State Leadership Conference

When a baby entered the neonatal intensive care unit in the St. Charles Health System in Bend, Ore., the infant weighed just 2 pounds, 12 ounces. Such a small patient comes with a huge price tag: A baby in the NICU can cost Medicaid as much as $10,000 a day. But because the facility employed a psychologist who worked to promote the family's resilience, the baby went home much sooner than NICU babies usually do, saving Medicaid $40,000 to $50,000, estimated Robin Henderson, PsyD, director of government affairs for the health system. The psychologist's services cost less than $500, she said.

Top: Dr. Arthur C. Evans Jr., commissioner of Philadelphia’s Department of Behavioral Health and Intellectual disAbility Services. Bottom: Speakers at the State Leadership Conference:(left to right) Dr. Stephen R. Gillaspy, of the University of Oklahoma Health Sciences Center, Shirley Higuchi, of APA’s Practice Directorate, Dr. Arthur C. Evans Jr., of Philadelphia’s Department of Behavioral Health and Intellectual disAbility Services, and Dr. Robin Henderson, of the Central Oregon Health Council.Despite such success stories, there are often barriers to psychologists' participation in Medicaid, Henderson and others told participants at the State Leadership Conference in March. But with health-care reform set to open the Medicaid rolls to 16 million more consumers, psychologists must find ways to expand their participation and get consumers the help they need.

"We sometimes talk about Medicaid as if it's a monolithic program," said Arthur C. Evans Jr., PhD, commissioner of Philadelphia's Department of Behavioral Health and Intellectual disAbility Services. "But if you've seen one Medicaid program, you've seen one Medicaid program."

That's because Medicaid is a partnership between states and the federal government. While all must cover a basic package of services, states can also offer optional services or get approval to waive rules, Evans said. Scope of practice can differ, meaning that psychologists may be able to offer services in one state that their counterparts in another state cannot. And payment structures and rates vary tremendously.

Part of the problem is how policymakers view psychologists, said Evans. "In the policy world, psychologists are often viewed as therapists who cost a lot of money or doctors who can't prescribe," he said.

Medicaid's coming expansion gives psychologists a chance to change those perceptions, especially if they go beyond psychotherapy, said Evans. For example, psychologists can help in the push for greater accountability and the trend toward pay-for-performance by offering their measurement and data analysis skills. "It's a very powerful way to shape provider behavior," said Evans, explaining that health systems need a lot of help with this kind of work.

Psychologists are already helping to improve care and lower Medicaid costs in central Oregon. In 2009, Henderson and others began experimenting with ways to achieve better health, better care and lower cost. They first placed psychologists in primary-care clinics, then lobbied to get legislation passed in 2011 to create the Central Oregon Health Council. The council oversees the region's coordinated care organization, an umbrella group of hospitals and providers all working together to improve residents' health.

"Coordinated care organizations are based on principles psychologists know and love, such as the idea that mind and body are connected," said Henderson, who also serves as the council's executive director. In contrast, many Medicaid plans have behavioral health carve-outs that break that connection. Today, Henderson and her colleagues are working on more than 40 transformation initiatives, including 17 pay-for-performance measures. Goals include integrating behavioral health into primary care and advancing patient-centered primary-care homes. "Primary care is the mental health home of the future," said Henderson. "Primary care is where we need to be."

In other states, psychologists are finding different ways to improve Medicaid beneficiaries' access to care. In Oklahoma, for instance, Stephen R. Gillaspy, PhD, and others have successfully fought to obtain Medicaid reimbursement for health and behavior assessment and intervention billing codes, which cover behavioral services provided to patients with physical health problems.

While Medicare and most private insurance companies now accept health and behavior codes, "the last big challenge is Medicaid," said Gillaspy, an associate professor of pediatrics at the University of Oklahoma Health Sciences Center. It took five years for Gillaspy and others to convince the state Medicaid agency to begin reimbursing for the codes in 2010. Patients' access to needed services was the key selling point, said Gillaspy.

Another achievement was persuading the Medicaid agency to allow psychology interns and fellows to get Medicaid reimbursement for services provided under supervision, just like medical residents and fellows and master's-level trainees.

"There's a lack of providers out there," said Gillaspy. "If [health-care authorities are] interested in having more psychologists treat patients, this is one way to do that."

Rebecca A. Clay is a writer in Washington, D.C.