CVS To Offer In-Store Mental Health Counseling

[DynamicDidactic]

CVS job posting

It sounds like a lot of case management and health psych designed to push their other services in HealthHub than a lot of long-term mental health. Skills mentioned are very PC-MHI (problem-solving therapy, motivational interviewing, CBT).

Required Qualifications
Proven excellent diagnostic... leveraging evidence-based methodologies

Good luck getting either of those for a position like this.

Preferred Qualifications
Evidence of strong crisis intervention skills

annnnddd, a red flag

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[cara susanna]

Interesting that they're only hiring LCSWs. Is this another area of psychologists getting pushed out due to costs?

 

[WisNeuro]

Interesting that they're only hiring LCSWs. Is this another area of psychologists getting pushed out due to costs?

One of many. Gonna see a lot of openings for MH providers in teh future due to demand. An ever decreasing proportion of those will be for doctoral providers as time goes on.

 

[futureapppsy2]

annnnddd, a red flag

To be fair, all clinicians should be skilled in crisis management—they all aren’t, but they should be.

 

[beginner2011]

Interesting that they're only hiring LCSWs. Is this another area of psychologists getting pushed out due to costs?

One of many. Gonna see a lot of openings for MH providers in teh future due to demand. An ever decreasing proportion of those will be for doctoral providers as time goes on.

I know I'm preaching to the choir, but it's odd to me that psychologists are being pushed out of mental health care within health care systems. Neuropsych testing seems to be one of the few exceptions, for obvious reasons.

Having a few years now under my belt in a health care system with a lot of MSWs, I see the rationale behind pushing psychologists out. Just straight provision of case management and coordination of care with group therapy can generally be accomplished by someone with MSW training as well as a psychologist. The same is true for manualized EBPs. Some of the MSWs I know are fantastic therapists, and have occasionally provided me with more useful consultation on EBP delivery than my formal clinical supervisors.

Where the wheels seem to come off is with imprecise/inaccurate diagnoses leading to inappropriate treatment or referrals. Given that diagnoses are often a moving target, especially in cases of co-occurring disorders or other complex presentations, this creates a ton of downstream chaos for providers. If a provider has not received extensive training in assessment (beyond their specialty area) or the principles behind the EBPs then it creates a huge burden and I believe increases burnout, decreases job satisfaction, and increases job dissatisfaction. This is all to say that there is a massive cost to the healthcare system of hiring folks to do jobs that are not adequately specialized to fit their training (e.g., MSW in PCMHI, in my opinion). Even if 75% of the cases ARE a good fit (straightforward PE, CPT, CBT-I, BA, etc.), that other 25% creates havoc in the system because they don't benefit from care, continue to seek treatment, and contribute to an accumulation of case management duties for the provider that are burdensome.

In my mind, the generalist and specialty clinics are both settings that ought to benefit from some portion of care provided by psychologists given the psychodiagnostic and assessment training requirements for licensure. I'm obviously speculating here, but I do believe that at some point in the future a health care system will recognize the relative benefits outweigh the costs of hiring psychologists, instead of just seeking to minimize costs.

Yea you can hire someone for 60k/y to do straight ahead case management and EBPs, but you're going to end up with this compounding 25% float of continually unwell patients, or you can hire someone for 100k/y to provide a higher level of care and reduce that float from 25% to 5% or something.

This is of course very unscientific and the numbers are made up, but that's my theory.

 

[Ollie123]

I've been told by private practitioners in my area (everything from master's level to PhD) that they are totally booked out with full caseloads and they're getting 10+ new contacts per week looking for a therapist.
If this is a "boutique" market, I wonder if the business decision behind this CVS program is based on the massive imbalance between supply and demand even in more well-resourced communities. An imbalance that is likely to get worse before it gets better now that there has been increased awareness about mental health and increased stressors in context of the pandemic.

Could be. Now that I know the Aetna piece, it could also be some geographic oddity where need intersects with an unusually high proportion of people with aetna insurance for whatever reason.

We'll see what happens. I still don't see boutique working in that kind of setting. I'd wager anything a large portion of minute clinic's business is based on things a toddler could diagnose that people just need an rx for. That parallel doesn't quite work in mental health and I think the equivocal patient will want someone who can offer things that just aren't going to be viable in CVS (e.g. regular appointments). Maybe I'm wrong. Time will tell.

 

[WisNeuro]

I know I'm preaching to the choir, but it's odd to me that psychologists are being pushed out of mental health care within health care systems. Neuropsych testing seems to be one of the few exceptions, for obvious reasons.

Having a few years now under my belt in a health care system with a lot of MSWs, I see the rationale behind pushing psychologists out. Just straight provision of case management and coordination of care with group therapy can generally be accomplished by someone with MSW training as well as a psychologist. The same is true for manualized EBPs. Some of the MSWs I know are fantastic therapists, and have occasionally provided me with more useful consultation on EBP delivery than my formal clinical supervisors.

Not hard to see why the trend has been happening when you see who is in the position making the decisions. Usually people with business backgrounds and little to no clinical experience. They are just looking at costs (salary/benefits) vs collections in certain areas, and see where they can save a good chunk of change within a larger dept. My last hospital job had a fairly large OP MH service, maybe 25-ish providers. All Masters and SW. I'm sure they looked at how much to pay one of those people vs a psychologist and the decision on job postings was pretty easy. Now, they have no one who can proper extensive psych evals, which I regularly cancelled consults for, but MidLevelExec McSpreadhseets doesn't really care about that particular problem.

