What's Happening at VTMHCA

It’s My Turn... Psychotherapy—State of the profession

By Scott Earisman, LCMHC, LADC

With so much attention now focused nationally on "The Healthcare Debate," and with Vermont in the forefront of changes to the healthcare system, I thought that it is time to look at the part of that system that delivers mental health and substance abuse services.

Nationally, it is estimated that up to 70% of visits to primary care doctors have a psychosocial component that may best be treated by a psychotherapist. Psychiatric medications account for roughly 60-70% of all prescriptions written by those doctors. (C.J. Peek, at the Bridging the Divide conference, 11-16-09.) Roughly 10% of all Vermonters covered by the private managed care organizations are receiving care for mental health or substance abuse reasons. (2009 Insurer Mental Health and Substance Abuse Report card.)

In terms of the capabilities of the profession, we are developing a powerful theoretical, clinical, and scientific foundation. Integrating elements of neurobiology, cognitive science, trauma studies and attachment theory, and backed by rigorous research, the therapeutic relationship can now be "a developmental crucible within which the patient's relation to his own experience of internal and external reality can be fundamentally transformed." (Wallin, 2007, pg. 3.)

The realm of psychotherapy now includes help for chronic pain, weakened immune systems and inflammation. We can direct neural plasticity in creating healthier brains and minds. Our clinical knowledge about love enables us to heal marriages and families, and foster the type of relational security that enhances long term sobriety.

That psychotherapy works for depression, anxiety, and substance abuse is no longer in any doubt. Our outcomes are robust, and the profession continually moves towards greater refinement of technique and theory. In 2008 in Vermont, 90% or more of managed care members seeking mental health or substance abuse care report that the y were helped "a lot " (60-70%) or "somewhat" (20% plus )by the counseling they received. (2009 Insurer Mental Health and Substance Abuse Report card.)

We accomplish this using one primary tool, that being the person of the therapist within the therapeutic relationship. We use our knowledge and our experience, and more essentially, our ability to be fully available, empathic, and reflective, to help our clients create these therapeutic changes. When we are successful in guiding the relationship so that our clients feel safe, emotionally understood, and fully supported, then our clients are successful in healing their wounds, their anxieties and depressions, grieving their losses, and regaining the feeling of being present, powerful and valuable.

The second reality is that the therapist described above is soon to be, if not already, an endangered species. In 2001, when I entered private practice, a licensed mental health counselor seeing 5 clients having a range of insurances (BCBS, MVP, Medicaid, CBA, and Cigna) would have grossed $300.12. At the end of 2009, that same work would gross $302.11. So as a therapist who accepts most insurance, my costs are up 30% and my income is flat. Therapists practicing in the previous decade will note that this is a continuation of a trend starting with the advent of managed care in the early 1990's.

We are paid significantly less than similar professions. Our typical reimbursement is about $55.00 per 50 minute session. Occupational therapists make roughly $75 and physical therapists $80 to $90. Registered dieticians make $75 to $90. (Extracted from BISHCA Provider Reimbursement Report, Volume 2, 2008)
Mental health and substance abuse have a special carve-out within the Catamount Program, paying us significantly less and on a different scale (the scale of whatever MVP and BCBS want to pay) than every other provider and profession. Fletcher Allen Health Care also delegates mental health to Cigna Behavioral Health, with whom provider satisfaction is significantly worse than with the other managed care organizations, (2009 Vermont Health Care Satisfaction Survey) and who haven't increased provider reimbursements at all in the 9 years I have been in practice.

So, income is flat, expenses increase, parity is a joke in terms of fair reimbursements, and the physical therapist who exercises your shoulder is paid more than the professionals who treat your mind, your brain, and your relationships. The gap between what I have trained and know how to do, and what I actually am capable of with my 7th client of the day or 33rd of the week, is ever-widening. I am my best tool, and I am tired and angry and poor. I can't come close to affording for my family the insurances I accept, and those premiums have doubled since 2001 while my reimbursements from those same healthcare organizations are unchanged.

The very essence of the therapy is the mentalizing, mindful, and empathic therapist within the relationship, and the possibilities for healing go deep and wide. Access to these possibilities is seriously threatened, however, by the financial dead-end that the profession has become for so many of us.

Just to be clear, at our best we are not victims. I know that I can do other things to pay my bills. I am available for most of my clients most of the time, and like most of us, often very good.

