Practical Practice: Toward better models for mental health treatment

By Ellen Anderson, Ph.D
October 4th, 2022

I recently came across a job posting with an ambitious mission statement that included the goal of creating a “rockstar psychologist thinktank.” The company seeks “gifted, dedicated, wholehearted, crafty, Jedi psychologists.” While being a rockstar would seem just a trifle incongruent with the role of a psychologist, the posting reflects the need to stand out amid the proliferation of new online mental health startups.

Searching for a therapist has never been more confusing for consumers. The number of licensed therapists hasn’t magically increased to keep pace with the demand created during the pandemic. The Rural Health Information Hub indicates that every New England state has one or more counties with a shortage of mental health professionals.

Most of my psychologist colleagues in private practice don’t participate in insurance panels. Reimbursement rates are subpar and the practitioner is challenged to keep pace with the patient’s changing copays and deductibles, chasing down copays ranging from $5 to $30 and apportioning part of that to credit card merchant fees.

Add in the cost of malpractice, office rent, electronic medical record keeping, self-employment tax, online directory fees and other hidden costs of private practice, it is understandable that from the provider perspective, it is a challenge to rely on insurance as a primary form of reimbursement.

Nonetheless, from the consumer perspective, it can be cost prohibitive to spend hundreds of dollars a month on mental health treatment.

I am often in the position of helping a consumer to find a therapist, but I rarely recommend checking to see if an Employee Assistance Program is available. My perception had been that such programs offered only very short-term counseling. Indeed, the cost of EAP programs of the past was based typically on usage, creating disincentives for the employer to promote use of the EAP.

I had some recent personal experience as a contractor for one such organization that changed my perspective. I had been contacted by a recruiter. She had connected with me on LinkedIn, sent me two emails and a voice mail message. The voice mail message caught my attention. The company is a multi-billion, dollar valuated organization that partners with employers to deliver behavioral health services and contracts many of the services out to community clinicians.

They tout fair market rates, motivated referrals, tools for the clinician’s practice, and clinical support. As a senior career professional, I was skeptical, knowing that most behavioral health online service providers pay far below market rates.

Still, the recruiter stimulated my curiosity. I booked a phone call that turned out to be a brief interview. I gamely played along, responding to questions about my therapeutic approach, continuing education, evidenced based care, and routine outcome evaluation. I asked questions and remained skeptical, but the reimbursement rates were fair. I couldn’t see any harm in joining their organization as an independent contractor.

Like others, EAP provides technology enabled behavioral health services, meaning that they incorporate standard screening questions and an algorithm utilizes the data to match patients to providers.

I worked for years in clinical research and like the idea that of analysis of aggregate data to improve practice. To date, I find that clients are a good fit for my practice, reimbursement is fair with quick turn around and routine distress screening provides clinically useful data to me in real time.

I’m able to see clients with subclinical distress and no psychiatric diagnosis is required. Employed members and their immediate family are covered. Client files are privately maintained in my electronic medical record. The EAP’s outcome data allows the company to conduct research that has demonstrated value in the form of decreased utilization of out of network mental health providers, decreased costs in yearly health claims, and rates of improvement.

The sessions’ limits range from 12-26/year. Stepped care is available within the EAP for more severely ill patients. Importantly, this model also employs psychiatrists and psychiatric nurse practitioners for patients who need medication consults.

This model is more efficient for consumers in that they are matched with a vetted provider and don’t have to spend time searching for a provider who accepts their health insurance. Since the model incorporates routine data collection from patients, the company can demonstrate the effectiveness of psychological treatment using hard outcomes such as reduced use mental health inpatient facilities, emergency room visits and pharmacy costs.

Can EAPs be trusted to maintain employee privacy? EAPs are required to comply with federal Health Insurance Portability and Accountability Act (HIPAA) that protects health information. Research of this type is typically conducted with aggregate data from de-identified datasets.

It is well documented that mental health treatment is more likely to be sought out of private health insurance networks compared to medical or surgical treatment. The current private health insurance reimbursement model for mental health is not working, for the provider or the consumer. Consumers can’t easily access psychologists or other behavioral health providers. It is even more difficult to access a psychiatrist, even when paying out of pocket.

Not long ago, there was great hope that the integration of behavioral health providers into primary care settings might address the challenges in accessing mental health care. Behavioral health integration into primary care has indeed allowed for earlier identification and triage of people with psychological distress. However, there are not enough embedded behavioral health providers in primary care and these professionals quickly become overwhelmed by demand. The challenge of helping patients to connect to longer term care remains.

This model of EAP is a paradigm shift in that it collects data to measure outcomes and provides fair reimbursement for psychologists and other behavioral health providers who use evidence-based treatment methods. Providers have access to continuing education at no charge which in turn, is beneficial to the consumer. The post-COVID proliferation of online mental health services have made it difficult for consumers to navigate the mental health system of care. As psychologists, we don’t have to be part of the “rockstar psychologist thinktank” to advocate for models of mental health treatment that work.

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