 

[Sanman]

Not hard to see why the trend has been happening when you see who is in the position making the decisions. Usually people with business backgrounds and little to no clinical experience. They are just looking at costs (salary/benefits) vs collections in certain areas, and see where they can save a good chunk of change within a larger dept. My last hospital job had a fairly large OP MH service, maybe 25-ish providers. All Masters and SW. I'm sure they looked at how much to pay one of those people vs a psychologist and the decision on job postings was pretty easy. Now, they have no one who can proper extensive psych evals, which I regularly cancelled consults for, but MidLevelExec McSpreadhseets doesn't really care about that particular problem.

It is largely this. The mid-level professions embracing and pushing for it likely does not help anything. The other part of this is the larger economic system. With wealth inequality spreading, those with the money (health insurance companies, hospital systems) have to find a way to keep their clients getting services without those lacking funds complaining too much, So cut out the physicians and psychologists ( and other expensive overhead), go to mid-levels and keep their piece of the pie for longer. If the divide gets too large, you see what happened with Bernie Sanders and it scares them because they might be legislated out of existence.

 

[cara susanna]

It is largely this. The mid-level professions embracing and pushing for it likely does not help anything. The other part of this is the larger economic system. With wealth inequality spreading, those with the money (health insurance companies, hospital systems) have to find a way to keep their clients getting services without those lacking funds complaining too much, So cut out the physicians and psychologists ( and other expensive overhead), go to mid-levels and keep their piece of the pie for longer. If the divide gets too large, you see what happened with Bernie Sanders and it scares them because they might be legislated out of existence.

Wait, what happened with Bernie Sanders?

 

[Sanman]

Wait, what happened with Bernie Sanders?

He embraced the word socialism, threatened to decimate one of the largest privatized industries in the U.S., has threatened to increase taxes significantly on millionaires and billionaires, and somehow came very close to becoming the Democratic nominee for president two elections in a row. If that does not scare those in power, what do you think will?

 

[cara susanna]

He embraced the word socialism, threatened to decimate one of the largest privatized industries in the U.S., has threatened to increase taxes significantly on millionaires and billionaires, and somehow came very close to becoming the Democratic nominee for president two elections in a row. If that does not scare those in power, what do you think will?

Oh, for sure, I'm just not sure how that would change scope of practice for midlevels. Unless you think that'd be more regulated.

 

[Sanman]

Oh, for sure, I'm just not sure how that would change scope of practice for midlevels. Unless you think that'd be more regulated.

You take away the profit motives in healthcare what is the case for mid-level creep? Take a look at the VA system. No idea where reimbursement would land in a single payor system, but who goes to the less educated alternative if cost is no longer a factor?

 

[beginner2011]

The other part of this is the larger economic system. With wealth inequality spreading, those with the money (health insurance companies, hospital systems) have to find a way to keep their clients getting services without those lacking funds complaining too much, So cut out the physicians and psychologists ( and other expensive overhead), go to mid-levels and keep their piece of the pie for longer. If the divide gets too large, you see what happened with Bernie Sanders and it scares them because they might be legislated out of existence.

Totally agree that the incentives currently in place are perceived to favor mid-level preference (lower cost for the same billables). My thought is that if you take a step back (as @WisNeuro implied) and take a larger perspective than that of Mr. McSpreadsheets there are likely to be ancillary benefits that are not captured by whatever metrics they're using.

Taking this CVS mental health clinic as an example. I wonder what sort of metric might highlight the relative value of a licensed psychologist vs. a minimally trained therapist? One of the things I struggle with providing clinical services in a health care system is even figuring out how to explain the value my services. If I can't explain the value of my services in a succinct and quantifiable way, what hope do I have that Mr. McSpreadsheets will ever see it?

 

[Sanman]

Totally agree that the incentives currently in place are perceived to favor mid-level preference (lower cost for the same billables). My thought is that if you take a step back (as @WisNeuro implied) and take a larger perspective than that of Mr. McSpreadsheets there are likely to be ancillary benefits that are not captured by whatever metrics they're using.

Taking this CVS mental health clinic as an example. I wonder what sort of metric might highlight the relative value of a licensed psychologist vs. a minimally trained therapist? One of the things I struggle with providing clinical services in a health care system is even figuring out how to explain the value my services. If I can't explain the value of my services in a succinct and quantifiable way, what hope do I have that Mr. McSpreadsheets will ever see it?

In terms of quantifiable success, there are only a few ways to show evidence of value

1. Provide a service the mid-level does not or can not
2. Show evidence of increased symptom remission or decreased utilization of services in comparison to them

So, which one can you prove?

 

[WisNeuro]

In terms of quantifiable success, there are only a few ways to show evidence of value

1. Provide a service the mid-level does not or can not
2. Show evidence of increased symptom remission or decreased utilization of services in comparison to them

So, which one can you prove?

I'm sticking with #1 for now. Even there I suspect midlevels will eventually encroach though.

 

[Sanman]

I'm sticking with #1 for now. Even there I suspect midlevels will eventually encroach though.

Same here. It is nice to have legislation to reinforce your job security. It may change, but that is why people should learn to diversify and invest. I'll be okay if the bottom falls out (not thrilled, but okay) and the longer that takes the better my position will be.

 

[WisNeuro]

Same here. It is nice to have legislation to reinforce your job security. It may change, but that is why people should learn to diversify and invest. I'll be okay if the bottom falls out (not thrilled, but okay) and the longer that takes the better my position will be.

Time will tell. At this point it would seem that we're just buying time. Fewer people and resources with which to fight with, and a change in how our members want to utilize those resources. Call me Chicken Little, but I would not want to be a student entering the field in a few years.

