Almost no Change in Waiting Times for Outpatient Psychotherapy After an Amendment to the Law

Editorial to the article: “Outpatient Psychotherapy in Germany—an Evaluation of the Structural Reform“ by Johannes Kruse et al. in this issue of Deutsches Ärzteblatt International

With the aim of improving psychotherapeutic care in Germany, a reform of the psychotherapy guideline was decided in 2016 (1). This reform was primarily intended:

• to reduce waiting times for diagnosis and treatment
• to make the psychotherapy services offered more flexible, and
• to simplify the application and expert procedures.

In November 2018, the Federal Joint Committee (G-BA) published a funding announcement for the evaluation of this reform. The study “Evaluation of the Structural Reform of Guideline Psychotherapy—Comparison of Complex and Non-complex Patients (ES-RiP)“ by Johannes Kruse et al. received 1.6 million euro funding from this pool. This working group is now presenting the key findings of its analyses—and these are highly relevant for outpatient care (2).

Waiting times not reduced

Compared to other research projects funded in this context, the ES-RiP study is set apart above all by its focus on persons with complex disease, i.e. those with physical comorbidity. Not only are they often under particular psychological stress, but they also face higher barriers to access to psychotherapy (3). The data of Kruse et al. shows that unfortunately the structural reform of guideline psychotherapy has not changed this. While 8% of the BARMER insured persons with non-complex disease were able to have an initial contact with a psychotherapy clinic, only 4% of those with complex disease managed to achieve this (prior to the reform, the situation was similar [7% and 4%, respectively]).

On a positive note, there was no difference in waiting times for psychotherapy between the two groups. The period between an initial contact with a psychotherapy clinic (defined as the first service billed) and the start of guideline psychotherapy was on average 80 days and 112 days before and after the reform, respectively. Such an increase in waiting times was also found in the PT-REFORM study (4), from an average of 126 days before the reform to 141 days after. However, this does not necessarily imply that patients are left without care during this time and actually waiting. On the contrary, newly introduced services are usually utilized between initial contact and start of psychotherapy, for example further psychotherapeutic consultation times.

Goals of the reform not achieved

What is more important is how long patients have to wait for an initial consultation, i.e. how much time passes between the initial contact, for example a telephone call or an e-mail, and the initial consultation for information/clarification. To reduce this time was an important goal of the reform. However, billing data cannot provide any information on this aspect. So it is of particular value that the team of authors was also able to survey a large sample of persons seeking psychotherapy who provided information about how long they had to wait for an initial consultation. This revealed that there was no difference before and after the reform. While this finding contradicts the responses of the psychotherapists surveyed by the Federal Chamber of Psychotherapists (5), who reported a shortening of waiting times from 12 to 6 weeks, they are in line with the file-based results of the PT-REFORM study (4).

The psychotherapy-seeking persons surveyed by Kruse et al. frequently (68%, both before and after the reform) perceived the time to start of therapy as adequate or even shorter than expected. However, the authors caution that this could also be due to the fact that those who seek psychotherapy prepare themselves for long waiting times from the very outset and are then rather pleasantly surprised when they find out otherwise. This is consistent with the findings from qualitative patient interviews, showing that those who seek therapy prepare themselves for a hard time and also tend to give up their preferences over the course of the search (6). In any case, the ES-RiP study found no evidence to suggest that the waiting time for initial consultations had been shortened by the reform.

Limitations of the study

Of course, even such a broad and well-designed study has its limitations. It is unfortunate that children and adolescents as well as persons aged 79 years and over were excluded.

This is regrettable because both age groups receive below-average psychotherapeutic care, although demand is increasing, especially in the younger group (7).

However, there are multiple aspects which have only been evaluated in the ES-RiP study and not addressed in any of the other projects, or at least such findings have not yet been reported.

Seekers give up

It is interesting to read the reasons given by the respondents as to why they ultimately gave up seeking psychotherapy. These reasons can be found somewhat hidden in eSupplement (2). Their main concerns were a lack of access to psychotherapy and excessively long waiting times for consultations. This again is evidence that the reform has not achieved its goals.

