Strengthening IDENTITY | Preserving INTEGRITY | Advocating PARITY
I just received guidance from CMS on whether we can be reimbursed for telemental health beyond the accepted treatment in rural areas. Their response is attached.
Basically the answer is no at this time. I recommend calling CMS at1-866-288-8912, x3 to ask for more guidance.
CSWA is developing a Legislative Alert to send to members of Congress to request an expansion of coverage for telemental health during this health crisis.
Laura Groshong, LICSW, Director, Policy and Practice, Government Relations Chair
Clinical Social Work Association
The National Voice of Clinical Social Work
Strengthening IDENTITY | Preserving INTEGRITY | Advocating PARITY
CSWA - Medicare on Distance Sessions - 3-9-20.docx
The Covid-19 virus is spreading and LCSWs need to anticipate the impact that this may have on our patients and our practices. Many of the suggestions below were gathered from the World Health Organization and other sources. CSWA hopes we may be helpful to you as this health crisis evolves.
More information can be found at https://www.who.int/emergencies/diseases/novel-coronavirus-2019/events-as-they-happen
Another comprehensive article can be found at https://www.washingtonpost.com/health/2020/02/28/what-you-need-know-about-coronavirus/?arc404=true
Clinical Practice Action Plan:
- Develop a plan for limiting in-person sessions if there is a public health recommended limitation for being in public places, or a perceived need for such limitation
- Review the CSWA Technology Standards for Social Workers if you have not done so recently ( https://www.clinicalsocialworkassociation.org/Social-Work-Technology-Standards)
- Check with insurers as to coverage of telephone or videoconferencing
- Make sure that any videoconferencing platform you use is HIPAA compliant (VSee, Zoom, etc.)
- Decide if patients with symptoms should have sessions by telephone or videoconferencing
- Decide if you should be working if you have symptoms
- Discuss a plan with patients in advance of the need to limit in-person contact, including arranging for phone or video sessions
- Sanitizing doorknobs and other surfaces touched by patients
- Be aware of own anxieties and try to contain
- Be prepared to acknowledge the anxieties of patients, should they occur
Public Health recommendations to reduce infection from flu or Covid-19:
- Perform frequent hand washing and use of hand sanitizer after being in public spaces
- Cough into elbow or shoulder, not covering your mouth with your hand
- Stay more than 6 feet away from individuals who are coughing or otherwise appear ill
- Avoid social ways of touching others, including handshakes
- Avoid touching your own face as much as possible
- Avoid public transportation such as buses or trains if recommended distance cannot be maintained
- Use hand sanitizer after going through TSA if flying by plane
- Use sanitizing wipes on plane armrests and tables and rental car keys and steering wheels
- Be aware of countries and cities where Covid-19 virus is increasing if traveling
- Engage in immune enhancing activities, i.e., get enough sleep, reduce alcohol intake, get exercise)
- Do not go to an emergency room unless absolutely essential; for a cough, fever, or other respiratory issues contact your primary care doctor first.
- Self-quarantine at the first sign of illness and wear an N-95 face mask in public spaces
Helping Children with Meaning of Restrictions Due to Covid-19
Suggestions can be found at https://onedrive.live.com/view.aspx?resid=D589777FC7C86E35!118&ithint=file%252cdocx&authkey=!ALcOpxBYPPJR_h4
Striking a balance between being overly cautious and overly optimistic may not be easy but as clinical social workers, I think we can achieve it. As you may know, here in Seattle we have a cluster of Covid-19 cases and two deaths, so I will be applying these principles to my own practi
Laura W. Groshong, LICSW, Director, Policy and Practice
The abuse of immigrant minors continues. This article from the Washington Post details how a 17-year-old who was seen by a therapist while in detention and then had his confidentiality violated with serious emotional consequences.
The article is called "Trust and Consequences", written by Hannah Drier, and was published on February 15, 2020. You can find it at https://www.washingtonpost.com/graphics/2020/national/immigration-therapy-reports-ice/
CSWA's commitment to confidentiality includes anyone who is seen by an LCSW. We condemn this act and will continue to work for the right to privacy of all clients.
