The Supreme Court’s decision to uphold the Patient Protection and Affordable Care Act has given the green light for partial application now with full implementation of the law slated for 2015. While the Affordable Care Act (ACA) provides more Americans with insurance coverage, including equal access to medical and mental health services, the role psychologists will play in the delivery of services remains unclear.
According to the Substance Abuse and Mental Health Services Administration (SAMHSA), the ACA eliminates coverage exclusion due to pre-existing conditions; removes annual or lifetime caps on coverage; forbids rescinding coverage; and creates a basic benefit package that includes treatment for mental health and substance abuse disorders, expanded access to prevention, enhanced rehabilitation, prevention, wellness and community-based services; and incentives to integrate primary care with behavioral health and addiction services.
Claudia B. Rutherford, Ph.D., private practitioner in Deerfield, Mass. and clinical psychology supervisor for doctoral students at the University of Massachusetts Amherst, says that the Commonwealth is better positioned to weather the health reform mandates than most other states. “A lot of these things are already occurring or are close to reform in Massachusetts,” she says. “We’ve worked out some of the kinks here as far as insurance goes. But it will be a huge overhaul in other states.”
Although practitioners in the Bay State have already begun to adapt to some of the new health laws, there are several other changes that complicate psychology practices, including modifications to the current procedural terminology (CPT) psychotherapy codes and potential Medicaid reimbursement reductions. “Psychologists are feeling discouraged. I’m not sure how much change they can handle,” Rutherford says, adding that financial concerns are prompting some psychologists to explore new revenue streams. “People have already diversified with all of the changes that have gone on. They are trying to pick up health related expertise, such as more training in health psychology, doing assessment, bariatric evaluations, pre-surgical evaluations, things that make them more attractive to physicians.”
Although she hails the health reform bill as necessary and overdue, Rutherford believes it doesn’t go far enough. “Psychologists are left stuck in the middle,” she says.
Rick Barnett, Psy.D., LADC, private practitioner in Stowe, Vermont, voices cautious optimism for the reform. “It’s hard to determine what will happen. We are all hoping it will be beneficial. Most psychologists agree changes are needed and it will be good in general. How it will affect the delivery of mental health care though is uncertain. Patient quality of care is to be determined. The more details you get, the more complicated it is,” he says.
Barnett says that the Vermont Psychological Association (VPA) has been exceptionally proactive in addressing health care reform. He notes that at VPA’s annual meeting Anya Rader Wallack, chair of the Green Mountain Care Board, which is charged with implementing health care reform and educating members about the changes, called for collaboration to ensure that “psychology’s voice is ultimately heard.” Interest in future initiatives prompted members to suggest VPA host several meetings in various regions of the state in 2013 to continue the discussion of how psychologists can implement the changes. “We want to be uniform so patients get quality care,” says Barnett.
Once the law is fully implemented and more citizens have insurance, Barnett foresees some potential problems for the profession because of an aging workforce and ever declining reimbursement. He explains that psychologists receive diminished return for their work efforts and have fewer private pay clients. “In the last 10 to 20 years, reimbursement has decreased significantly and we are on the cusp of facing more cuts,” he says. “Starting salaries are deplorable, around $35,000, and we pay our own health insurance. We are getting squeezed to produce more for less,” he adds.
However, Barnett sees somewhat of a silver lining on the horizon. “Integrated practices will grow. So will independent practices. The two are not mutually exclusive. One need not take the place of the other,” he says. “Due to ACA mandates, there will be more streamlined health care delivery. It will be less fragmented. However, where independent psychology practices come in is very much unclear.”
One of the biggest potential outcomes of the health legislation could be a push toward granting psychologists prescribing privileges, Barnett says. “I believe health care reform will provide an excellent opportunity to introduce and implement legislation for appropriately trained doctoral level psychologists,” he says, pointing out that appropriate medication regimens combined with psychotherapy will facilitate more effective treatment.
Barnett agrees with Rutherford that diversification will become more common. “As a rule, psychologists have already branched out. We are not just doing frontline care. It’s not sustainable. The trend is that mental health workers will be looking to teach, consult, wear any number of hats to supplement their income. The ACA and the changes in the pipeline will potentially provide psychologists with all kinds of entrepreneurial activities.”
As a leader in health reform, Massachusetts has first-hand knowledge of the mental health benefits to the new law. “The Affordable Care Act acknowledges that health care includes behavioral health care and gives us the opportunity to fully integrate in a meaningful way behavioral health and primary care for adults, children and families. I am very pleased to be chairing the Behavioral Health Integration Task Force created by the ACA, which will accomplish two important things,” says Marcia Fowler, commissioner of the Department of Mental Health. “First, we need to ensure that everyone understands and recognizes that mental illness is a chronic, prevalent disease that reduces life expectancy by 25 years, nearly twice the years of all cancers combined and costs as much as cancer to treat each year. And it will help us roll out prevention activities because mental illness is a childhood disease, it most often begins before age 14, and early intervention and prevention is critical not only to the success of the ACA, but to the physical and mental health of our citizens.”
According to Paul Block, Ph.D., director of Psychological Centers in Rhode Island, the ACA will bring two main changes for mental health professionals. “Although the ACA maintains parity, the biggest new step is that it has pilots to put medical providers in mental health agencies,” he says. “The other big change is the increase in the number of people who have insurance.” However, Block adds that a round of steep fee cuts, as well as significant delays in receiving payment, “makes expansion of insurance much less helpful to private and smaller providers.” “So, while behavioral health concerns are recognized as one of the main drivers of out of control costs, there’s relatively little in the ACA that does anything to help make it affordable to offer behavioral health services in any volume,” says Block.