Health Care Reform Blog

The article, "Population Health: The Risks & Rewards," primarily focuses on population health rewards. It is a useful reminder about what health care providers, as well as psychologists, can expect to grapple with during the next few years. The article defines population health, how provider reimbursement is changing and will continue to change, and the need for clinical integration.

As the new co-chairs of the Div. 31 Health Care Reform (HCR) Task Force, we are eager to roll up our sleeves and get to work. As we have been witnessing, the landscape of health care has been changing rapidly, and there are more changes yet to come. Given how health care is rolling out on the ground, the impact on our field, and ultimately the people we serve, it is clear that psychologists will need to work together en masse if we are to survive and thrive in this new health care environment. 

As chairs, our hope is to provide you with links, posts and comments regarding the changes in health care that are important, inspiring, thought provoking and at times even provocative. 

There are numerous psychologists developing innovative ideas to thrive within HCR - psychologists who are developing important advocacy efforts. Important conversations are also being held on key legislative, professional and training issues impacting our field. We feel confident that if we can all come together and share ideas, pool advocacy efforts and work together to help each other, we can continue to help those we serve to the best of our ability. 

To connect psychologists and pool key information that they will need to know/have access to, our task force will be working on three main initiatives throughout the course of the year: 

1. We will post regularly on the Div.31 HCR Blog. This blog will continue to be a place where all SPTAs can go to obtain information regarding HCR including developments, advocacy efforts and ways to navigate HCR. Please feel free to contact us if you feel there is information that may be useful to share with other SPTAs through the blog. 
2. During the year we are planning to develop an HCR online library that contains information that psychologists can refer to and use within their own States. This might include templates outlining certain advocacy efforts, innovation in relation to private practice, information regarding the Affordable Care Act, training to work within integrated care settings and so forth. Again, feel free to contact us with information that might be useful to include in our online library. 
3. Our task force is planning on developing an HCR email list whereby representatives from SPTAs who are involved in HCR can share important information in a timely manner. 

The more we can pool information and share ideas, the more psychologists can access information that can help them in their work, and at the state level. We look forward to working to inform and connect STPAs on matters pertaining to health care reform. 

Lubna Somjee, PhD and Jon Marrelli, PsyD
Co-chairs, APA Div. 31 Health Care Reform Task Force

Adam Benton, PhD, describes changes in the Arkansas payment system for healthcare providers as follows: 

