ACA less friendly to psychologists than expected

By Dana Beezley-Smith, Ph.D.
May 31, 2019

Affordable Care Act Mental HealthWith the Affordable Care Act’s implementation in 2014, many mental health providers rejoiced. Improved parity protections and mental health/substance abuse (MHSA) coverage would benefit 62 million Americans, federal officials said.

John Grohol, Psy.D., founder and CEO of PsychCentral, expressed hope. “With more people obtaining either private insurance or joining an expanded Medicaid program, the bet is that more people will have inexpensive access to mental health treatment… including psychotherapy and medications.”

Yet as the nation is challenged by surges in opioid addiction, anxiety, major depressive disorder and suicide, especially among the young, patients are struggling to access treatment, reports Kaiser Health News. The APA says 11.8 million American adults had unmet needs for mental healthcare in 2016, 38 percent because of expense.

The ACA will benefit those able to secure care, the Cato Institute’s Michael Tanner predicted in 2014, and harm “the general population of those seeking treatment.” Demand for care will outstrip supply, he said, and cause price increases.

MHSA spending from all public and private sources totaled $171.7 billion in 2009, reached $201 billion in 2013, and by 2020 is expected to equal $280.5 billion.

In its Access to Care Data-2018 publication, Mental Health America (MHA) says 56.4 percent of mentally ill adults are receiving no treatment and 20.6 percent are unable to locate care. The nonprofit cites high costs and inadequate insurance coverage as barriers.

By far the ACA’s greatest coverage increases occurred through expansion of the Medicaid program, which now oversees care for one-fifth of the nation. Attention to the Medicaid population is considered an important feature of the ACA, since many low-income individuals have untreated and expensive medical conditions.

As the single largest MHSA payer, Medicaid finances more generous coverage than most commercial insurers, and enrollees are more likely to receive MHSA treatment than those with private insurance. According to Healthcare Dive newsletter, more than 30 percent of depressed adult patients with managed Medicaid receive both psychotherapy and medication, a percentage almost 10 points higher than that for privately insured individuals.

Citing the program’s rich benefits, Washington Post columnist Paige Winfield Cunningham says, “Democrats should be talking about Medicaid-for-all instead of Medicare-for-all.”

Private insurance remains costly for many people, notes MHA, and managed care organizations (MCOs) tend to direct care to those in greatest distress. “Under these circumstances severe mental illnesses receive more coverage, possibly deterring individuals from seeking help until they have reached a point of crisis.”

Other obstacles are steep deductibles, narrow provider networks and stiff penalties for patients utilizing out-of-network care. MHSA providers face preauthorization requirements, medical necessity and pre-payment audits, stagnant or reduced reimbursements and restrictions on session length and frequency.

Some believe MCOs are violating federal parity law. State regulators and multiple lawsuits have targeted Kaiser Permanente, regarded by ACA architects as the model for health systems, for deficient MHSA care. The large MCO recently settled a suit alleging that it urged severely mentally ill inpatients to cancel Kaiser insurance plans so they could be transferred elsewhere.

The ACA was never intended to expand access to the type of private outpatient psychotherapy Americans have come to expect. In fact some 2014 analysts predicted that independent psychotherapy providers would be forced to shutter their businesses.

“It won’t happen right away, but private practice will essentially be a thing of the past,” said former APA president Nick Cummings. “Ninety-five percent of practitioners will be on salary.”

“ ‘Mom and pop’ operations are going to be gone,” claimed Ron Manderscheid, director of the National Association of County Behavioral Health and Development Disability Directors. “I expect a lot of behavioral health entities to disappear.”

University of Nebraska Omaha psychology professor Robert Woody, Ph.D., JD, told his 2014 APA convention audience that independent psychological practice would soon cease to exist.

And in 2015, Peg Richards Mosher, Ph.D., then-president of the Ohio Psychological Association, told members that the practice of traditional outpatient psychology “will likely work for another five years, give or take.”

The ACA calls for a redistribution of MHSA resources, with a change in emphasis from care of the individual to “population management” and “an inch deep and mile wide” approach.

The country doesn’t have the workforce to meet specialty demands, claimed Michael Miller, MD, medical director of Wisconsin’s Herrington Recovery Center.

In its goal of shifting from fee-for-service reimbursement to performance-based payments, the ACA also mandates expensive infrastructures for electronic referrals, data-sharing, data-analytics and proof of treatment quality and effectiveness.

Psychologists are advised to join medical practices, hospital systems, large behavioral health entities and public clinics. To improve patients’ health and reduce costs, these settings offer fast-paced brief and group counseling, psychoeducation, motivational interviewing and “curbside consults.” Psychotherapy is to be reserved for complex cases, say experts.

“It’s not going to be our world – it’s going to be a medical world,” Woody told psychologists.

Insurer scrutiny under the ACA will make psychology practice harder to sustain, said panelists in a seminar sponsored by The Trust. They suggested that those who offer cash-only services will appeal to patients concerned about privacy and averse to cookbook treatment protocols.

NBC’s Better website describes options for Americans who can’t afford MHSA treatment: local social services agencies, federally qualified health centers, academic hospitals, college health centers (for students), psychoanalytic training institutes, telemental health providers and third-party-free practices, some of which offer reduced or income-based fees.

Smartphone apps and computer-based cognitive behavioral therapies, self-driven or provider-assisted, are also being promoted as alternatives to traditional psychotherapy.

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Dana Beezley-Smith, Ph.D., is in private practice serving children, adults and families in Green, Ohio. Her email is:

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