From disparities to shortages.
|Article Type:||Brief article|
Health care industry (Services)
Health care reform (Analysis)
Prospective payment systems (Medical care) (Analysis)
|Publication:||Name: Annals of the American Psychotherapy Association Publisher: American Psychotherapy Association Audience: Academic; Professional Format: Magazine/Journal Subject: Psychology and mental health Copyright: COPYRIGHT 2011 American Psychotherapy Association ISSN: 1535-4075|
|Issue:||Date: Spring, 2011 Source Volume: 14 Source Issue: 1|
The concept of the business of therapy can be foreign to new therapists. For some, the concept may trigger images from a corner convenience store to a medical clinic. Such a wide range may explain, in part, why some therapists prefer to work in government, schools, or hospitals. Being sensitive to one's limitations or preferences can be an asset. While others jump into the pool of private practitioners because of an early life dream, they do so ignoring the signs of danger. For the balance of the time in private practice, they will play catch-up, feeling dragged along by demands of licensing boards, health maintenance organizations (HMOs), and managed care organizations (MCOs).
Every day, we pass 18-wheelers speeding products and supplies to the next town or the next state. The transportation industry is colossal in its reach and in the number of tons transported each day. While this industry has restrictions and guidelines attached to its operating policies, as any American corporation does, transportation companies are not told what they can charge or how they can charge, as health care providers are. However, health care providers are primarily reimbursed by organizations that represent the individual patient when it comes to paying for health care benefits. In the transportation comparison, providers receive payment for invoices from those sending the package or cargo.
The basic concept of letting the market determine the price is what motivates investors, small or large. Supply and demand has been a key philosophy of the marketplace since Adam Smith wrote his often quoted book An Inquiry into the Nature and Causes of the Wealth of Nations in 1776. America was formed by immigrants searching for freedom of religion, freedom from tyrants, free speech, and the pursuit of happiness. Smith argued that individuals can attain wealth for themselves and their country when they are free to use their skills and capital in their own self-interest, which translates into when individuals feel free to make the choices that benefit their family. Smith was a firm believer in education because knowledge tends to increase the value of an individual, both in the marketplace and in their community. Today America is a proud leader in global commerce, which explains why there are more employees in small businesses than in giant corporations.
Physicians once practiced without all the outside interference of today and enjoyed a sense of autonomy, which has been lost in all the process of change. HMOs and MCOs were created, in large part, at the urging of congressional leaders, including some presidents, who saw how hospitals were growing rapidly and wanted a way to control their expansion. Many of these hospitals were built by physicians who controlled access and delivery. Criticisms of this practice led to federal regulations that determined when and where a new hospital could be built and who could or could not own shares in the hospital. As Medicare and Medicaid grew, the national budget also became a concern. Since the development of HMOs and MCOs, there has been an rapid growth of organizations bidding for the right to represent patients who need medical services.
Over the past 35 years, these organizations have learned to redefine the power structure that places bean counters in the driver's seat for health care access and delivery, rather than medical/clinician trained professionals. This has occurred on a fast track because of the rising expenditures for health care services; in other words, more people want some form of health care services. In economic terminology, the demand for quality health care has steadily risen above the capacity to meet the need. Then graduate schools quickly saw a way to increase their profits, so they developed more degree programs in physical and mental health. However, graduate schools have been very slow in adding business courses to their curriculum, which has led to a shortage of therapists with business degrees.
Shortages are part of the business cycle of change, including supply and demand. Just as fads change, there are times of the year when people shop more than at other times. In health care, providers will talk about "the flu season" or the time just prior to the start of school when mothers bring their children to the doctor for school required physicals. Psychotherapists who specialize in working with children and adolescents will have their schedules slowed by more no-shows at spring break, in the summer months, and during weeks of testing at the schools. Many have closed their offices or are only working part time.
A larger contributor to the growing shortages in health care, but more prominent in mental health, has been the declining rates of reimbursement. Last summer, licensed professional counselors (LPCs) in Texas, and perhaps in most states, lost almost 30% overnight on reimbursement, beginning with Medicaid but spreading to other MCOs. The vast majority of those who provide mental health services in rural communities are LPCs. Over the past seven years, the number of rural communities experiencing shortages has grown. Today, many rural residents can access mental health care services only by driving two or more hours one way. While Medicaid patients do receive some cash reimbursements for their travel, few are driving new cars, thus they are vulnerable to breakdowns and flat tires that will take more than their cash reimbursement to fix. They have an alternative; Medicaid-sponsored vans drive to metropolitan communities, but they normally pick patients up at their home around 4:30 a.m. and often return them around 8 p.m.
Health care providers have seldom been comfortable with asking for money. Perhaps they grew up thinking that they were "called" to service and may have seen the discussion of money as an invasion of their clinical space. Others have commented that when they are successful financially, they feel embarrassed. Still others hire staff to deal with billing and collection tasks. Over time, the costs of a practice drain the payroll funds.
With each passing election, we witness more physicians running for office. They have learned something that other health providers have not yet acknowledged. If you let others go to Congress, they will make the decisions affecting health care. Lawyers, businesspeople, and teachers do not understand the dynamics and obstacles facing health care providers as well as the providers do. However, few providers even write or demonstrate in favor of, or against, any health care reform bill. Health care providers are normally more willing to complain than to act. That is why there has been no concerted effort to form a national health care association that could provide a more united stance on issues of concern. Another reason is the issue of turf and fears that other specialists will take tasks or jobs away.
According to Miller, MCOs are paid by the states or the federal government at a flat rate of service for a predetermined number or population in a state. In his research, Miller found that MCOs are keeping 25% to 30% for administrative costs and profit, with the rest going to providers. For mental health, he discovered that MCOs use creative accounting methodology when considering the formula to reimburse behavioral health care services. He found that using a formula is similar to physical medicine, they take their 25% to 30% fee for administrative costs and profit but then give mental health providers a smaller piece of the remaining funds, which leaves another large amount of money for the MCO, increasing their profits from 25% to 50%! What may be needed in the reform discussion is a high-level audit that is made public and with testimony to Congress. But in the meantime, what the field of mental health needs is more activists such as Miller.
Note: Ivan Miller's Open Letter About Financial Discrimination Against Mental Health Services is available online at www.ivanjmiller.com/disparity_article.html. Miller can be reached at 350 Broadway, Suite 210, Boulder, CO, 80305; (303)499-3888.
Miller, I. J. (2009). An open letter about financial discrimination against mental health services. The Independent Practitioner, (29)3, 151-157.
By Ronald Hixson, PhD, LPC, LMFT, BCPC
RONALD HIXSON, PhD, LPC, LMFT, BCPC, has been a therapist for more than 25 years. He has a Texas corporation private practice and has founded a nonprofit group mental health organization where he serves as president and executive director. He has a PhD in Health Administration from Kennedy-Western University, an MBA from Webster University, and graduate degrees from the University of Northern Colorado and the University of California (Sacramento).
|Gale Copyright:||Copyright 2011 Gale, Cengage Learning. All rights reserved.|