Psychotherapy Finances

Gender differences were front and center in a new study released by the Chicago-based EAP giant ComPsych. One surprise: Men outpaced women in the number of calls to EAP and work-life resources when it comes to relationship counseling. The percentage compared to women was 22% to 18%.

The data should be used to customize employee assistance programs based on gender, age and occupation, ComPsych CEO Richard Chaifetz said.

The study also concluded that workers in the retail industry had the highest percentage of calls related to behavioral disorders, such as depression. On the other hand, employees working in the health care business called more often about stress and anxiety.

Men and employees in their 20s were more likely to seek help for alcohol or chemical dependency issues–and those in the construction industry were most likely to call about these problems.

Managers, meanwhile, were more likely to call EAP and work-life professionals about employees in their 50s and 60s due to performance issues, absenteeism or interpersonal problems.

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The National Institute of Mental Health (NIMH) is unhappy about with upcoming release of the DSM-5.

In a post on the NIMH website written by NIMH Director Thomas Insel, the DSM-5 was referred to as “at best, a dictionary” of mental health disorders, “creating a set of labels and defining each.”

Insisting that “patients with mental disorders deserve better,” Insel said that the NIMH Research Domain Criteria (RDoC) project, launched two years ago, will “transform diagnosis by incorporating genetics, imaging, cognitive science, and other levels of information to lay the foundation for a new classification system.”

He said diagnoses must be based on biology, not just symptoms.

“As long as the research community takes the DSM to be a bible, we’ll never make progress,” Insel told The New York Times on May 6. “People think that everything has to match DSM criteria, but you know what? Biology never read that book.”

The DSM-5 is the first major revision of the diagnostic manual by the American Psychiatric Association since 1994.

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Congress, the White House and the media have spent much of the year talking about gun control–and why we need it or don’t need it. But a new California State Senate bill offers a possible alternative to the hot-button political issue by requiring additions to the school curriculum regarding violence.

The bill would introduce materials into the grades 7-12 curricula to discuss the “risks, harm and danger associated with violent behavior,” according to a supportive article in the May issue of the National Alliance of Professional Psychology Providers (NAPPP) newsletter, The Clinical Practitioner.

Senate Bill 552 hasn’t received much press, though, and its prospects are unknown.

- John Nelander, Editor

States cut a total of $4.35 billion from budgets for mental health care between 2009 and 2012, a Mother Jones magazine reported last week.

The deepest cuts came in South Carolina, Alabama, Alaska, Illinois, Nevada, the District of Columbia and California. The South Carolina cuts have been so severe that the state is now funding public mental health care at 1987 levels.

What’s happening to mentally ill people who were at one time eligible for services? One answer is that they’re in jail. The number of mentally ill in prisons quadrupled between 1998 and 2006, the magazine said. They number now stands at 1,264,300.

In 2004, the percentage of inmates in local jails who have mental health issues had grown to 64.2%.

Mental health care spending per capita was $75 or less in Idaho, Nevada, Utah, Texas, Oklahoma, Arkansas, Louisiana, Ohio, Kentucky, West Virginia, South Carolina, Georgia, and Florida.

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The American Psychological Association will take a closer look at changes coming up under the Affordable Care Act at its August convention in Hawaii. A first-look program includes a session on New Opportunities for Practicing Psychologists Through Implementation of the Health Care Reform Law.

Also on the schedule is Building the Future of Practice in America; and Reframing Psychological Practice for Health Care Reform: Is a Recovery-Oriented Framework the Answer?

Here’s a session that may be popular with practitioners and academics: Smarter Than You Think: Understanding the Mind of a Dog.

The APA is meeting July 31-August 4 in Honolulu, Hawaii this year. Next year’s convention returns to Washington, DC and the 2015 meeting is in Toronto.

One topic sure to come up in Honolulu is the impact of the ACA on reimbursement rates for practitioners. That was discussed at the 2013 State Leadership Conference in Washington and March.

Mark McClellan of the Bookings Institution told psychologists that they shouldn’t focus on trying to boost reimbursement rates. He said the trend toward squeezing providers to save costs is unsustainable, according to the May issue of the APA’s Monitor on Psychology.

He added: “We’re moving away from paying providers based on volume and intensity and instead paying providers based on what we really want: better results with lower costs.”

- John Nelander, Editor

It’s still five months before the first health care exchange plans begin to appear under the Affordable Care Act. Not only is the impact on consumers unclear, but health care providers are largely in the dark, too, about how it will impact their practice.