I would like to see us be paid equitably and on par with equivalent professions. I would like to limit the number of client we have to see to the number we can reasonably attend to, and still be able to pay my middle class bills. I would like to see us be paid for our specialties and our advanced skills, so that the cost of the specialized education can be recouped. I want this group of licensed and dedicated professionals to be able to afford to stay in business and provide the life-transforming services that psychotherapy can provide.

What I think that we need to do, therefore, is to be ever moving towards the first and exciting reality, while working steadily and effectively to change the second. Here are some ideas:

  1. Attend one workshop every year from a nationally known "expert." Consider developing, through ongoing training, an advanced specialty. We need to be really good.
  2. Find one way to educate our clients about all that we can do. Many do not know. Make articles about the type of work you do, or what other therapists are doing, available in your waiting room.
  3. Reflect on what you accept for payment, from whom, and if any of it is objectionable, make your feelings known. Some therapists have left the "worst" insurance panel or panels, and some call their provider relations rep and ask for reimbursement increases. Take some action in line with your values and situation.
  4. Using information from this letter, VTMHCA website, your practice, and wherever, open a dialogue with your elected state legislators. Discuss access to quality care, parity, and how case loads can affect the type of collaboration that the Vermont Blueprint for Healthcare recommends.
  5. Get active in VTMHCA by paying dues, attending annual meetings, getting a colleague to join, visiting and using the website, etc. We are making a real difference, and you can be a part of that. When we create the change we want and need in this profession, you will be able to know that you helped.

VTMHCA welcomes your input, views and positions. Please submit any writings you would like to share with the mental health community to Heather Pierce.

LEGISLATIVE ALERT
American Mental Health Counselors Association
801 N. Fairfax Street, Ste. 304
Alexandria, VA 22314

Reps. Rooney and McMahon Introduce CARES Act to Allow for LMHC TRICARE Independence

Alexandria, VA — October 16, 2009 — AMHCA commends Reps. Tom Rooney (R-Fl), a member of the U.S. House of Representatives Armed Services Committee, and Michael McMahon (D-NY), a member of the Foreign Affairs Committee, for today introducing legislation that would strip TRICARE of its licensed mental health counselor "supervision and referral" requirement, thus giving TRICARE beneficiaries immediate access to licensed mental health counselors.

This legislation, appropriately titled the CARES Act, "The Counselor Accessibility Reform and Expansion for Soldiers Act," would permit TRICARE beneficiaries the same direct access to licensed mental health counselors currently available to numerous beneficiaries of private insurance plans. Disturbing statistics about recurring incidents of post traumatic stress syndrome in soldiers returning from Iraq and Afghanistan inspired Reps. Rooney and McMahon to introduce the CARES Act. Rep. Rooney says, "An important part of properly treating PTSD and other mental health problems facing our soldiers is to ensure them access to professional counselors." Rep. McMahon identifies "face to face counseling with mental health professionals" as the means to ensuring America's men and women of the Armed Forces "adequate, efficient mental health services."

Before the genesis of the CARES Act, Congress tasked the Institutes of Medicine (IOM) to convene a panel and hold several meetings to make a recommendation to Congress as to whether to retain or strip TRICARE of its current "supervision and referral" requirement for licensed mental health counselors. The IOM panel has not yet issued a recommendation to Congress, and it is not expected to for several months. AMHCA is committed to working with Reps. Rooney and McMahon, in addition to responding to the needs of the IOM TRICARE panel, to see the elimination of TRICARE's current "supervision and referral" requirement for licensed mental health counselors.

Contact Julie A. Clements, J.D., AMHCA Director of Legislative Affairs, by email or phone at 1-800-326-2642 if you have further inquiries.

California is Final State to License Mental Health Counselors

Alexandria, VA – October 12, 2009
With today’s signing of California Senate Bill 788 by Governor Arnold Schwarzenegger, mental health counselors are now licensed as master’s degreed mental health professionals in all 50 states and the District of Columbia.

"Achieving licensure in every state is a tremendous victory, both for mental health counselors and for those seeking their services," said AMHCA president Linda Barclay, PhD, LPCC/S, LICDC, NCC.

AMHCA recognizes the efforts of the California Coalition for Counseling Licensure (CCCL), which worked actively for licensure of mental health counselors, to be known in California as licensed professional clinical counselors (LPCCs). AMHCA assisted the CCCL in its lobbying efforts, producing letters in support of SB 788 to Assembly and Senate Business and Professions Committee chairs and members.