 

[Sanman]

Time will tell. At this point it would seem that we're just buying time. Fewer people and resources with which to fight with, and a change in how our members want to utilize those resources. Call me Chicken Little, but I would not want to be a student entering the field in a few years.

Fair enough, However, I feel like people in all fields are saying this to some extent with some being worse than ours. Those entering the field in a few years are going to have to be smarter about debt and more willing to pivot with changes in the larger healthcare system that are coming. It may be good or it may be bad depending on where the chips fall, but artificial intelligence won't replace us and neither will people on the other side of the globe.

 

[beginner2011]

Such doom and gloom! What are you two foreseeing as worst case scenario for psychologists?

 

[WisNeuro]

Such doom and gloom! What are you two foreseeing as worst case scenario for psychologists?

Moreso just a decline in reimbursement and status until psychologists are paid roughly the same as midlevels in all but PP and academic settings.

 

[WisNeuro]

Fair enough, However, I feel like people in all fields are saying this to some extent with some being worse than ours. Those entering the field in a few years are going to have to be smarter about debt and more willing to pivot with changes in the larger healthcare system that are coming. It may be good or it may be bad depending on where the chips fall, but artificial intelligence won't replace us and neither will people on the other side of the globe.

You're going to see fewer and fewer resources spent fighting reimbursement issues at the state and federal levels. In terms of manpower and capital, advocacy is a zero sum game, and priorities are changing.

 

[cara susanna]

One thing you have to give the VA, I guess.

 

[WisNeuro]

One thing you have to give the VA, I guess.

That'll be the last bastion. The GOP will always be trying to chip away and privatize it, but that will be a long process.

 

[cara susanna]

That'll be the last bastion. The GOP will always be trying to chip away and privatize it, but that will be a long process.

I think it will take some time and effort to do that with mental health. Even at the height of the privatization efforts that I saw under Trump, they were admitting that the VA does mental healthcare super well.

 

[Sanman]

Moreso just a decline in reimbursement and status until psychologists are paid roughly the same as midlevels in all but PP and academic settings.

Agreed with this as my worst case scenario. Best case is that reimbursements are set higher. If we end up in a Medicare for all scenario, the question becomes where the powers that be value us. Will 40 hours of work be $65k or will it be $165k? Someone will take a haircut in that scenario. The questions remains whether it will be us.

 

[WisNeuro]

Agreed with this as my worst case scenario. Best case is that reimbursements are set higher. If we end up in a Medicare for all scenario, the question becomes where the powers that be value us. Will 40 hours of work be $65k or will it be $165k? Someone will take a haircut in that scenario. The questions remains whether it will be us.

I can guarantee that the powers that be will value it a lot closer to the former than the latter.

 

[WisNeuro]

I think it will take some time and effort to do that with mental health. Even at the height of the privatization efforts that I saw under Trump, they were admitting that the VA does mental healthcare super well.

Agree, but if they start letting the business people run things like other healthcare orgs, they'll start to see about replacing psychologists with midlevels. I don't think it will happen soon, but I wouldn't be surprised to see the VA in the midst of that shift later in my career.

 

[Sanman]

Such doom and gloom! What are you two foreseeing as worst case scenario for psychologists?

$65k salary and $300k in debt from a PsyD

 

[Fan_of_Meehl]

Agree, but if they start letting the business people run things like other healthcare orgs, they'll start to see about replacing psychologists with midlevels. I don't think it will happen soon, but I wouldn't be surprised to see the VA in the midst of that shift later in my career.

Yup. Probably just a matter of time. They already are doing everything they can to virtually eliminate the practice of exercising any form of clinical judgment or independent thought.

 

[beginner2011]

Yup. Probably just a matter of time. They already are doing everything they can to virtually eliminate the practice of exercising any form of clinical judgment or independent thought.

Just using those made up numbers (65k vs 165k), that's the difference between 200 MSWs vs 79 psychologists.
Based on my experience in the VA, many of the tasks expected of psychologists could be better accomplished by 2+ MSWs.
When you have a caseload of 90 vets, a psychologist isn't going to be providing any better care than an MSW. You can't do psychotherapy with 90 people experiencing housing and food insecurity. It's just not possible.

That's fine -- I don't think most psychologists want that job anyway. (I know I don't.) Often, MSWs do want that job, though. I remember being on a big region-wide call regarding revising case management expectations, and there were social workers who were advocating for case management being an essential part of how they viewed their role as a therapist. I'm talking housing, transportation, etc. I respect that, and I agree that those are undoubtedly essential elements of a person's wellbeing. However, that's not where I chose to focus my training. I want to do what I've been trained to do -- what I believe I'm good at -- psychotherapy and assessment.

The question I have is what are psychologists trained to do well in a large health care system? The more I see of the healthcare systems at present, the more I don't see a psychologist as a front-line provider anyway. This is, on the whole, a good thing. Health care systems need people to provide case management services. I think our task as a profession in the next decade has something to do with actually carving out our place in the health care system (hint: it's not case management). I'm trying to imagine what a health care system would look like if psychologists were "in charge," so to speak. Not that health care should be centered around psychology, but as an exercise to figure out where we fit. I think it's mostly dealing with those complex presentations with co-occurring disorders or diagnostic uncertainty. From my perspective, a more effective mental health service clinic in a large health care system would be 80% MSWs providing case management and ad-hoc therapy to larger caseloads, and 20% psychologists providing evaluation and management of those more challenging cases mixed in with time-limited psychotherapy cases.

