Psychotherapy Finances

Marriage and couples counseling is a cornerstone of many therapy practices. The real question is, how do you carve out your own particular niche within that specialty?

A new book discusses one possible alternative: Marriages that are being wrecked by adult Attention-Deficit Hyperactivity Disorder (ADHD).

Actually, adult ADHD has been getting lots of ink in the press—it’s no longer a term that leaves the public puzzled. At Psychotherapy Finances, we’ve spoken to several therapists who have worked this niche into their practice with good success.

A new book coming out in September, The A.D.H.D. Effect on Marriage, is getting some attention in the commercial media, with a post this week in The New York Times’ Wellness Blog.

The book was written by Ned Hallowell and Melissa Orlov, who offer “marriage consulting” with a focus on understanding how ADHD may be impacting a relationship.

“Typically people don’t realize the ADHD is impacting their marriage because there’s been no talk about this at all,” Orlov told The Times. She says the disorder had been ruining her marriage before she teamed up with Hallowell, a researcher on the subject.

She said her husband was “consistently inconsistent. I could never count on him. It goes from feeling responsible for everything to just chronic anger. I didn’t like the person I’d become either.”

But the couple worked things out and are now happily married, The Times is pleased to report.

By the way, Orlov and Hallowell also publish a blog on this topic if you’re interested in finding out more about what could be a new and trendy niche market.

The potential for violence often looms in a therapy office, particularly when a clinician is working with a patient who has a serious mental illness. Two horrific attacks over the past five years illustrate the threat.

A psychologist was hacked to death in her Upper East Side office in New York two years ago by a man with a meat clever. The killer, who was caught, had come into the office looking for the psychologist’s colleague, a psychiatrist.

In 2005, San Francisco area psychologist Ira Polonsky was shot to death in his office. The masked killer was never found despite a $50,000 reward offered by the governor’s office.

A July 9 Psychiatric Times piece, Safety in the Evaluation of Potentially Violent Patients, outlines a few of the steps clinicians can take to lessen the threat. They include: maintaining a personal “safety zone” of at least four to six feet around you; staying at least two steps away from a patient who looks to be on the offensive; and making sure you have access to an exit door.

In previous Psychotherapy Finances pieces on this topic, clinicians have also recommended making sure there is furniture – such as your desk – between you and the patient.

After the New York murder two years ago, there was renewed discussion of installing panic buttons in therapy offices. But in extreme cases you may want to conduct interviews with the door open or another staff person present.

Statistics from the Crime Victimization Survey conducted by the Department of Justice show that the annual rate of nonfatal crime against psychiatrists was 68.2 per 1,000 people. The rate for all occupations is just 12.6.

Clearly, this is a subject that should be front and center when you’re developing office policies in your private practice. Planning for “what if” scenarios can help you reduce risk.

Psychiatry is the hot medical specialty of the coming decade, according to a July 1 piece in USA Today.

Merritt Hawkins, a national physician recruiting firm, reported receiving 179 requests for psychiatrists, according to the paper. That’s a blowout 121% increase from the firm’s 2006-2007 survey.

Psychiatrists were the third most requested physician after family practice doctors and internists. And the U.S. Bureau of Health Professions is forecasting a 100% rise in demand for psychiatrists by 2020.

But there’s a downside for those who opt for psychiatry, according to those already in the profession: Less income potential. Apparently that’s largely due to the “move-’em-on-through” philosophy of much of the medical profession.

Psychiatry, on the other hand, normally requires more patient contact.

“I get paid more for treating a zit than I get for sitting down for a half an hour talking to a patient,” one psychiatrist grumbled.

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Is mental illness over-diagnosed? A July 6 piece in Psychiatric Times raises the question, and it’s getting attention on mental health web listervs.

One study found that half of the general population qualifies for an anxiety disorder by the age of 32. Forty percent have diagnosable depression, and 30% qualify for alcohol dependence.

In, Normality Is An Endangered Species: Psychiatric Fads and Overdiagnosis, physician author Allen Frances asks: “Imagine what the rates will be like by the time these people hit fifty, or sixty-five, or eighty. In this brave new world of psychiatric overdiagnosis, will anyone get through life without a mental disorder?”

