Health Care Reform Blog

Regular blog postings will keep you updated on health care reform.

A group of psychologists in Massachusetts worked with Representative Ruth Balser (a licensed psychologist) to file an act to promote efficient access to mental health services. This bill aims to provide important protections for behavioral health providers and the vulnerable citizens that we serve.  The bill recognizes the importance of the therapeutic relationship in psychotherapy and aims close loop holes in our insurance laws that allow health plans to use aggressive tactics to terminate contracts with behavioral health providers as punishment for advocacy efforts or as a negotiating strategy. This bill would require a longer period of notice for health plans to non-renew provider contracts. It would also require health plans to show cause for not renewing provider contracts, and demonstrate that any lawful communication concerning regulations and statutes that effect service delivery is not a factor in said nonrenewal. Further, should a behavioral health plan not renew a behavioral health provider contract, said plan would be required to cover payment for an existing patient receiving services prior to the termination date of the contract, until such treatment is no longer medically necessary consistent with terms of contract in place at the time of nonrenewal and usual and customary utilization management processes. Further, behavioral health providers would not be prohibited from collecting any portion of a deductible for services rendered at the time of service. 

This bill received a favorable vote in the Mental Health Committee but stalled in the Insurance Committee in the 2012 legislative session. It was revised and refilled for 2013. The grass roots legislative action was welcomed and supported by the Massachusetts Neuropsychological Society. Given the new revisions that clarify some language that was unclear, we are hoping for unequivocal support of Massachusetts psychologists in passing this bill in the current legislative session.
 
Michael A. Goldberg, PhD
Director
Child & Family Psychological Services, Inc., d/b/a Integrated Behavioral Associates
Pioneering the Integration of Behavioral Health in Massachusetts Since 1994
169 Libbey Parkway, Second Floor
East Weymouth, MA 02189

For many years, the U.S. government and the APA have been discussing health care reform. Psychologists have been working in health-related settings [http://drerlangerturner.blogspot.com/2013/04/psychologist-healthcare.html] for a number of years addressing mental and physical health conditions. Given priorities in health care reform and policies related to the Affordable Care Act (ACA), APA has been positioning itself to make sure that psychologists have a seat at the table. For a complete description of APA’s goals and priorities visit their website.

ACA and Health Care Reform

The ACA was passed by Congress in 2010 and they are in process of clarifying ACA’s implementation. There are several benefits of ACA such as eligibility for prevention services at no additional cost (e.g., wellness visits and cancer screening), coverage of pre-existing conditions for children, and improved services for older adults. There are also implications important for behavioral health practitioners. The APA Practice Directorate recently published an article discussing integrating behavioral and physical health.

Implications for ECPs

Whereas there is potential great benefits of health care reform, there are some serious implications for early career practitioners (ECP). For many ECP’s, we graduate with concerns about paying off debt and succeeding in practice. One potential limitation of ACA is implementation by insurance companies. If you're not working fee for service then you may suffer considerable financial difficulties as a result of billing for your services. Many ECPs are unaware of billing issues prior to obtaining their license to practice. This is primarily due to little information being provided as a graduate student about business of practice issues. Many insurance companies have requirements for becoming a provider (e.g., length of licensure). I personally had to deal with this issue a few months ago where I practice in Virginia. I could not provide services to this child and their family because I was not a provider for their insurance (due to not having my license more than 3 years). That being said, this limitation not only impacts ECP’s ability to bill for services but it also lowers the number of qualified practitioners available to meet the needs of individuals suffering from mental health difficulties.

Several months ago, I had the opportunity to write a piece in The New York Times on President Obama’s policy related to gun violence and mental health. The president called for increase gun control legislation and mental health services. APA also published a statement in support of initiatives to address gun violence of which includes calling for mental health coverage at parity in private and public health insurance plans. There are many opportunities available to increase access to mental health services through health care reform. However, early career practitioners may not benefit from these changes for years. It is important for us to pull together as a field to work towards advocating for more appropriate regulations for psychologists who work in a number of setting including integrated health care systems. Our future as practitioners is at stake let’s be involved in the conversation.