It's probably no coincidence that this is more or less how psychiatry functions within the VA system, except replace psychotherapy with pharmacotherapy. It seems like psychiatry refers out for basically anything not pharmacotherapy related, and won't see someone if they don't already have a case manager ("treatment coordinator").

 

[Sanman]

Just using those made up numbers (65k vs 165k), that's the difference between 200 MSWs vs 79 psychologists.
Based on my experience in the VA, many of the tasks expected of psychologists could be better accomplished by 2+ MSWs.
When you have a caseload of 90 vets, a psychologist isn't going to be providing any better care than an MSW. You can't do psychotherapy with 90 people experiencing housing and food insecurity. It's just not possible.

That's fine -- I don't think most psychologists want that job anyway. (I know I don't.) Often, MSWs do want that job, though. I remember being on a big region-wide call regarding revising case management expectations, and there were social workers who were advocating for case management being an essential part of how they viewed their role as a therapist. I'm talking housing, transportation, etc. I respect that, and I agree that those are undoubtedly essential elements of a person's wellbeing. However, that's not where I chose to focus my training. I want to do what I've been trained to do -- what I believe I'm good at -- psychotherapy and assessment.

The question I have is what are psychologists trained to do well in a large health care system? The more I see of the healthcare systems at present, the more I don't see a psychologist as a front-line provider anyway. This is, on the whole, a good thing. Health care systems need people to provide case management services. I think our task as a profession in the next decade has something to do with actually carving out our place in the health care system (hint: it's not case management). I'm trying to imagine what a health care system would look like if psychologists were "in charge," so to speak. Not that health care should be centered around psychology, but as an exercise to figure out where we fit. I think it's mostly dealing with those complex presentations with co-occurring disorders or diagnostic uncertainty. From my perspective, a more effective mental health service clinic in a large health care system would be 80% MSWs providing case management and ad-hoc therapy to larger caseloads, and 20% psychologists providing evaluation and management of those more challenging cases mixed in with time-limited psychotherapy cases.

It's probably no coincidence that this is more or less how psychiatry functions within the VA system, except replace psychotherapy with pharmacotherapy. It seems like psychiatry refers out for basically anything not pharmacotherapy related, and won't see someone if they don't already have a case manager ("treatment coordinator").

There's no more money in managing complex cases than simple cases. So, why have psychologists at all? Just have a psychiatrist diagnose it and move on. Congrats, you just put us all out of work.

 

[beginner2011]

There's no more money in managing complex cases than simple cases. So, why have psychologists at all? Just have a psychiatrist diagnose it and move on. Congrats, you just put us all out of work.

I know you've been in this business 10X longer than I have, but it's possible (probable?) that there are opportunities to change the business. As @Ollie123 mentioned, value based care is an opportunity for behavioral health. I think the greatest value to the health care system (regardless of billable potential as currently conceived), would be to place psychologists in a model like I described. That's fine if you disagree, but to just say, "That won't work with how things are right now" is kind of beside the point. Yes, right now things are ****ed. Isn't the point of this discussion to try to figure out how we can better demonstrate our value to the system? What are you proposing, exactly?


Highlighting the parts of Ollie's original post that stood out to me.

Said it here before, I'll say it again. VBC is a big opportunity for behavioral health and I feel like we're letting it slide by unnoticed.

CMS (and already some of the bigger private) insurers are already beginning the process to gradually restructure away from the fee-for-service model that was never going to be work well for us financially (and quite frankly was a boneheaded way to approach healthcare in the first place). This seems an utterly massive opportunity for fields like ours, family/preventive medicine, etc. to essentially renegotiate our standing in the field. Tying reimbursement for expensive services to outcomes we help influence could get us a seat at tables we weren't allowed at previously. Shouldn't be news to anyone here that our patients tend to have crummy outcomes across the board. Mr/Mrs heart surgeon is going to be a lot more attentive to mental health if reimbursement drops 20% for every patient too depressed to exercise post-op. In fact, I'd think we are deserving of a reasonable cut of that 20%?

We're starting to have those conversations here, but I really don't see this being discussed in the broader field anywhere to the extent that it should be given we're looking at such a fundamental shift.

 

[Fan_of_Meehl]

I know you've been in this business 10X longer than I have, but it's possible (probable?) that there are opportunities to change the business. As @Ollie123 mentioned, value based care is an opportunity for behavioral health. I think the greatest value to the health care system (regardless of billable potential as currently conceived), would be to place psychologists in a model like I described. That's fine if you disagree, but to just say, "That won't work with how things are right now" is kind of beside the point. Yes, right now things are ****ed. Isn't the point of this discussion to try to figure out how we can better demonstrate our value to the system? What are you proposing, exactly?


Highlighting the parts of Ollie's original post that stood out to me.

What I've observed of psychologist behavior over the course of my career is that we are, as a group, very disorganized, idealistic and masochistic (and very very tough on our own [and ourselves] in the context of healthcare systems). This explains a lot of variance in terms of why--despite advanced training and having a lot to offer--we are treated so poorly in terms of compensation and likely to be out of business soon (unless you're in some sort of niche or specialty practice). Outside of psychologists themselves, there isn't any real recognition of their 'real value' in terms of why they should be paid more than, say, master's-level social workers for conducting psychotherapy.

 

[Sanman]

I know you've been in this business 10X longer than I have, but it's possible (probable?) that there are opportunities to change the business. As @Ollie123 mentioned, value based care is an opportunity for behavioral health. I think the greatest value to the health care system (regardless of billable potential as currently conceived), would be to place psychologists in a model like I described. That's fine if you disagree, but to just say, "That won't work with how things are right now" is kind of beside the point. Yes, right now things are ****ed. Isn't the point of this discussion to try to figure out how we can better demonstrate our value to the system? What are you proposing, exactly?


