Reconsidering delegated psychotherapy
Since the beginning of 2018, certain health insurance companies in Switzerland have systematically investigated how so-called delegated psychotherapy is performed in psychiatric practice . Some insurance agencies have also demanded that fees be back-paid when they suspect that a psychiatrist did not personally see a patient but delegated a psychotherapy [2, 3].
Delegated psychotherapy is a specific form of work in which psychotherapists (psychologists) are employed by psychiatrists but practice autonomously, while all legal and professional responsibilities lie with the psychiatrists [4, 5]. Under some circumstances, physicians of other specialialities can delegate a psychotherapy – this issue is not a subject of the present article.
Psychiatrists, as employers, are obligated to supervise the psychotherapist’s work. In 2016, the Swiss Society for Psychiatry and Psychotherapy published a short position paper with recommendations regarding the professional relationship between psychiatrists and psychologists in this arrangement .
The establishment of a legal regulation for delegated psychotherapy began in 1981 . In the most recent legal case regarding delegated psychotherapy, the Swiss Federal Court decided that psychiatrists must have a sufficiently intensive contact with the patient, which should be adapted to specific situation .
The current development of the regulation of psychological psychotherapy goes back to 2011 and 2013 [9, 10], with the aim to include psychological psychotherapy in basic health insurance coverage. Since 2016, neuropsychology, as a sub-speciality of psychologists, became the first qualification of psychologists that is covered by the basic health insurance . However, psychologists cannot yet bill their psychotherapy services through basic health insurance. This issue remains unsolved, mainly because of the differing views of psychologists and insurance companies on payment structure and on whether patients should go directly to psychologists or must first acquire a referral from a physician. The additional costs that would be generated by psychologists are at the centre of the controversial debate between politicians, healthcare representatives and insurance companies.
Insurance companies have a right and an obligation to monitor whether psychiatrists are meeting formal criteria when practising delegated psychotherapy; psychiatrists are expected to indicate, supervise and follow the set criteria. However, this obligation of psychiatrists is not defined by the law. A statement by the Swiss Society of Psychiatry and Psychotherapy sets forth several recommendations, leaving a large latitude to psychiatrists regarding how they organise and work with psychologists, emphasising case-specific settlement .
In the current legal frame, delegated psychotherapy should be indicated and monitored by psychiatrists. Insurance companies claim that if psychiatrists have not responsibly and personally examined a patient, the criteria for delegated psychotherapy are not being met. As mentioned previously, some insurers expect a back-payment if they assume delegated psychotherapy is occurring without an examination by a psychiatrist. The obligations of psychiatrists to examine a patient are, however, not explicitly required by the law. Therefore, the main point of dispute is not whether a psychiatrist has personally examined a patient at the beginning of psychotherapy, but how the supervisory role of psychiatrists is defined. Note that several responsibilities will remain within physicians’ expertise (pharmacotherapy, comorbidity analysis, organic disorder diagnosis, etc.) and are not part of this discussion.
There are several issues which require further analysis.Conflicts of interest
Insurance agencies, in their function of providing insurance in exchange for payment, and as a means to control of their own payment obligations, face a systemic conflict of interest: they are controlling their own payments. They can access the bills issued by physicians, but specific information regarding treatment is available only to external medical experts. This enables insurance companies to control treatments while preserving patient confidentiality and at least partially leveraging their conflicts of interest.Confidentiality
Confidentiality plays a major role in any medical procedure, but especially in psychotherapy [12, 13]. Insurance companies should not be informed of any reason a patient may request psychotherapy. A general and unspecific diagnosis is often an integral part of the billing system, a precise diagnosis (a full diagnosis according to the international classification of diseases, ICD-10) is by default not offered to insurance agencies, although patients are entitled to permit a diagnosis be sent to insurers. As a result, insurance companies have no way to evaluate whether a treatment fulfils all requirements. This problem is solved by requesting that psychiatrists report to an external medical examiner, who has a control function and evaluates the prolongation of psychotherapy after 40 sessions. In this manner, patient confidentiality is preserved and the insurance company’s control is maintained. Psychiatrists and delegated psychotherapists must both generate and sign a therapy report, which gives the insurance agency confidence that psychiatrists are knowledgeable about the case.