1. In a nutshell, Arkansas Medicaid is completely revamping the way it reimburses, the rates it reimburses, and services that are billable through Medicaid. It is exploring national averages for payments and offering payment for many services that it currently does not reimburse but that research suggests are effective, such as psycho-education. 
2. The intent of Medicaid's reforms is to create a Medicaid behavioral health system that rewards higher quality of care while reducing cost. The proposed system will create three new entities that will help manage and coordinate the mental health needs of Medicaid patients. Many of these processes and functions are still being defined. The new entities include Patient Centered Medical Home, Behavioral Health Home, and Independent Assessors. In their own roles, each entity will be responsible for ensuring that patients get quality care and that providers communicate with each other. 
3. Medicaid is switching from a "fee for service" model to "episodic payment packages" for its more expensive mental health problems. In this switch, providers and agencies who treat patients more efficiently than the average, will receive a share of the financial gain. Those whose average cost per client group (grouped by diagnosis) is higher than the state average will share in the financial risk.  As you may know DHS has already implemented an episodic payment structure for ADHD, and has designed packages for ODD, and Comorbid ADHD / ODD. ArPA was involved in the design of all three models. Last I heard, the ODD and Comorbid packages were held up in congress. My view of these three models is that the ADHD model will probably work sufficiently. It provides ample range of services and may be financially beneficial for a lot of providers, but is slightly restrictive in the amount of funds allowed for treatment. The ODD and Comorbid packages are generous in the services offered and designed to reflect what research suggests is good treatment for these conditions, such as family therapy, teacher consultation, parent education, and parent training.
4. Starting in July of 2014 Medicaid patients will be assigned to a Patient Centered Medical Home, or PCMH, who will be reimbursed not only for providing medical services but also for managing and coordinating services provided by other clinicians, such as psychological or speech therapy.  The PCMH will most likely be the patients current PCP. 
5. All patients will maintain their PCMH while still receiving outpatient care to private practices, local clinics, or community health centers, but hopefully with increased communication between providers, since the PCMH will be reimbursed for coordinating care. The PCMHs will function like case managers and will be reimbursed at a rate between $1 and $30, for each patient per month.
6. Mental health services will be divided into three tiers of available services to be reimbursed by Medicaid.  Tier 1 will include the vast majority of patients seen for mental health services. Tier 2 will include those with higher levels of severity and Tier 3 will be those with the greatest need for services.  At each Tier, Medicaid patients will have access to all the services available in the previous Tiers and then additional services, such as residential treatment, respite and therapeutic communities for those in Tier 3.
7. All Medicaid patients will have access to Tier 1 services without prior authorization. Those needing more services than allowed for Tier 1 will progress to Tier 2 and will have to be evaluated by an Independent Assessor, and an Independent Care Plan will be created. The Independent Assessment will be conducted by a contracted organization who provides assessment only, no treatment.  The assessment will measure functional impairment, not diagnostic clarification. Medicaid will release the proposal and seek bids for this new entity, "Independent Assessor." 
8. Most community providers will function under Tier 1. Tier 1 services include individual therapy, group therapy, marital/family therapy, multifamily group therapy, psychoeducation, mental health diagnosis, interpretation of diagnosis, substance-abuse assessment, psychological evaluation, psychiatric assessment, and pharmacological management. No prior authorization needed, although the services will have a limit. The larger organizations, with hospitals, day treatment, and substance abuse treatment, will likely be Tier 2 and Tier 3 sites.
9. All patients, regardless of Tier, will have access to Crisis Services and hospitalization. Although hospitalization will put in place an immediate referral for the Independent Assessment, placing them in Tier 2 or 3, and assigning them to a Behavioral Health Home (BHH), which will function like a mental health-specific care coordinator. At such time, the patient will have a PCMH to coordinate medical needs and BHH to coordinate mental health needs. DHS will release criteria for agencies to apply for BHH status.
10. The DHS committee charged with making reforms remains open to ideas, concerns and discussions. They have a large team at DHS and an outside organization, the McKenzie Group on the project. They hold public forums for anyone interested in attending, in addition to our core workgroup meetings and other focus groups among stake-holders.

For additional information, see Arkansas Payment Improvement Initiative. This article is posted in full on our clinic website for anyone interested. 

Adam Benton, PhD 
Licensed Psychologist 
ArPA Vice President-Elect 
Telephone: (501) 812-4268

Michael Goldberg, PhD, Acting Director of Professional Affairs for the Massachusetts Psychological Association (MPA), has provided this update regarding a recent legislative victory in the battle for transparency in the use of "proprietary" guidelines to approve or restrict benefits for neuropsychological care of patients. Congratulations to our colleagues in Massachusetts for effectively advocating for transparency in the decisions made by health plans in the medical necessity criteria they use to determine access to care for patients. Follow the progress of this bill.

In 2010 Elena Eisman, Karen Postal and I debriefed after a meeting with BCBSMA related to their implementation of new medical necessity criteria that they purchased from McKesson, a large out of state corporation. BCBSMA refused to give us information about these criteria citing that they were "proprietary." We believed that they were using these criteria to justify unreasonable restrictions in access to legally mandated neuropsychological services. At that meeting I proposed a legislative initiative to combat this by requiring "transparency" from the health plans in the medical necessity criteria that they use.
 
MPA worked with House Representative Ruth Balser, PhD (Psychologist-Democrat-Newton), to file legislation to require such "transparency" from health plans for all health care services. This legislation: 

1. Required health plans to make the criteria available to providers, even if they were proprietary. 
2. Required that any adverse determinations or other denials for coverage must be made by a provider in the same licensure category as the ordering provider.
   