Highlighting the parts of Ollie's original post that stood out to me.

I think that is fine, but trying to argue that we are only needed for complex cases is painting us into a corner. So, the financial case for us can't be that we can help increase reimbursements 20% in 20% of cases. That will never justify a salary and they may decide to leave that on the table.

In geriatrics, for example, patients in skilled nursing facilities are deemed too complex for mid-levels. Psychologists have protected turf there. I handled my share of complex cases involving demented patients with problem behaviors, complex psych issues, etc. However, that was not where the money was, it was a time suck. The bread and butter money was in mildly depressed and anxious old folks dealing with adjustment issues and loneliness. The complex cases got us the whole protected pie, not just the difficult work. That is how you make the case for yourself.

Want to create value? Why not screen all geriatric patients for mild neurocognitive disorder in pc-mhi fashion to identify dementia earlier. Involve psych in all diabetes cases from the initial diagnosis, etc.

 

[beginner2011]

I think that is fine, but trying to argue that we are only needed for complex cases is painting us in a corner. So, the financial case for us can't be that we can help increase reimbursements 20% in 20% of cases. That will never justify a salary and they may decide to leave that on the table.

My thought is more along the lines of reduce total health service utilization by for pts in the clinic by 60% or something. If 20% of cases stick around for 10x as long as the rest (30 months instead of 3 months, e.g.), or end up using 10x more in services (end up in the ER multiple times per month or on the inpatient psychiatry unit, e.g.). I believe that would justify a salary. Again, this is speculative, but it's a theory that's based on observation.

If clinics were to have clinical case managers who were devoted to case management and increasing access (the type of role a LCSW would excel in), streamlining care to refer complex cases to psychotherapists who are adept assessors and trained in evidence based principles (the type of role a psychologist would excel in) then health service utilization would be lower than the current system... at least that's the theory. Is this sort of model in practice in any health care systems right now?

 

[Sanman]

My thought is more along the lines of reduce total health service utilization by for pts in the clinic by 60% or something. If 20% of cases stick around for 10x as long as the rest (30 months instead of 3 months, e.g.), or end up using 10x more in services (end up in the ER multiple times per month or on the inpatient psychiatry unit, e.g.). I believe that would justify a salary. Again, this is speculative, but it's a theory that's based on observation.

If clinics were to have clinical case managers who were devoted to case management and increasing access (the type of role a LCSW would excel in), streamlining care to refer complex cases to psychotherapists who are adept assessors and trained in evidence based principles (the type of role a psychologist would excel in) then health service utilization would be lower than the current system... at least that's the theory. Is this sort of model in practice in any health care systems right now?

Yes, your model makes a great case for including social workers to reduce care costs. It also makes them the gatekeepers for care as the case managers/treatment coordinators. They will include us in care because we better than them at psychotherapy (says who? not social workers) and because that is what we want? Social workers can be trained in EBPs as well. Why not cut us out entirely? After all, they are licensed to provide therapy as well in addition to being case managers.

The problem that you have is you are trying to compare us to a cheaper alternative to save money in an area we are already being utilized. I would argue that the case management that will reduce ER utilization and inpatient stays (ensuring meds are taken, outpatient physicians are called, etc. Not sure that our treatment will have much is any effect on that. Especially if they are already utilizing mental health care. Wrong direction, the way to make a case is to point to how we reduce physician visits and issues like non-compliance and depression related to medical illness in patients not currently seen by mental health. That brings us more work.

 

[R. Matey]

Interesting that they're only hiring LCSWs. Is this another area of psychologists getting pushed out due to costs?

There's a reason Julia Roberts played a social worker (and not a psychologist) in Homecoming. We would ask too many questions.

Yes, your model makes a great case for including social workers to reduce care costs. It also makes them the gatekeepers for care as the case managers/treatment coordinators. They will include us in care because we better than them at psychotherapy (says who? not social workers) and because that is what we want? Social workers can be trained in EBPs as well. Why not cut us out entirely? After all, they are licensed to provide therapy as well in addition to being case managers.

Except their noncompliance with EPBs because they are more vulnerable to pseudoscience, which contributes to healthcare waste. You can force the issue through tracking or something, but people will find a way to subvert it. This is less of a problem with a properly trained psychologist.

My thought is more along the lines of reduce total health service utilization by for pts in the clinic by 60% or something. If 20% of cases stick around for 10x as long as the rest (30 months instead of 3 months, e.g.), or end up using 10x more in services (end up in the ER multiple times per month or on the inpatient psychiatry unit, e.g.). I believe that would justify a salary. Again, this is speculative, but it's a theory that's based on observation.

If clinics were to have clinical case managers who were devoted to case management and increasing access (the type of role a LCSW would excel in), streamlining care to refer complex cases to psychotherapists who are adept assessors and trained in evidence based principles (the type of role a psychologist would excel in) then health service utilization would be lower than the current system... at least that's the theory. Is this sort of model in practice in any health care systems right now?

This 100%

Ill-equipped midlevels contribute to healthcare waste in the form of unnecessarily prolonged services.

 

[beginner2011]

They will include us in care because we better than them at psychotherapy (says who? not social workers) and because that is what we want?

