are headedfor extinction or whether there si’ill be new vitality for this program into the /980s.
nity mental health center (CMHC) is in danger of cxtinction. This is the story of that program, conceived and nurtured in the optimism and abundant budgets of the 1960s but coping with a precarious adolescence in the 70s, increasingly burdened by fiscal constraints and multiple levels ofaccountability. The ending of the story is still in doubt. Whether the program will end with a whimper, collapsing under the weight of its own problems and changing times, or whether it will generate a new vitality, producing a second generation of service programs fitted for survival in the l980s, will become evident in the next two years.
SURVIVAL
FROM
1963
TO
1977
At the time of its inception in 1963 the community mental health center represented a bold new approach’ toward meeting the mental health needs of the community. The scope of its mission was delibenately writ large-a minimum of 5 essential services to be made readily accessible to all in need, regardless of ability to pay, a commitment to service to the community at large as well as to troubled individuals. At the same time it was assumed that after a 51-month period of declining federal financial support, the centers would generate alternative sources of funding and become self-sufficient. After the first 51 months, when significant nonfederal sources did not materialize, the period of federal support was extended to 8 years. The CMHC prognam continues to nest on the notion that after federal “seed money” initiates a program, it will be replaced over time with increasing amounts of non‘ ‘
‘
IN THE
ices,
GENUS
a species
Revised
version
the American 2-6,
of social programs called human servknown as the federally funded commuof a paper
Psychiatric
presented
Association,
at the
130th
Toronto,
annual
Ont.,
meeting
Canada,
of
May
1977.
Dr. Sharfstein is Director, Division of Mental grams, National Institute of Mental Health, Rockville, Md. 20857.
Health 5600
Service ProFishers Lane,
Views expressed herein are those of the author and do not necessarily reflect the opinions, official policies, or positions of the Alcohol, Drug Abuse, and Mental Health Administration or the National Institute
of
Mental
Health.
1363
