CVS To Offer In-Store Mental Health Counseling

[ClinicalABA]

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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.

**Assume ad hominem here**

so the argument is:

1)raise prices so the population you serve can’t afford

2) figure that out later

3) make more profit

I think are differences in opinion are at a higher level than service delivery.

 

[Sanman]

**Assume ad hominem here**

so the argument is:

1)raise prices so the population you serve can’t afford

2) figure that out later

3) make more profit

I think are differences in opinion are at a higher level than service delivery.

There will always be a market for improved services for those with more money regardless of the system. Even in systems with government run healthcare, private hospitals and doctors offices with decreased wait times and better services exist. The question becomes what level of services should be affordable to all.

 

[PsyDr]

**Assume ad hominem here**

so the argument is:

1)raise prices so the population you serve can’t afford

2) figure that out later

3) make more profit

I think are differences in opinion are at a higher level than service delivery.

If you want to categorize the Law of Supply Demand as an argument.....

Supply and demand - Wikipedia

en.wikipedia.org

Which is how pricing is created for things like salaries, hotel rates, and rental cars rates.

 

[beginner2011]

If you want to categorize the Law of Supply Demand as an argument.....

Supply and demand - Wikipedia

en.wikipedia.org

Which is how pricing is created for things like salaries, hotel rates, and rental cars rates.

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).

Huh? It sounds like the law of supply and demand is at play. The demand is higher than supply, but only because the service is essentially free (government/insurance funded) to the consumer.

If ClinicalABA were to try to raise the price beyond what the govt is willing to reimburse for then the demand would drop to a minute fraction of what ClinicalABA is currently receiving. Maybe some fraction of the clientele could still afford it, but far fewer. In other words, the government has inflated the demand by decreasing the cost through subsidization/reimbursement. No?

 

[Sanman]

Huh? It sounds like the law of supply and demand is at play. The demand is higher than supply, but only because the service is essentially free (government/insurance funded) to the consumer.

If ClinicalABA were to try to raise the price beyond what the govt is willing to reimburse for then the demand would drop to a minute fraction of what ClinicalABA is currently receiving. Maybe some fraction of the clientele could still afford it, but far fewer. In other words, the government has inflated the demand by decreasing the cost through subsidization/reimbursement. No?

That only matters if Clinical ABA could not fill slots. If 1000 people want services the government pays for and ClinicalABA only has 100 slots, he can afford to raise the price until he only has 100 takers. Whatever that price is. If you increase access/supply, then no one will be willing to pay extra for those 100 slots and there will be no extra money. No reason to pay ClinicalABA a nice salary when there are others taking less. Maybe the government lowers their rates since there is plenty of competition.

 

[PsyDr]

That only matters if Clinical ABA could not fill slots. If 1000 people want services the government pays for and ClinicalABA only has 100 slots, he can afford to raise the price until he only has 100 takers. Whatever that price is. If you increase access/supply, then no one will be willing to pay extra for those 100 slots and there will be no extra money. No reason to pay ClinicalABA a nice salary when there are others taking less. Maybe the government lowers their rates since there is plenty of competition.

It also works for salaries. A clinic has 100 appointments per month that cannot be met with the current staff. If you advertise a salary that is too high, you will get too many applicants. If you advertise a salary that is too low, you will get too few applicants.

 

[beginner2011]

That only matters if Clinical ABA could not fill slots. If 1000 people want services the government pays for and ClinicalABA only has 100 slots, he can afford to raise the price until he only has 100 takers. Whatever that price is. If you increase access/supply, then no one will be willing to pay extra for those 100 slots and there will be no extra money. No reason to pay ClinicalABA a nice salary when there are others taking less. Maybe the government lowers their rates since there is plenty of competition.

Unless I misunderstood, it sounded like CABA was saying that if they tried to increase price then they wouldn't fill slots because the govt wouldn't be subsidizing for that increased rate.

 

[Sanman]

Unless I misunderstood, it sounded like CABA was saying that if they tried to increase price then they wouldn't fill slots because the govt wouldn't be subsidizing for that increased rate.

While I don't want to speak for @ClinicalABA, my understanding was that raising prices or only accepting higher paying clients would make care less accessible for those of fewer means who might not he able to afford higher rates. That is a fair argument. However, I think @PsyDr was pointing out that providing reimbursement even at current levels is taking money out of the pot of those needs, so why not accept even less pay? Point being, there needs to be a balance between supply (accessibility) and demand if we want to be paid well. There are likely larger arguments on both sides regarding good for the individual provider vs society at large. Is pumping out so many clinicians that everyone that needs can get treatment a good thing? Perhaps. Does it also mean that the provider will be compensated what they consider fairly? Unlikely. So, where is the balance?

