Voices of reform.
Health care reform (Political aspects)
Mental health (Management)
|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 2009 American Psychotherapy Association ISSN: 1535-4075|
|Issue:||Date: Winter, 2009 Source Volume: 12 Source Issue: 4|
|Topic:||Event Code: 290 Public affairs; 200 Management dynamics Computer Subject: Company business management|
|Product:||Product Code: 8622000 Medical Associations NAICS Code: 81392 Professional Organizations SIC Code: 8621 Professional organizations|
|Geographic:||Geographic Scope: United States Geographic Code: 1USA United States|
Members of the American Psychotherapy Association and other experts
speak out about what a change to the nation's health care means to
The country is one step closer to some sort of nationalized health care reform, now that the House of Representatives passed the Affordable Health Care for America Act (H.R. 3962) on November 7, 2009. It passed by a very slim margin--a vote of 220-215. Like the voices in Congress, members of the American Psychotherapy Association have mixed views about what reform will mean for their practices.
"Who knows what the right one is?" said Ron Hixson, PhD, BCPC, MBA, LPC, LMFT, DAPA, and therapist in San Antonio. "The right wingers will see their golden goose cracking, and the left wingers are confused about which egg to pick, so it will probably come down to the lobbyists having the greatest impact on the written amendments or legislation selected to support."
"I'm not a fan of the current legislation that is moving through Congress," said Dr. Gary Brown of Los Angeles. "If passed in its present form, it will in the long run virtually eliminate fee-for-service. Reimbursement rates will go down to the Medicare level, and it will eliminate competition in the private sector. It will decimate private practice." "I believe that we do need health care reform, but I believe we need to do it incrementally," Dr. Brown continued. "I would start with tort reform, portability, tax-free savings accounts; tying premiums to lifestyle choices; covering young adults, and [applying] refundable tax credits for the uninsured. Implementing these ideas could certainly lower the overall health care costs we face as a nation, but none of this is being contemplated by the current majority in Congress."
Americans now predominately believe that tackling health care reform is more important than ever before--57%, up from 53% in August, according to a September poll conducted by the Kaiser Family Foundation. The proportion of Americans who think their families would be better off if health reform passes is up six percentage points (42% versus 36% in August), and the percentage that thinks the country would be better off is up eight points (to 53% from 45% in August) (Kaiser Family Foundation 2009).
"Without insurance coverage, more people with mental health problems would withdraw from the service due to stigma," said Linda Song, MD, PhD, and licensed clinical psychologist in Kensington, Maryland. "The coverage of [the] insurance company indicates that the mental health service is an official, scientifically-proven health service with the same concept as another medical service. We should increase the access to the mental health service at an early stage. Insurance should also increase the coverage of preventive services, such as family therapy/counseling parenting education, group therapy, and marital/premarital counseling/therapy, which, in a long-term run, should reduce the cost of the service of mental health."
A substantial majority of Americans continues to back individual reform components designed to expand coverage, including an individual mandate (68%), an employer mandate (67%), and an expansion of state programs such as Medicaid and the Children's Health Insurance Program (82%) (Kaiser Family Foundation 2009). "Health care reform has been an agenda item for recent presidents," said Noah Hart, Jr., EdD, DAPA. "There is no question about the need for it; what [the] reform will be is the issue. As the nation's population evolves, health care needs to evolve and migrate. Much of the recent debate, particularly town hall meetings, has been about cost. Who is going to pay for health care reform? Much of the current health care cost is not clearly identified. Specifically, a large percentage of the homeless, the working poor, the unemployed, and others who have no health care insurance use hospital emergency rooms. All taxpayers pay for their care.
"The need for health care reform is emphasized by the current H1N1 flu pandemic which underscores the potential impact of globalization, immigration, migration, and tourism on the U.S.'s population. Americans live in a world wherein illness and disease can be easily transmitted among global communities within hours. For this reason and others, health care reform which acknowledges and is responsive to contemporary global health issues is a national imperative."
The component that draws the strongest support across the political spectrum is the requirement that health insurance companies cover anyone who applies, even if they are sick or have a preexisting medical condition. Overall, eight to 10 people support the idea, including 67% of Republicans, 80% of independents, and 88% of Democrats (Kaiser Family Foundation 2009).