However, there is the issue of confidentiality between psychiatrists and psychologists, which can be encountered as part of the setting of delegated psychotherapy. An explanation about confidentiality should be given at the beginning of treatment as part of their disclosure obligation  and the patient’s informed consent [15, 16].Qualification and legal frame
Psychologists are qualified to conduct psychotherapy. This is recognised by legal instances. Therefore, pinpointing the differences between psychotherapy that is performed by psychologists themselves and delegated psychotherapy is a legitimate goal. Delegated psychotherapy is a different setting and different legal frame as compared with psychotherapy performed by one psychotherapist or psychiatrists on their own responsibility. There should not be any difference between psychotherapy if done in a legal frame of delegated psychotherapy as compared with psychotherapy performed by psychotherapist on his or her own responsibility. The guidelines for psychotherapy are setting–related, but independent of setting.
For the future inclusion of psychological psychotherapists in basic health insurance, psychotherapists’ professional duties are defined and there is a register of accredited psychotherapists at the state level. Requirements for psychotherapists who work on their own are primarily defined by canton law, but there is a strong harmonisation between cantons. Essentially, the requirements for psychotherapists apply when they work on their own are the same as when they are employed by a psychiatrist. There is no reason to assume that psychotherapists would practise differently when working alone than when employed by psychiatrist. This is considered alongside the planned inclusion of their work in basic health insurance packages. Note that the lists of accredited institutions where psychiatrists and psychologists learn psychotherapy are overlapping and almost the same [17, 18].Quality criteria
In order to be covered by insurance, every procedure must meet the following criteria regarding effectiveness, expediency and economy ( paragraph 32, 56). An ethical dimension is increasingly considered as inseparable from psychotherapeutic work .Effectiveness
Psychologists are qualified to diagnose and assess the indication for psychotherapy. Additional examination by psychiatrists could reveal further information, as any other diagnostic procedure could, and is often unnecessary and unspecific (in some cases, psychotherapists consult colleges as a part of quality control, which will be excluded here). As its name implies, delegated psychotherapy is a therapy which psychiatrists would also perform themselves.Expediency
The same arguments for effectiveness count here as well. External experts who evaluate the need to prolong psychotherapy after 40 sessions make a judgement based on a therapy report. As psychiatrists and psychologists create a report and work closely together, it can be assumed that psychiatrists have more information about patients than the external experts.Economic
From this point of view, additional examinations by psychiatrists have only negative economic effects as they generate additional costs. However, psychiatrists are obliged to minimise the costs of therapy ( paragraph 56). It can be argued that psychiatrists act as gatekeepers by avoiding unnecessary treatment and reducing costs. Similar duties are described in a statement by the Swiss Society of Psychiatry and Psychotherapy regarding delegated psychotherapy. Potential exists for a conflict of interest through the characteristics of multiple relationships, as psychiatrists would be less likely to deny an indication for psychotherapy by psychotherapists with whom they share the practice. However, no empirical data regarding this argument exist. Additionally, an indication for psychotherapy cannot be made based on personal preferences, but must be grounded in scientifically proven evidence.
There are no empirical studies about how psychiatrists charge their work while supervising delegated psychotherapy, and there is certainly a variety of models from different psychiatrists as to how it can be done. Previous versions of the billing system TARMED  did not include a specific position regarding pricing, and there is a question if the position 02.0074 in the current version of TARMED  can be used to cover the supervisory work of psychiatrists in delegated psychotherapy. In any case, many psychiatrists perform their part of the work in frame of delegated psychotherapy free of charge .Ethics
From an ethical point of view, unnecessary examination is wrong. Interfering in psychotherapeutic processes could cause damage to the patient. This does not mean that the supervisory function of a psychiatrist, as defined by law, is principally unethical; supervision has historical justification from a time when the qualifications of psychologists were incompletely defined by law.
Currently, insurance agencies question patients regarding their treatment settings. The psychotherapeutic setting is part of the psychotherapeutic method in both diagnostic and therapeutic ways , and inquiries about the setting of an ongoing treatment may influence its therapeutic process. Therefore, it must be discussed whether such inquiries have the character of a clinical study and whether they must be approved in advance by an ethical committee. A brief analysis by the ethical committee disproved this (personal communication). However, a recent request of the Swiss Society of Psychiatry and Psychotherapy addressed to the Federal Office of Public Health ended in a recommendation that certain modifications in the structure of the inquiries which insurance agencies send to patients must be made . In some cases, the insurance companies send a questionnaire regarding delegated psychotherapy to patients, with instruction that patients should not inform psychiatrists about this questionnaire, but the Federal Office of Public Health ordered that insurers must remove this sentence. Judgements considering economic interests of insurers, patients, physicians, confidentiality issues, distribution of good and more require ethical consideration as well as legal consideration. From the psychotherapeutic point of view, the instruction not to inform psychiatrists is a massive interference in the ongoing psychotherapeutic process and should be reviewed in advance by an ethics committee. It is clear that additional proof from ethics committees would make monitoring of medical procedures by insurance agencies more difficult but would enhance patients’ rights, security and autonomy.
