Health Care Reform: A Work in Progress

The Aware Advocate – SPECIAL EDITION

 Health Care Reform: A Work In Progress

4/2/09

Laura Groshong, LICSW, Director, Government Relations

      Last week I spent three days in Washington D.C. discussing health care reform in a variety of arenas including meetings with NASW; a small group sponsored by the Center for American Progress with Sen. Max Baucus (D-MT), Paul Begala, and Norman Ornstein; the Kennedy “Workhorse” group studying recommendations for health care reform; and the National Academies of Practice Forum with presenters from private and public system who have begun implementing coordinated care systems.  Coordinated care is likely to be a key element of changes to health care delivery, one reason the electronic medical record is so crucial to the changes being proposed.  Without electronic records, the coordination of care needed will be much more difficult to implement.  It may be that new clinics emerge which include all medical and mental health services, or contract with providers to provide a virtual clinic including all health care services.

       As for the impact this will have on licensed clinical social workers, the discussions I was privy to reminded me of a talk given by Rep. Jim McDermott (D-WA) at an NMCOP Conference in Seattle in 1997.  Congressman McDermott, a former psychiatrist, was somewhat irritated by the way that the Conference focused on the work of clinical social workers without considering how our work could be integrated with the whole range of mental health and health care services.  In retrospect, his message was very prescient, as this is precisely what is being proposed in different ways now.  Licensed clinical social workers who work with third payers may have more responsibility for communicating other providers than they do now, may be working in new environments besides mental health agencies or private practice, may have new challenges in terms of reimbursement, but may also have new opportunities for clinical practice.

       There is a deadline for implementing health care reform, a fact which is not well known.  A plan must be given to the President by August 1, 2009 to move forward.  That is warp speed for changes of this magnitude and may scuttle the process.  The chances of another opportunity arising soon are slim.

 Background on Health Care Reform

       Cost is the driver of health care delivery reform.  Unless a change produces cost savings, it is unlikely to be implemented.  The causes of increased costs are 1) increasing levels of the uninsured receiving the most expensive care, i.e., in emergency rooms; 2) duplication of health care services and/or omission of needed health care services; 3) lack of coordination among health care providers leading to duplicated and/or omitted services, 4) use of extreme measures for beginning of life or end of life care; 5) businesses that have low co-pays and/or high levels of insurance coverage; 6) and 7) increasingly high salaries for insurance executives and administrators.   All changes will be designed to address the expense of these areas.   

      One of the main points in a New Yorker article on health care reform (Gawande, Atul. “Getting There from Here: How Should Obama Reform Health Care?”, The New Yorker, January 26, 2009) was that each national health care system has grown out of the health delivery systems that were in place in each country and specific conditions which existed at the time of implementation.  For the US, that would mean building on our Medicare and Medicaid programs, i.e., possibly making Medicare available for the uninsured down to age 50-55 (with increased premiums for younger enrollees), and making Medicaid available to those who earn up to 150-200% of the poverty level, instead of the current 100% (some states have already covered at this level and above; the recession make eliminate some of this state funding).   In addition, covering all those who are eligible for Medicaid is a likely goal – at this time only about 50% of those who are eligible are covered (Anne Gauthier, The Commonwealth Fund, “Achieving a High Performance Health System”, NAP Forum.)

     What seems unlikely at this time, according to all the legislators and analysts I spoke with, is the implementation of a ‘single payer’ health care delivery system.  This would require the removal of the private insurance market, a change that would be highly difficult to implement, and one that President Obama has explicitly said he would not support.  Though this type of system is appealing, in the same way that a ‘flat tax’ system is appealing, i.e., it is ‘fair’ in that it gives everyone basic health care, there are other ways to move toward meeting this goal.  If Medicare and Medicaid are expanded, the uninsured will become a much smaller group.  Finding ways to integrate the public and private health care systems, as Germany and France have done successfully,  and provide more communication within and across these systems, seems more realistic at this time.

 Health Care Delivery Paradigm Changes

     In line with more coordination of care by health care providers, the ‘bundling’ of Medicare services is a possibility being explored.  This could impact the delivery of services in private insurance as well.  As you probably know, ‘bundling’ for cost saving was used in Skilled Nursing Facilities in 1997 and resulted in the inability of clinical social workers to independently charge for services in Medicare Part A. This was due to a misunderstanding of the clinical social work scope of practice, which is still being clarified. The Congressional Budget Office is developing a report on the financial impact of bundling all health care services, including the services of psychologists and psychiatrists.  A report to the Senate Finance Committee last September by the Medicare Payment Advisory Commission discussed this possibility:

“The health care delivery system we see today is not a true system: care coordination is rare, specialist care is favored over primary care, quality of care is often poor, and costs are high and increasing at an unsustainable rate.  Part of the problem is that the Medicare’s fee-for-service (FFS) payment systems create separate payment “silos” (e.g., inpatient, physician).  They do not encourage coordination among providers within each silo or among different types of providers across payment silos.  We must now move beyond those limitations – creating new payment systems that will encourage providers to change how they interact with each other.  Providers need to increase care coordination and be jointly accountable for quality and resource use.  The objective is a delivery system that is focused on the beneficiary, improves quality, and controls spending. (Report to the Congress: Reforming the Delivery System, September 16, 2008, Statement of Mark Miller, Executive Director, Medicare Payment Advisory Commission, to U.S. Senate Finance Committee,  http://www.medpac.gov/documents/20080916_Sen%20Fin_testimony%20final.pdf)  

      The removal of “silos” in health care, and fundamentally changing the fee-for-service system, was also a major topic at the National Academies of Practice Forum which I attended on March 27.  The impact of these changes on clinical social work practice could be a return to the principles of ‘person-in-situation’ casework; reimbursement may depend on coordination of care with other health care providers. 