"AMHCA deeply appreciates the hard work of CCCL in this historic achievement," said Mark Hamilton, PhD, AMHCA executive director and CEO.

Governor Schwarzenegger will appoint two LPCCs to the Board of Behavioral Sciences, which is already comprised of two licensed clinical social workers, a licensed educational psychologist, and two licensed marriage and family therapists. SB 788 defines "professional clinical counseling" as being focused exclusively on the application of counseling interventions and psychotherapeutic techniques for the purposes of improving mental health. Under SB 788, the LPCC profession does not include the assessment or treatment of couples or families unless the LPCC has completed additional training and education beyond the minimum education and training required for LPCC licensure.

The law will go into effect on January 1, 2010. At that point, the Board of Behavioral Sciences will have the responsibility for developing the rules and regulations to implement the bill and it will prepare to accept LPCC applications.

Applications for grandparenting and reciprocity will be available on January 1, 2011, through the Board of Behavioral Sciences. Applications for regular licensure will be available on January 1, 2012, for those not eligible for grandparenting or reciprocity. Click here to learn about requirements.

Act 129, Leg. Committee Report

September 24, 2009
After a month off for summer, the Legislative Counsel resumed monthly meetings. The unofficial and unpublished agenda included discussions on how to bring reimbursement disparity to the attention of legislators in meaningful ways. Alex Forbes suggests that we use the review by the Legislative Committee on Administrative Rules (LCAR) to insure that Act 142 is being implimented as desired by the legislature, including clarity in coding for services and the elimination of bundled codes. This review is not scheduled as of yet, but at the Act 129 meeting on 9-21 Christine Oliver (BISHCA Dep. Commissioner) suggested that LCAR will take this up in Nov., and she will inform Act 129 members of the date as soon as she knows.

We also met with Doug Racine, State Senator for Chittenden County, head of the Senate Committee on Health and Welfare, and candidate for governor. He spoke of the serious economic situation the state is in, but was not overly impressive in terms of awareness of our concerns and the issues relevent to the mental health and substance use treatment world (reimbursements, loss ratios, impact of managed care on healthcare, etc.) He did seem to be concerned with access to care for lower income Vermonters.

The invited guest to our next meeting on Oct. 1st is Floyd Neese, Democratic Leader in the VT. House, member of the Mental Health Oversight Committee.

Act 129 Task Force met on Sept. 21. We looked at the results from the Healthcare Satisfaction Survey (see attached) noting that 55% of the 280 respondents from the fields of psychotherapy, psychiatry, primary care medicine, internal med., etc were from mental health fields. Thank to everyone who took the time to respond. I have emailed BISHCA to ensure that there is no reason that we cannot distribute the results to our members, as I think that these are telling numbers, especially our views on reimbursements, insurance company support for chronic care, drug formulary, and overall satisfaction.

Comments from the managed care reps suggested concern with the adequacy of the survey. BISHCA is going to give us the report including only mental health specialists, with raw numbers so that we can better assess the meaning of the data. The committee generating the report will report back on any other follow-up.

We also discussed the 2008 Experience of Care survey, given to mental health consumers in an attempt to assess their satisfaction with both insurance organizations and providers. Ann Donahue, (Consumer Rep ) noted that the survey revealed problems. Managed Care Organization (MCO) input was that the data, again, isn't specific enough to suggest any courses of action. Alex Forbes, from Vt. Psychological Assoc., suggested that the task force actually could talk about the results in a meaningful way, given some focus on what specific areas of concern could be addressed. A subcommittee of Alex, Ann Donahue, Lou M. (MVP) and John B. (BCBS) has been formed, and tasked with distilling the essentials as a precurser to a fuller discussion. Follow-up to be on the agenda for the next task force meeting.

Ken Libertoff, from Vt. Assoc for Mental Health, announced the date of their annual conference, on Thursday, November 12, 2009. VTMHCA should probably have representation at that conference, for a variety of reasons.

Scott Earisman, Legislative Chair, Act 129 rep.

AMHCA North Atlantic Region Email Blast

AMHCA Celebrates Leadership Training & Annual Conference

Alexandria, VA - July 28, 2009 - AMHCA has concluded its annual leadership training and conference with impressive results. A record 60 state leaders attended Leadership Training with 31 state chapters represented. Conference attendance was up 20 percent over the previous year. W. Mark Hamilton, PhD, AMHCA's Executive Director and CEO, commented, "This is a wonderful sign of AMHCA's vitality and member dedication."

