Psychologists brace for insurance changes

Open enrollment for state health insurance exchanges mandated under the Affordable Care Act (ACA) kicked off October 1 and psychologists are preparing for its impact.

Deborah C. Baker, J.D., director of legal and regulatory policy for the American Psychological Association (APA) Practice Directorate, says the direct impact won’t be as clear until after coverage takes effect Jan. 1.

Baker says, “We’re going to be experiencing a whole new area and I think we’re going to find a lot of good things and also areas for improvement.”

The exchanges are state-level marketplaces for individuals and small businesses to buy coverage. States can design and run the insurance exchange themselves; let the federal government do it; or share the duties. The number of insurance providers who participate in the exchange varies across states and can include both private insurers and new non-profit entities.

About one-third of states are operating their own exchange, including Conn., Vt., R.I., and Mass., which pioneered its exchange in 2006 and configured its existing model to comply with ACA requirements.

In Maine, where the exchange is federally-run, psychologists were actively involved in working with one of two providers, Maine Community Health Options (MCHO), in revising reimbursement rates.

MCHO is a new not-for-profit insurance plan that will be board-run by consumers. Christine A. Gray, Psy.D., of the Maine Psychological Association (MePA), praises the MCHO model. She says MCHO solicited input from consumers and providers and is emphasizing good preventative care.

The MCHO approached MePA to be involved in provider advisor meetings and solicited its input on treatment issues. “After they shared the name of the third-party administrator (TPA) for behavioral health, this TPA’s fee schedule turned out to be quite low,” Gray says. “MePA was able to contact MCHO and share our concerns about the fee schedule and MCHO collaborated with MePA to explore a more reasonable fee schedule, which resulted in a revision that was more in line with other Maine insurers.

“It was a positive collaboration and I was pleased that we were able to make our concerns known and have the insurer listen and respond favorably.”

Maine’s other exchange insurance provider, Anthem Blue Cross Blue Shield, partnered with MaineHealth, the state’s largest owner of hospitals and other medical facilities. The network is expected to include 32 of the state’s 38 hospitals. It’s drawn criticism because of its exclusion of central Maine hospitals and could mean insurance subscribers in certain parts of Maine will have to travel farther to reach plan doctors.

In Connecticut, the exchange – Access Health CT – is a quasi-public agency overseen by a board of directors. One participating insurance provider, Healthy CT, a non-profit CO-OP (Consumer Operated and Oriented Plan), released its provider fee schedule at the end of the summer. The Connecticut Psychological Association (CPA) expressed concerns that behavioral health providers were to be reimbursed at the same rate – regardless of level of education and training in their respective health fields.

In letters to the board and state officials, Traci Cipriano, Ph.D., CPA director of professional affairs, and CPA President Barbara Bunk, Ph.D., questioned how master’s-level and doctoral-level providers could all be lumped together in one reimbursement group.

“This classification system does not recognize the years of education and training which go into becoming a psychologist (typically five to seven years of graduate education, as well as at least one to two years of postdoctoral training), nor does it recognize psychologists’ specialized training in research and measurement, which are unique qualifications of psychologists, enabling comprehensive evaluation, conceptualization and treatment of the most complex behavioral health cases.

“We are concerned that such a system will lead to current psychologists leaving the practice arena and would-be psychologists choosing to not enter the field, which would leave a gap in patient care and would be a great disservice to patients,” they wrote.

The CPA also expressed concerns that APRN’s (advanced practice RN) had a separate fee schedule that reimburses for diagnostic evaluation and psychotherapy at a higher rate than that for psychologists. Also, while it is primarily psychologists who are trained in neuropsychological assessment, only the fee schedules for MDs and APRNs provide for reimbursement for this assessment, Cipriano says.

Cipriano adds the CPA was scheduled to meet with Healthy CT in late October to discuss issues. It has also reached out to express concerns to a private insurer that released a fee schedule that does not provide reimbursement for any psychological testing and provides reimbursement based on licensure, not academic credentials. “So the same flat-rate across disciplines (in this case, including physicians) applies,” Cipriano says.

In Vermont, state officials embraced the exchange early, as the state moves toward a single-payer reimbursement system.

The exchange – called Vermont Health Connect – has two insurance providers and Rick Barnett, Psy.D., LADC and president of the Vermont Psychological Association, says he doesn’t expect anything to change for state psychologists in the way of reimbursement rates and procedures under the exchange in 2014. “But we have to be very on top of what happens each week and each month, because this is all leading toward Vermont’s goal of a single-payer system in 2017,” he says.

“I think there will be subtle changes along the way that will lead toward single payer and if we’re not aware of what those changes are, then there’s reason to be concerned.”

Barnett says it’s particularly important for independent practicing psychologists to establish a solid bridge between these new systems of care while still retaining independence, amidst a system that for the time being, appears heavily focused on primary care/behavioral health integrated care models.

Barnett says the VPA is trying to assert itself into the process. He and other VPA members – concerned that high deductible plans may affect access to mental health services – successfully advocated to the health care reform board that such services be considered primary prevention. “Some of the plans now will actually have three mental health visits for which the deductible is waived,” he says. Also, as the exchange was being developed, the VPA was instrumental in advocating for and successfully implementing copay parity. “So in all of the exchange plans, the (mental health care visit) copay will be exactly the same as for primary care visits,” he says. “In the Vermont healthcare exchange, mental health is not considered a specialist co-pay. That was a huge success on behalf of the VPA to have made that impact.”

While Vermont moved early to set up the exchange, neighboring N.H. saw political battles over the mandate, how it should be designed and whether or not to accept federal money to implement it.

New Hampshire has a “partnership exchange” – the state retains control over managing insurance plans and consumer assistance functions; while the federal government designed and set up the marketplace.

“There was a lot of back in forth in the legislature about what funds (the state) would accept and what funds we wouldn’t,” says Sheila Gardner, Ph.D., president, N.H. Psychological Association.

Currently, Anthem Blue Cross Blue Shield is the only insurance company selling plans on the exchange. Gardner says having one insurance company participate is not an ideal scenario. “I think part of what hurt N.H. is this uncertainty with how the state would go,” she says. “There was a lot of political wrangling about it. Probably insurance providers were reluctant to make a commitment on it.”

Gardner says there has been some indication that another insurance provider may join the marketplace in 2015.

Gardner hopes to help empower psychologists to be resilient as the exchange goes into effect. “We by-and-large are trying to take a wait-and-see approach,” she says. “Obviously, psychologists support access to mental health care and health care in general for the people who need it. We clearly see mental health as a key component to overall health and access to mental health is an important piece of the reform process.”

Gardner says N.H. has struggled to finance and secure the basic safety nets of mental health care and a large number of seasoned clinicians will retire in the next five-eight years. “Depending on whether or not this reform results in an increase in the people with more complex conditions (seeking treatment), the challenges of this will compound an already somewhat fragile system,” Gardner says. “So there is likely to be a period of some instability.”