   Thanks to immense grass roots advocacy by Karen Postal, PhD, Andi Piatt, PhD, and others the legislature and governor acted favorably on our initiative. The legislation was eventually worked into Chapter 224 of the Acts of 2012 (the health care reform law), which was passed.
    
   This has been four years in the making; final implementation of this legislation reflects a great victory for us and will give us one more tool to combat unfair practices by health plans in preventing access to behavioral health services. 

In their article, “Moving Towards Population Health Management What You Need to Know,” the members of the New York State Psychological Association Health Care Reform Taskforce discuss how primary health care is adopting the “practice-based population health” model, which assumes that medical providers are responsible for improving the overall health of the population they manage, and not just for treating individual patients who come to them for care.

Glenn Ally, PhD, a consulting psychologist in Louisiana who provides services at a hospital in addition to maintaining a private practice, shared his approach to negotiating hospital fees on the Div. 42 email list recently. He graciously permitted Div. 31 to repost his response to provide information to psychologists who negotiate fees for hospital-based consultation and testing services. As psychologists look for integrated care practice opportunities, they can benefit from learning from colleagues' experiences in fee negotiation for specialty services. 

As first posted on Div 42's email list, Dr. Ally wrote:

I've always negotiated contracts based upon my private practice hourly rates. I say rates because I give them the range...my hourly rate for psychotherapy, my hourly rate for testing, my hourly rate for forensic work, and my hourly rate for deposition. I indicate that I will not go below the lowest of these figure...why should I when I can stay in my office and make that amount rather than the inconvenience of travel time to and from the hospital (for which you will probably not get paid). 

A second approach is to get figures on the reimbursement rates from the various providers for which you may have fee schedules and charge what would be the highest on those fee schedules. Why the highest? Because, very often the reimbursement rate is lower than your hourly fee and there is inconvenience in traveling to and from the hospital and inconvenience of lugging testing supplies and equipment to and from the hospital, etc. Also, keep in mind that you may not be able to provide the reimbursement schedule given to you by insurance companies (proprietary info), but it is quite likely that the hospital has access to this info since they tend to be providers for many insurers. So, I will indicate to the hospital which insurers I provide services for and without attaching a provider to a fee, I will indicate the range of fees that are paid by these insurers. 

I ALWAYS negotiate to get paid for the time whether or not the patient shows up. They have scheduled your time, time for which you could have been reimbursed had you stayed in your office to see patients. Finally, I also negotiate to get paid whether or not the hospital gets reimbursed for the service. I have been able to convince the hospital that they can avoid scrutiny by regulatory agencies by them providing needed services to those who can pay and not providing needed service to those who cannot pay. So by having the hospital pay me as a contractor, I will see all patients, regardless of ability to pay, because I will be paid by the hospital and they can avoid scrutiny regarding discrimination against those who may not be able to pay. The hospital may indeed be able to find some way to avoid providing some services if a patient cannot pay, but very often then would simply rather pay me to see everyone rather than draw the attention of any regulatory agency. 

Thank you, Glenn Ally, for sharing your experiences in negotiation with Div. 31 members. 

Leslie Riley, PsyD, HCRTF Chair

As we begin to focus upon our forthcoming annual APA Convention, to be held in Hawai’i, we should reflect upon the challenge issued by Practice Directorate Executive Director Katherine Nordal at this year’s exciting State Leadership Conference (SLC) to get personally involved in our state association’s legislative efforts. 

Nordal has a wonderful gift of vividly capturing the most critical agendas:  This year, “Our practitioners increasingly will need to promote the value and quality they can contribute to emerging models of care.  No one else is fighting the battles for psychology… and don’t expect them to.”  Last year, “If we’re not at the table, it’s because we’re on the menu.  And I quite frankly don’t want to be on anybody’s plate to be eaten.”

