The Politics of Evidence-Based Practice
Evidence-Based Practice provides a "scientific" rationale for providing less service while garnering greater profit.
Evidence-based practice (EBP), which promises “the integration of best research evidence with clinical expertise and patient values,” currently dominates the healthcare world. In mental health it has become synonymous with cognitive behavioral therapy (CBT), code for short-term treatment approaches that have proved “ineffective for most people most of the time.” Those who do not practice CBT are left vulnerable to treatment denials, audits, and lawsuits, and depth-oriented longer-term therapy as embodied by psychoanalysis has been especially damaged. Experientially, there is a stigma and shame that haunt those in the psychoanalytic, humanistic/existential, and family systems clinical worlds, as well as justified anger at the effort of CBT proponents to rewrite, if not eliminate, the research-supported history of the general effectiveness of psychotherapy.
Understanding the rise of EBP requires situating it in the recent history of healthcare in the U.S. Until the 1980s, healthcare was essentially a “ma-and-pa” operation, with services provided by private practitioners, stand-alone hospitals, and medical centers, many with a religious affiliation. Thanks to the corporate takeover of this industry in the 80s, the United States now has the most expensive healthcare system in the world, costing almost three times as much as other industrialized nations and accounting for more than ⅙ of GDP. This despite the fact that the U.S. consistently ranks very low in health outcomes across the board. In short, Americans get fewer services, including outpatient visits, hospital days, and surgeries, for far greater cost with far worse results.
This situation has only been exacerbated by the Affordable Care Act, which has helped the stock prices of the four major health insurance companies more than double since its passage. One of the prime objectives of the ACA is to eliminate the fee-for-service system and replace it with a capitation model, wherein a fixed amount is given to provide services for an individual regardless of actual need. The popular term often used regarding capitation is “value over volume.” In reality, the incentive is to provide less service under the guise of “accountability” (code for austerity). Under the rubric of “medical necessity,” a term created by the health insurance industry to control cost and increase profit, services that are not deemed to be evidence-based can be categorically denied.
Set against this backdrop, EBP serves an important function as a vehicle to curtail services, and thereby increase the profit of the health insurance and drug industries, while also cutting government costs. In other words, EBP provides a “scientific” rationale for providing less service while garnering greater profit. It is also consistent with the neoliberal ideology that prioritizes individual control, however illusory, over vulnerability, self-understanding, and interdependence.
The American Psychological Association has largely been complicit in this paradigm shift. In the mid-1990s, under the auspices of the APA’s Division of Clinical Psychology’s Task Force on Promotion and Dissemination of Empirically Validated Psychological Procedures, the formalization of EBP began to take shape. Thanks to the pressure of practitioners of psychoanalytic, humanistic, and family therapy traditions, the APA adopted a broader definition of EBP consistent with the one formulated by the Institute of Medicine, allowing for practitioner expertise and patient characteristics to be included alongside empirically validated treatments. However, due to the fact that many academic psychologists, who thought it unethical for practitioners to use anything but empirically validated treatments, served on this task force, no guidelines as to how psychoanalytic treatment might represent itself as bearing the requisite “evidence” were offered, effectively upholding the narrow definition of EBP.
This exclusion of psychoanalytic therapies from being considered “evidence-based” represents the general trend within the APA toward collusion with the cost-cutting and service-limiting demands of managed care. Worse still, the APA is now developing practice guidelines based on CBT evidence-based treatments that will further limit public access to psychodynamic treatment and any depth-oriented or longer-term treatment, as well as actively promulgating CBT in graduate training and internship placements.
Worth highlighting is that the APA’s Board of Professional Affairs and Division 12 (The Society of Clinical Psychology) consisted largely of academic psychologists during this period. The president of Division 12, David Barlow, was also chair of the Board of Professional Affairs and had published an approved manual for the treatment of panic disorder. He and others stood to gain both professionally and financially from EBP, narrowly defined, and thus served the same role that psychiatric consultants play for drug companies. The development of EBP is thus the story of compliant professionals bending to corporate interests for their own benefit.
The “pay for performance” model enshrined in the ACA is now embodied in the Physician Quality Reporting System, which classifies conditions based on the possibility and amount of reimbursement for treatment. A given diagnosis is accorded a defined level of reimbursement and no more, regardless of the complexity and individual nature of the case. Thus payment is “capitated”, and legitimate individual needs for service are limited or denied. There are now reimbursement penalties for those practitioners who do not follow these guidelines.
The Physician Quality Reporting System is based on standards derived from studies now largely discredited, yet which are considered to be evidence-based. There is no evidence that pay-for-performance schemes improve quality of care or save money, but rather than question the validity of the practice guidelines and the cost-cutting agenda they serve, the APA is now offering training for psychologists to comply with the system.
“Pay for performance” also undergirds the growing importance of national provider identifier numbers and electronic medical records. The national provider identifier evolved out of the Health Insurance Portability and Accountability Act of 1996, an act that does not preserve privacy but rather informs people how precisely their privacy could be breached, and was implemented in 2006. Contrary to what many psychologists are told, there is no requirement to hold an national provider identifier unless the provider files insurance forms electronically, is a Medicare provider, or is on an insurance panel. Most mental health workers nonetheless attain one, which allows insurance companies access to practice patterns. This information in turn allows them to finely hone their practice of treatment denials, therapist audits, and privacy violations.
Electronic medical records have improved quality of care no more than national provider identifiers, but there is substantial evidence of their enormous cost (in the tens of billions of dollars). Moreover, there is the ever-present threat of breaches of privacy and security via leaks and hacking, which have occurred with increasing frequency and scope over the last years. And since there are hundreds of different electronic medical record systems, they do not and likely cannot ever communicate effectively with one another. This doesn’t stop insurance companies from using data they gather from this system to scrutinize claims and deny care.
“Pay for performance” relies on standards derived from evidence-based practice, which cannot be fully implemented without electronic medical records and national provider identifiers. The whole system constitutes an effort toward top-down social engineering that both serves the profitability of the health insurance industry and allows for hidden austerity measures on the part of the government under the guise of accountability and technological efficiency. In the end, it is but another scheme for the upward redistribution of wealth, made more odious by the fact that it is undermining our sanity.
Allan Scholom is Immediate Past President of the Psychoanalyst Practitioners Section of the Division of Psychoanalysis of the American Psychological Association.