Dear CSWA Members,
I want to call your attention to a terrific article called 'The War for the Future of Psychotherapy". on the conflict in psychotherapy regarding manualized algorithms as the basis for treatment and the treatment alliance as the basis for treatment. The article is by Todd Essig, PhD, a psychologist/psychoanalyst, who writes a column in Forbes Magazine and can be found here
This is not a new battle between short term and in-depth treatment but according to the article, there is new support for using algorithms to guide treatment from the American Psychological Association Guidelines.
CSWA has members who provide all methods and lengths of treatment but the human connection is seen as primary, not one-size-fits-all research. I urge all members to read the article and send me your thoughts, which I will share with other members.
This article came out of the Psychotherapy Action Network (PsiAN) Conference which was held in San Francisco the past month. Full disclosure: I spoke at the conference on clinical social work education in schools of social work (diminishing) and psychotherapy advocacy (time-consuming). Let me know if you want information about those topics. It was heartening to see the many LCSWs in the audience.
Here's to a happy productive new year for clinical social workers.
Laura Groshong, LICSW, Director, Policy and Practice, Government Relations Chair
MHLG 2019 Hill Staff Champion Awards, given to the members of Congress for their outstanding support of the goals of the Mental Health Liaison Group. These legislative aides are identified below. Peeking out of the second row is our own Margot Aronson, LICSW, CSWA Deputy Director of Policy and Practice.
The American Foundation for Suicide Prevention and the Suicide Prevention Resource Center have put together some excellent materials which may be helpful to members.
Here is a general overview of the scope of suicide, costs,vulnerable populations and more. The link is http://www.sprc.org/about-suicide
Here is a summary of the guidelines which states use to prevent suicide. The link is http://www.sprc.org/stateInfrastructure/tools
Here is a summary of the number of suicides that occur each year by state and the ranking per capita of the states. The link ishttps://afsp.org/about-suicide/state-fact-sheets/
I hope this may be useful to you and your colleagues.
Centers for Medicare and Medicaid Services
Director Seema Verma
RE: CY 2020 Revisions to Payment Policies Under the Physician Fee Schedule and Other Changes to Part B Payment Policies, CMS–1715–P
Dear Director Verma:
The Clinical Social Work Association (CSWA) is happy to provide these comments on the proposed Medicare rules for 2020. There are over 250,000 licensed clinical social workers (LCSWs) in the country, the largest group of behavioral health providers. We are proud to be able to participate in the Medicare program and serve the mental health needs of beneficiaries.
As we understand the proposed rules for LCSWs, they are similar to the Physician Quality Record Systems (PQRS) which were in place from 2010-2017 for LCSWs. When the Merit-based Incentive Payment System (MIPS) was created in 2018, LCSWs were not asked to report on the measures that were part of that system. The proposed rule, CMS-1715-P, is specifically considering that clinical social workers now be included in the MIPS reporting. The PQRS rule had many difficulties for LCSWs with denied reporting and we hope that if the MIPS measures are applied to LCSWs that the processing of the reporting will be improved.
CSWA understands that the Medicare Economic Index (MEI) is subject to change, and is hopeful that the proposed 6% decrease in overall RVUs for LCSWs may change as well. As has long been the case, we have concerns about the way that LCSWs, who use the same behavioral health codes as psychologists and psychologists for psychotherapy, have nonetheless been reimbursed at 25% less than the other two groups. We know this will take legislative change. This disparity continues to be patently unfair; groups doing the same work using the same codes should not have different reimbursement rates. CSWA encourages our members to become Medicare providers and serve this vulnerable population. However, decreasing reimbursement rates and increasing the paperwork burden could lead to fewer LCSWs choosing to do so.
As requested on p. 460, CSWA would like to offer the following comments on the Clinical Social Work specialty set, in the event clinical social workers are proposed for inclusion in the definition of a MIPS eligible clinician in future rulemaking. Measures which CSWA finds would fit with the clinical social work scope of practice are marked “ACCEPTED”. Measures which are not included, but recommended by CSWA, are marked “PROPOSED”.
