Hip, hip hooray…more help is on the way…!!

Most of us would agree that we are in a national mental health crisis.  Now more than ever communities are suffering from all time high levels of depression and anxiety (including suicidality) while at the same time our nation is witnessing a shortage of mental health professionals and services.  It is not unusual for our patients to wait 4-5 months to see a psychiatrist or 2-3 months to see a therapist.  When folks are in need of mental health interventions, this wait time is extremely painful which can cause an increase risk in additional emotional and psychological decompensation.

There are many causal and correlational factors to blame for this social service deficit such as: collateral damage from the Covid pandemic and a low workforce of professionals.  The need for counseling is so much greater presently due to: the by-products of social media, higher unemployment, social stressors such as an increase in bullying, political distress, recent police brutality, human trafficking, substance abuse and immigration related issues.

So, that’s the bad news…but wait…there is good news that should help you help your patients. Beginning January 1, 2024, 225,000 new highly qualified mental health practitioners will finally be granted access into the Medicare system.  President Joe Biden signed the Omnibus Mental Health Access Improvement Act 2021 also referred to as S.828 and HR 432.  The new law is P.L.:  117-328 allows Licensed Professional Counselors (LPC), Licensed Mental Health Counselors (LMHC) along with their cousins Licensed Marriage and Family Therapists (MFT) to serve as mental health providers.  This is a big, big deal! Variations of this bill have been in discussion in the House and Senate for the last decade. In addition, the Centers for Medicare and Medicaid have not updated their policy since 1989. The Center has released the 2023 Physician Fee Schedule final note which expands the role of counselors within the program to provide mental health and substance abuse services to those who qualify as being over 65 or meeting criteria for a permanent disability.

To understand the magnitude of this opportunity, it may be helpful to understand the historical background. To date, only Licensed Clinical Social Workers (LCSW) have been able to directly bill Medicare for the provision of mental health services. Licensed mental health counselors and marriage and family therapists have had to work directly under a physician (a doctor had to literally be on site) and had to bill as “incident to” under the MD which was very difficult for many clinicians and agencies.  While the new entourage of professionals will continue to work under the general supervision of the physician, the clinician can provide services independently.

To make this clearer, let’s use an analogy using mid-level medical providers.  So, a social worker is to a nurse practitioner as a professional counselor is to a physician assistant.   While the training and scope of practice is very similar, the degree of autonomy is very different.  A quick look at the program differences gives a glimpse of why there is such a discrepancy between the two disciplines.  The social work professional community has always had preferential access for many years.  Professional counselors, on the other hand, did not.  In the 1960’s the mental health profession actually “shot itself in the foot” as educational programs were not standardized across the board.  For example, some of us may have been sitting in a circle singing “Kum-ba-yah” and another was running a free style T-Groups. Then, in 1981, arrived CACREP (Council for Accreditation of Counseling and Related Educational Programs) which ensured that all graduate counseling programs were teaching the same standardized coursework of excellence.  With this, the counseling field finally started to earn professional respect. That said, there are some pedagogical differences in the mental health counseling versus the social work disciplines.  As a general rule, the Counseling discipline focuses on micro counseling skills with the underlying goal of empowering clients to take control of their lives with an internal locus of control.  The Social Work profession, on the other hand, tends to take a more global or macro-approach and focus on case management and social justice in referring clients to the appropriate social services that would help meet their needs as a more external locus of control. At the same time, Marriage and Family Therapy focuses on the dynamics of the family system and personal relationships.

Also, another contributing factor to the discrepancy in access to mental health professionals is the fact that historically the social work profession has had a very strong lobbyist representation in Washington, while the professional counseling and marriage and family therapy profession have not.  The National Association of Social Workers (NASW) movement has had strong advocacy in the national government since the 1960’s yet the MHC and MFT movement has only been more highly represented in the last several decades.

Additionally, in preparation for the great in-pouring, the national government along with Medicare had to be prepared to “pay out” more funds to providers once potential clients were given access to MHCs and MFT. Thus, with the new law, licensed mental health professionals will be able to provide services to outpatient clinics, hospice programs and rural and underserved geographical and social areas. Unfortunately, at this time, mental health care in nursing home facilities will not be included in this new law.

The bottom line here is that with the new legislation is a win-win for clients, programs and mental health providers. The obstacles to access have been significantly removed.  

Assuming that the average therapist maintains a caseload of 50 clients (which is a very low estimate), this would mean that over 1 million additional clients could be served.  Now, medical providers will have more options to refer Medicare qualifying patients for assessment and treatment than ever before.

Thank you to all the advocates, law makers and professionals who made this much needed and very overdue law a reality! ☤

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