I've been digging in to the literature on the impact of psychotherapy training on outcomes.
A lot of the meta-analyses I've come across would really qualify as Garbage In Garbage Out status (where was PRISMA when all these SRMAs were being published in the 90s!?).
For example, there is an interesting review from 1995 on the topic. They state, "It is concluded that a variety of outcome sources are associated with modest effect sizes favoring more trained therapists." (PDF) Graduate Training in Psychotherapy: Are Therapy Outcomes Enhanced?

When you really drill down into the individual studies and set a high bar for inclusion, there is evidence for a positive effect of training on outcomes. More training = less drop out. More training = more improvement in symptoms rated by independent clinicians.

Of course, some of the over all effects were not significant, but the heterogeneity of the populations, settings, and how "training" was rated was massive (e.g., in one study, training was a continuous variable of "years since began practicing" and psychiatrists, social workers, and psychologists were all thrown together in the same bin).
Also, the sample sizes for most of these studies were not very large (n<60 in many cases), so even with multiple effects trending toward favoring training the headline was "not significant".

The more I look in to this topic the more I think this shouldn't be ground that should just be ceded. Yes, of course there are many amazingly skilled LCSW folks. However, there's also evidence that more training = better outcomes. Just because it's hard to do research on this topic it doesn't mean we should give up as a field.

 

[cara susanna]

My thought is more along the lines of reduce total health service utilization by for pts in the clinic by 60% or something. If 20% of cases stick around for 10x as long as the rest (30 months instead of 3 months, e.g.), or end up using 10x more in services (end up in the ER multiple times per month or on the inpatient psychiatry unit, e.g.). I believe that would justify a salary. Again, this is speculative, but it's a theory that's based on observation.

If clinics were to have clinical case managers who were devoted to case management and increasing access (the type of role a LCSW would excel in), streamlining care to refer complex cases to psychotherapists who are adept assessors and trained in evidence based principles (the type of role a psychologist would excel in) then health service utilization would be lower than the current system... at least that's the theory. Is this sort of model in practice in any health care systems right now?

First, LCSWs can be skilled at more complex cases. It's diagnosis and assessment where they seem to be weaker (IMO). Furthermore, not every patient needs case management.

As mentioned by R. Matey, the biggest thing I've noticed about LCSWs is buying into junk clinical practices and not really understanding research (which obviously I wouldn't expect them to, since they aren't trained like us). I know a few who are awesome in this area too, but they seem to be more exceptions than the rule.

 

[Ollie123]

Just to be abundantly clear - my vision of what we could capture from VBC is actually a fair bit different from what you outlined beginner2011. Yes we still do therapy, but we capture that value in part by the fact that we can offer a lot more than that. Directing higher-acuity cases towards those with more training might be a small component, but overall I'm talking about a wayyy more dramatic re-envisioning of our roles in the healthcare system. I don't know that complexity or severity is necessarily the differentiating factor here. Maybe I'm just a bad therapist, but I absolutely have severe/complex cases that don't do well, patients I can't get rid of but absolutely cannot get to engage around evidence-based approaches, etc. These are folks I'd be happy to kick to a mid-level since quite frankly I'm really just doing case management and supportive therapy anyways. I have zero faith I'm offering anything even a poorly trained mid-level couldn't, let alone a well-trained one.

Matching patients to therapists/treatments hasn't gone well for us in the past, but I think we'll need to figure out a way to do this effectively at some point. Its also worth noting we can cede some aspects of care without ceding the entirety of it.

 

[Sanman]

I've been digging in to the literature on the impact of psychotherapy training on outcomes.
A lot of the meta-analyses I've come across would really qualify as Garbage In Garbage Out status (where was PRISMA when all these SRMAs were being published in the 90s!?).
For example, there is an interesting review from 1995 on the topic. They state, "It is concluded that a variety of outcome sources are associated with modest effect sizes favoring more trained therapists." (PDF) Graduate Training in Psychotherapy: Are Therapy Outcomes Enhanced?

When you really drill down into the individual studies and set a high bar for inclusion, there is evidence for a positive effect of training on outcomes. More training = less drop out. More training = more improvement in symptoms rated by independent clinicians.

Of course, some of the over all effects were not significant, but the heterogeneity of the populations, settings, and how "training" was rated was massive (e.g., in one study, training was a continuous variable of "years since began practicing" and psychiatrists, social workers, and psychologists were all thrown together in the same bin).
Also, the sample sizes for most of these studies were not very large (n<60 in many cases), so even with multiple effects trending toward favoring training the headline was "not significant".

The more I look in to this topic the more I think this shouldn't be ground that should just be ceded. Yes, of course there are many amazingly skilled LCSW folks. However, there's also evidence that more training = better outcomes. Just because it's hard to do research on this topic it doesn't mean we should give up as a field.

To be clear, I am not saying that psychologists don't provide better psychotherapy than midlevels. However, even if you win this argument we lose. Let's say that everyone agrees that 1. psychologists are better at managing complex cases and administering EBPs 2. That midlevels cannot be given training to get them up to par on this. Upthread it was mentioned that CVS was paying SWs $45k. I know my old company used to pay them in the $50s. Say that psychologists are 20% better at reducing clinic utilization than a SW. 20% of 50k is 10k and they want to save money. So, we will hire psychologists instead at $59k. Are you happy with that salary? Is that a win? What happens to the math when SWs accept $45k salaries instead? $40k? It would still be cheaper to hire a SW with worse outcomes than a psychologist at $80-100k.

Now, how much are psychologists worth to the healthcare system if we can reduce diabetics healthcare utilization of endocrinologists 20% and they can hire fewer of them at $200k-250k a pop. How about if we increase adherence in patients with heart disease and get them to make lifestyle changes that cause them to have fewer heart attacks. Less cardiologists at $300-500k a pop. How much are we worth now?