B.41 Clinical Social Work (p.664)
Measures in MIPS
#130, Medications for every patient listed in the Medical Record in each session ACCEPTED
#134, Depression Screening, once a year, followup treatment plan if positive screening ACCEPTED
#181, Elder Maltreatment Screening, once a year, with followup treatment plan if positive screening ACCEPTED
#182, Functional Outcomes Assessment, as needed, followup treatment plan if positive screening ACCEPTED
#226, Tobacco Cessation, once every two years or sooner if positive screening ACCEPTED
#281, Dementia Cognitive Assessment, once a year regardless of age, followup treatment if positive screening ACCEPTED
#283, Dementia Psychiatric Screening, once a year if positive cognitive assessment for dementia, for behavioral/psychiatric disorders, followup treatment if positive screening ACCEPTED
#286, Dementia Physical Safety Screening, as needed if danger to self or others because of physical limitations, followup treatment if positive screening ACCEPTED
#370, Adolescent Depression Remission Percentage at 12 months for 12-17 year old patients who have a positive screening for depression ACCEPTED
#382, Assessment of Suicide Risk for children/adolescents who have diagnosed suicidality with followup plan for continued suicidality ACCEPTED
#383, Assessment of adherence to anti-psychotic medication as needed for patients who have a diagnosis of schizophrenia or schizoaffective disorder and followup plan if positive screening for non-adherence ACCEPTED
#402, Assessment of tobacco cessation for adolescents 12-20 as needed with followup plan if cessation not achieved ACCEPTED
#431, Assessment of Unhealthy Alcohol Use for adults every two years with followup plan for cessation if not achieved ACCEPTED
PROPOSED: Assessment of Unhealthy Alcohol Use for adolescents 12-20 every year if cessation not achieved
PROPOSED: Assessment of Unhealthy Drug Use for adults every two years with followup plan for cessation if not achieved
PROPOSED: Assessment of Unhealthy Drug Use for adolescents every two years with followup plan for cessation if not achieved
Thank you again for the opportunity to offer our comments to CMS on these proposed rules. We are happy to discuss them with you further.
Britni Brown, LCSW, PresidentClinical Social Work Associationbbrown@clinicalsocialworkassociation.org
Laura Groshong, LICSW, Director of Policy and PracticeClinical Social Work Associationlwgroshong@clinicalsocialworkassociation.org
Margot Aronson, LICSW, Deputy Director of Policy and Practice Clinical Social Work Associationmaronson@clinicalsocialworkassociation.org
Donna Dietz, CSWA AdministratorClinical Social Work Associationadministrator@clinicalsocialworkassociation.org
Though I have not been sending the voluminous posts that I was sending last summer, the issue of immigrant children who are separated from their families, given inadequate housing, and denied basic care is one that CSWA is carefully tracking. Here is some information that will keep you up to date and provide options on how to stop these injustices. There are currently between 1000 and 3000 immigrant children in the US separated from their parents; some older (8 and up) children are being forced to care for younger children.
Summary of Harm – this article is a good summary of the current issues:
Agencies for Immigrant Children –Here are some good agencies that are working to improve the conditions of immigrant children and reunite them with their families:
Kids in Need of Defense (KIND) works to ensure that no child appears in immigration court alone without representation.
Women’s Refugee Commission offers Resources for Families Facing Deportation and Separation in English and Spanish.
Young Center for Immigrant Children’s Rights advocates for the safety and well-being of unaccompanied kids arriving in the United States. They recently announced a project specifically dedicated to helping children separated from their parents at the border.
Donations to Help – here is one of many organizations that are using donations to help immigrant children:
Let me know if you have any questions.
Laura Groshong, LICSW, Director, Policy and Practice, Government Relations Chair
Clinical Social Work AssociationThe National Voice of Clinical Social WorkStrengthening IDENTITY | Preserving INTEGRITY | Advocating PARITY
Laura Groshong, LICSW, Director, Policy and Practice
Margot Aronson, LICSW, Deputy Director, Policy and Practice
Texts are primarily used for social purposes: short missives conveying limited information. Much has been written about the negative impact of reliance on this mode of communication (Turkle, 2012), but the popularity of texting is obvious, particularly among those under the age of 30 who have texted regularly throughout their lives. Therefore, the increasing use of texting in the context of therapy cannot be ignored.
While there is no definitive research as yet, it appears that texting can play a useful role in some mental health treatment. Certainly for anyone who is most comfortable with texting as the preferred form of communication, this may be where a treatment relationship can best begin.
Responsibilities of the LCSW Providing Text Therapy
Clinical social workers should be knowledgeable about the promise of digital innovations in treatment, and equally about the potential downside. LCSWs choosing to engage in text therapy must be willing to explore ethical complications, perhaps even license violations, in the terms of agreement with the client and/or the texting platform.
The first issue: is text therapy really psychotherapy?