Recommendations for action

What measures would need to be taken to considerably improve this situation? Based on the results of the PT-REFORM study, a group of psychotherapists, patients and association representatives developed and reached consensus on various recommendations for action. Key recommendations included:

Needs planning should be reformed by modifying the ratios, focusing more on mental morbidity in the total care provided by SHI-accredited physicians over time.

The coordination services involved in making arrangements between various case-related treatment providers should be remunerated independent of the new guideline on complex treatment.

Uniform criteria should be defined for how patients with statutory health insurance can receive psychotherapy from licensed psychotherapists with specialist knowledge but without a registered practice.

Greater flexibility in telephone availability should be implemented.

For group therapies of children and adolescents, the possibility should be created to work with two patients if individual group participants are unable to attend at short notice.

The fact that short-term psychotherapy was split into two approval steps as part of the reform has led to increased administrative burden and consequently less time for psychotherapy. Thus, this provision should be repealed.

The full text of the recommendations and the reasons given for them are publicly available on the G-BA website (8).

Conflict of interest statement
The author is Chairwoman of the Working Group of Psychodynamic Professors.

Corresponding author
Prof. Dr. rer. med. Susanne Singer

Cite this as:
Singer S: Almost no change in waiting times for outpatient psychotherapy after an amendment to the law. Dtsch Arztebl Int 2024; 121: 313–4. DOI: 10.3238/arztebl.m2024.0067

References

1. G-BA: Tragende Gründe zum Beschluss des Gemeinsamen Bundesausschusses über eine Änderung der Psychotherapie-Richtlinie: Strukturreform der ambulanten Psychotherapie. Berlin: G-BA; 2016. www.g-ba.de/downloads/40-268-3842/2016-06-16_PT-RL_Aenderung_Strukturreform-amb-PT_TrG.pdf (last accessed on 4 April 2024).

2. Kruse J, Kampling H, Bouami SF, Grobe TG, Hartmann M, Jedamzik J, Marschall U, Szecsenyi J, Werner S, Wild B, Zara S, Heuft G, Friederich HC and the ES-RiP-Konsortium : Outpatient psychotherapy in Germany—an evaluation of the structural reform. Dtsch Arztebl Int 2024; 121: 315–22

3. Pichler T, Herschbach P, Frank T, Mumm F, Dinkel A: Barrieren der Inanspruchnahme psychoonkologischer Versorgung. Onkologie 2022; 28: 708–12

4. Singer S, Maier L, Paserat A, et al.: Wartezeiten auf einen Psychotherapieplatz vor und nach der Psychotherapiestrukturreform. Psychotherapie 2022; 67: 176–84

5. Bundespsychotherapeutenkammer: Ein Jahr nach der Reform der Psychotherapie-Richtlinie. Wartezeiten 2018. Berlin: BPtK; 2018. https://api.bptk.de/uploads/20180411_bptk_studie_wartezeiten_2018_c0ab16b390.pdf (last accessed on 4 April 2024).

6. Pantle V, Maier L, Schmalbach I, et al.: „Die passende Chemie wäre entscheidend…wenn man denn eine Wahl hätte“. Behandlungspräferenzen von Patient:innen bei der Suche nach einer ambulanten Psychotherapie. Psychotherapie 2023; 68: 311–8

7. Kohring C, Akmatov MK, Holstiege J, Heuer J, Dammertz L, Bätzing J: Inzidenztrends psychischer sowie Entwicklungs- und Verhaltensstörungen bei Kindern und Jugendlichen in der ambulanten Versorgung—Entwicklungen zwischen 2014 und 2021. Berlin: Zentralinstitut für die kassenärztliche Versorgung in Deutschland (Zi); 2023.

8. Singer S, Maier L, Engesser D, Büttner M: Evaluation der Psychotherapie-Strukturreform – Ergebnisbericht. Berlin: Gemeinsamer Bundesausschuss (G-BA); 2023. https://innovationsfonds.g-ba.de/downloads/beschluss-dokumente/452/2023–10–16_PT-REFORM_Ergebnisbericht.pdf (last accessed on 4 April 2024).