 

[R. Matey]

First, LCSWs can be skilled at more complex cases. It's diagnosis and assessment where they seem to be weaker (IMO). Furthermore, not every patient needs case management.

This is a very good point. LCSWs do provide case management services where I am doing my postdoc and it is quite helpful though not needed for everyone. I've worked with both good social workers from excellent top tier program and terrible ones from online programs. My experience across the board has been a reluctance to embrace evidenced based practices because they are seen negatively. To me, this hinders their ability to take on a complex case, but admittedly, I've never set foot in a VA where I would expect to encounter more social workers trained in EBPs.

 

[AcronymAllergy]

To be clear, I am not saying that psychologists don't provide better psychotherapy than midlevels. However, even if you win this argument we lose. Let's say that everyone agrees that 1. psychologists are better at managing complex cases and administering EBPs 2. That midlevels cannot be given training to get them up to par on this. Upthread it was mentioned that CVS was paying SWs $45k. I know my old company used to pay them in the $50s. Say that psychologists are 20% better at reducing clinic utilization than a SW. 20% of 50k is 10k and they want to save money. So, we will hire psychologists instead at $59k. Are you happy with that salary? Is that a win? What happens to the math when SWs accept $45k salaries instead? $40k? It would still be cheaper to hire a SW with worse outcomes than a psychologist at $80-100k.

Now, how much are psychologists worth to the healthcare system if we can reduce diabetics healthcare utilization of endocrinologists 20% and they can hire fewer of them at $200k-250k a pop. How about if we increase adherence in patients with heart disease and get them to make lifestyle changes that cause them to have fewer heart attacks. Less cardiologists at $300-500k a pop. How much are we worth now?

Related to this, I can't remember exactly how he phrased it, but I had a supervisor in grad school who would say he made an effort to treat at least a few panic disorder pts every year because the savings to the system in reduced ER visits basically paid for his salary.

 

[cara susanna]

Related to this, I can't remember exactly how he phrased it, but I had a supervisor in grad school who would say he made an effort to treat at least a few panic disorder pts every year because the savings to the system in reduced ER visits basically paid for his salary.

DBT is similar - you can save so much money by reducing ED visits/hospitalizations. Of course, administrators don't always care about long-term savings IMO.

 

[beginner2011]

To be clear, I am not saying that psychologists don't provide better psychotherapy than midlevels. However, even if you win this argument we lose. Let's say that everyone agrees that 1. psychologists are better at managing complex cases and administering EBPs 2. That midlevels cannot be given training to get them up to par on this. Upthread it was mentioned that CVS was paying SWs $45k. I know my old company used to pay them in the $50s. Say that psychologists are 20% better at reducing clinic utilization than a SW. 20% of 50k is 10k and they want to save money. So, we will hire psychologists instead at $59k. Are you happy with that salary? Is that a win? What happens to the math when SWs accept $45k salaries instead? $40k? It would still be cheaper to hire a SW with worse outcomes than a psychologist at $80-100k.

I gave an example above that would easily justify a larger salary bump than 20%. The above examples were not (to me) outlandish estimates, and would have reduced total health service utilization by 60% (ER visits for panic disorder, hepatology clinic visits for AUD, sleep clinic visits for insomnia, etc.). For example, whereas w/o psychologist health service costs from all 100 pts in a clinic would be 500k, with a psychologist (for $50k more), pts in the same clinic would be using $200k, because those 20 complex pts are accounting for an outsized portion of the total health services usage.

To be clear, I am not saying that psychologists don't provide better psychotherapy than midlevels. However, even if you win this argument we lose. Let's say that everyone agrees that 1. psychologists are better at managing complex cases and administering EBPs 2. That midlevels cannot be given training to get them up to par on this. Upthread it was mentioned that CVS was paying SWs $45k. I know my old company used to pay them in the $50s. Say that psychologists are 20% better at reducing clinic utilization than a SW. 20% of 50k is 10k and they want to save money. So, we will hire psychologists instead at $59k. Are you happy with that salary? Is that a win? What happens to the math when SWs accept $45k salaries instead? $40k? It would still be cheaper to hire a SW with worse outcomes than a psychologist at $80-100k.

Now, how much are psychologists worth to the healthcare system if we can reduce diabetics healthcare utilization of endocrinologists 20% and they can hire fewer of them at $200k-250k a pop. How about if we increase adherence in patients with heart disease and get them to make lifestyle changes that cause them to have fewer heart attacks. Less cardiologists at $300-500k a pop. How much are we worth now?

To me this ends up being the same issue. If the story that gets told to administrators is that midlevels can do everything that a psychologist does just as well then why not just hire a midlevel to increase adherence in pts with heart disease? At some point psychologists must demonstrate that their training is linked to improved outcomes relative to comparators. Why not psychotherapy? Yes we can say "oh that ship has already sailed," but has it? Says who?

 

[ClinicalABA]

Are you providing psychotherapy? Are you salaried by a third party payor?...

No and no. I have an assessment only practice, and am a salaried employee of what is best described as a private group practice. We are an assessment affiliated with ABA treatment agency, with multiple locations across the state (4 psychologists and some post-docs).. Admittedly, this gives me a different perspective and different set of contingencies than psychotherapy providers. I am not in competition with MA level practitioners, as my diagnostic evals (for ASD) are tied directly to state law requiring which requires insurance companies to pay for ABA services for anybody diagnosed with ASD by a Psychologist or Physician. Physicians in my area do not, as a rule, make such a diagnosis.

