Psychotherapy Finances

As an addendum to an upcoming article in Psychotherapy Finances about Medicaid, we recently spoke with Roger Smith, a senior attorney for the American Association of Marriage and Family Therapists (AAMFT). Smith tells us that 38 states allow MFTs to work with Medicaid patients “in some capacity.” So we would expect the discipline to benefit from the additional 16 million Medicaid patients who may be added to the rolls under the new health care reform law.

Some of these states allow MFTs to see Medicaid patients in private practice, while others require them to be seen in a clinic setting, according to Smith. (MFTs have been lobbying the feds to treat Medicare patients, but their efforts have fallen short so far.)

But Smith is hopeful that the Medicaid expansion could spur changes on the state level to allow more MFT participation. The remaining 12 states, for example, may need additional providers.

The problem is, as Smith points out, MFTs aren’t all that eager to see Medicaid clients with rates as low as $35 per session. And analysts for other provider organizations have told us that budget-squeezed states might actually try to cut rates further, despite an infusion of federal Medicaid money.

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In California, average MFT income is down 6% from 2008, according to a survey by the California Association of Marriage and Family Therapists (CAMFT). That’s $55,890 to $52,886. The survey was quoted by the online publication, MFT Progress Notes on August. 16.

Over the last eight years, MFT incomes in California have risen only slightly from $47,851 to $50,689 among those with master’s degrees. However, those with doctoral degrees have seen their incomes jump from $62,885 in 2004 to $72,165 in 2010.

One caveat: The CAMFT survey was based on a 16% response rate. But that was consistent with past CAMFT surveys, Progress Notes said.

As we’ve noted in past Psychotherapy Finances articles, smoking cessation is a viable niche market for some therapists, particularly those who have relationships with physicians or hospitals.

Now, there may be additional incentives for offering these services after the Obama administration approved therapy sessions for seniors on Medicare who are trying to quit smoking.

That’s not a small market: About 4.5 million Americans 65 and older smoke according to the Department of Health and Human Services. Another 1 million are younger than 65 but eligible for Medicare benefits.

Prior to the announcement this week, seniors could get smoking cessation counseling under Medicare but only if it was part of treatment for an existing tobacco-related illness.

But now Medicare will cover two tobacco-cessation attempts each year – including four individual therapy sessions per try.

“We know that older adults and other Medicare beneficiaries can be successful in their struggles to stop using tobacco, as long as they have the right resources available to them,” Assistant Secretary of Health Howard Koh said in an annoucement Wednesday. “Today’s decision will assure that beneficiaries can access that help from qualified physicians and other Medicare-recognized practitioners.”

The change is part of the administration’s new emphasis on preventive care. The ideas is that dollars spent now will result in savings later – something that makes a lot of sense when it comes to smoking.

Tobacco use causes about one of five deaths in the U.S. annually, The U.S. Centers for Disease Control and Prevention says. On average, adult tobacco users die 14 years earlier than non-users.

Tobacco-related illnesses will cost Medicare about $800 billion between 1995 and 2015, According to the Centers for Medicare and Medicaid Services.

Anyone in private practice ought to have a website, although we know therapists have been reluctant to take the time and effort. But even if you have no intention of advertising the site on search engines, a website is still important for potential clients who have heard about you and want to know more.

It could be the difference between making a final choice between seeing your or your competitor down the street.

It’s often difficult to come up with ideas for website content, though, and here’s something all clinicians should at least think about: an introductory video. Nothing – short of meeting you in person during a free initial consultation – helps a potential client make a connection with a therapist.

An article on a website is helpful, but once a visitor clicks on a video, chances are pretty good he or she will follow through and watch the whole thing.

Here are two examples of videos that therapists have put up on the web. The first is very professionally done. It’s by Huffington Post blogger Judith Orloff, a psychiatrist and author of Emotional Freedom: Liberate Yourself From Negative Emotions And Transform Your Life.

In this video she talks specifically about narcissists and how to deal with them in relationships. Orloff is a high-profile clinician, but this shows how getting very specific can produce a video that can “go viral” on the Internet – get spread around through listservs, blogs and other links.

The second is an example of a more modest effort from a counselor in Burnaby, British Columbia. Geoff Ayi-Bonte has put this video up on YouTube and although there are no bells and whistles, it’s a good “get acquainted” effort that has the potential to pay off. The straightforward title is: What is counseling and why should I have it?

By the way, Ayi-Bonte’s website, offers video introductions for all therapists in the office.