The full article is available at the Psychiatric Times website (free registration required).

The Department of Health and Human Services (HHS) launched its new consumer focused health care website yesterday at www.healthcare.gov. It’s supposed to become a “powerful tool” that consumers will use to find health insurance at competitive prices, as well as clinical information on diseases and prevention.

Of interest to private practitioners is this line in the news release that was published yesterday with the launch of the site: “The website will connect consumers to quality rankings for local health care providers as well as preventive services.”

Does this mean the new Healthcare.gov site will have a data base of practitioners ranked by consumers that can be accessed by prospective patients? I called HHS but a spokesman said he was swamped and didn’t have the details yet.

Second day of the launch and all that, and the site already contains 500 pages of content. That’s a lot of material to wade through—and right on the brink of a holiday weekend. (And such nice weather in Washington, too.)

So stay tuned.

One thing the site will have – eventually – is comparison prices for health care plans. This, we’ve been told, has irritated health insurance officials since some of their plans are closed but they were required to provide information to the feds anyway.

Naturally, everyone is on Twitter these days and HealthCare.gov is no exception. In the wee hours after the open, www.twitter.com/@healthcare.gov had just 11 followers, 0 followers and no tweets.

By this morning, there were 840 following, the site was following 12, and they’d posted two tweets.

Related: Speaking of social media, if you’re a TRICARE provider you can now receive updates about the military health benefits programs from Facebook and Twitter.

Find them at: www.facebook.com/tricare and www.twitter.com/tricare.

Therapists are still struggling with online social networking issues, in particular how to handle friend requests” on Facebook. We posted an item on this topic in April, referring to a Washington Post article that assessed the position of professional associations on social networking.

The topic comes up again in the new issue of Access, the newsletter of the Clinical Social Work Association. In his Clinical Focus column, LCSW Keith Myers writes what is essentially a good primer for therapists just thinking about getting into the Facebook/ Linked-in networks. It’s not a “how-to,” though.

In Social Media and Psychotherapy – Beginning in the Middle of the Conversation, Myers weighs the clinical, ethical and legal concerns surrounding Facebook.

If you’re looking to develop a policy for your practice regarding online networking, Myers refers readers to Keely Kolmes, a San Francisco psychologist who has a Website, blog (Mindful Musings) and social media policy.

She addresses “friending” and “fanning” (becoming a “fan” of a person or organization), following on Twitter and her policy on using search engines to Google clients.

Eventually, professional associations will doubtless recommend policies on these issues; for now you’ll have to check out what other therapists are doing and adjust your practice as you deem necessary.

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ValueOptions has introduced online re-credentialing. For details, check the new issue of the company’s newsletter, The Valued Provider.

Public relations has not been the strong suit of health insurers this year. As health care reform was being debated, for example, some companies announced double-digit premium increases.

And WellPoint was the target of scathing criticism in April when a Reuters report accused the company of canceling the policies of women diagnosed with breast cancer. Scrambling to counter the bad publicity, WellPoint announced on May 26 that it was “unilaterally” implementing the federal Breast Cancer Protection Act, which hasn’t even been passed by Congress yet.

Now comes an effort by UnitedHealth Group, one of the nation’s largest insurers and parent company of United Behavioral Health – the largest behavioral managed care organization in the country, surpassing Magellan Health Services. UHG announced last week that it had named a new “vice president of social responsibility.”

Kate Rubin will also become executive director of the United Health Foundation, with a budget of $55 million in 2009.

Speaking of social responsibility, CIGNA Health has this to say on its Website: “CIGNA is one of the fore-runners of displaying corporate social responsibility. CIGNA not only makes monetary donations, but donates water and time to individuals around the globe.

“CIGNA has worked to transform their business to become environmentally friendly. The company conducts most business online to avoid the use of paper and recycles four million pounds of paper every year.”

All of which is bound to make you feel warm and fuzzy about health insurance companies, right?