Dr. Erlanger Turner
Assistant Professor of Psychiatry
Virginia Commonwealth University

Check out Sue Franz's, Division 31's technology specialist, simple steps for using free videoconferencing services.

The Coalition for Patients' Rights (CPR) issued the press release, "State Health Insurance Exchanges, Legislation Keep Scope of Practice Issues Front and Center," in which APAPO staff provided input and APA Executive Director for Professional Practice Katherine Nordal, PhD, is quoted in the release on behalf of CPR. APAPO is a founding member of the CPR.

With 42 million more people due to have insurance by 2014, there will be a great need for psychologists and other professionals to practice to the full extent of their licenses. This has caused a backlash by those in the medical profession wanting to protect their scope of practice and deny expansion to other groups. Such a backlash will deny access to care for many Americans.

Emergency Department Diversion (PDF, 506KB) is a pilot project that was executed in Central Oregon, as part of the larger Health Integration Project. It aimed to demonstrate how integrated care can reduce emergency room visits. Below is an excerpt from the report that summarizes the project and the importance of collaborative care: 
 

The Central Oregon region created the 'Central Oregon Health Council,' (COHC) a public/private partnership that includes Crook, Deschutes and Jefferson Counties, the region's health system, the region's Medicaid payer, the region's safety net clinics and the Oregon Health Authority. Over the past 18 months, COHC has overseen the Health Integration Projects, focusing specific attention on high utilizing/high need patients who are disconnected from the regular healthcare system and suffering from the social disparities that impact an individual's overall healthcare. This approach began with the Primary Medical Home pilot at Mosaic Medical, next extended to the Emergency Department (ED) Diversion project, and has now expanded into the Integrated Primary Care project, the Program for the Evaluation of Development and Learning (PEDAL Clinic), and the Affordable Medication project. This report highlights only the Emergency Department (ED) Diversion project....The Central Oregon Health Council has determined that the ED diversion project has been successful in achieving the goals of the Triple Aim: better health, better care, and lower cost, and as such has become an important intervention in the Central Oregon community. Learnings from this project continue to inform the development of integration projects locally and across the state, using the collaborative care models developed in this initial project.

Sue Frantz discusses upgrades to desktop sharing software in a post, "Join.me: New Functionality," on her Technology for Academics blog [SueFrantz.com]. Sue will continue to publish articles about how technology can increase leadership and advocacy efficacy.

Sue Frantz
APA Division 2: Society for the Teaching of Psychology; Vice President for Resources
Editor, APA's Online Psychology Lab
APA Membership Board

Dr. Jerry Grodin, the recently hired Director of Professional Affairs and past president of the New York State Psychological Association, discusses the future of reimbursement for services in his article, "Capitation vs. Fee for Service: Guess What's Coming?" (PDF, 58KB).

Preparing the Interprofessional Workforce to Address Health Behavior Change (PDF, 1.3MB) provides resources about how to engage in integrated behavioral health care. Among other critical findings, the report found that Electronic Healthcare Records (EHRs) enable collaborating professionals within the integrated health care settings to understand the behavioral risk factors that exist in each case and to be kept informed about the health behavior changes that occur with psychological service interventions. The APA Board of Educational Affairs provided technical support to Dr. Ron Rozensky, a distinguished psychologist, who chaired this report for the Secretary of the Department of Health and Human Services.

Coming soon from Division 31 and 42, a digest of the law of each State regarding record keeping and accompanying State specific EHR templates to assist psychologists to move into integrated health care communities in a competent and efficacious manner.

Early career psychologist and Division 31 member Dr. Samantha Slaughter advocated on behalf of psychologists in Washington state during the Washington State Senate Health and Long-term Care Committee work session. She was part of a panel of providers testifying about mental health parity, reimbursement, integrated healthcare and healthcare reform. Read and view a video of Dr. Slaughter's excellent testimony about the problems of reimbursement rates for psychologists below:

Watch Dr. Slaughter's Testimony

Insurance Reimbursement Issues

Good afternoon Madame Chair and members of the Committee. My name is Samantha Slaughter. I am a licensed psychologist in private practice in Seattle. I am also the assistant director of the Fremont Community Therapy Project, a low-cost mental health services clinic. Today, I am representing the members of the Washington State Psychological Association.