Making a video doesn’t require great amounts of skill. A modestly priced video camera that allows you to upload the file to your computer is all you need. To place it on YouTube, here’s the latest video tutorial from the service on how to do it.

It’s a low-priced – but effective – way to promote your practice.

Have you ever Googled a patient’s name? The practice is controversial, with some practitioners believing that it’s unethical. Others say it can provide some valuable insight.

But a study presented at this week’s American Psychological Association convention in San Diego reveals that many graduate students are already doing it. About 22% say they’ve Googled patients for additional information.

A larger percentage – 41% – had Googled their supervisors and 3% said they knew their supervisors had Googled them.

Study author Ashwini Lal, of Argosy University in Chicago, suggested that clinical training should include discussion of online issues. (Only 23% say they had talked about cyber issues at their training sites.)

“We are in this area that’s new, that’s growing – the use of MySpace, Facebook, LinkedIn,” Lal said. “At the same time, we need to be more on top of these things. There should be some discussions of these issues in training, at least in orientation programs.”

The American Psychiatric Association addressed this issue last year and concluded that a Google search may be helpful in supplementing information gleaned from face-to-face interviews with a patient. But this information shouldn’t be taken at face value.

“Googling a patient is not necessarily unethical,” the Psychiatric Association concluded. “However, it should be done only in the interests of promoting the patient’s care and well-being and never to satisfy the curiosity or other needs of the psychiatrist.”

The Clinical Social Work Association also discussed the issue of social media this summer in its newsletter, Access. An article by Keith Myers weighs some of the pros and cons.

As Myers points out, it may be worthwhile to incorporate these cyber issues into your practice policy statements. In particular, your use of Facebook — or a decision not to use Facebook — will be of interest to many clients.

The U.S. District Court decision striking down California’s Proposition 8 gay marriage ban came at just the right time for the American Psychological Association, which is holding its annual convention in San Diego next week and has packed the agenda with programs related to the issue.

APA President Carol Goodheart immediately posted a news release calling the decision “a victory for both science and basic human dignity,” and added: “The American Psychological Association is gratified that the court agreed that there is no justification for denying marriage equality to same-sex couples.

“The research shows that same-sex couples are similar to heterosexual couples in essential ways and that they are as likely as opposite-sex couples to raise mentally healthy, well-adjusted children. There is no scientific justification for denying marriage equality, when research indicates that marriage provides many important benefits.”

The issue is ultimately expected to be addressed by the U.S. Supreme Court.

Some of the programs and research being showcased by the APA at the convention, August 12-15, include: Intersection of Law, Policy and Scholarship in the Gay Rights Debate; In Their Own Voices — Lesbian, Gay, Bisexual and Transgender Activists on Marriage and Gay Rights; Opposing Discriminatory Legislation and Initiatives; and APA’s Role in the Battle for Marriage Equality — Bringing the Research to the Courts.

There’s also an Invited Address on Freedom to Marry, and a Presidential Program: Marriage Equality for Same-Sex Couples: Science and the Legal Debate Part I.

The APA, by the way, has set up a blog dedicated to the convention. Find it at http://apaconvention.typepad.com/2010_apa_convention_blog.

Featured celeb this year will be former first lady Rosalynn Carter, 82, who will talk about a book she’s written on mental health, Within Our Reach: Ending the Mental Health Crisis. It is Carter’s fifth book, her second on mental health.

More than 12% of emergency department (ED) visits were due to a mental health disorder or substance abuse, according to new data released by the U.S. Department of Health and Human Services.

The Agency for Healthcare Research and Quality (AHRQ), an arm of HHS, says almost 12 million emergency room visits fell into one of these two categories, or both, in 2007, the most recent year statistics are available.

Depression and other mood disorders made up 43% within this group, 26% were for anxiety disorders, and 23% were alcohol related. Other mental health related disorders were: drug disorders (17.6 percent); schizophrenia and other psychoses (9.9 percent); and intentional self-harm (6.6 percent).

Also, patients were reported to the ED with these problems were 2-1/2 times more likely to be admitted to the hospital compared with the general ER population.

The most common payers involved were Medicare (30.1%); private insurance (25.7%); uninsured (20.6%) and Medicaid (19.8%).

AHRQ researchers conclude: “Not only is this of concern to members of the mental health community, but also to the members of the emergency medicine community who are concerned that ED overcrowding results in decreased quality of care and increased likelihood of medical error.”

For the full PDF of the report, released in July, click here.

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.