This simple definition of psychotherapy, paired with the already quoted Talkspace web advertisement, illustrate the very real differences that exist between psychotherapy and text therapy. Psychotherapy (whether in person or through synchronous videoconferencing) is a continuous process based on an established emotional relationship, an ongoing dialogue between two people in real time about complex issues with deep emotional content. Texting, on the other hand, is by its nature short, often with a gap in the timing of communications between client and therapist; it is not consistent with a dialogue based on emotional meaning, as with psychotherapy.
While texting platforms may emphasize, in the small print of the User Agreement, that the services provided are not psychotherapy, most continue to display the term “text therapy” prominently in their ads. This can create confusion for clients seeking psychotherapy and may give an appearance of misleading advertisement.
How, then, do we as LCSWs conceptualize and engage in text therapy? Perhaps “text therapy” might more accurately be called “text assessment” or “text coaching”. Texting might also be the means for starting the therapeutic process, to be converted to an in-person or videoconferencing process if it becomes an ongoing psychotherapy.
Reading any contract with care is essential, and this is most certainly true for provider contracts offered by texting platforms. Does the contract address issues such as diagnosis, HIPAA compliance, state-to-state licensing laws, and dual relationships? Does the platform set limitations on helping a client understand the differences between in-person treatment and text therapy, or on recommending in-person therapy when such treatment is indicated?
LCSW Standards of Practice
The use of ongoing asynchronous texting changes the process of therapy for LCSWs. The therapeutic alliance is significantly different when the primary means of communication is not direct ongoing communication between the client and therapist, as the asynchronous method of communication tends to preclude in depth exploration of emotional understanding. Further, a key part of psychotherapy, the “frame”, is lost if client and therapist text and reply at different times, or if the client is limited – as with some agreements - to making and receiving two texts a day to a therapist five days a week.
LCSWs base their understanding of a client on a biopsychosocial assessment, leading to a diagnosis. ASWB Technological Guidelines (2015) identifies additional factors that may contribute to determining whether a client is suitable for text therapy: age, technological skills, disabilities, language skills, cultural issues, and access to emergency services in the client’s community. How does the platform provide for assessment? Can you ensure that our standards of practice will be upheld by the texting platform?
When more intensive treatment is called for, will the platform respect and support the licensed provider’s clinical judgment? LCSWs know that a client with a psychotic disorder, an autistic spectrum disorder, or an acute episode of depression or anxiety may need in-person communication or hospitalization. Are there contractual provisions for such a situation?
Benign as texting seems, some texting platforms ask clinicians to communicate in ways that may violate state laws and regulations and/or federal laws and rules.
Most states require a clinical social worker to be licensed in both the state where the LCSW resides and the state where the client resides, if different, to provide therapeutic services. A text platform’s claim that text therapy is not psychotherapy but rather “therapeutic communication” is a blurry distinction not necessarily recognized by state social work boards. It is the LCSW’s obligation to ascertain and comply with relevant regulations of both state boards.
Licensed therapists are also responsible for making sure that the text platforms used by both client and therapist are HIPAA compliant. Further, the texts themselves are personal health information sent electronically (PHI) and must be kept private and secure. It has been reported that one text platform permitted employees – even non-clinically-trained employees – to review the content for training purposes. A Business Associate Agreement might provide a guarantee of the LCSW’s confidentiality standards, if the platform agrees to sign (HIPAA Basics for Providers, 2018, https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/HIPAAPrivacyandSecurity.pdf )
Most states use the NASW and CSWA Codes of Ethics as the basis for ethical clinical social work practice. Some text platforms have contractual terms that require the therapist to meet sales targets through their text exchanges. For a clinical social worker to engage in such a dual relationship, i.e., as a corporate representative for the texting services and, at the same time, as a therapist addressing mental health problems is a clear and serious ethical violation.
Some companies use marketing techniques that also may be ethical violations. One example, potentially misleading advertising, has been mentioned. Advertising with testimonials from former clients is another. From the NASW Code of Ethics (2016)
4.07(b) Social workers should not engage in solicitation of testimonial endorsements (including solicitation of consent to use a client's prior statement as a testimonial endorsement) from current clients or from other people who, because of their particular circumstances, are vulnerable to undue influence.
Would the company agree to keep the LCSW provider from being caught up in these sorts of business-driven ethical dilemmas?