Phelps’ vision:

APA launched its new Center for Psychology and Health under the direction of CEO Norman Anderson in January. One component of that center is a new Office of Health Care Financing (OHCF), which we are currently setting up and will be directed by me.  First, some background. As Anderson has indicated in a number of venues, the purpose of the new APA Center for Psychology and Health is to vigorously pursue Goal Two of APA’s Strategic Plan: Expand psychology’s role in advancing health. The center pulls together top leadership, staff, and major initiatives across all of APA to focus the association’s efforts on four inter-related challenges outlined by Anderson towards achieving this goal. They are:  1) Workforce, education and training challenges; 2) Influencing how we are viewed by policy makers, the scientific community, other disciplines and the public; 3) Addressing how we view and define ourselves; and, 4) What Anderson calls the ‘getting included, getting paid’ challenge. There is, and has been, a tremendous amount of work by APA on each of these challenges, and we will keep the membership informed.

Health Resources and Services Administration (HRSA):

Having finally completed deliberations on its very contentious Fiscal Year 2013 budget, the administration recently submitted its request for Fiscal Year 2014.  Administrator Mary Wakefield, who has participated in Cynthia Belar’s Education Directorate Advocacy Breakfast: 

As a result of the continuing diligent efforts by Belar and Nina Levitt, the HRSA budget request includes $2,892,000 for the Graduate Psychology Education (GPE) program, which was the level provided in FY 2012 (with a slight increase in FY 2013).  This APA sponsored program funds accredited health profession schools, universities, and other public or private nonprofit entities to plan, develop, operate, or maintain doctoral psychology schools and programs and programs in mental and behavioral health practice to train psychologists to work with underserved populations.  The program is designed to foster an integrated and interprofessional approach to addressing access to behavioral health care for vulnerable and underserved populations.  Fifty-five percent of graduates were underrepresented minorities and/or from disadvantaged backgrounds and 29 percent report practicing in a medically underserved area.  In support of the program, HRSA noted that mental disorders rank in the top five chronic illnesses in the U.S. and that the National Alliance on Mental Illness reported approximately six percent, or one in 17 Americans suffers from a serious mental illness.  Serious mental illnesses cost society approximately $193.2 billion in lost earnings per year.  Individuals suffering from a serious mental illness earned at least 40 percent less than people in good mental health, confirming that mental disorders contribute to significant losses of human productivity.  Over the years, we have come to appreciate that the federal government is much more sympathetic to paying for clinical services rendered by practitioners when it has supported their training.

The Office for the Advancement of Telehealth (OAT) would receive $11.5 million, which was also its level in FY 2012.  Funds would be provided for two grants under the Licensure Portability Grant Program, as well as associated technical assistance and evaluation activities.  OAT anticipates that 204 communities will have access to adult mental health services and 239 communities will have access to pediatric and adolescent mental services by FY 2014.  The OAT programs are viewed as an integral component of the overall DHHS Improve Rural Health Care Initiative to expand the use of telecommunications technologies that increase access to and improve the quality of health care provided to rural and underserved populations.  Telehealth programs strengthen partnerships among rural health care providers, recruit and retain rural health care professionals, and modernize the health care infrastructure in rural areas.

Very Timely Steps  - Division 31:

Intriguing Incremental Steps:

Those involved in shaping APA’s Guidelines for the Practice of Telepsychology, which is a collaborative effort by APA governance entities, the Insurance Trust, and the Association of State and Provincial Psychology Boards (ASPPB), have taken notice of the parallel evolution of the notion of an “E. Passport” by ASPPB.  This would address a number of issues surrounding interjurisdictional telepsychology practice and ASPPB is currently seeking public comment on their preliminary proposal.

The ASPPB Telepsychology Task Force is considering the E. Passport proposal as such a mechanism to monitor and regulate interjurisdictional telepsychology practice.  This goes directly to the underlying issue of licensure mobility which, with the advent of technology and integrated health systems, must be effectively addressed in a timely manner if psychology is to remain competitive within the global health care environment.