Demand for my services in my area is insane (I'm currently booking in January/February, 2022). As @PsyDr suggested, we advocate constantly with insurance companies and the state insurance board for appropriate rates. My agency retains a lobbyist, we have frequent events with key state legislators, and we frequently run employees for leadership positions within state and national level professional organization. While me don't necessarily have an big issue with current reimbursement rates for neuro-assessment, we recognize that it is important to stay on top of the issue, get included in legislation, let insurers know that we are at the table, and just generally be friends and benefactors of folks in high places. However, the suggestion to raise prices in response to demand would simply result in people (mainly minority, ESL, or low SES) not getting the services. out of 100 or so assessments per year, maybe a dozen or so are private insurance, and none are private pay (there are a few clinicians in the area who do private pay assessments for ASD, but it's not the norm). In focusing on an underserved population, I think it's a big leap to say "psychologists should not be priests." My "clients" are toddlers, and not providing services to then because of their parent's financial status would just be a bit cruel, dontcha think?
I am not giving away my services personally (I make a 6 figure salary), or as an agency.

In my area, it's as much an issue of supply as demand. It's a good gig (IMO), with very competitive salaries and benefits. We are, however, about 90 miles from the nearest major city. There are no doctoral programs in the area that produce clinicians who do this work, and trying to hire the regional Psy.D. company is like playing Russian roullette. but with bullets in five chambers instead of just one! If we could address the supply side issues, continue with reasonably fair rates, with the same level of demand, I could see a "drive up" model of service delivery It would take some adjustment of some of the pre-auth procedures (don't get me started on the ridiculousness of having to do an intake appointment and submit an auth request form that is never- and legislatively probably COULD never be- denied). We do our work in offices, in intervals of 1 hours because that's what we've always done, not because it's been shown to be related to the best outcomes.

 

[Sanman]

I gave an example above that would easily justify a larger salary bump than 20%. The above examples were not (to me) outlandish estimates, and would have reduced total health service utilization by 60% (ER visits for panic disorder, hepatology clinic visits for AUD, sleep clinic visits for insomnia, etc.). For example, whereas w/o psychologist health service costs from all 100 pts in a clinic would be 500k, with a psychologist (for $50k more), pts in the same clinic would be using $200k, because those 20 complex pts are accounting for an outsized portion of the total health services usage.



To me this ends up being the same issue. If the story that gets told to administrators is that midlevels can do everything that a psychologist does just as well then why not just hire a midlevel to increase adherence in pts with heart disease? At some point psychologists must demonstrate that their training is linked to improved outcomes relative to comparators. Why not psychotherapy? Yes we can say "oh that ship has already sailed," but has it? Says who?

I never took issue with your statement that total health service utilization could be reduced. I took issue with your idea that 80% of mental health cases can be handled by SWs with 20% of complex cases would be managed by psychologists. My point is that that psychologists need to differentiate their services from SWs and it can't just be that we do it better in more complex cases. I am saying that psychologists should be embedded more widely in primary care clinics to address behavioral issues in medical care because then we are comparing our services to no services not mid-level services. If a patient who walks into a cardiology or hepatology clinic is non-compliant, who is better placed to diagnose whether this is depression vs poor understanding to due lack or education vs mild neurocognitive disorder? We should be the ones triaging, diagnosing, and formulating the treatment plan for all patients. The difference is that your model relegates us to identified complex cases. Mine argues that we should be triaging everyone first. More jobs for us in the primary care end rather than fewer in the specialty care end.

Think of it this way. Do you want the physician diagnosing you and sending you to the NP/PA for treatment if the case is not complicated or do you want to rely on the NP/PA to recognize that the case is complicated and refer you to the physician? They don't know what they don't know.

 

[R. Matey]

My point is that that psychologists need to differentiate their services from SWs and it can't just be that we do it better in more complex cases. I am saying that psychologists should be embedded more widely in primary care clinics to address behavioral issues in medical care because then we are comparing our services to no services not mid-level services.

I'm embedded in primary care and do some of this, but most of it is done by midlevels in the system where I work and there is no financial incentive for me to stay past postdoc. LPCs/SWs usually end up referring for issues that could've been dealt with there (i.e.: panic attacks) thus contributing to waste. An example of this is that an LPC referred a case for me to follow for a person who they diagnosed with panic disorder, but actually was suffering from cannabis withdrawal. So yeah, we can do better.

 

[PsyDr]

My "clients" are toddlers, and not providing services to then because of their parent's financial status would just be a bit cruel, dontcha think?
I am not giving away my services personally (I make a 6 figure salary), or as an agency.

Private schools would disagree with you.

Resources are finite. It is cruel to not pay people for their work. You are accepting resources that could be used for toddlers.

 

[Sanman]

I'm embedded in primary care and do some of this, but most of it is done by midlevels in the system where I work and there is no financial incentive for me to stay past postdoc. LPCs/SWs usually end up referring for issues that could've been dealt with there (i.e.: panic attacks) thus contributing to waste. An example of this is that an LPC referred a case for me to follow for a person who they diagnosed with panic disorder, but actually was suffering from cannabis withdrawal. So yeah, we can do better.

There will not be an incentive for you to stay until the system transitions to a 100% value based care model and healthcare systems notices a significant decline in reimbursements. As it stands, there is no money in it for the most part. Mine is the only job I know of that is based on value based care (HBPC programs were put in place in order to keep veterans at home and the VA from having to pay for nursing home care for veterans).