This subject deserves further research and discussion.
From the perspective of global justice in the healthcare system (as measures that enable the fair distribution of goods), a consultation between a psychiatrist and a patient, strictly required by law, where the psychiatrist does not consider the consultation as medically indicated for the treatment in a particular case, is unjust. Research overwhelmingly demonstrates that the therapeutic relationship is a crucial factor in the outcome of psychotherapy . Ethical considerations that weigh the pros and cons of protecting and respecting a therapeutic relationship while fulfilling vague requirements of the law simultaneously can only be made on a case-by-case basis. Consequently, the modalities of co-working psychiatrists and psychotherapists should lie in their respective competences.
An ethical dilemma that can arise for psychiatrists is to examine patients routinely in spite of their professional attitude. As an additional examination of patients with or without clear medical indication guarantees coverage of costs of delegated psychotherapy for patients, it clearly ensures a legal certainty for a patient (that the psychotherapy will be covered by the insurance) and is consequently ethical.
The Swiss mental healthcare system is well studied [26, 27]. Unfortunately, there are no empirical studies on the modalities of the working relationship between psychiatrists and psychologists, though this information would be invaluable in the precise definition and accurate analysis of this form of work. However, it is too late to investigate this topic, as the psychotherapy performed by psychologists will soon be included in basic health insurance.Therapeutic dimension
Although a therapeutic facet does not belong to the criteria defined by the heath law, this aspect is crucial for psychotherapeutic treatment and is one of the fundamental duties of psychiatrists and psychotherapists.
Sometimes delegated psychotherapists master therapeutic techniques that psychiatrists do not have, or therapeutic splitting is required for adequate treatments. In both cases, a combined therapy is indicated.
Generally, an additional examination by psychiatrists is not necessary from a diagnostic or therapeutic point of view because it can cause confusion, regression, loss of confidence, or splitting [28, 29].
Intensive involvement of psychiatrists could have a negative influence on the therapeutic process. Eventually it can result in acting out . For example, a patient in delegated psychotherapy could develop anxiety and a desire to consult a psychiatrist. This can be understood as acting out, a form of resistance or defence mechanism, which should be handled by psychotherapists with a psychotherapeutic intervention protected by psychotherapeutic boundaries. This emphasises not only the value of the psychotherapeutic relationship, but also a necessity for careful, fine-tuned and case-related involvement of psychiatrists in a particular treatment, because too intense involvement can prolong psychotherapy. Psychotherapists are educated and familiar with such situations, which can occur not only in the setting of delegated psychotherapy, but also in many other therapeutic settings, such as between family physicians and psychiatrists or psychotherapists. However, therapeutic situations are complex and probably impossible to be conceptualised as a part of insurance legislation.Conclusion
Swiss society is built on trust. Patients trust health workers, insurance companies trust health workers, health workers trust insurers and health workers trust patients.
However, all agents follow their own interests.
It is reasonable to expect that insurance agencies seek to control their expenditure, psychiatrists and psychotherapists make a living from their work, health policy leaders monitor the sustainability of the healthcare system and all actors follow the law and professional guidelines. What we should not forget is that this system exists to treat patients. Therefore, any treatment can only be analysed within the specific contexts of each particular patient. Here, psychiatrists and psychotherapists are key factors in this particular forms of psychotherapy. When we acknowledge that the patient is the most important subject, and that those involved in his or her treatment are in the best position to treat the patient, the logical choice is to leave the definiition of the treatment structure to those who are knowledgeable in the field. Of course these steps must be documented, but owing to patient confidentiality, they cannot be sent to the administration of the insurance company. This does mean that “doctors know best.” As in all procedures, delegated psychotherapy involves an understanding that patients are involved in diagnostic and therapeutic decisions that are grounded in informed consent.Addendum
Since submission of the manuscript (October 2018) health insurance companies and representatives of psychotherapists settled the conflict (January 2019, not publicly available) which however in most parts overlap with the arguments discussed in the present publication.POTENTIAL COMPETING INTERESTS
D. Novosel works in psychiatric-psychotherapeutic practice and a part of his work includes delegated psychotherapies.
Dragutin Novosel: Psychiatric-psychotherapeutic practitioner
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