       Electronic health records seem to be a given within the next 2-4 years.  CSWA is committed to maintaining the privacy of our patient records as much as possible within this new framework.  This new form of record keeping can also be seen as symbolic of the sea-change in the way providers interact with each other.  More coordination of care and understanding of overall care are likely to break down the silos that have created the unsustainable way health care is now delivered.  This may require a change in the way that clinical social workers and other clinicians have customarily provided treatment, i.e., coordinating with physicians or ARNPs who provide medication, but not with other health care providers as a rule.

 Examples of New Health Care Systems

     The minimizing of costs and increased positive outcomes by coordination of care in hospitals, clinics, and home care are substantial, according to some early reports.  One example was presented by Marie DiCowden, Ph.D., Executive Director of Biscayne Institutes in Florida, which has shown substantial lowering of health care costs by using an integrated system of care, including mental health care.  Thomas Edes, M.D., Director of the Home and Community-Based Care for the Veterans Administration, also showed significant savings by treating the physical and mental health needs of veterans in their homes whenever possible.  The somewhat disturbing part of these presentations is that they viewed clinical social workers as serving casework functions, not providing treatment services, though they both valued the coordination skills of the social workers they used highly.  The education of health care providers and administrators about the training and skills of licensed clinical social workers is still a work in progress.

      This new coordinated care paradigm is also being discussed in terms of “medical homes” or an identified provider who is responsible for coordinating and ‘housing’ all the records of a given patient.  The way that all providers for a given patient will communicate if they are not in the same location, or how treatment decisions will be jointly made, is not yet clear.  Some clinicians prefer to see this new paradigm as “health homes”, in which all participants would have the right to make treatment decisions within their scope of practice. The lack of knowledge about other health care professionals’ scopes of practice is a handicap which contributes to the “silo-ing” of health care and increased costs.  As an aside, the move to clinic-based care may help clinical social workers with the increasingly difficult billing problems which take more and more time.  Having administrators who handle this chore would be a big advantage.

 Mental Health Benefits

       It seems likely that the benefits available in whatever health care reform system is implemented will include some coverage of psychotherapy, very likely with a cap on outpatient sessions, through a more integrated form of private and public systems. With a form of mental health parity established at the Federal level and in the majority of states, the chances that psychotherapy will be included in basic benefits are good.  The ‘floor’ for these benefits will be a matter of some debate in all areas of health care.  My view is that a realistic goal would be a ‘floor’ of 25-30 outpatient sessions a year.  Additionally, a more long-term goal would be the inclusion of coverage for V codes and Axis II codes on a regular basis.  As noted above, it is likely that LCSWs will need to demonstrate coordination with other mental health and health care providers for third-party reimbursement in public or private systems.

 Reimbursement

        The reimbursement levels for clinicians will be based on current practices, i.e., co-pays, in-network and out-of-network providers, and the fee structure of private insurers, often based on Medicare rates.  Equal pay for equal codes is a major goal for CSWA, and one that we will likely need more time to reach than the next few months. The continuing decline in payment for outpatient psychotherapy will likely be halted as a floor for services is combined with a floor for fees.  Finally, it is likely that there will be a group of LCSWs who will continue to work independently from the third-party systems, and that they will be able to charge higher fees than LCSWs who work within these systems do.

 Miscellaneous Factors Being Considered

      Though it may not be called rationing, the limitations on coverage of mental health treatment that exist, and those which are to come, can best be understood as a form of rationing.  The current cost of our health care system is unsustainable and will have to be cut back, though the ‘floor’ for outpatient mental health treatment may be higher than many insurers currently allow.  Additionally, outcomes may be assessed on the provider’s ability to demonstrate positive results and there may be a ‘pay for performance’ component to new systems, the reward for positive outcomes.

      There are debates going on about what level of subsidization should be implemented for private insurers who take on some of the Medicaid market; whether there should be “age rating” so that the healthiest groups share the burden of cost for the sickest groups; how to develop different ‘packages’ for different parts of the Medicaid market; and how to address patients who show poor self-care, i.e., use of tobacco, overuse of alcohol, obesity, etc., by behaving in ways that create health problems.

       The exponential rise in diabetes was mentioned several times in the discussions I heard as a major problem.  This condition has so many other problems that go with it including ulcers, high blood pressure, feet and leg problems, etc., that it is almost the bellwether condition for what we face as our population ages.  It made me wonder about the possible mental health components of diabetes, e.g., depression and anxiety, for example.

 Summary

      In a moment of dark humor, Norman Ornstein made the comment at the Center for American Progress Forum that instead of trying to prolong life and pay for the increased medical care that comes with aging, “Maybe we should give everyone a bunch of cigarettes and red meat at 65.” (He is somewhat beyond that age.)  The problems in changing our health care system and the place that LCSWs have in this system, are daunting.  

     It seems likely that many LCSWs will find there are changes in the way we get reimbursed for our services over the next 5 years or so if health care reform takes place. I hope all LCSWs will educate themselves about the problems that exist, the ways they can be addressed, and the realistic ways LCSWs can become part of the solution.  The divide between fee-for-service and third-party LCSWs will not serve us well.  We need to come together and work toward the need for change.