On direct patient participation in the cost of their psychiatric care. Part II: Access to services, impact on practice and training implications.

A review of the relation between insurance and psychiatric services addresses the economic concerns involved. Under third-party reimbursement, a range of predictability and stability of treatment costs is observed; overall cost benefit and effectiveness for a variety of therapeutic procedures is demonstrated and socio-cultural factors play a role in the users demand behavior. The cost of medical care is a small percentage of the system's total cost and judicious use of psychiatric consultation reduces medical and surgical expenditures. Inherent difficulties for the profession exist in a universal health care scheme. The acceptability of psychological impairment and the confidentiality dilemma are among the issues reviewed. Further attention must be paid to the therapist's fee, behaviour and income needs. A traditional defensiveness regarding these matters should be overcome through a peer review process in order to further delineate responsible financial norms of psychiatric practice. The "laissez-faire" attitude observed in most of our training programs towards financial matters must be addressed in order to participate effectively in the ongoing sociopolitical dialogue on the funding of health care.

On direct patient participation in the cost of their psychiatric care. Part I. A review of the empirical and experimental evidence.

In the midst of a sociopolitical debate regarding access to health services, an evaluation is required of the therapeutic impact of the direct participation by some patients in the cost of their psychiatric treatment. Empirical clinical concepts regarding the need for a direct payment of treatment by the patient have evolved. Initial rigorous practice systems have lead to more flexible methods allowing for the recognition of third-party financing. Psychoanalytic theory has addressed the issue most extensively, but other conceptual frameworks have reached similar conclusions as well. The experimental evidence to either support or refute the position that the direct payment of a fee has a beneficial effect on therapeutic outcome remains limited. The focus has been on studying the impact of fee manipulation, but a tested correlation of other motivators such as patient's insight, therapist's attitudes and behaviour and social pressures is mostly lacking. Two patient populations appear to be delineated. Fee participation is of particular value to the financially secure and to the educated while patients in need of less intensive involvement, with reality testing disturbance and limited insight benefit particularly from third party insurance. Different patient populations should have the right to choose different payment options.

Payment for psychiatric services under Canada's insurance system.

The authors review the impact of Canada's universal health insurance system on the delivery of psychiatric services. They believe that, on balance, Canadian psychiatrists and their patients have benefited from the system. However, certain categories of patients still do not have access to private care, and public facilities in some provinces have long waiting lists for services because of manpower shortages. A substantial number of psychiatrists have opted out of the system because of dissatisfaction with the intrusion of third-party payment on practice. The Canadian system presently discourages copayment by patients, and thus has reinforced the public's belief in free medical care as a right. The authors discuss the benefits to some patients of direct payment for services and emphasize the need for direct payment to remain an option under national health insurance.