Outpatient Psychotherapy in Germany

An evaluation of the structural reform

Background: A structural reform of the German psychotherapy guideline in 2017 was intended to facilitate access to outpatient guideline psychotherapy. In the present study, we evaluate the effects of this reform in particular for patients with a comorbidity of mental disorders and chronic physical conditions (cMP).

Methods: Pre-post analyses of the two primary endpoints “percentage of mentally ill persons who have made an initial contact with a psychotherapist” and “waiting time for guideline psychotherapy” were carried out employing population-based and weighted routine statutory health insurance data from the German BARMER. The secondary endpoints included evaluations from the patients’ perspective, based on a representative survey of patients in psychotherapy, and an overview of the health care situation based on data from the National Association of Statutory Health Insurance Physicians (Kassenärztliche Bundesvereinigung, KBV) (study registration number: DRKS00020344).

Results: From 2015 to 2018, the percentage of mentally ill persons who had made an initial contact with a psychotherapist rose moderately, from 3.7% (95% confidence interval, [3.6; 3.7]) to 3.9% [3.8; 3.9] among persons with cMP and from 7.3% [7.2; 7.4] to 7.6% [7.5; 7.7] among those with mental disorders but without any chronic physical condition (MnoP). The new structural elements were integrated into patient care. The interval of time between the initial contact and the beginning of guideline psychotherapy became longer in both groups, from a mean of 80.6 [79.4; 81.8] to 114.8 [113.4; 116.2] days among persons with complex disease and from 80.2 [79.2; 81.3] to 109.6 [108.4; 111.0] days among persons with non-complex disease; most patients considered the waiting time. Approximately 8% of the patients who sought psychotherapy reported that they had not obtained access to a psychotherapist.

Conclusion: Neither in general nor for patients with cMP did the introduction of the structural reform appreciably lower the access barriers to psychotherapy. Further steps are needed so that outpatient care can meet the needs of all patients and particularly those with cMP.

In the framework of stepped care, outpatient guideline psychotherapy—as defined in the German Psychotherapy Guideline (Psychotherapierichtlinie, PT-RL) (1)—is a key component of specialized guideline-compliant care. It covers a broad spectrum of defined psychotherapy services in which behavioral therapy, systemic, psychodynamic (including psychoanalytically oriented and depth psychology-based) methods and procedures are used. The aim of the PT-RL is to ensure adequate, appropriate and cost-effective psychotherapy for insured persons in the context of the care provided by statutory health insurance (SHI)-accredited physicians.

In Germany, the majority of persons with mental or psychosomatic disorders are treated by their primary care physicians. To facilitate access to outpatient guideline psychotherapy, a structural reform of the PT-RL was undertaken in 2017 that aimed at shortening waiting times and reducing insufficient provision of psychotherapy services for acute and seriously ill patient groups (1, 2, 3). New care elements, such as psychotherapeutic consultation times, acute treatment (acute short-term psychotherapeutic interventions) and relapse prophylaxis were introduced. At the same time, group therapy, improved telephone availability of psychotherapists for patients and arrangement of appointments of consultation times via appointment-service points were promoted. To evaluate the structural reform, the Innovation Fund of the Federal Joint Committee (Gemeinsamer Bundesausschuss, GB-A) funded three projects dedicated to this purpose (3). Among these was the study “Evaluation of the Structural Reform of Guideline Psychotherapy—Comparison of Patients with Complex and Non-complex Disease“ (ES-RiP).

The primary questions to be addressed by the ES-RiP study are: the investigation of (1) the changes in the initial utilization of psychotherapeutic services (first contact with a psychotherapist); and (2) the waiting time for guideline psychotherapy, before and after the reform. The focus was on patients who have a comorbidity of a mental disorder and a chronic physical condition (cMP). This patient population is considered to be particularly at risk (4) because the comorbidity of mental disorders and physical conditions is associated with decreased quality of life (5, 6, 7, 8), an increased mortality rate and increased treatment costs (9, 10, 11, 12, 13, 14).

Given that one of the goals of the reform efforts was to improve the care of patients with severe conditions, it was assumed that two years after the introduction of the reform, the initial utilization of psychotherapy services (initial contact) had increased more strongly among adults with cMP and the waiting time for treatment in this patient group had decreased more sharply than among patients with mental disorders but without any chronic physical condition (MnoP). Secondary endpoints included the changes in the health care situation based on health insurance billing data as well as evaluations from the perspective of the patients (including perceived waiting time, satisfaction with the waiting time) and of the service-providing persons.

Methods

In the ES-RiP study (study registration number DRKS00020344), the structural reform of the German psychotherapy guideline was viewed as a complex intervention, and therefore, the evaluation was based on the theoretical framework of the throughput model and designed as an observational study using a multilevel approach (patients, service providers and payers), integrating various data sources (primary/secondary data), and incorporating various methods (qualitative/quantitative). The approach taken allowed both (A) an outcome evaluation of the structural reform and (B) an evaluation of the reform process, as well as (C) an additional health economic evaluation.

