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Delegated psychotherapy – a special organizational form

Walter Aeschimann / June 23, 2019 –

Delegate psychotherapy came from an emergency. The system worked as long as the health insurance did not pass.

In the context of the "psychooboem" of the 1970s, demand for psychotherapeutic services increased. Psychiatrists were no longer able to meet the needs and increasingly referred their clients to the practice of non-medical psychotherapists. Among the clients there were more people who could not afford the therapy. However, most health insurance companies refused to pay contributions from basic insurance to non-medical psychotherapies. The unclear legal situation supported this often arbitrary practice. The condition has become unbearable to many non-medical psychotherapists. As a way out, during the 1970s a special organizational form was created, "Delegated psychotherapy".

In 1979, a foundation for psychotherapy and psychoanalysis was established. He wanted to treat patients who could not afford treatment by their own means. Physicians officially put an account, therapists worked on their behalf (delegated). In a "quasi-legal room" this system was "informally pretty good," wrote a physician from Cirillo and psychotherapist Emilio Modena. He was the driving force of the foundation and representatives of delegated psychotherapists. The system proved until the health insurance company decided that psychotherapy was basically not delegated. It was personal achievement of a doctor, she claimed, and stopped paying to doctors.

Psychotherapists as doctors

The Foundation filed a lawsuit against this decision with the Cantonal Administrative Court. He failed and forwarded an appeal to the Federal Insurance Court (EVG) in Lucerne. In its May 1981 judgment, TOE stated that delegated psychotherapy was a mandatory health insurance provider. However, it is a prerequisite for psychotherapists who work in the treatment to work in the doctors' offices and under their direct supervision and responsibility. They were therefore legal practitioners.

The TOE ruling has resulted in fierce disputes and disputes between health insurers, medical representatives, associations and foundations, which advocated non-medical delegated psychotherapy.

The basic idea of ​​enabling psychotherapy for the less well-off was undeniable from the humanistic and socio-political point of view. However, because of the judgment of the European Court of Justice, a strange legal constellation was created. Doctors did not have any psychotherapeutic qualifications. Still, they assessed the mental illness of the patients and delegated their treatment to employed psychotherapists. They did, however, have no proof of their education. Her work is legitimate by being admitted to the clinic. Physicians gave their employees a fixed salary and calculated their health insurance benefits.

Loss of autonomy and loss of income

In the Canton of Zurich, for example, a medical association and associations of health insurers from Zurich concluded a contract regulating the relationship between a client and delegates of delegated psychotherapy. They agreed on collective bargaining for delegated psychotherapy. That was far below the medical fee for psychotherapy. Delegate psychotherapists did not even get half of what psychiatrists got for the same job. In Zurich, they received 80 francs per hour of therapy compared to about 180 francs for psychiatrists. With the introduction of Tarmed on January 1, 2004, although the approach of non-medical psychotherapy was raised. In the canton of Zurich now they spent about 133 francs a full hour and 191 francs for doctors.

The financial disadvantage of non-medical psychotherapists was one aspect. Heavy and stressful was also the dependence on doctors. But this form of co-operation has remained the only option for non-medical psychotherapists to meet the basic health insurance of health insurance.

Business gifted doctors now have new opportunities. They significantly increased their income by fulfilling their practice with delegated psychotherapists. There were no numerical limitations of employed therapists. During the flourish, there have been practices with several employees, including some without adequate qualifications. Physicians paid a minimum salary and could note the difference in health insurance payments as profits and did not achieve the lowest results. That was not a rule, but it was legal and unusual. On the other hand, due to low time, delegated psychotherapists agreed with their clients and provided separate accounts. That was illegal. To stop these abuse and protect interests, in 1993, "The Society delegated labor psychotherapists (GEDs)", who understood themselves as a "union", and less as a professional organization.