Clinical Pharmacy:

Pharmacy’s visionary approach proactively addresses the complex issues surrounding providing telehealth services by their profession. 

Aloha,
Pat DeLeon
former APA President

Multidisciplinary, interdisciplinary, trans-disciplinary, multispecialty, integrated, interrelated, interprofessional, and collaborative. These terms suggest the concept of teams of health care providers working together offering comprehensive, quality, affordable health care. The idea is not new. "The concept of medicine as a single discipline concerned with only the restoration of individual health from the diseased state should be replaced by the concept of ‘health professions’ working in concert to maintain and increase the health of society as well as the individual” (Coggeshall, 1965; Mills, 1966).

APA's recently published "Core Competencies for Interprofessional Collaborative Practice" (APA, 2009) defines ”interprofessional” or “Interprofessionality” as “the process by which professionals reflect on and develop ways of practicing that provides an integrated and cohesive answer to the needs of the client/family/population… [I]t involves continuous interaction and knowledge sharing between professionals, organized to solve or explore a variety of education and care issues all while seeking to optimize the patient’s participation. Interprofessionality requires a paradigm shift, since interprofessional practice has unique characteristics in terms of values, codes of conduct, and ways of working.”

What Are Barriers to Interprofessionalism?

Although the need for collaborative approaches to health care delivery is clear, barriers exist which hinder implementation. One of the biggest barriers to accessing behavioral health services is the critical shortage of treatment capacity. Currently, 55 percent of U.S. counties have no practicing psychologists, psychiatrists or social workers (NAMI, 2011). Another barrier can be legislative. A remnant of the 19th century, the Corporate Practice of Medicine Doctrine holds that physicians should make medical decisions autonomously. The logic was that if businesses owned by non-physicians controlled the delivery of health care, health care could be decided based on a profit motive, rather than the best interests of the patient. The Doctrine prohibited "lesser licensed" providers from controlling or directing health care. This limitation is particularly onerous in an era of technological advances including electronic health records, computerization and the need for capital to grow a business.  Because states vary in the application, requirements and limitations of the doctrine, it is costly for providers wanting to practice interprofessionally to navigate this legal minefield. Violating the doctrine can put providers at risk of running afoul of licensing laws. Twenty-two states currently allow differently licensed health care providers to form corporate entities, while five jurisdictions have some flexibility to do so. The remainder of the states do not allow these entities (Nessman, 2011).

Other barriers to interprofessional practice include: hierarchical attitudes, differential and declining reimbursement rates for similar services, lack of understanding of the advantages of interprofessional care, fear of change, risk aversion and the challenge of developing an entrepreneurial spirit. These challenges, coupled with psychologists having little formal business training, hinder the transition to interprofessional mental health care delivery.

While innovation and interprofessional groups are the cutting edge of mental health care delivery, according to an APA Practice Survey of Practitioners (2011) with over 2,500 respondents, fewer than 12 percent reported working in a group practice, while 49 percent indicated they were solo practitioners. Those solo practitioners with established practices, or with niche practices, will likely continue to thrive as health care reform unfolds due to supply and demand and having an established referral base, while many other psychologists will move into groups with interprofessional practice opportunities. Early career psychologists will be challenged as they compete in a crowded and confusing marketplace.

The Group Practice Turnkey Model: Rainier Behavioral Health, PLLC — A Thriving Model of Interprofessional Practice

Rainier Behavioral Health in Tacoma, Wash. was established in 1985 as an interprofessional mental health clinic. We currently see approximately 18,000 patient visits yearly, with almost 2,000 new cases each year. Initially configured as a partnership due to existing Corporate Practice of Medicine Doctrine laws preventing a psychologist and psychiatrist from incorporating, the partnership had extensive liability exposure. In 1995, the Washington State Psychological Association, in partnership allied health providers, lobbied successfully to repeal the Corporate Practice of Medicine Doctrine.  Over the years, as the value of interprofessional care became acknowledged as an effective approach to mental health provision, the clinic evolved into its current complement of 17 therapists, including four physicians, a pediatric advanced registered nurse practioner, eight psychologists and four social workers. The practice is incorporated as a Professional Limited Liability Company (PLLC).