Outside of vague predictions that there will be more people needing health care because millions more will be insured under Medicaid and other programs, the actual mechanics of the ACA remain a mystery. Part of that is because, according to HHS Secretary Kathleen Sebelius, the feds have been deliberately holding off on publicizing the exchanges because they feel people won’t pay attention this early.

(That didn’t satisfy Senate Finance Committee Chairman Max Baucus, who said last week he doesn’t think HHS is moving quickly enough to get programs established.)

One thing that is clear, though, is that there will be an emphasis over the coming years on prevention and wellness programs that could stop some lifestyle-related illnesses in their tracks. There’s the obesity-diabetes relationship, for example.

One source we talked to last week pointed out that this could open up new opportunities for coaching. Health and wellness coaching has been around for years, and it’s becoming increasingly popular. And with the effort to treat the whole person, rather than just specific diseases, coaches could be a valuable cog in the new ACA health care machinery.

Already, master’s degrees are being offered in health and wellness coaching at the University of Miami and Duke University, according to Patrick Williams, director of training for the Institute for Life Coach Training. Hospitals are opening up “wellness” departments, he adds.

“People are going to learn to take more responsibility for their health,” Williams tells us. “And it’s not just gong to be about diet and exercise.”

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There’s a new twist to substance abuse as more teenagers turn to pharmaceuticals such as Ritalin and Adderall that have not been prescribed for them, according to HealthDay News and WebMD. An astonishing new survey shows that one in four high schoolers are taking these meds without a prescription, up 33% from 2008.

The survey by The Partnership at Drugfree.org also shows 20% of the teens who experimented with the drugs did so before the age of 14, and 27% said they believed that the prescription meds were safer than street drugs like cocaine or ecstasy.

More problematic is that parents seem to agree–a third of them said Ritalin and Adderall can improve their child’s academic performance even without a diagnosis of ADHD.

Steve Pasierb, president and CEO of the Drugfree Partnership, calls it “a real public health crisis.” He adds: “The key here is that kids and often their parents are buying into the myth and misunderstanding that prescription drug abuse is a safer way to get high, a safer alternative to street drugs, and that they can control it.”

- John Nelander, Editor

It’s been a big month for Medicare news, starting with the 2% provider reimbursement reduction that went into effect April 1 as a result of sequestration in Washington.

But that may only be the beginning for a program that could see more radical changes in the years ahead. Not only are political alliances forming around various Medicare ideas, but think tanks are coming up with their own plans. President Obama addressed Medicare in his budget proposal released earlier this month, although that seems dead in the water due to Republican opposition.

Laura Groshong, a Seattle clinical social worker and lobbyist for the Clinical Social Work Association, told us last week: “Most providers I know feel kind of shut out of the process.

“There are the big insurers and the drug companies, and the Affordable Care Act is creating all these plans for the uninsured. They’re all stakeholders, but so are we. And we don’t really have a seat at the table at this point.”

On Thursday, the Bipartisan Policy Center–headed by a group of former Republican and Democratic congressional leaders–released a detailed plan for Medicare reform that proposed “Medicare Networks” in addition to traditional fee-for-service and Medicare Advantage plans.

The group proposes scrapping the Sustainable Growth Rate, which threatens a 24.4% provider reimbursement cut at the end of each year that Congress has to reverse. Read a PDF of the proposal online by clicking here.

In its review of the Bipartisan Center’s proposal, ModernHealthcare.com pointed out: “The catch for providers is that they would never receive another increase in their fee-for-service payments, unless their area is given a rural exemption from the HHS secretary.”

In fact, the Obama budget takes a similar approach, apparently without specifying that providers will never see another rate increase in fee-for-service plans. Instead, the White House budget would freeze reimbursement rates at current levels for physicians–and presumably other providers–as a way of achieving “payment stability.” Here’s a more detailed report on the Obama plan from Medscape.

Under the Medicare Networks envisioned by the Bipartisan Policy Center, providers could be rewarded for participating and achieving more cost-effective health care.

With Washington in perpetual political conflict, it’s hard to predict what eventually will come out of Medicare reform, if anything. But there seems to be a growing chorus for more fundamental reform, and those changes appear likely to hit behavioral health professionals and other health care providers in the pocketbook.

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After a three-year drop, the number of senior medical students opting into psychiatry jumped more than 10%, from 616 in 2012 to 681, Psychiatric News reported Friday.