"Not a good state"

Delegate psychotherapists were willing to accept a certain loss of autonomy and revenue. Behind this was the socio-political attitude towards the perceived reality of unfair health policy. But the advantages and disadvantages of this cooperation were in great imbalance. "That was not a good state," recalls psychoanalyst Pedro Grosz. Grosz came as a medical student from Argentina to Switzerland. His medical study was not recognized in Switzerland. He studied psychology at the University of Zurich and opened the classroom practice for classical psychoanalysis. Grosz was politicized in Argentina in the context of military dictatorships and their violations of human rights. In Zurich he joined groups who did not want to be considered psychotherapy independent of socio-political constellations. Since he spoke several languages, many seekers of assistance from all countries, including many traumatized children from South American dictatorships, came to his practice. That was one of the reasons why Grosz also temporarily worked as a delegated psychotherapist.

The Swiss Association of Psychotherapists (SPV) was skeptical about delegated psychotherapy. Vice President Ernst Spengler criticized in 1982 an article in the NZZ ECG 1981 judgment and a "questionable agreement" on delegated psychotherapy between Zurich and the Health Insurance Association. Ten years later, he even more clearly formulated his position: "It is a grotesque insurmountable" irony of destiny "that, on the one hand, qualified self-employed psychotherapists are not approved as providers of health services but on the other hand the activity of hired psychotherapists without any qualification requirements in Tests of Disease performed the medical and SPV commissions showed that only 27 percent of the applicants for performing delegated psychotherapy fulfilled the actual working conditions.

Fighting Medical Monopoly

At the beginning of the nineties in Switzerland, according to GEDP, there were about 3000 psychotherapists. SPV felt their actions as "backshot". He fought for the independence and acceptance of its members as independent service providers under the KVG basic insurance. "Delegated psychotherapy represents the problem of health policy and constitutional law," SPV chairman Heinrich Balmer wrote. GedaP accepts its current medical monopoly with its activities, he claims. Concession on autonomy and income due to health political reality dismissed the association for professional reasons. "In fact, each of us must be angry that we have to go back to social cases of serious suffering if we do not want to jeopardize our own material base, but if we do not fight, we will lose our credibility," Balmer formulated the official policy of SPV. there was a successful association between SPV and GEDP.

The regulation at national level is awaiting

The coherent solution was also not seen at the legislative level. The state of employment policy at the beginning of the 1990s was as follows: By 1991, 17 cantons had legal guidelines for psychotherapy, but not Zurich. Basel has been a pioneer in psychotherapy laws, but practically almost half of all psychotherapists in Switzerland practice in the canton of Zurich. In Zurich, there were the most important institutes for psychotherapy. Various designs, revisions or regulations for health services to regulate non-medical psychotherapy in the canton of Zurich have either failed in cantonal parliament or national referendums. Cantonal authorities have finally been waiting for the upcoming revision of the Swiss Health Insurance Act (KVG) and the Medical Practice Act (MedBG). Psychotherapy, hoping in the parliament in Zurich, would definitely have been regulated at the federal level of the 1990s.

Fear of "cost explosion"

Like the legal definition of psychotherapy, co-operation with health insurance companies was difficult. Most health insurance companies still refuse to cover basic insurance costs. Costs would "explode", was a common argument of health insurance representatives and politicians. The room of the eighties had an additional 250 million francs a year. The number has never been substantiated.

In 1984, Paul Manz, then director of Krankenfürsorge Winterthur (KFW), announced that KFW wants to compensate psychotherapists and psychologists for basic insurance in the future. Pilot trials started three years with SPV. In 1990, KFW discovered its real costs of non-medical psychotherapy after the trial. Per hour, she spent 4.82 francs per member of the board. That amounted to 2,265 million francs to 470,000 insured persons. If this amount was extrapolated to all 6.185 million insured persons in Switzerland, that amount would be CHF 29.6 million. Thus, non-medical psychotherapy accounted for only 0.28 percent of the services provided by health insurance companies. By comparison, in 1991, health insurance companies spent only CHF 218 million on psychotropic drugs. KFW's number is still the only real cost calculation for psychotherapy.

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Psychotherapy Series

In several episodes, Infosperber illuminates the history of psychotherapy. You can find all the posts in

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Walter Aeschimann is a historian and publicist. On behalf of the Association of Swiss Psychotherapists (ASPs), he wrote a historical discussion on the history of psychotherapy in Switzerland on the occasion of their 40th anniversary. Walter Aeschimann: Psychotherapy in Switzerland. Since the struggle for recognition of the profession. Anniversary 40 years of ASP. Zurich 2019.