State Leadership Conference

Medicaid's expansion under the Patient Protection and Affordable Care Act represents a huge opportunity for health-care providers. But will psychologists be able to take full advantage of that opportunity? Not until certain barriers are removed, said speakers at the 2012 State Leadership Conference.

Health-care reform is expected to bring 16 million more Americans into the Medicaid system, said Carrie Valiant, JD, a partner at Epstein Becker Green in Washington, D.C. Medicaid is already the country's single biggest payer for mental health services.

"But just because mental health services will expand doesn't necessarily mean that psychologist services will be covered," warned Valiant, whose research on behalf of APA's Practice Directorate has uncovered several impediments to psychologists' participation.

One barrier is the fact that most states don't cover health and behavior codes, which focus on behavioral aspects of medical conditions. Of the five states Valiant reviewed, only Maryland covers such codes. In addition, states don't uniformly reimburse psychologists for psychotherapy services. States also aren't required to cover telehealth, which could help fill the gap between already-overloaded programs and an expanded Medicaid population. And while reimbursement rates in some states aren't as low as some believe, low rates can keep psychologists from participating in Medicaid.

Despite these barriers, Medicaid's expansion also brings plenty of opportunities. Fifteen states have received funding to create demonstration projects designed to improve coordination of care for so-called "dual-eligibles" who have both Medicare and Medicaid coverage. "There's a big opportunity for psychologists to shape what the future of that may look like," said Valiant. Another opportunity lies in a demonstration project designed to provide health homes for people with heart disease, diabetes, mental health conditions, obesity and other chronic disorders, some of which will be based in mental health rather than primary care. Health-care reform also includes provisions aimed at increasing the supply of mental health professionals.

Maryland already has such generous Medicaid coverage for psychological services that the state could serve as a template for others, suggested Paul Berman, PhD, professional affairs officer of the Maryland Psychological Association. And thanks to health-care reform, he said, the number of people in the state's medical assistance program and state insurance exchange will more than double. The exchange will cover individuals who make up to 400 percent of the poverty level. For a family of three, that means coverage for those making up to $76,000; the median income in Maryland is $70,000.

"Anyone who thinks we're just blowing smoke when we're talking about opportunities is missing what's real here," said Berman.

Currently, most Maryland private practitioners don't participate in Medicaid. But the huge influx of middle- and working-class residents into the system may make participation more attractive to them, Berman said. "It's really not just because of the low rates being paid," he said, explaining that the state's reimbursement rate is on par with that of commercial carriers. Instead, it's the no-show rate among traditional Medicaid beneficiaries that's the problem. "As higher incomes are eligible to move into medical assistance and the exchange, then the percentage of no shows will be the same as in standard outpatient practice," Berman predicted.

These newly covered individuals will also have more moderate mental health and substance abuse disorders than the traditional Medicaid population, predicted Brian Hepburn, MD, executive director of the Maryland Mental Hygiene Administration. "Twenty years ago, we were dealing with the severely mentally ill," said Hepburn. With health-care reform's emphasis on prevention, he said, states now have to focus on everyone.

Maryland has committed itself to being No. 1 in the country for health-care reform, Hepburn said. The state is streamlining regulations, re-examining its Medicaid mental health carve-out and studying such issues as housing and employment that keep individuals with behavioral health problems from recovering if they're not addressed.

Psychologists need to be involved in every aspect of health-care reform, Hepburn said.

"There's so much that needs to be accomplished—we're small players," he said. "It's very important for psychologists to be involved in planning ... so that people with behavioral health needs continue to get those needs met and aren't left behind."

—R.A. Clay