AMHCA on the Hill
Dodd On Thursday, July 23, 2009, 70 licensed mental health counselors (LMHCs/LPCs) representing LMHCs/LPCs across 30 states made visits to U.S. Senators' Capitol Hill offices. AMHCA state chapter leaders met with health legislative assistants in their legislators' Washington, DC offices to push for inclusion of S. 671's LMHC/LPC Medicare reimbursement language in the greater health care reform bill that will soon be introduced by the Senate Finance Committee. Forty U.S. Senators received visits from AMHCA's state leaders. AMHCA state leaders relished the opportunity to meet with their U.S. Senators and/or their staff members and discuss how their outpatient mental health services promote preventative mental and physical health as well as economic efficiency. (Above, Virginia LPCs Joan Normandy-Dolberg and Theresa Johnson Sion meet Senator Christopher J. Dodd of Connecticut on their visit to the Capitol.)

AMHCA leaders commented that the lobbying experience was "informative" and "fun" and enhanced their understanding of the civic process. Following AMHCA leadership's meetings with Senate staff, Senator Johnson of South Dakota signed onto S. 671 as a cosponsor. Many members' offices expressed an interest in supporting S. 671 and including Medicare reimbursement of LMHCs/LPCs in the greater Senate's health care reform legislation. (Above, a coalition of LPCs from several states met with Senator Webb's Counsel, Douglas Ierley (center), to discuss Senate Bill 671.)

Capitol AMHCA recognized three legislators for their commitment to mental health counselors and mental health awareness during its annual awards luncheon, held at the Washington Court Hotel on Friday, July 24, 2009. Senator Blanche Lincoln, the Senate sponsor for S.671, received the President's Award. Former AMHCA President Victoria Sardi presented Gretchen Alkema, Senator Lincoln's chief health staffer, with the President's Award. Congressman Bart Gordon and Congressman Bob Filner appeared at the luncheon and were recognized by AMHCA Policy Committee Chair, Dan Holdinghaus, as "Legislator of the Year" for their use of Medicare legislation and Veterans' Affairs legislation to promote the LMHC/LPC profession. (Left, AMHCA state leaders tour the U.S. Capitol, guided by Ronald A. Sarasin, former US Representative from Connecticut.)

The mission of the American Mental Health Counselors Association is to enhance the profession of mental health counseling through licensing, advocacy, education and professional development.

E-News from Washington
Vol. 09-07
February 19, 2009

VA to Request New Occupational Category for Counselors

AMHCA and ACA are pleased to announce that the Department of Veterans' Affairs (VA) has approved the establishment of a new occupational category, or categories, for licensed professional counselors and marriage and family therapists working within the VA's Veterans Health Administration (VHA) health care system. The move is a step toward implementation of Public Law 109-461, the "Veterans Benefits, Healthcare, and Information Technology Act of 2006," which established explicit recognition of both mental health counselors and marriage and family therapists within the VHA. Until the VHA's endorsement of a new occupational category, it was unclear if counselors and marriage and family therapists would be considered merely subcategories of an existing occupational category for a different profession.

Establishment of an occupational category for professional counselors has been a key objective for AMHCA and ACA in implementation of the law. Federal occupational categories are developed by the Office of Personnel Management (OPM), but only at the request of federal agencies such as the VA. Creation of an occupational category will mark a key step in achieving recognition of the profession, although the process is likely to take another year or more.

The VHA's announcement of the new occupational category came after the House Veterans' Affairs Committee—which has direct jurisdiction over the agency—wrote to Secretary Eric Shinseki urging the VA to "move quickly" to establish regulations enabling counselors and marriage and family therapists to "work to their full potential within the VA." The letter also stated that federal job classifications for each of the professions should be established, "in order to recognize their status as full-fledged, independent mental health professions."

The House Veterans Affairs Committee letter was developed and promoted jointly by AMHCA, ACA, and the American Association for Marriage and Family (AAMFT). Our three organizations—recently joined by the California Association for Marriage and Family Therapy (CAMFT)—have been working closely together to push for implementation of P.L. 109-461. Our organizations' close collaborative working relationship with AAMFT and CAMFT will increase our effectiveness in pushing for new occupational categories for each profession, and for continued progress by the VA and Congress in expanding the role of counselors and marriage and family therapists in serving our nation's veterans.

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