We examined 7 years of non-medical mental health provider reimbursement data from 2007-2013, adjusting for inflation. The results for the most part show a slow decline in psychotherapy reimbursement. However, there are winners and losers. Some—a minority of clinicians–have actually seen an increase in their incomes; most have seen a decline, from a modest 2% to a more significant 8%.
The graphs below have two lines: the actual line (blue) represents the average reimbursement we saw in our data. The expected line (red) is the reimbursement we would have expected if reimbursement had kept up with inflation.
This graphs shows the 5% decline in inflated-adjusted reimbursement for all mental health services, including psychiatric services:
This graph shows a 2% decline in inflation-adjusted reimbursement for all non-medical psychotherapy services (i.e. include 90806 and 90808 for years 2007-2012 and 90834 and 90837 for the year 2013):
This graph shows an 8% reduction in inflation-adjusted 45′ psychotherapy (90806 through 2012 and 90834 in 2013). Some clinicians are now able to substitute 90837, however, many cannot.
This graph shows a 2% reduction in inflation-adjusted non-medical intakes (90801 through 2012 and 90791 in 2013):
The biggest positive in psychotherapy reimbursement is the willingness of some payers to reimburse for 90837. In 2007 the closest equivalent to 90837 was 90808. It was for 75-80′ sessions and was hard to justify, rarely used and very rarely reimbursed. In 2013, 90837 (53′ session mininimum) accounts for fully 28% of all psychotherapy charges. This code is easy to justify, because it approximates closely the standard 50′ session, and widely used. The mean reimbursement for 90837 is $104.26 whereas mean reimbursement for 90834 is $78.41.
Clinicians whose primary payers reimburse for 90837 will obviously be doing better, however, many payers (including most commercial payers) do not reimburse for this code. (Anecdotal evidence suggests that it is the Blue Cross Plans that are most likely to pay for this code.)
The biggest negative in psychotherapy reimbursement is the 8% decline in inflation-adjusted 45′ psychotherapy. Clinicians whose primary payers restrict reimbursement to this code will be significantly affected. The modest decline of 2% for intakes is holding up better than other non-medical codes. It affects all non-medical clinicians, but represents only 7% of total revenue.
While hardly a consolation, it might be borne in mind that since the recession in the US started in 2007, median income for working-age households has fallen by 9.3 percent, after adjusting for inflation. This continues a decade-long downward trend. Against this trend, psychotherapists are faring pretty well.
In order for mental health care to be truly accessible, mental health care needs to break out of the confines of the consulting room. It needs to be available in the community and even in people’s homes. It is startling to remind ourselves that before 1940 most doctor’s visits in America were provided in people’s homes!
One way to accomplish this is via videoconferencing. A new technology WebRTC, has been developed that will make online therapy routine. WebRTC is a breakthrough: it uses only a browser, i.e. involves no plugins, downloads, or installs. What this means is that the clinician sends the patient an email link and the patient simply clicks on it and they are in the virtual consulting room together. But what is truly astounding is the quality of the video and audio: there are no latencies, clinicians detect shifts in tone and expression in a way not possible with legacy technologies such as Skype, Google Talk, Face Time, etc. WebRTC is also HIPAA compliant. Almost all state medicaid programs reimburse for telepsychiatry and most states have either passed or are passing bills requiring reimbursement from commercial payers. (CarePaths will be offering this module to our users in the next month or so.)
WebRTC will extend outreach dramatically, in part because it is convenient. Access to care will be extended to: people who live in rural areas; can’t afford to take time off from work to commute to weekly appointments (the average drive time for a therapy appointment is 45 minutes); don’t have transportation; are unable to leave their homes (agoraphobics etc); fear the stigma of going to a “shrinks” office; etc.
Another way of extending outreach is reaching into the community and providing care where people get care. This means virtual co-location. Currently, almost a third of all Americans live within a ten minute drive of a retail clinic, such as a CVS Minute Clinic, etc. The number of such clinics is expected to double over the next two years and the number of people receiving care will grow exponentially as well. These retail clinics are usually open during holidays, evenings and weekends, meaning increased access to care. These clinics also accept most insurance options, and were designed to be affordable. CVS, for example, now has 800 such clinics, in 28 states and the District of Columbia. Since 2000 when they opened, they have provided more than 18 million patient visits.
Carepaths has proposed a service delivery model, based in part on WebRTC, for such clinics in order to make mental healthcare more accessible. The proposal has three components: 1) a web portal that provides instant access (via tablet, smart phone or computer) to a range of screening instruments–these can be universally administered (built into intake) for all new patients, or selectively administered; 2) telephonic consultation for clinic professionals as needed; and 3) videoconferencing with a virtually available mental health professional via WebRTC.
We have recently made a proposal to the Scattergood Foundation to deploy our model in a retail clinic in Philadelphia. (The Thomas Scattergood Behavioral Health Foundation is a Quaker-based, philanthropic, grant-making foundation focused on improving behavioral healthcare delivered in the Philadelphia region.)
To learn more go to http://www.scattergoodfoundation.org/design-challenge/2014#.UxhfcPldWAg
If you like our proposal, please vote for it as it will help our proposal.