Organizational Structure of Rainier Behavioral Health

There are eight full-time and two part-time support staff. Two full-time support staff handle triage, insurance verification and authorization and initial appointment scheduling. Front desk staff are responsible for patient check in, rescheduling, co-payment collection, phone calls, faxing and file management. Billing support staff handle billing issues and insurance submission, while the part-time bookkeeper manages accounts payable, payroll, tax filing and benefits management. Therapist and support staff benefits include health insurance, a flex benefit plan, retirement plan access, life, disability and accidental death and dismemberment insurance, optional dental and vision coverage and vacation and sick leave.  Prescription refills, supplies, equipment maintenance contracts, repairs and support staff management are handled by the office manager.

Employees are W-2 employees. The practice pays malpractice, a yearly continuing education allowance, Social Security, Medicare, unemployment and other mandated taxes, furniture, office supplies, Internet and telephone access, utilities and maintenance. Our philosophy is that Rainier Associates hires well trained, quality therapists who can work as a team in providing excellent mental health care in an interprofessional environment. Our motto is: "Quality is Economy." Each therapist who joins the group automatically qualifies as a member of the insurance panels we contract with, as we have clinic status. Early career psychologists have an advantage in this regard as panels that might exclude them because of inexperience, or panel closure, include them as part of our group.

Therapists are paid a percentage of what they collect, with more revenue yielding a higher percentage. There are no set working hours, no set vacation periods, no micromanaging of time on site. While we hope that productivity will be high and that therapists will work full time (defined as 20-25 weekly billable patient hours), we understand that life happens and that productivity varies over the course of a therapist’s career. Because we are a large group, when a therapist is out, we cover for each other, maintain referral, scheduling, billing and continuity of care. Insurance companies only have to deal with one tax ID number, one point person for credentialing and one payment to the group. Insurance companies are businesses, too, and efficiencies of scale matter.
       
Group practices can provide a valuable and viable model for interprofessional practice. This article briefly describes Rainier Behavioral Health's turnkey model as an example. Rainier Behavioral Health does not have rigid controls on productivity, a competitive work environment or the lowest overhead costs. What Rainier Behavioral Health offers, however, is a collegial interprofessional mental health clinic model that maximizes the therapists’ skills and training, while benefitting from its larger scale in both insurance collections and the value of support staff. 

References

American Psychological Association. (2011). APA practice practitioner survey. Washington, DC: Author.

Coggeshall, L. T. (1965). Planning for medical progress through education. Washington, DC: American Association of Medical Colleges.

D’Amour, D., & Oandasan, I (2005). Interprofessionality as the field of interprofessional practice and interprofessional education: An emerging concept. Journal of Interprofessional Care, Supplement 1, 8-20.

Interprofessional Education Collaborative. (2011). Core competencies for interprofessional collaborative practice: Report of an expert panel. Washington, DC: Author.

Mills, J. S. (1966). The graduate education of physicians: Report of the citizens commission on graduate medical education. Chicago: American Medical Association.

National Alliance on Mental Illness. (2011, January). Workforce development: Policy brief. http://www.nami.org/template.cfm?Section=About_the_issue&Template=/ContentManagement/ContentDisplay.cfm&ContentD=114129.

Nessman, A. (2011). APA Practice Organization legal research. Unpublished raw data.

Barry Anton is in independent group practice in Tacoma, Washington. He is board certified in clinical child and adolescent psychology. He served three terms on the APA Board of Directors, and is candidate for APA president-elect.  For information about his candidacy, see his campaign website.

Contact information:

Barry S. Anton, PhD, ABPP

Rainier Behavioral Health

5909 Orchard West

Tacoma, WA 98467

Telephone: (253) 475-6021

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).