Two years ago, when the Uniform Medical Plan changed its third party administrator contract to Regence BlueShield and adopted Regence's reimbursement system, income for psychologists providing mental health services to public employees dropped, in some cases by up to 30 percent. This year, Premera Blue Cross reduced reimbursements to psychologists over 11 percent. In the best cases, our reimbursement rates have remained stagnant for a number of years.

Of course, psychologists know that neither the Legislature nor the Office of the Insurance Commissioner (OIC) regulate reimbursement rates in commercial insurance. We know that the lowering of reimbursement rates is a trend unlikely to change in the near future and that we must take command of our careers and how we individually respond to this reality. We are doing just that.

Psychology is a leader, both through research and practice, in supporting the notion that good health care supports both the mind and the body. In 1998, we drafted the state's wonderful mental health parity mandate in order that patients could afford to use both medical/surgical and mental health care. We have actively supported state legislation creating health care homes and integrated systems of care. In 1996, WSPA sponsored and passed legislation amending this state's professional services corporation laws allowing differently licensed health care providers to form corporations in order to integrate care and to address new payment systems.

But we also know that issues involving reimbursement have broad and significant implications for the Legislature as you consider federal health reform implementation and the impact of this situation on access to mental health services.

The irony was not lost on WSPA when one of our members made this observation subsequent to the Premera fee reductions this past spring:

"Since I became licensed as a psychologist, all the major insurance panels in Washington State have been closed to new behavioral health providers. After years of effort, I have finally become credentialed, only to discover that I now earn less as a paneled psychologist than my newly licensed colleagues who are on no panels."

Our colleagues strive to become credentialed on insurance panels because they know what we knew when WSPA drafted the state mental health parity legislation: that access to mental health services increases when copays are reasonable, when there is one family deductible, and residents can actually afford to use their insurance coverage. But, we are now left to wonder if we can still afford to remain in insurance systems that attempt to effect health care savings on the backs of providers.

We urge this committee, the legislature, and the OIC to pay close attention to network adequacy and the implications of fee reductions on network adequacy right now, and most importantly, going forward as rules governing the new Exchanges are developed. Even as reimbursements go down, health costs still rise. As networks are affected, the delivery of health services becomes more fragmented. This is not the way to successful integration of health services.

This committee knows from testimony by both the Boeing Company and Group Health Cooperative integrated care pilot programs that health care costs are reduced when we reduce hospitalization and inappropriate use of Emergency departments. Nationally, approximately 12 million ER visits result from a mental health or substance abuse disorder — that is one in eight ER visits. Of these, approximately 40 percent result in hospitalization. In testimony before this committee in 2012, both Boeing and Group Health reported significant reductions in ER use and hospitalizations when mental health treatment was included in integrated care.

Psychologists want to continue to provide appropriate and effective mental health services to all residents in Washington state, whether in commercial insurance, the Exchanges, or expanded Medicaid services. We have actively supported implementation of the federal health reform law and legislation to implement integrated care programs. We urge you to consider the issues we have raised here today as reform implementation continues. Thank you.

Dr. Slaughter's testimony truly is advocacy for all psychologists in action. Now that's how it's done.

Dr. Terry Koller, executive director of the Illinois Psychological Association (IPA), deftly summarizes the benefits of supporting prescription privileges for specially trained psychologists in Illinois in the following concise and informative video from the IPA:

California has been a leader in the implementation of health care reform. In spite of not knowing if the Supreme Court was going to approve the mandate, a consortium of various mental health organizations including the California Psychological Association (CPA) has been actively working to define the essential health benefits for health care exchanges. Shortly after the Practice Directorate’s State Leadership Conference in March 2012, CPA had the opportunity to give input into the policies of California's Health Exchange. It was helpful to contact staff at the Practice Directorate to gain additional input into the role of psychology in essential health benefits (PDF, 540KB).