Overall, 4.2% of seniors chose psychiatry this year compared with 3.9% last year.

The percentage fell each year since 2010 when 670 students chose psychiatry. That dropped to 640 in 2011 and 616 last year. The lowest of the past decade was in 2008 when 595 went into psychiatry.

- John Nelander, Editor

As we prepare a report on the best coaching niches, we note that Aetna is in the process of beefing up its Healthy Lifestyle Coaching (HLC) program, which they claim has resulted in a 150% return on investment for employers.

You have to wonder how they come up with these statistics. But Aetna announced on Friday that due to the HLC program:

- 55% of employees are exercising more.

- 54% have lost weight.

- and 51% said they’ve experienced reduced stress.

The Aetna program offers workers one-on-one coaching or group coaching, but it also promotes self-help. Workers can join online communities created by a company called CafeWell. The online service does promote coaching, but also gives people a chance to participate in “peer support” from other members who are working toward the same goals.

CafeWell tells members to “continually challenge yourself and others” in the areas of fitness, stress prevention, and nutrition. Then they’re encouraged to “read, discuss and ask questions” to other members, coaches and health professionals. Finally, people can “cash in” on their efforts with store discounts and gift cards.

Aetna says more than 400 companies are using HLC. “Employers can receive comprehensive reports on employee participation and outcomes on a quarterly basis through all of these programs,” the insurer says.

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The drive to expand mental health coverage in Congress is losing steam, Politico reported last week. A bill proposed by Sen. Debbie Stabenow (D-MI) and Roy Blunt (R-MO) that would have added more Medicaid reimbursement at community heath centers at a cost of $1.4 billion could be dead in the water.

Instead, existing programs are being reauthorized, but not much new is coming down the pike.

Stabenow told the news organization that her bipartisan bill will be introduced this week, but it faces one big stumbling block: Nobody knows where the money’s coming from. The bill would designate some mental health centers as Federally Qualified Behavioral health Centers, which would qualify them for more Medicaid dollars.

- John Nelander, Contributing Editor

How insurers react to the implementation of the Affordable Care Act at year’s end remains a key question for federal health officials, consumers and health care providers. Although a certain basic level of benefits will be required by law, will these benefits be provided or will loopholes open up that lead to denial of services?

A new lawsuit in New York is probing some of these issues six months before the first health care exchanges open up to the public.

The class action suit in U.S. District Court involves three plaintiffs and the New York State Psychiatric Association. It alleges that UnitedHeath Group and United Behavioral Health are already violating the federal parity law and the ACA.

A NYSPA official told Psychiatric News in a story published Friday that the organization is concerned about “systemic denial of mental health and substance abuse” services by United.

The newspaper reported that there have been “numerous member complaints” about restrictions on psychotherapy, particularly those who need longer-term treatment. Beneficiaries have even complained about “extreme difficulty” getting intensive outpatient treatment for mental health and substance abuse issues.

The suit also accuses the company of harboring a bias against psychotherapy as opposed to medication-based treatment. Pre-authorization is required for “alternative levels of care,” but “the same limits are not placed on medication management,” the suit claims.

UnitedHealth said it was reviewing the suit; no response has been posted on the company’s website.

For more details on the specific cases involved in the lawsuit, you can access the full 102-page document by clicking here.

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A set of safety standards has been released for social workers.

“Social workers have been the targets of verbal and physical assaults in agencies as well as during field visits with clients,” notes the report, issued March 21 by the National Association of Social Workers. “Establishing safety guidelines for the profession is timely as it is expected to grow by 25% before 2020.”

Among other things, the organization calls for working spaces with easy exits, alarms, “risk room” for meetings with potentially violent clients so that other staff can be present, making sure that paper weights, scissors and other items that can be used as weapons are secured, and well-lit hallways to working spaces.

The NASW suggests using cell phones dedicated to the work environment rather than personal phones, in order to “reduce exposure of their personal information.” The organization recommends keeping the phone fully charged at all times, getting familiar with coverage limitations and keeping emergency contacts on speed dial.

See the full report by clicking here.

- John Nelander, Contributing Editor

Lawsuits over therapist sexual misconduct are becoming far and few between–but not necessarily because fewer incidents are occurring. It’s just that the money is no longer there to make a suit worthwhile, a California consultant tells us.