By the way, look for insurers to become increasingly competitive in the Medicaid market, both in terms of medical services and behavioral health. That’s because a major prong of the health care reform law will be increasing Medicaid rolls throughout the 50 states (using federal money).

Magellan’s First Health Services, which targets the Medicaid market, is changing its name to Magellan Medicaid Administration on July 1. Coincidence? Perhaps not.

The APA’s Monitor on Psychology has a lengthy piece this month on the health care reform law and declares: “The landmark legislation offers new opportunity for psychology.”

The APA likes the overall tone of the law and the idea of expanding health care to 32 million people.

More specifically, leaders are applauding the law’s $10 million set aside for doctoral, internship and postdoctoral training. That would triple the size of existing programs for psychologists.

And health care reform extends a 5% Medicare psychotherapy payment restoration through the end of 2010, retroactive to Jan. 1. The cuts had been scheduled for 2007, 2008 and 2009, but psychologists have convinced Congress to delay them each time. This is yet another reprieve.

APA President Carol Goodheart predicts: “There’s going to be increased demand for mental health services under the new law.”

But the National Conference of State Legislatures has an interesting juxtaposition to The Monitor’s celebratory article, which you can read by clicking here.

The NCSL June 5 report points out how widespread the opposition is at the state level to the reform law. At this point, things appear to be chaotic.

“Members of at least 39 state legislatures have proposed legislation to limit, alter or oppose selected state or federal actions, including single-payer provisions and mandates that would require purchase of insurance,” according to the organization.

Attorneys general in 20 states have also mounted legal challenges to the constitutionality of health care reform, as passed and signed by President Obama.

State legislators are confused about how the law will be implemented. The NCSL says lawmakers are scrambling this summer to come up with a game plan—and not all is going smoothly.

Peggy Welch, an Indiana state rep, says nevertheless states need to push ahead even while legal challenges continue.

“We are overwhelmed, but so are the feds,” she says.

Primary care physicians have steadily drained business away from behavioral health care providers over the years by prescribing – often without evaluation by a mental health professional – pharmaceuticals to their patients suffering from depression, anxiety and other disorders.

This trend has been maintained despite evidence that a combination of talk therapy and medication is often most effective for mental health treatment.

Now, The National Alliance of Professional Psychology Providers (NAPPP) has hired a Washington, DC public relations company to help make a case that physicians should not be able to provide behavioral health services unless “they can specifically demonstrate that they have had and passed the requisite education, training, supervision, and testing.”

That’s according to John Caccavale, one of the NAPPP founders, writing in the organization’s June issue of The Clinical Practitioner newsletter.

“Most primary care physicians, while well meaning, simply do not have the skills or training to evaluate and diagnose serious behavioral disorders,” Caccavale said. “As a result, patients are not receiving the appropriate standard of care that they require and healthcare resources are being misused and squandered.”

There are no limits to a physician’s scope of practice, and that’s wrong, NAPPP argues. “There is a fairly simple remedy: Medical licensure boards should subject physicians to the same limited licensing that every other healthcare professional provides services under,” said Caccavale.

NAPPP hired the firm M+R Strategic Services to orchestrate “a campaign to educate the public” about the issue and “to require physicians to obtain an evaluation and appropriate diagnosis before medications are prescribed.”

But can the ant really move the rubber tree plant? The American Medical Association has one of the most powerful lobbies in the country, and any effort to tinker with physicians’ scope of practice would have to clear some very heavy political machinery.

M+R specializes in “grassroots mobilization,” as well as direct lobbying. “We work with clients to employ creative staging tactics – rolling out a series of events, media tours or other activities around the country (and on the Internet) – in order to build toward bigger events in the country’s major media markets,” according to company’s promotional material.

One of their recent clients was the American Civil Liberties Union (ACLU) in 2007, “a time when the fundamental freedoms that the organization protects were under attack by the Bush Administration.

“M+R helped plan and promote a national ‘Day of Action to Restore Law and Justice’ to raise awareness of the situation within the Democratic Congress and pressure them to act.”