"We are the only one in the top 10 industrialized nations that doesn't have health care," said American Psychotherapy Association member Julia Bays, M.Ed., LPC, of Alva, Oklahoma. "You can't let people die; mental illness kills people, too."
When it comes to paying for reform, two ideas now under discussion among policy makers garner initial majority support. Fifty-seven percent of the public say they would support "having health insurance companies pay a fee based on how much business they have" and 59 percent would support "having health insurance companies pay a tax for offering very expensive policies." In both cases, Republicans are evenly divided while Democrats and political independents tilt in favor. The poll did not test arguments for and against the policies (Kaiser Family Foundation 2009).
"Right now, the state governments are restricting competition by a system of arcane laws that tie the hands of insurance companies," said Dr. Brown, who is a member of the American Psychotherapy Association. "President Obama is saying we're needing more competition and [yet] his end goal is to have a universal single-payer health care system that the government runs. Depending upon what data source you use, somewhere between 78% and 84% percent of people who currently have health insurance are happy with their health insurance company. Why have the government control over one-sixth of the economy for just 10 to 12 million people who are uninsured?"
One in four Americans suffers from a mental or substance use disorder each year; 50% during the course of their lifetimes, according to Dr. Hoyd Sederer, medical director for the New York State Office of Mental Health, who spoke out in a column in the Huffington Post (2009).
Although mental and substance abuse disorders are more common than diabetes, heart disease, and cancer, only 40% of people get any treatment for these common, painful and potentially disabling conditions. "Worse still, quality is typically abysmal with a highly noted national study showing that only one in eight people with mental health problems in primary care settings (the major site where people go for care) get 'minimally adequate care,'" Sederer said.
"This probably goes without saying, but then again, it should be said loud and clear: research has long determined that, for example, 85% of visits to a primary care physician are related to stress; stress is the number one contributor to most health problems; billions of dollars each year are lost in productivity due to 'presenteeism,'" said Paul J. Schweinler, LMHC, NCC, DAPA, Coral Springs, Florida. "I believe the major impact on the health care crisis is the lack of support and encouragement for mental health. Psychotherapy doesn't only treat symptoms, it resolves the issues."
Psychotherapists and other mental health professionals celebrated when the Mental Health Parity and Addiction Equity Act were signed last October. "The Mental Health Parity Act passed and was supposed to have regulation by October 3," said APA member Linda D. Whitten Stalters, MSN, RN, MTAPA, chair of the Schizophrenia and Related Disorders Alliance of America. That was delayed until January 10, and there are loopholes with the parity--it's only covered for employers with 50 employees or more."
Health care systems are looking for new ways to make mental health more accessible. "Major systems are beginning to shift, and I think we are going to be integrating psychologists, therapists, social workers, and advanced practice nurses with strong psychological clinical training to step up and be in medical offices," said Maria E.J. Kuhn, a psychotherapist and owner of the Geneva, Illinois-based Kuhn Counseling Centers. "There is a tremendous opportunity rising--if we don't get too rigid in our traditional ways of thinking."
Kuhn said major medical centers are already trying to figure out how to incorporate mental health professionals into their traditional medical models. "The federal government and the VA will probably do it first, but I am also seeing major hospital associations getting into it," she added.
A nationwide effort to coordinate mental health with primary care is already underway, the Philadelphia Inquirer recently reported. The idea is to give simple interventions in 15- to 30-minute visits that will address behavioral issues ranging from stress to traumatic reactions that often go untreated. The goal is to help lower the costs of health care in the long term. Some clinics have coupled licensed social workers with their other clinical staff; the mental health experts provide services while patients and family members receive physical care. Insurers, however, have been slow to pay even for brief visits, so the model is catching on, mostly in settings where the same entity provides insurance and medical care (Kaiser Health News 2009).
Carol A. Gleason, MM, RN, CRRN, CCM, LRC, BCPC, chairman of the Case Management Society of America's Public Policy Committee, advocates the implementation of case managers and said that case management programs must be sponsored as part of the health care initiatives moving through Congress.