“The reason is that nearly all malpractice coverage virtually excludes payments for claims that involve therapist-patient sex–there’s a policy limit of $25,000,” says Martin Williams, a psychologist who consults with attorneys and mental health clinicians on malpractice cases and licensing board complaints. “For attorneys, it’s not worth their time.

“The only ones I’ve worked on lately have been therapist-patient sex cases where there has been institutional liability. The claim was that the institution that employed the therapist should have known what was going and was therefore liable for the claim. In those cases there is a way for the plaintiff to recover damages.”

He said “the big trend” in licensing board cases now is violation of confidentiality in matters involving parental custody. The problem is when the therapist becomes an advocate for his or her patient. “There’s nothing wrong with that,” Williams says, “but when the patient asks, ‘Would you write a letter showing that I would be the better custodial parent?’ some therapists just go ahead and write the letter.”

But you’re wading into legal quicksand if you accommodate the client, particularly if you haven’t evaluated the client’s spouse. It’s problematic even if you write the letter based on the knowledge of your own client, without a thorough custody evaluation. What’s worse, Williams notes, is making implied comparisons with the other parent.

“In these cases the person bringing the complaint is the spouse who has not been treated by the therapist and feels harmed by the therapist’s offering a custody recommendation based on an improper assessment.

“And believe it or not this isn’t rare–it happens quite often. Therapists like to please people and want to support their patients.”

A licensing board complaint means time and effort, and legal fees, to defend yourself. Read more about what Williams and other experts have to say about therapist-legal problems in an upcoming issue of Psychotherapy Finances.

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One of the main arguments for allowing psychologists to prescribe medication is that there’s a shortage of psychiatrists, especially in rural states. That’s one reason why efforts have been successful in New Mexico and Louisiana.

A new article in the National Association of Professional Psychology Providers’ (NAPPP) newsletter, The Clinical Practitioner, shows the scope of the problem. It reports data from the American Medical Association stating that the number of psychiatrists shrank a hefty 27% from 1990 to 2002. At the same time, demand for services shot up 16%.

Shortages are particularly acute for child psychiatrists.

The problem could be quickly resolved, at least in hard-hit California if specially-trained psychologists were allowed to prescribe psychotropic medications, says John Caccavale, a psychologist and a founder of the NAPPP group. “All it takes is a change in the scope of practice,” he says. “But how likely is this to occur?

“My best guess is that it will not be nearly as long as it is taking for psychologists to achieve national RxP, which will soon be going into its third decade of trying. Adding millions of newly insured patients into the system will cause so many problems that policy makers will have little choice but to address this problem in the most effective and efficient way possible.”

- John Nelander, Contributing Editor

Is the sequester that hit March 1 beginning to take a toll on individual therapy practices? There are some hints that this could be happening, especially in areas where the economy is closely tied to government services and the military.

There have been comments by practitioners on Listservs, including one pointing to “a distinct slowdown in referrals from government agencies for assessments.”

Another clinician said a client dropped out of therapy due to a cut in pay from a government contract.

Critics of the sequester (yes there are supporters) point out that cuts of $1.2 trillion by 2021 are bound to drain money out of an already wobbly economy and that this will have a ripple effect that impacts everything, including consumer spending.

Half of the cuts are coming out of defense programs that include construction and base operations, so if your practice draws on non-Tricare clients who rely on defense-related income, get ready for some cancellations.

In Virginia alone, sequestration could cost the state 200,000 jobs. Prime defense contractors were already cutting subcontractors.

Case example in Nevada: At Nellis Air Force Base outside Las Vegas, civilian furloughs will begin at the end of April and those workers will see their pay cut by around 20%, according to Friday’s Las Vegas Sun.

At airports, air traffic controllers are being cut and some smaller airports face closure.

With so many facing an income squeeze, it seems inevitable that health care providers will start to feel the impact — perhaps by as soon as this summer.

If you’re already tracking sequester-related cancellations or a slow-down in your practice, let me know. Email: john@pbeditorialservices.com

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Weight loss was the top concern of employees surveyed earlier this year by the EAP giant ComPsych.

In a survey, workers were asked about their top health concerns in 2013. Thirty-nine percent said losing weight topped their agenda, following by stress (26%); more exercise (17%); and improving their diet (9%).

Weight loss concerns and diet concerns add up to an impressive 48 of employees in the survey.

ComPsych CEO Richard Chaifetz said he was more surprised that an increasing number of workers are aware that stress is a major contributor to health issues.