CPA has been active in communicating to its members how to stay current with changes in the delivery of care necessitated by the passage of the Accountable Care Act. Dr. Charles Faltz disseminated to CPA members in a special edition of PROGRESS NOTES (an e-publication for CPA members), an article by Dr. Charles Cooper, the Director of Professional Affairs for the North Carolina Psychological Association. The article first appeared in the NC Psychologist newsletter (January February 2012 Issue). Citation: Charles Cooper, PhD; NC Psychologist, January/February 2012 and described what psychologists will need to do to adapt to the changes in practice based on passage of the Affordable Care Act. Dr. Faltz noted, “In it Dr. Cooper cited the Collins study which is an especially valuable resource with some very detailed material regarding implementation” (Collins et al., Evolving Models of Behavioral Health Integration in Primary Care, Milbank Memorial Fund, May 2010 (PDF, 907KB)).

In addition to disseminating information to our members, CPA and Division I of Independent Practice have been active in coordinating a health care think tank entitled the Integrated Health Care Summit.  In some ways this is fashioned on the think tanks that have occurred in other states; however, the CPA one-day conference in late September will be multidisciplinary. As CPA was in the beginning stages of planning, we were contacted by consultants from the Integrated Behavioral Health Project (IBHP), which is a group funded by the California Mental Health Services Act whose monies come from Proposition 63. Their goal is “to reduce stigma and improve mental health outcomes,” according to their website. They have also developed a Tool Kit (PDF, 3.2MB), which has a great deal of interesting information in it for those wanting to create integrated behavioral systems.

The featured speakers at the Integrated Health Care Summit will include Drs. Ben Miller, Elena Eisman and Katherine Nordal. The president of the California Medical Association will also be in attendance along with leaders in the Exchange movement, CPA leaders in practice and education, and leaders from other health care specialties. Participation is by invitation only and according to the Dr. Michael Ritz, the chair of the conference planning, “The spotlight for the program would be to focus on directions in which health care/behavioral health care appears to be emerging for the State. Health care reform appears to be state-centric and thus our primary focus will be on potentialities within California. In addition, we will be creating mutually productive and rewarding relationships to craft effective models of integrated health delivery systems for primary care — respecting the interplay between the body and the mind. Clinical research has documented that integrated health care systems can augment healthy outcomes; may reduce system cost based upon medical cost-offsets; and are consistently well received within a patient centered delivery system. You should consider this summit as the beginning of a process — the next steps for action will be carefully defined.” Once the next steps are defined, information will be disseminated to CPA chapters and divisions and planning for a follow-up summit will begin.

Sallie Hildebrandt, PhD

Division 31 member George Harris just published a column in the The Kansas City Star, "Time for Romney to Get Specific About Health Care," about the striking differences between the Affordable Care Act coverage and the coverage most likely to be provided if President Obama loses the election and Congressman Ryan's thrall continues to influence the Republicans. An excerpt follows:
 
...under the Ryan plan Medicare recipients would receive a voucher to help pay for insurance premiums and that the value of the voucher would be adjusted annually to partially offset increases in costs...
Now let's look at the cost of insurance for people age 65 and older. There aren't a lot of data on this because most people 65 and over have the existing Medicare plan...

Missouri's High Risk Insurance Pool plans can be found on the internet. There are five plans. Let's examine the high and the low cost plan. On Plan 1 a 65 year old male can buy insurance for $1925 per month with a $3000 out of pocket maximum. On Plan 4, a 65 year old male can buy insurance for $812 per month with a $10,000 out of pocket maximum. An 85 year old male would be charged $3615 monthly on Plan 1 and $1527 on Plan 4.
As you can see, a voucher for $1,000 wouldn't go very far in covering premiums and deductibles even on the plan with the least expensive premiums. People with uncovered preexisting conditions would for their first year have to pay those costs, which would be in addition to the deductible and premiums...

Well, you may say, those are the high risk pool premiums. People in good health could get cheaper coverage. But I suspect that most 65 year olds have a preexisting condition that would put them in a high risk category, and almost all 85 year olds would have a health condition that would exclude them. Just do a Google search on "uninsurable medical problems" and you'll see that insurance companies exclude almost everyone who takes any medication, such as statins to control cholesterol, or anyone who has any chronic condition, such as diabetes, or anyone who has had cancer, even if successfully treated.

Thank you George for your dedication to social justice and efficacious health care. Please contribute other postings about Health Care Reform to our Task Force Chair, Leslie Riley.