The primary questions were part of the outcome evaluation and aimed at the pre-post comparison of the primary endpoints:

• Changes in the percentage of persons among patients with cMP and with MnoP who had an initial contact with a psychotherapist (initial utilization of psychotherapy services from a medical or psychological psychotherapist) and
• Waiting times from initial contact to guideline psychotherapy, based on billing data from the German statutory health insurance (SHI) company BARMER.

The group of psychotherapists included medical and psychological psychotherapists as well as specialists in psychosomatic medicine and psychotherapy and specialists with an additional qualification in psychotherapy whose main area of activity is psychotherapy. Secondary utilization analyses were based on data from complete surveys of the National Association of Statutory Health Insurance Physicians (Kassenärztliche Bundesvereinigung, KBV) in the years 2015 and 2019. Additional ad-hoc evaluations on the utilization of services in accordance with Chapter 35 of the German Uniform Value Scale (Einheitlicher Bewertungsmaßstab, EBM) which were utilized by patients between the initial contact with the psychotherapist and the start of guideline psychotherapy, are based on BARMER data.

Further evaluations of waiting time, which is included as a secondary endpoint in the outcome evaluation, are based on a representative psychotherapy-utilization population of 1820 patients which was obtained from a population-representative sample of 32 573 screened persons. Details of the procedure and the samples are described in the study protocol (16). Operationalizations and definitions can be found in eSupplement 1; explanations of the methodology for BARMER data, KBV data and the population survey are provided in the eSupplements 2–4.

The ES-RiP study’s reform process evaluation for determining the service providers’ perspective (medical/psychological psychotherapists and primary care physicians) as well as the health economic evaluation are described separately.

Results

Primary endpoints

Initial contact with psychotherapists

For Germany, the analysis of the population-based and weighted routine data from the BARMER showed an increase in the administrative 1-year prevalence (prevalence based on routine statistical information) of defined mental disorders from 20.9% (13.3 million persons) in 2015 to 22.3% (14.3 million persons) in 2018 (eSupplement-2 Table 1). Of these, approximately 8.5 million people (13.3%) in 2015 and approximately 9.1 million people (14.2%) in 2018 had had no contact with an outpatient psychotherapist in the previous two years. These patient groups made up the BARMER study population. At 59.4% and 61.6%, respectively, the majority of persons had cMP. In the BARMER study population, the absolute number of patients with initial contact with an outpatient psychotherapist rose by 3.4% from 2015 to 2018, from about 436 000 to 482 000, while the percentage rose from 7.3% (95% confidence interval [7.2; 7.4]) to 7.6% [7.5; 7.7)] for persons with MnoP and from 3.7% [3.6; 3.7] to 3.9% for persons with cMP [3.8; 3.9] (Table 1).

Table 1

Initial contact with an outpatient psychotherapist and utilization of services in accordance with the German psychotherapy guideline in the ES-RiP study population (BARMER data)

More detailed ad hoc analyses were intended to address shifts in the study population with regard to age, gender, and place of residence. Based on results on initial-contact rates within the various subgroups in 2015, the initial contacts were calculated—as an indirect standardization—for the populations in 2018 that, based on the rates from 2015, would have been expected for 2018. In patients with cMP, the initial-contact rate observed in 2018 was by 4.6% [3.1; 6.0] higher than expected and in patients with MnoP by 4.4% [3.1; 5.7] above the expected 2018 rate. Reflecting the widely overlapping confidence intervals, there was no significant difference in the increase in initial contacts between the patient groups (p = 0.9; Table 1). After the structural reform, persons with cMP were still significantly less represented in the group of persons with initial contact with an outpatient psychotherapist. Psychotherapy services utilized after the initial contacts are listed in Table 1.

Waiting time

In the BARMER study population, the mean waiting time between initial contact with a psychotherapist and the first guideline psychotherapy service billed within 365 days increased from 80.4 days before the structural reform to 112.1 days (+ 39.4%) after the reform. It increased in persons with cMP and persons with MnoP from a mean of 80 days in 2015 to 115 and 110 days, respectively, in 2018.

Inconsistent with the second study hypothesis, an increase in waiting times compared to the largely identical starting levels was observed in both groups as a result of the reform; this increase was greater in persons with cMP with an increase from 80.6 to 114.8 days than in persons with MnoP with an increase from 80.2 to a mean of 109.6 days (Table 2).