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The Illinois Psychological Association has hired a marketing firm to help them convince the state’s legislature to OK a bill allowing some psychologists to prescribe certain medications, according to the American Psychiatric Association.

The IPA said 500 psychologists nationwide have completed training to prescribe under the conditions set forth in the state bill, a master’s degree in clinical psychopharmacology. There are 16 in Illinois who have completed the training or are currently enrolled.

The bill passed a state senate health committee earlier this month and was sent on to the full senate.

Psychologists have made the Illinois effort “a national effort,” said Daniel Yohanna, past president of the Illinois Psychiatric Association.

“We should not be taking this lightly,” Yohanna told Psychiatric News. “They are pulling out all stops.”

- John Nelander, Contributing Editor

Another year begins — along with another drive to expand prescription privileges for psychologists.

An early battle has been won by psychologists in Illinois after the state’s Senate Health Committee voted unanimously to approve a bill that would allow psychologists with a master’s degree in psychopharmacology to prescribe medication.

As has been the case in other states where the issue tends to come up annually, supporters in Illinois argue that access to psychiatrists is too limited and their number continues to drop. That’s the thrust of Sen. Don Harmon, who sponsored the bill, which passed the committee on Wednesday.

The Illinois Psychiatric Association has already jumped into the fray with the usual counter argument that allowing psychologists to prescribe is unsafe for patients.

“It’s an invasive procedure when somebody takes medication — it affects their entire body,” Linda Gruenberg, president of the Illinois Psychiatric Society, told the Chicago Tribune. “Without comprehensive medical education that you get from four years of medical school, four years of residency training and practice, you are not prepared to prescribe psychotropic medication.”

So far, the only successful efforts to allow psychologists to prescribe have been in New Mexico and Louisiana. New Mexico passed the measure in 2002; Louisiana in 2004. In the flush of victory that followed, supporters insisted that the floodgates had been opened.

And other states, such as Oregon and Hawaii, have come close but governors ultimately vetoed successful legislative bills.

Other efforts have gained some traction in Arizona, Missouri and Mississippi. But so far, nothing has made it to the governor’s desk in these states.

It’s not for lack of effort. According to a survey by the American Psychologist, 88 different bills were introduced around the country, with varying success, from 1985 — when the first was brought up in Hawaii — to 2009.

Psychologists who favor prescription authority — and not all of them do — argue that the problem of access to psychiatrists is particularly troubling in rural states, which is one reason why New Mexico and Louisiana were able to pass laws.

- John Nelander, Contributing Editor

We’ve talked with therapists in the past who have found the college crowd to be a good source of private pay clients. It’s not that students themselves have a lot of available cash, but their families are usually willing to make sure their sons and daughters get the best possible health care–and treatment for mental health issues that could compromise their academic success.

A couple of things have happened in the past several years that make serving college students an even better niche market for practitioners.

One is that the passage of the Affordable Care Act keeps young adults on their parents’ health care plans up to age 26, so decent benefits packages are more likely to be in place for the college crowd. Second, the need for mental health services among young adults continues to grow.

One example: The number of students looking for counseling at the University of Maryland jumped 35% from 2007 to 2012, from 1,466 to 1,986. The school has hired more part-time counselors and has been looking for a staff psychologist, according to a recent article in the Baltimore Sun.

The paper said counseling centers “are nearly overwhelmed” by the numbers of students lining up for mental health services. And the University of Maryland isn’t unique.

There’s been a 92% increase nationwide in the number of students seeking help over the past three years, the American College Counseling Association says. Among the reasons for the growth is that students are more savvy about mental health these days, and there’s less stigma. On top of that, many young adults entering the university system have already been diagnosed with mental health problems.

Amid shrinking budgets, campus counselors can’t keep up. And the problem is even more pronounced at two-year community colleges, since these counselors have other duties, including academic advising and career counseling.

“Most people wear several hats, which a lot of times can really interfere with the process of working with a student, particularly if they’re in a crisis,” Amy Lenhart, a counselor at Collin County Community College in Texas, told the publication, Inside Higher Ed, last fall.

“When you’re expecting people to do all those other things and — oh, by the way — be there for the student, you know something’s got to give.”

Community college and university counselors are increasingly referring students to off-campus resources. Parents may not know where to turn to find help for their adult children. But private practice clinicians who have established a relationship with schools in their area may find that it’s a steady source of referrals — and the work can be rewarding.

- John Nelander, Contributing Editor