"Case managers are licensed professionals with the experience to support individuals and their families," she noted. "Case managers provide services that are crucial to saving costs and improving quality in the health care system, especially with the majority of health care dollars being spent on chronic illness. With such a fragmented health care system, case managers provide critical services to help patients and their caregivers navigate, coordinate, and transition through a dynamic approach to better achieve their health care goals" (CMSA 2009).
With the promise of changes on the horizon, Congress and President Obama are also concerned with the infrastructure needed to support a reformed health care system. The President said all Americans' medical records are to be computerized within the next five years, noting that electronic records system will improve quality, lower costs, and save lives by reducing preventable medical errors.
There is a myriad of obstacles to moving the nation's health care system--and its abundance of paper records--into the computer age. The President earmarked $19 billion in the American Recovery and Reinvestment Act of 2009 to incentivize doctors and hospitals to adopt electronic record keeping and, by 2014, every organization is supposed to move toward electronic health records. The cost and complexity is daunting and will pose a challenge and expense for non-physicians.
"I do not see how government health care, or for that matter the insurance conglomerates, will help the clinical counseling profession," said Fredderick J. Nastri, MA, LCPC, in Williamsport, Maryland. "There is already too much paperwork and too many roadblocks for professionals to overcome attempting to recover their fees. One must hire a billing specialist just to recover billable revenues. I accept EAP referrals from a HMO-like provider. I have little paperwork and fees are okay. I also do not take any insurance in my practice and by keeping the paperwork to a minimum I can keep fees lower and offer clients CCC--Complete Confidential Counseling. No third parties, no computer billing where names are in cyberspace ... etc. Clients are receptive and like that there is no "paper trail" for their counseling. So, in all, I feel the system probably is better as it stands now with some better oversight of potential fraud. Sadly, the lesser of two evils is where we are now and with government I can only see more fraud, waste, and mismanagement."
Advocates of electronic record keeping say better documentation will help system auditors determine the value of services provided. "Performance measures of ongoing treatment is going to be a huge issue," said Clifton D. Croan MA, LPC, DAPA, and CEO of Enigami Systems Inc., a health information technology company located in Denver. "With the different ways that HIT [Health Information Technology] is tracking symptoms, that is going to be a very direct measurement of what we as clinicians do."
Today's health care is evidence-based, and psychiatry needs more research to qualify that it is evidence-based care, some professionals say. "It means a lot more documentation, and they are going to expect a lot more outcome documentation from the patient and the clinician," Stalters said. "Researchers will have to devise valid research studies and they will have to show how they can reduce costs to the system." Clinicians may have to "rethink the art of diagnosing" since insurance companies have shown interest in Axis I and Axis II as well as using DSM [Diagnostic and Statistical Manual of Mental Disorders] as a diagnostic tool, Kuhn said.
"My fear is that we are not at the table and the big boys are at the table making choices," Hixson said. "I wish we had someone in Washington. I know the APA [American Psychological Association] has and the social work people have people there. We need someone to be part of that, outside of the phone calls and e-mails we sent to our representatives."
Today, about 15% of the U.S. population lacks health care coverage (Parente & Bragdon 2009). "People forget that when you have a large population that is simply not insured, we all pay for them anyway," Kuhn said. "If we could get them insured, then I think the next issue with health care will be really holding people accountable for their health choices, where right now, we don't do that.
"It's all about values and priorities," Hixson stated. "We pay enormous amounts of money for oil, and we give billion of dollars to corporations and trillions of dollars in foreign aid to other countries. But if little Joey needs a shot or a $10,000 operation, he can't have it. It's too costly. In the end, it is about national priorities."
APA (2008, October). APA Practice Organization. The Wellstone-Domenici Mental Health Parity Act of 2008: Questions and Answers for Psychologists.
CMSA (2009, August 27). CMSA Announces New Model Act Supporting Case Management Programs. Press Release. Retrieved November 6, 2009, from http://www.cmsa.org/PolicyMaker/Health careReform/tabid/445/Default.aspx
Kaiser Health News (2009, September 29). New 'Movements' Seek to Introduce Preventative Mental Health Care in New Settings. Retrieved October 19, 2009, from http://www.kaiserhealthnews. org/Daily-Reports/2009/September/29/care-models.aspx
Kaiser Family Foundation (September 29, 2009). Public Support For Health Reform Increases in September, Reversing Summer Declines as Congress Takes Up Legislation." Press release. Retrieved September 29, 2009, from http://www.kff.org/kaiserpolls/ posr092909nr.cfm. Retrieved 2007-11-23.