Table 2

Waiting times in the Es-RiP study population (BARMER data)

Secondary endpoints

Changes in the care situation

As part of the reform, new services were introduced in guideline psychotherapy, including psychotherapeutic consultation times and acute treatment. The determination of the utilization of psychotherapy services of all patients with mental disorders who had contact with an outpatient psychotherapist (Table 3) is based on KBV data (complete survey). The number of persons with mental disorders who received at least one outpatient psychotherapy service increased from 1 614 458 in 2015 to 2 110 205 in 2019 (+ 30.7%). The percentage of persons with cMP who utilized psychotherapy services rose from 26.8% to 28.2%.

Table 3

Utilization of guideline psychotherapy services by patients with documented mental disorders

The increase in the number of persons receiving psychotherapy is primarily associated with the integration of the newly developed psychotherapy elements into routine care. In 2019, for example, a psychotherapeutic consultation time was billed for 1 179 281 patients and acute treatment for 198 138 patients. The number of persons undergoing short-term or long-term psychotherapy rose by 6.5% from 1 184 876 in 2015 to 1 261 609 in 2019 (Table 3).

Waiting time from the patients’ perspective

In the screenings of the population-representative survey (n = 32 573), 2181 persons stated that they had sought psychotherapy since 2012. The weighted analysis population after a drop-out ultimately comprised 1985 persons. Of these, 165 persons (8.3%) were unable to establish a personal contact with a psychotherapist despite seeking psychotherapy. The remaining persons (n = 1819) were surveyed about the health care situation (eSupplement 4).

Half of the respondents reported waiting times for an initial consultation of less than four weeks (59.2% before the reform, 55.3% after the reform). 87.7% (before the reform) and 89.3% (after the reform) reported having attended an initial consultation within three months of deciding to seek psychotherapy. Asked about waiting times between the initial consultation and regular guideline psychotherapy appointments, 82.7% of respondents reported waiting times of less than four weeks before the reform and 76.1% after the reform, while 96.7% and 96.1% of respondents waited up to three months, respectively (Table 4).

Table 4

Self-reported waiting times for a psychotherapeutic initial consultation/regular psychotherapy appointments*

Two thirds of respondents (before the reform: 67.7%; after the reform: 68.1%) stated that the waiting time for an initial consultation was shorter than expected. About 85% of the respondents thought the waiting time for regular psychotherapy appointments was shorter than expected or appropriate. Patients mostly rated waiting times of over three months as too long. Details on satisfaction with the waiting time are provided in eSupplement-4 Table 3.

Services received during the waiting time

Descriptive ad hoc analyses of the BARMER-data were performed to obtain a better understanding of the high level of satisfaction with the waiting time. It was found that persons made use of a variety of psychotherapeutic services after an initial contact and prior to the start of guideline psychotherapy (EBM Chapter 35). During this period, a biographical history was taken in about half of the persons and a more in-depth exploration was performed in approximately one quarter of persons (eTable).

eTable

Services provided before the start of guideline psychotherapy based on BARMER data

Discussion

The reform of the psychotherapy guideline sought to facilitate access to outpatient psychotherapy as well as shorten waiting times and reduce the inadequate provision of psychotherapy services to certain patient groups. The findings of the study suggest that after the reform the number of persons who were able to gain initial access to an outpatient psychotherapist increased only slightly. Rather than being shortened, the waiting time between initial contact and start of guideline psychotherapy actually increased considerably. In addition, the risk group of persons with cMP is still underrepresented in the population of persons receiving psychotherapy. In this respect, the reform has failed to achieve its goals.

However, the overall number of patients who received at least one outpatient psychotherapy service increased to 2.1 million in 2019. This increase of 30.7% in the total number of persons who received treatment cannot be explained solely by population growth and an increase in the number of psychotherapists licensed by the statutory health insurance funds (SHI) to treat patients (SHI data: 2016: 32 298; 2019: 38 588). New structural elements, such as psychotherapeutic consultation times and acute psychotherapeutic treatment, were integrated into patient care and billed for about 1.2 million and 200 000 persons, respectively. This is an indication that the health care system is performing at a high level.

Still, the increase in the number of services provided occurred predominantly among patients who had already had contact with outpatient psychotherapists in previous years. Consistent with the study by Hentschel and Böker (17), the findings of our study indicate that the smaller proportion of the population receiving psychotherapy (approximately 480 000 persons) had no contact with a psychotherapist within a two-year period.

In line with the PT reform study (18), we identified a significant increase in the waiting time between the initial contact with an outpatient psychotherapist and the initiation of guideline psychotherapy. With a mean waiting time of 112 days, our SHI data-based results are slightly below the mean waiting time of 142 days reported by the Federal Chamber of Psychotherapists in Germany (based on information from psychotherapists) (19) and the value of 139 days determined by the Bavarian SHI “Krankenversicherung Bayern” (based on SHI data) (20).