But scope of practice isn’t exactly a hot button issue with the American public, and it will be interesting to see what a Washington lobbyist does with it.

A new report on salaries for social workers published on Huffington Post has the National Association of Social Workers (NASW) – and the profession in general – riled up.

The data was presented under the title, The WORST-PAYING college degrees, and was based on an analysis by PayScale.

“The quest for social welfare doesn’t pay much, even if you commit to it for the long haul,” Huffington Post said. “Average starting salary is just over $33,000, and the average mid-career salary barely tops $40,000.”

The NASW responded that PayScale “limited its data collection to social workers with bachelor’s degrees…” and added: “Those median salary levels are below those in a new National Association of Social Workers Compensation Study, which includes data from social workers with master’s degrees. That study puts the median annual salary for all social workers at $55,000 a year.

“Social workers with less than five years experience earn a median annual salary of $43,700; those with 10- 19 years of experience earn a median annual salary of $52,000; and those with 20 -29 years of experience earn a median annual salary of $60,000, according to the NASW study.”

An Adobe Acrobat (PDF) summary of the study is available by clicking here.

One writer on Huffington Post responded to the PayScale report: “This article is 100% correct. SW are the worst paid professionals. Many in the field continue to maintain this fixed delusion system they operate on re: salaries. Please spare me the BS!

“Why doesn’t the NASW send out a mass mailing questionnaire as to how many SW/LCSW are stressed/burned out because: 1) they can barely meet living expenses, 2) pay their NASW dues, 3) declare or on the verge of bankruptcy, 4) barely pay (if that) student loans, 5) drive 10 yr old cars that are barely maintained, 6) share living accommodations with others or 7) work 2 jobs cause they can’t manage a family with their SW salary. Why? NASW represents 155K SW and not once have they addressed this with all their members.”

On the Social Workers Facebook page, the topic drew 43 comments. A few samples:

* “I went into the field knowing I would not make millions. I wanted to make a difference.”

* “[Social workers] with licsws need to be paid and considered at the same status level as doctors.”

* “The Huffington Post article was a little odd to me. I assume the starting salaries for BA’s in sociology or psychology are also not very high. I think psychology, sociology and social work are the kind of majors you go into knowing that grad school is in your future.”

More kids than ever are taking prescription medications on a regular basis, while the use of behavioral drug treatments is skyrocketing in young adults, according to a report released this week by Medco Health Solutions, a pharmaceutical benefits manager.

Overall prescription drug spending for children jumped 10.8% in 2009, a figure that includes both higher utilization and higher prices. It was four times the rise seen in the general population.

One in four insured children and 30% of adolescents took at least one medication to treat a chronic condition last year.

The most substantial increases were seen in the use of antipsychotic, diabetes and asthma drugs over the past nine years, Medco said in a news release on Thursday.

“While H1N1 caused a spike in antiviral use among children last year, the far more alarming trend since the beginning of the decade is the increasing use of medications taken by children on a regular basis and in some cases, for conditions that we don’t often associate with youth, such as type 2 diabetes,” said Dr. Robert Epstein, Medco’s chief medical officer and president of the Medco Research Institute.

“The fact that one-in-three adolescents are being treated for a chronic condition points to the need for additional health education and lifestyle changes that can address the obesity issue that is likely a driving force behind such conditions as type 2 diabetes and even asthma.”

Behavioral drug treatments continued to rise in children, with 13.2% of drug benefit dollars spent on medication for ADHD. But young adults age 20-34 saw the biggest jump — 21.2% in the use of behavioral medications.

“Atypical antipsychotics are extremely powerful drugs that are being used far too commonly - especially in children - given their safety issues and side effects,” said Dr. David Muzina, a specialist in mood disorders and national practice leader of the Medco Therapeutic Resource Center for Neuroscience.

“We’re seeing them prescribed for a number of different conditions including depression and anxiety for which there is not good evidence that they are an effective treatment and yet we’re exposing children to the possibility of extreme weight gain that could lead to a host of health problems including diabetes.”

To download the full version of the 2010 Drug Trend Report, click here.