As the nation awaits the Supreme Court's decision regarding the constitutionality of the Patient Protection and Affordable Care Act (PPACA) (or if the Court can even make a decision about the constitutionality of the PPACA given the Anti-Injunction Act's provision that a lawsuit cannot be filed to challenge a tax until a tax is assessed), important questions remain unanswered regarding the exact boundaries of the PPACA's provisions and how ambiguous language in the PPACA will be interpreted for years to come. Read the entire bill (PDF, 2.2MB) or a summary.

Mental health care providers have a particularly large stake in the Supreme Court's upcoming ruling as the passage of the PPACA brought with it, finally, mental health parity. However, as with other provisions, it remains to be seen exactly what mental health parity will mean should the Supreme Court hold that the PPACA does not violate the Constitution. Rather than simply await the Supreme Court's decision, psychologists have a unique opportunity to proactively engage stakeholders on the demand side of the mental health parity equation—the patients, clients, or consumers of mental health services—in an effort to empower them to advocate for themselves in shaping how the PPACA will be enacted. Several national advocacy groups, with chapters in almost every state, represent important forums in which psychologists can engage recipient stakeholders to advocate for themselves.

• National Alliance on Mental Illness (NAMI): NAMI "advocates for access to services, treatment, supports and research" and local meetings are an excellent forum in which psychologists can describe the areas of the PPACA that require further definition and learn from recipient stakeholders what services are most valuable and essential.

• Mental Health America: Mental Health America "works to inform, advocate and enable access to quality behavioral health services for all Americans," and like NAMI, local meeting represent an ideal opportunity for psychologists to engage with recipient stakeholders, their families, and loved ones regarding the most important aspects of mental health care.

• National Federation of Families for Children's Mental Health: Federation of Families is somewhat different than NAMI and Mental Health America in that it focuses specifically on children's mental health, which provides the perfect opportunity for child psychologists to engage parents who are already involved in advocacy for their children

Of course, there are many other organizations the engage in advocacy at the local, state, and federal levels. If there is an organization you have worked with and you think others might benefit from similar collaboration, email me, and a future installment of this blog will be dedicated to reader contributions and activities in their home states that could translate into action for others in other parts of the country.

Psychologists, highly educated, highly motivated, and often highly independent, have a chance to put their training and expertise to use in exciting and collaborative ways as the nation is more focused than ever on healthcare and health insurance. Professional psychology, for all its contributions and attempts, cannot affect the necessary changes alone, and even the entirety of the nation's mental health care providers probably could not affect these changes in collaboration. It is essential to acknowledge the recipients of mental health care as key stakeholders and engage them in their own advocacy to successfully define the provisions of the PPACA to make mental health parity a reality.

Troy Ertelt, PhD
Division 31 Health Care Reform Task Force

In a recent issue of Progress Notes, an online newsletter for California Psychological Association (CPA) members, Dr. Chuck Faltz, CPA Director of Professional Affairs and Division 31 Board Member noted, "ACA (Affordable Care Act) expressly identifies mental health and addictions treatment services as essential benefits, along with rehabilitative and 'habilitative' services.

However, the extent to which specific behavioral health services are covered will depend in large part on which existing insurance plan each state selects as its 'benchmark' plan — that is, the plan on which the EHB (Essential Health Benefits) package in that state will be based. If the state selects a plan with slim coverage of behavioral health services or a strict interpretation of what is considered 'rehabilitative' services, it could affect individuals' ability to access these services."

In addition, Dr. Faltz wrote, "The HHS guidance confirms that the 2008 Mental Health Parity and Addictions Equity Act applies to individual plans as well as small group plans — a provision that was inserted into the law as amendment by Senator Debbie Stabenow (D-Mich.) during the health reform debate. If the plan that a state selects as the benchmark plan does not currently comply with the parity law, modifications must be made to the benefits package to bring it into compliance with parity."

Recommendations for Future Consideration

1. It is recommended that further investigation of the practices of Blue Cross Blue Shield (BCBS) and United Healthcare (UHC) be conducted. A further survey focusing on these insurers' records with reimbursement would be a start. If the data are compelling, a referral to APAPO for possible legal action and/or meetings with BCBS and UHC officials may be indicated.

