The Birth of Coverage for Psychotherapy
When Cummings started out as a young psychologist in the late 1950s, not a single health plan included psychotherapy. For the actuaries of the health insurance world, psychotherapy was simply too vague and ethereal to be taken seriously. But Sidney Garfield, cofounder of Kaiser Permanente, the nation's first HMO, had become increasingly aware of complaints from overworked physicians within the Kaiser system about the time spent dealing with "hypochondriacs"--patients who required attention for problems that had little to do with physical disease. Believing that psychotherapy might be the key to reducing the workloads of his physicians and realizing enormous cost savings, Garfield hired Cummings, who had recently resigned from the graduate faculty at Cornell University after only three weeks, unable to tolerate the bureaucratic snail's pace of academic life. Cummings's assignment was to investigate the impact of including psychotherapy as a benefit in the Kaiser plan.
Instead of viewing "hypochondria" as evidence of pathology, Cummings began by normalizing what he termed "somatization"--the predictable symptoms of the stress or underlying psychological issues that are part and parcel of any major medical condition. He designed a pilot project with 30,000 Kaiser subscribers, offering them--for the first time--the option of seeing a physician-referred psychotherapist for a $5 co-payment. By the end of his three-year study, Cummings concluded that as many as 60 percent of physician visits were based on somatized complaints and demonstrated that therapy could save medical and surgical dollars far beyond the money necessary to provide psychological services. Hence the term "medical cost offset," the economic rationale that fueled the growth of mental health coverage--and, ultimately, the mass impact of therapy on American culture--was born. As a direct result of Cummings's work, in 1963 Kaiser Permanente became the first health insurer to include psychotherapy as a regular benefit, with the rest of the insurance industry soon following suit.
Over the next two decades, Cummings became a member of a core group of insurgent psychologists within the American Psychological Association (APA), dubbed by their adversaries "the dirty dozen" (even though there were 14 of them) because of their penchant for unconventional guerrilla tactics in challenging the association's status quo. Along with his co-conspirators, Cummings set out to galvanize the staid, academically oriented APA into furthering the growth of psychology as an independent clinical practice. Cummings and his allies led the way in the battles for "freedom-of-choice" legislation in the '60s and '70s that opened the way for psychologists (and later social workers and other mental health professionals) to gain licensure and the right to be reimbursed alongside psychiatrists. Determined to offer an alternative to traditional academic clinical training, in 1969 Cummings also founded the California School of Professional Psychology, the first professional school of its kind, that offered doctoral-level clinical training emphasizing experiential learning, personal therapy as a requirement for trainees and a faculty of practicing clinicans rather than academics who, as Cummings puts it, "had never seen a patient in their lives."
By the mid-1980s, Cummings became convinced that the issue for therapists was no longer recognition and reimbursement, but a sea change in the fundamental economy of contemporary health care. His assessment: "The cottage industry which constituted a fractionated and disorganized non-system of health care was about to industrialize." He urged psychologists to become leaders in the inevitable movement toward a more coherent, cost-conscious approach to health care, rather than ceding the field to corporate interests. He argued that efficient, targeted treatment was not incompatible with effective clinical services and, by way of example, he founded American Biodyne, a model for the kind of practitioner-run national company he advocated that grew to serve 14.5 million enrollees in 39 states by the time he sold his interest in it in 1993.