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The Actuary and the Therapist: A Love Story

Definition Actuary :

1. Insurance. a person who computes premium rates, dividends, and assesses risk via probabilities based on statistical records.

2.(formerly) a registrar or clerk.

Monetary risk is something we all contend with when we take out our healthcare wallet —especially when it comes to investing in mental health. Whether you’re an individual consumer or a corporation contracting for benefits, it can be hard to measure the value of a medical endeavor. How can we make these choices in a sensible way? Although I see the value for people who have left my office with a successful treatment in their back pocket, for today’s blog I won’t plead the case for the intuitive gift of therapy. I will also leave questions for when to integrate both medication and talk therapy to a different time. Today I’m more interested in seeing what possibilities may exist between psychiatric treatment inclusive of talk therapy and the actuary. Could a cold hard look at the numbers be more warm than previously thought? Could it have more to do with the tender first steps of love?

The idea for this blog came up after a weekly therapy session with a woman who has been my patient for many years . I considered this patient’s treatment with me and began thinking of where she started . She was lost in the misery of a broken heart, leading a stagnant, reclusive life, unable to productively use her talents and skills. Her early life had not made it easy to address relationships in a healthy fashion, and she appeared to be on a trajectory towards greater isolation. Fast forward to this week….. she left our session happily embroiled in negotiating conflicts inside her successful company while simultaneously trying to figure out how these issues might be affecting her intimate relationship. How has she achieved this? My vote is “Aye” for treatment with me and “Nay” for the healing sands of time. Evidence for the success and realistic expectations of treatment are a separate topic to be addressed in a later blog.

A Brief Pause…. I want to take a moment and clarify a particular aspect of combined talk therapy and medication treatment. In this blog, I’m not attempting to correlate a patient’s level of need to how long (or short) the duration of his or her treatment. The relationship between these two factors is complex. In my practice, treatment length and termination are most often not determined by the therapist. Typically outside elements such as a job, location or insurance change might artificially end a treatment. Otherwise it is a more or less natural process of meeting treatment goals and reviewing with the person that characterize the ending of a treatment.

Back to the love story … Still I wondered, could I justify all those sessions as a cost-effective use of resources. Perhaps I thought, I should just avoid the question as she pays out of pocket and answers to herself regarding choice of treatment. Although it's a viable option for her, not everyone has the ability to insulate themselves from actuary-driven private insurance companies or payors. Many of my patients depend on coverage choices made by their insurance provider. In the end I knew that I wanted to take a closer look at the cost of a treatment with me. I wanted to focus on the actuarial dollar; the cost an employer or insurance company may use to determine where to spend their healthcare dollar. So, I closed my eyes and put my finger down on a random week’s list of appointments to explore. In other words, I went over my therapy cases for a single week. I tallied people who were in a consistent therapy and converted folks seen less than weekly to their weekly year equivalent. Keep in mind that these are rough sketch statistics. Here is what I came up with:

About 40 percent of treatments from this snapshot are under one year, 60 percent are under two and 80 percent under three. The median treatment time is at 1.2 years. How did this compare with other medical procedures? For a cost comparison, see USA Today’s table for various procedures below. It may seem initially jarring to compare mental health treatment to some of the life saving procedures listed. There is, after all, no quality of life (or chance for it) with no beating heart. Still, I would say it deserves mention that the pursuit of a “quality life” for the life saved is of essential importance. There actually are measures that try to get at this quality of life to inform healthcare policy. One in particular goes by the name QALY or Quality of Life Years. More on this in a separate blog.

Medical Procedure Costs (USA Today)

Let me provide a bit more information about the current conventional definition of therapy length. Short term treatment is considered usually between 6-16 sessions and definitely less than 25. Long term therapy is generally thought of as open ended and over a year in length. An unfavorable truth about short term therapy is that the academic literature tells us benefits are often short lived. Unfortunately, within 18 months about 75% of responders have either relapsed or sought another mental health treatment. To me this high relapse rate seems intuitive, and I ask the question, “What complex habit/performance/practice based endeavor has been learned to any degree of mastery after 6-16 sessions? Why would we believe learning to harness our emotions, beliefs, feelings would be any different?” Interestingly, a body of literature suggests 1 to 1.5 years or 50 to 75 sessions as a general the tipping point for more durable success in treatment. This suggests that the costs of treatment I list could provide a better chance for a durable solution at the treatment’s endpoint. Great initial results in short term treatments might really be more like the drip, drip, drip of the leaky faucet of ongoing repetitive treatments and patients failing to gain resiliency. This idea might be helpful when an actuary deliberates on the true cost of mental health treatment.

What are the optics and take away points of this rough sketch? First, in this small sample, treatment is not unending in psychiatric psychotherapy as performed at Pondworks; nearly half of treatments are at or under a year. Second, median treatment cost numbers are around $10k and mean costs are at $20k, which do not seem out of step with other general medical procedure costs. The third takeaway, not addressed here, relates to the indirect costs such as days off from work, poor work performance, and ripple effects of stress on family/friends relationships. In conclusion, should these cost numbers sound the strings of love for any actuary? I’m not sure about love, but perhaps the thoughts of a workable relationship.

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