Parente, Stephen T. & Bragdon, Tarren (2009, October 17). Why Health Care is So Expensive in New York. Wall Street Journal.
Sederer, Dr. Lloyd (2009, September 24). Where is Mental Health in Health Care Reform. Huffington Post. Retrieved September 24, 2009, from http:// www.huffingtonpost.com/lloyd-i-sederer-md/ whereis-mental-health-in_b_295776.html&cp
Health Care Reform Proposals Features Resident Obama's House Democratic Proposal Bill: Affordable Health Care for America Act Who is Covered All Americans 96% of Americans Cost Obama said in a The Congressional September speech Budget Office that his plan would estimates $1.2 cost around $900 trillion. billion over 10 years. How It Is Costs will be paid An income tax Paid For by cuts to Medicare surcharge on high- and taxes to high- income individuals value insurance and reduced plans. Would spending for dedicate $630 Medicare and other billion over 10 programs would off- years toward a set the pricetag, Health Reform bill leaders say. Reserve Fund in budget. Requirements Supports an Individuals will be for Individuals individual mandate responsible for as long as hardship obtaining coverage waivers were or face a penalty provided. capped at 2.5% of adjusted gross income above a specified level. Requirements Businesses with more Employers will have for Employers than 50 employees the option of would be required to providing insurance offer coverage or or contributing pay a fee. funds on their behalf, Small employers are exempt. Mental Health Covers mental and Covers behavioral Coverage behavioral health health treatments care. and mental health services. Establishes training program for behavioral health professionals. Public Option Offers a public The Health Insurance health insurance Exchange, starting option to provide in 2013, will be the uninsured and financed by those who can't find premiums. Insurance affordable coverage companies can't choices. decline coverage due to preexisting conditions. Details Ends discrimination Insurance companies against people with can no longer preexisting condi- exclude coverage due tions. to preexisting conditions. Features Senate Democratic Bill: America's Health Future Act Who is Covered 94% of Americans Cost Less than $900 billion over 10 years. How It Is Fees on insurance companies, drug Paid For makers, and medical device manufactures. Fines for people who don't purchase premiums; tax levies on insurance companies. Requirements Everyone will get coverage through work, for Individuals a government plan, or their own. Individuals would be able to buy their insurance from an exchange created in their state, which would be created in 2010. Premiums would be capped at 13% of the buyer's income, with the rest of the costs paid by subsidies. Requirements Requires businesses with more than 50 for Employers employees to pay fees going towards the aforementioned subsidies. The maximum possible fee would either be $400 per full-time employee or the average cost of the subsidies a firm's employee's take in multiplied by the number of those receiving them. Mental Health Covers behavioral and mental health Coverage services. Public Option No public plan. Details Bans insurance companies from restricting coverage based on preexisting conditions. The insurance premiums can take into account tobacco use, age, family size, and geographic location. Insurance companies would also be forbidden from setting up lifetime or annual caps that specify a maximum amount of care that customers can receive. Sources: Kaiser Family Foundation, Wall Street Journal. Paying for health care overhaul Congress is considering several ways to pay for the health care overhaul. How Americans feel about some of the options: Tax companies on the money they spend to offer health insurance to employees Favor 17% Oppose 74% No opinion 8% Increase income taxes paid by people who earn more than $250,000 a year Favor 57% Oppose 136% No opinion 6% Increase income taxes paid by all Americans Favor 18% Oppose 75% No opinion 8% Tax sugary soft drinks Favor 44% Oppose 49% No opinion 6% NOTE: Figures do not total 100 percent due to rounding or because 'Don't know' response not included [c] 2009 MCT Source: AP poll of 1,502 adults, Oct. 29-Nov. 9, 2009; margin of error: +/-2.5 percentage points Graphic: Judy Treible Note: Table made from bar graph.
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