2. Reporting insurance companies which appear not to be following parity to APAPO and/or appropriate regulatory and enforcement agencies may also be useful.

Thank you to Dr. Faltz for this article and for the important reminder to monitor reimbursement practices for violations of mental health parity.

Leslie Riley, PsyD
Chair, Division 31 Health Care Reform Task Force

The Division 31 Health Care Reform Task Force blog is pleased to note the achievements of the Arkansas Psychological Association, under the leadership of Dr. Leslie Riley, in ensuring that the implementation of the Affordable Care Act in Arkansas included critical aspects of integrated behavioral care for childhood ADHD.

The ArPA initiative was successful through strategies of alliance building and asserting psychological evaluation and treatment interests throughout the regulatory process. While initially psychology was not invited to the table, Dr. Riley describes the step-by-step process (PDF, 138KB) involved in accomplishing the results. ArPA members are continuing to work on the clinical content of the ADHD treatment package and recognize that additional psychological services must be included in the summary (PDF, 323KB) that describes to date the design and implementation of this new payment system.

In the spring of 2011, Arkansas' Gov. Beebe launched the Arkansas Payment Improvement Initiative (PDF, 513KB) to reform AR Medicaid payment across nine initial clinical areas, including behavioral health. This initiative, known as APII, aimed to reduce inefficiencies in Arkansas' health care system and to promote "important" (i.e., medically necessary), coordinated and patient-centered care. The Arkansas Department of Human Services, the Arkansas Centers for Medicaid Services, the U.S. Dept of Health and Human Services, and Arkansas Blue Cross and Blue Shield are all funding this effort to reform the existing fee for service payment system to a system of bundled packages of treatment, called episodic care packages (ECPs) to provide care to patients across a multitude of clinical areas see the official APII website. Not only is the goal to maximize quality care and minimize wasteful and inefficient care, Gov. Beebe intends for APII to serve as a national model for payment reform.

Last fall, ArPA's executive director attended stakeholder meetings and informed ArPA of the formation of workgroups to develop ECPs. ArPA leadership organized a psychologist team before the first workgroup for ADHD payment reform. In preparation for the workgroup, ArPA consulted with Russell Barkeley, PhD, on the best psychological practices of assessment and treatment of ADHD.

ADHD was selected as the initial behavioral health diagnosis, because ADHD constitutes the largest amount of Medicaid spend on children in AR ($100 million). Current Medicaid data indicates that $48 million is spent on paraprofessionals in agencies. Thus, the ADHD workgroup's task was to develop an ECP for children with ADHD that ensured accurate diagnosis and "[treatment] guideline concordant care." The workgroup meetings consisted of large workgroup meetings for public comment, and then a small, "core" workgroup, which has decision-making power.

Through effective advocacy, ArPA successfully secured a psychologist on the core workgroup. Additionally, ArPA successfully achieved the inclusion of psychologists as "Principal Accountable Providers (PAPs)." Only psychologists, pediatricians, and child psychiatrists can serve as PAPs, enabling psychologists to diagnose and "certify" ADHD and to manage clinical care and the distribution of treatment funds. The payment model will be "retrospective reimbursement," where PAPs will share in profit gains and losses, depending on the use of treatment funds at the end of a one-year period from the initiation of the ECP.

ArPa's current challenge is advocating for the inclusion of best psychological practices in the clinical content of the ADHD care package. At present, the head of the workgroup, a psychiatrist, favors psychiatric guidelines, which are biologically based and not biopsychosocial in nature. ArPA is advocating for research-based guidelines (e.g., CADDRA) that include, in addition to medication, recommendations for diagnostic instruments for ADHD, parent and teacher training, and psychotherapy when indicated. Questions and suggestions can be directed to Leslie Riley, PsyD (ArPA President).

How far has your state come in the implementation of the Affordable Care Act? See the state-by-state fact sheets and the state-by-state data. Throughout the next months, the Division 31 Health Care Reform Task Force blog will broadcast practical bottom-up approaches to include psychological services in this uncertain period of implementation of the Affordable Care Act, state by state. The task force will be publishing "just-in-time" information about successful efforts that have affected the legislative and regulatory processes of other jurisdictions. Division 31 will share the resources that are most efficacious.