Expand the pie to get a bigger piece

By Jeffrey Axelbank, Psy.D.
June 2, 2013



Expand the pie to get a bigger pieceThe listservs have been humming with questions and complaints like never before. The issues are significant: Medicare payments are cut, yet again. The Medicare PQRS system must be used now to avoid penalties in the future. New CPT codes are confusing.

Insurance companies are taking advantage of the new codes to redesign payment systems in ways that are cutting fees.

The new CPT codes make it impossible to get reimbursed for sessions longer than 60 minutes. Authorizations are getting harder to get, with insurance companies asking ever-more intrusive questions, putting providers in an ethical bind. And many of these issues raise questions about Mental Health Parity. Then there’s the Newtown massacre and the attention paid to the mental health system and gun control, issues about which psychologists have a lot to say.

Psychologists are worried, and with good reason. Many of the responses to these challenges are understandable and amount to “circling the wagons,” attempting to preserve our piece of the mental health system “pie.” Prescription privileges are a tempting way to expand our scope of practice and to provide services, especially where psychiatrists are hard to find. There are a multitude of efforts to “beat back” the threat of masters-level clinicians, who are willing to work for lower pay. And there are plenty of proposals to lobby and protest and complain, and no shortage of targets for these efforts: Washington, state legislatures, insurance regulators.

None of these responses will work.

The problem with all these responses is that they focus on trying to preserve psychology’s “piece of the pie,” but the pie keeps shrinking at a rate faster than our slice could ever be expanded. Mental health funding continues to decline in the public sector, and mental health insurance coverage continues to be cut by the private sector in all kinds of ways. So regardless of our best and well-intentioned efforts, the overall size of our segment is just never going to get bigger, and in fact is going to keep shrinking.

Right now, each professional group is focused mostly on preserving their own business.

Psychiatrists are beating back psychologists who want prescription privileges. And they extol the virtues of medication, working with drug companies and sometimes disparaging the value of therapy. Social workers clamor to increase their own pay and to market themselves as “just as good” as psychologists. The effect of all this protecting of parochial interests is to keep the pie shrinking. There is plenty of unmet need for mental health care to keep us all very busy, so we needn’t be worried about running out of patients!

So what’s the alternative? The only way to increase psychology’s slice is to work with other stakeholders to increase the size of the whole pie. We have to collaborate more across disciplines. By banding together to advocate for our substantial common interests and to work with mental health consumer groups and other stakeholders, our impact can be multiplied.

But how to do this? Other attempts have been made and some are still ongoing. There was a Coalition of Mental Health Providers and Consumers, now defunct. There is the American Mental Health Alliance- USA, which picked up where the Coalition left off. But none of these efforts have included the major professional organizations, and none of them have ever really effectively organized and had a substantial national impact.

What is needed is for all the disciplines to really join forces, and form an enduring coalition to advocate for mental health care in general, and to advocate in general that all mental health care is cost-effective and reduces human suffering, something of great value. This would have to be a multi-pronged campaign involving PR, legislative lobbying and social media etc.

All the professional and consumer groups would have to be involved and to commit substantial resources to the effort. They don’t have to give up on their advocacy for their own constituencies, but there is still plenty of room to find areas of common interest.

This is easy to say, but not so easy to make happen. But it’s not impossible. I believe there is a great technology available to create such a campaign, using Future Search. (For more information see www.futuresearch.net.)

Future Search has been used for over 35 years all around the globe to bring disparate stakeholders together to find common ground and effectively organize, plan and act, even in situations where it seems unlikely. It is based on the idea of “getting the whole system in the room,” bringing together all stakeholder groups for a three-day interactive meeting.

In this meeting, participants review the past and take stock of present trends affecting the system; all stakeholders see the whole system, not just their own “silo.” Only then can creative visions of the future be seen and effective realistic planning take place. The whole effort is focused on finding common ground for the future, not resolving differences based in the past.

In order for an effort like this to occur, there has to be willingness among leaders of the different professions to put aside narrow parochial interests, to have the attitude that no one wins unless we all win and to realize that competing with one another for an ever-shrinking pie just accelerates the shrinking.

It’s so sad to see the field “shoot itself in the foot” repeatedly. But it doesn’t have to be that way.

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