In the discussion after the film yesterday, someone asked an interesting question -- does accepting insurance alter the therapy? The person asking wanted to believe it does not. But as I have thought about it, I believe it does, though subtly.
One way that comes to mind for me is how diagnosis is made and assigned. Insurance companies require a diagnosis before they will pay and not all diagnostic categories are reimbursable. We might protest that it is mere formality to select a diagnosis and does not impact the therapy itself, I suspect that is not completely true. Because in doing this, there is already a third party involved in the treatment, a third party who can significantly effect the duration of the therapy.
Then comes the issue of missed sessions. Which cannot be billed to insurance. Therapists may hesitate to charge the patient for these sessions, fearing the patient's reaction. Or that the patient cannot afford the fee charged to insurance.
Another way concerns notes. Insurance companies can audit records and ask for case notes. So the therapist has to think about how detailed to make the notes and what can and cannot be written.
None of these things seems to be present in the room in the hour with the patient but they are part of the background of the work and it must be considered that they exert influence, however subtle. Because a therapy contract which involves insurance involves 3 parties, not just the therapist and patient.
This is not to say that therapists who accept third party payment are unethical but I do believe the full range of implications of this practice really does need to be carefully considered and made as conscious as possible by therapists.