When interpreting the data, the possibility of bias should be taken into account. For example, before the structural reform, some psychotherapy clinics often only offered the opportunity of an initial consolation if it was clear that a space for guideline psychotherapy would be available as well. After the reform, however, the introduction of the new care elements “consultation times” and “acute treatment” prolonged the period until the start of guideline psychotherapy. Thus, not surprisingly, the waiting time between probatory sessions and the start of guideline psychotherapy decreased significantly after the reform. Our analyses indicate that in the period between initial contact and start of guideline psychotherapy, a large number of services are utilized, including consultation time appointments, probatory sessions and biographical anamnesis. Thus, this waiting period should not be viewed as a psychotherapy-free time, but rather as a preparation time that is filled with content. This interpretation is supported by a recent analysis of billing datasets of the German substitute health insurance funds (“Ersatzkassen”) (21).

With the introduction of psychotherapeutic consultation times, psychotherapists have taken on the task of establishing whether there is an indication of a clinically relevant mental disorder and whether further specialist help is needed. The decreasing percentage of those who receive further psychotherapeutic services after an initial contact may also be a consequence of the increasing importance of the screening and counseling function of outpatient psychotherapists.

Of the patients who participated in the survey, 68% considered the waiting time for an initial consultation and 85% the waiting time between initial contact and the start of regular psychotherapy sessions as adequate. One limitation to be noted here is that when assessing the waiting time from the patients’ perspective, it remains unknown to what extent their level of expectations has already an effect on their response: They may already be prepared for long waiting times and frequent attempts to contact a psychotherapist.

At the same time, the data points to existing challenges in providing psychotherapeutic care. Of the persons who had sought outpatient psychotherapy, 92% stated that they had received an appointment with an outpatient psychotherapist. However, of the persons who sought therapy, 8% were unable to make an appointment, partly because the accessibility of the practice was inadequate or the waiting time was too long, but also due to patient-related reasons, such as concerns from family members or because their symptoms had subsided spontaneously.

Of the respondents who had an initial contact with an outpatient psychotherapist, 12% before and about 11% after the reform reported waiting times for an initial consultation of more than three months, which was considered inadequate. Based on a patient survey conducted in 2022, the National Association of Statutory Health Insurance Funds also reported waiting times of 60 days in about 10% of patients (22). There is a need to further analyze the access barriers for these patient groups, whose percentage was not reduced by the reform—also against the backdrop of regional differences.

Despite the fact that about 60% of patients with mental disorders have a concomitant chronic physical disease, this group is still significantly underrepresented in the population of persons receiving psychotherapy. The measures taken as part of the structural reform of the psychotherapy guideline are not sufficient to meet the needs of this risk group. An adapted range of psychosomatic care services and better networking with the physical health care sector within a more structured patient care system could address these care challenges.

Limitations and strengths

The results presented in this article are subject to various limitations. The routine data of the BARMER and the KBV are based on billed services. The data from the population survey is based on self-reports, in some cases relating to events that occurred a long time ago; thus, these data are subject to a certain bias and distortions.

A fundamental strength of the ES-RiP project is its multi-level approach, incorporating billing data (BARMER, KBV) and self-reports (population survey). While the routine data provides an objective view of the outpatient psychotherapy care situation in Germany, the population survey adds the subjective view of patients, enabling an evaluation of the psychotherapy guideline from various perspectives. In addition, the results of the population survey were weighted according to age, gender and place of residence at federal state level in order to ensure the representativeness of the analyses.

Conclusion

Further development steps are required to accomplish the intentions of the reform and to achieve needs-based outpatient care, especially for the underrepresented risk group of patients who have both a mental disorder and a chronic debilitating physical condition.

Acknowledgement

We would like to thank all patients who took the time to support the ES-RiP project and participated in the surveys, the staff of the KBV, in particular Dr. med. Ekkehard von Pritzbuer and Dr. med. Bernhard Tenckhoff, Natalia Frejnik and Diana Kurch-Bek as well as the other team members of the ISI department of the KBV for their extremely helpful collaboration in the analysis of the health care data and their active support in the secondary data analysis, as well as USUMA GmbH, especially Martin Liebau and Dr. Jürgen Schunter, and the interviewers involved and the supervisors who supported the population survey so persistently and thus helped to make it possible.

Funding

The ES-RiP study was funded by the Innovation Fund of the Federal Joint Committee (G-BA) (01VSF19004).

Conflict of interest statement
The authors declare no conflict of interest.

Manuscript received on 18 September 2023, revised version accepted on 20 February 2024.

Translated from the original German by Ralf Thoene, M.D.

Corresponding author
Prof. Dr. med. Johannes Kruse

Klinik für Psychosomatik und Psychotherapie

Universitätsklinikum Gießen und Marburg GmbH

Standort Gießen

Friedrichstr. 33, 35392 Gießen, Germany

Cite this as:
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. DOI: 10.3238/arztebl.m2024.0039

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