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The
health care reform package approved in March provides for a hefty
25% expansion of the Medicaid rolls by 2014, so you would expect
opportunities to open up on the mental health side. But looking
beyond the headlines, it’s apparent that any new business for
private practitioners will entail the same old low fees and much red
tape.
The
Patient Protection and Affordable Care Act calls for 16 million
Americans to be added to the 60 million already on Medicaid. And
although that won’t be fully implemented for four years, at least
some growth will take place prior to the kick-off date.
While
the White House and Congress have been making noises about austerity
in the lead-up to the November elections, an additional $16.1
billion in Medicaid spending was approved by the House and Senate
and signed by President Obama on August 16. That money will go to
the states to beef up existing Medicaid programs.
(A
similar bill was killed in June amidst battles over its impact on
the deficit. This time around, Democrats attracted sufficient GOP
support for new Medicaid money by cutting spending elsewhere.) But
additional "available money" doesn’t always mean
"money spent." Here’s why:
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Just because 16 million more Americans become Medicaid eligible
doesn’t mean all of them will sign up. The current participation
rate varies widely by state, but the average is about 57%, according
to a report by the Kaiser Commission on Medicaid and the Uninsured.
It’s estimated that the "maximum" participation rate
would only be about 75%.
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Medicaid funds aren’t generally aimed at the outpatient services,
although mental health groups are lobbying to change that.
"There are a disproportionate number of Medicaid patients who
need mental health care," notes Julie Clements, director of
legislative affairs for the American Mental Health Counselors
Association (AMCHA). "But most of it goes to inpatient
care."
AMCHA
has been trying to get state legislatures to warm up to preventive
care, which would entail more outpatient services. "They need
to know that it will save a lot of money," Clements says.
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A majority of practitioners shy away from Medicaid anyway--because
reimbursement is low, and there’s usually more paperwork involved.
For instance, only about 30% to 50% of AMHCA members have Medicaid
contracts, according to Clements. The number’s a lot lower for
psychologists.
Clements
says clinicians are reporting rates of $50 per session now,
"and our main concern is that reimbursement rates are going to
go lower under Medicaid."
Actually,
says Laura Groshong, director of government relations for the
Clinical Social Work Association (CSWA), fees have already slipped
under $50--at least for some. According to data she gathered for the
CSWA, Medicaid reimbursement for LCSWs in 2008 ranged from a low of
$43 in Missouri to a high of $73 in Delaware. "If rates stay
this low, I’m not sure if they’ll find people to do the
work," she tells us.
According
to the American Psychological Association, 55% of psychologists have
opted out of Medicaid due to low rates. Psychologists do make more
than their master’s-level colleagues, however: $70 and up in some
states.
MFTs
are not eligible to provide Medicare services but are
Medicaid-eligible in some states. Reimbursement rates vary but are
generally low, says Tracy Todd, director of public affairs for the
American Association for Marriage and Family Therapy (AAMFT).
New
regulations for mental health parity were issued by the Obama
administration on July 1. One result is that Medicaid programs will
have to cover mental health on par with medical benefits.
"Parity
doesn’t have to lead to higher rates," says Groshong.
"It’s about access...And I think overall rates could actually
go lower." Managed care companies with Medicaid business will
try hard to hold onto the profits they make on these already lean
government contracts.
"You
can bet they’ll be putting up more roadblocks to care,"
Clements says. "That’s something we’re going to have to
work on." (See more in the box, opposite.)
(We’re
continuing to assess the potential impact of the health reform law
as details gradually emerge--see PsyFin January, February,
March, and April, 2010. The true picture for psychotherapists in
private practice continues to develop--so look for more coverage in
the months ahead.)
Contacts:
1) Julie Clements, AMHCA, Alexandria, VA, (800)326-2642, ext. 105,
email: jclements@amhca.org; 2) Laura Groshong, CSWA, Seattle, WA,
(206) 524-3690, email: lwgroshong@comcast.net.
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