Basic to mental health treatment is thoughtful consideration of the conditions being treated and of the biopsychosocial needs of the client. The challenge for the LCSW is incorporating these basics, along with accepted standards of practice, regulatory requirements, and ethical considerations, into the texting format as contracted by the particular text platform. It is the responsibility as LCSWs to apply clinical social work standards of practice, ethics, and regulations to any work we choose to do.
THE AWARE ADVOCATE
Implications of the UBH Decision for LCSWs
Laura Groshong, LICSW, CSWA Director, Policy and Practice
April 17, 2019
Much excitement has been generated in the mental health community since “the UBH decision” – that is, the decision in the US District Court in Northern California case of Wit et al versus United Behavioral Health, filed March 5, 2019 - found UBH liable with respect to the denials of benefits claims. The clarity and detail of Chief Magistrate Judge Joseph Spero’s 106-page Findings of Fact and Conclusions has provided us with an extraordinary resource for moving forward.
At the same time, there are clear limits to this big win: this is not the end of insurance denials and parity violations. UBH will surely be appealing the judgment, and other judges may or may not uphold the present ruling. Further, the insurance arena is complex. Each state has its own insurance regulations, and each type of plan (ERISA, Medicare, Medicaid, Exchange Plans, or private) has a different source/s of oversight. (CSWA has posted information to clarify the differences in the Clinical Practices section of our website.)
How, then, can we use this decision effectively to affect access to mental health and substance use treatment? At the individual level, if your client is being denied care that you deem critical, the detailed court document provides a list of “generally accepted standards of care” that may prove very helpful in your discussion with the insurance representative.
Judge Spero spent considerable time during the hearing determining what is meant by generally accepted standards of care. Many sources exist, and CSWA will post the judge’s summary of these on our website. The standards listed below were agreed upon by both plaintiffs and UBH; the wording is taken from the court document itself:
The nine plaintiffs whose cases were reviewed during the ten-day bench trial included denials of residential treatment for substance use disorder, for rehab, for mental health treatment, and, in two cases, for teenagers with substance issues, as well as denials of outpatient mental health treatment two to three times per week, and Intensive Outpatient Treatment (IOP) for a minor with SUD. The Judge provided detail for each case considered, noting the discrepancy between the UBH stated standard of care and the actual guidelines that the reviewers was expected to follow. His descriptive language throughout, when referring to the UBH testimony, tended toward generous use of the words “evasive” “even deceptive” and “not credible”.
Given the widespread interest in this case, LCSWs may want to be assertive in appealing denials of care, especially where there is any failure to meet the standards. As you present your argument - even if you are dealing with a different insurer and a different type of plan - a mention of the UBH case will likely have an effect on the discussion. (The CSWA website has an Appeals template in the Members-only section; the generally accepted standards of care list will also be there, as well as a description of the five types of insurance plans.)
Another important avenue for LCSWs may be their state insurance laws/regulations and then perhaps their legislators. The plaintiffs came from different states, and three of these states – Illinois, Connecticut and Rhode Island - have legislation mandating use of the American Society of Addiction Medicine (ASAM) Standards in their insurance laws/regulations; it was not difficult to demonstrate that the UBH denials violated the state laws/regulations. A fourth state, Texas, has Department of Insurance criteria for standards of care; this proved equally effective.
The UBH decision is a good step toward making mental health and substance use parity a reality but is far from the end of making this happen. For now, we can speak out strongly on standards of care, ensure that standards in the client’s policy is being respected in any review process, and feel comfortable noting the UBH loss in court based on violation of these standards, as a basis for appealing a denial of care. As for the next steps, LCSWs should look to state laws/regulations governing insurance, including any standards of care or enforcement of parity. (Such information may be online at the website of the Office of the Insurance Commissioner). Insurance is a state-based system and it may be possible to make a legislative proposal about mental health and substance use that would appeal to your state legislators. Watch for more information from CSWA on this topic soon.
Footnote: Case 3:14-cv-02346-JCS Document 18 (Findings of Fact and Conclusions of Law). Heard and ordered UBH liable 2/28. Filed 3/05/19. 106 pages. United States District Court, Northern District of California.
Clinical Social Work Association
The National Voice of Clinical Social WorkStrengthening IDENTITY | Preserving INTEGRITY | Advocating PARITY
PO Box 10Garrisonville, Virginia 22463