Who will pay for the mental health crisis?

A global pandemic, lockdown, sanitary restrictions, the environmental and energy crises, the war in Ukraine,… All are impacting the mental health of many. Yet, the discussion between the national health fund and psychotherapists on pricing and reimbursement keeps stalling.

On 29 April, a requesting public health insurer CNS to refund psychotherapy was deemed receivable. A few days later, it had already nearly reached the 4,500 target, counting 4,473 signatories as of 6 May. Many people with lower incomes cannot seek the help they need, the petitioner states, because they can’t afford it. The need for a solution is palpable, as on the same day member of parliament Sven Clement (Pirate Party) submitted a , asking when an agreement will be found on reimbursement.

The debate on who should cover the costs has been going on for years now. In the meantime, patients are “held hostage”, said Luxembourg’s patient rights group, the Patientevertriedung, on 4 April. The hourly price the psychotherapist union Fapsylux recommends to its members--€175--is too high, the group says, and so far has to be paid in full by the patient. Georges Klees from the Patientevertriedung tells Delano: “It’s too high a price compared to other specialisations. The issue is that for many patients who until now paid €100, a €50 increase is a big difference. Some patients contacted us to say that they couldn’t afford that.”

Though the patient union in its press release points its finger at Fapsylux’s suggestion, “it’s clear for us that the CNS should take over the costs. The CNS sees that, otherwise they wouldn’t even have started negotiating.” There is a will from both parties. The issue, he says, is defining the extent of the reimbursement and the price of a session. The recommendation of €175 could discourage the CNS, he adds.

With growing awareness and the de-stigmatisation of mental health issues changing the way people think about this aspect of their health, demand keeps growing. The offer in this sector is not large enough, says Clees. Even if they can afford it, “people have to wait a long time for treatment, unfortunately,” he adds.

For Clees, the two parties have to come to an agreement, soon. The details of the agreement can always be worked on after, but in the meantime, “the patient will be able to get help.”

Psychotherapy, a specialisation in its own right

“Psychotherapists until now have applied a price that society could afford,” says Fapsylux president Delphine Prüm. They have also been waiting on a law on pricing since 2015, she adds. “We’re there to help people get better mentally. We know how important mental health is for the equilibrium of people.”

But the price psychotherapists have been settling for isn’t enough to cover their own needs, she explains. Direct expenses include things like rent, energy or water bills, as well as office supplies. As psychotherapists are also independent, they also have to pay their contribution to the state and CNS, “like all independent workers.”

Being a psychotherapist who exercises their profession is regulated by a strict legislative framework too. “It’s a good thing that the profession is regulated,” says Prüm. This allows patients to receive adequate treatment. Psychotherapists have to undergo training and gather certificates--it takes over eight years of studies to complete this course. On top of a medicine or psychology master’s degree, students have to do a postgraduate degree in psychotherapy, which often is expensive. Additional training throughout their career is also required by the state. The profession is thus, like other medical specialisations, legitimate and should be treated as such, according to the union.

The price also includes the research before and after the actual session with the patient, as well as administrative tasks relating to treatments, the president says.

Mental health affects physical health

As to why the agreement has stalled, Prüm reckons that the CNS worries that psychotherapy will cost them a lot. She doesn’t want to put words in their mouth though. Delano contacted the CNS for comment several times, but did not receive an answer. “For €1 invested in psychotherapy, society wins €3-€4, according to studies,” Prüm says. Mentally well people are also healthier, which would also alleviate the CNS’ expenses.

In the end, psychotherapists care about the well-being of others. Increasing the price is “a true dilemma for us,” Prüm explains. The patient should have the right to reimbursement for their treatment, and the fact that it takes so long for an agreement to be reached is puzzling. “How can it be that the health ministry says yes, and that the ministry of social security stalls?” Prüm asks.

She says the national health fund has a choice: they can decide how much to cover. They just have to take a decision. In the meantime, “the patient is stuck there, and has to be able to afford treatment on their own. That, for us, is grave.”

A national mental health plan, postponed

Mentioned in the coalition agreement of 2018, a mental health plan was promised for 2021. It has been postponed, however.

According to the ministry, it will take a few more months, as it is currently still a work in progress. A consultative platform should be organised at the latest in July, a spokesperson told Delano. One of the focus points of the strategy will be access to psychotherapy, be it in a hospital or a private practice. For now, “the ministry supports the reimbursement of psychotherapy,” the spokesperson said.

Until the unions can come to an agreement with the CNS, however, the costs will fall on patients and professionals. And ultimately, as mental health wounds remain untreated, on society.