 

[clausewitz2]

While I don't want to speak for @ClinicalABA, my understanding was that raising prices or only accepting higher paying clients would make care less accessible for those of fewer means who might not he able to afford higher rates. That is a fair argument. However, I think @PsyDr was pointing out that providing reimbursement even at current levels is taking money out of the pot of those needs, so why not accept even less pay? Point being, there needs to be a balance between supply (accessibility) and demand if we want to be paid well. There are likely larger arguments on both sides regarding good for the individual provider vs society at large. Is pumping out so many clinicians that everyone that needs can get treatment a good thing? Perhaps. Does it also mean that the provider will be compensated what they consider fairly? Unlikely. So, where is the balance?

That depends on what one thinks the marginal utility of the dollars going to @ClinicalABA are. That is, to what purpose will the funds that would be used to pay them be used for if they are not spent on reimbursement? If, say, they are going to some equally critical need and the pot is fixed in size, then your point is a good one. If, however, one thinks either that a) those dollars will otherwise be spent on a less worthy project than enabling them to continue their practice or b) that the pot is not really fixed in size, I'm not sure it has force. I am not a healthcare economist but my impression and understanding of how Medicaid/Medicare operate is that they try to control costs based on eligibility and specification of services they will pay for, +/- audits and clawbacks. they don't seem to decline to reimburse claims because they have hit the end of their operating budget for the quarter. Thus it might really be the case that if those dollars are not going to @ClinicalABA, they might not be spent at all.

 

[Sanman]

That depends on what one thinks the marginal utility of the dollars going to @ClinicalABA are. That is, to what purpose will the funds that would be used to pay them be used for if they are not spent on reimbursement? If, say, they are going to some equally critical need and the pot is fixed in size, then your point is a good one. If, however, one thinks either that a) those dollars will otherwise be spent on a less worthy project than enabling them to continue their practice or b) that the pot is not really fixed in size, I'm not sure it has force. I am not a healthcare economist but my impression and understanding of how Medicaid/Medicare operate is that they try to control costs based on eligibility and specification of services they will pay for, +/- audits and clawbacks. they don't seem to decline to reimburse claims because they have hit the end of their operating budget for the quarter. Thus it might really be the case that if those dollars are not going to @ClinicalABA, they might not be spent at all.

While that is true that there are no quarterly decreases to the budget based on caps, Medicare sequestration means that Congress spends time reviewing areas where Medicare reimbursements should be restored and where cuts can go through to avoid across the board sequestration. Do you think that they choose what gets cut strictly on what will do the most good or based on what they can get away with based on economic and lobbying factors? In which case a group with less leverage may get harder hit.

There is also the intermediate layer of the company he works for and whether the revenue he generates will be returned to him. The company I used to work for required clinicians to generate ~$200k in billables annually and paid them $80k because it was market rate. Is that good use of funds?

 

[clausewitz2]

There is also the intermediate layer of the company he works for and whether the revenue he generates will be returned to him. The company I used to work for required clinicians to generate ~$200k in billables annually and paid them $80k because it was market rate. Is that good use of funds?

I really, really, devoutly hope that being booked clear into next year means has the @ClinicalABA negotiating leverage to demand a fee split or productivity arrangement.

 

[ClinicalABA]

I really, really, devoutly hope that being booked clear into next year means has the @ClinicalABA negotiating leverage to demand a fee split or productivity arrangement.

Thanks for your concern. I assure you, I'm doing just fine🙂. If I felt like I needed more, I have the leverage to make that happen. I have always believed in working good (not necessarily hard) and being reinforced adequately for doing. Where employers have not shared my view, I've found new employers, to the benefit of both them and me, and very much to the detriment of my previous employers.

Listen- I get the free market stuff (and thanks to the Adam Smiths above for provided supply/demand charts). I guess the gist of my argument is that I don't work in free market system, and I don't think it should be. If I can't afford a hotel or rental car, I don't get to go on that vacation. If families can't afford to get their toddlers evaluated and given a diagnosis, then that kid might not learn to communicate, play, or refrain from beating up his siblings. In the vacation example, I can stay somewhere cheaper, use the bus, or even skip vacation altogether. In the toddler example, there is no comparable "inferior good" for them to purchase.

 

[ClinicalABA]

Huh? It sounds like the law of supply and demand is at play. The demand is higher than supply, but only because the service is essentially free (government/insurance funded) to the consumer.

If ClinicalABA were to try to raise the price beyond what the govt is willing to reimburse for then the demand would drop to a minute fraction of what ClinicalABA is currently receiving. Maybe some fraction of the clientele could still afford it, but far fewer. In other words, the government has inflated the demand by decreasing the cost through subsidization/reimbursement. No?

Only if you assume that there is no fair ceiling on rates, and they should be based solely on demand. In the case of my clinic, I see big issues on the supply side. We are not interviewing psychologists who are turning down offers because of low salaries. We are not getting even minimally qualified applicants, and our salary, benefits, productivity expectations, and clinical population (imho) are VERY desirable.

 

[PsyDr]

Unless you’re making minimum wage, your salary is the result of a free market system.

 

[ClinicalABA]

Unless you’re making minimum wage, your salary is the result of a free market system.

Of course it is. I still think that there are very big access to care issues, and a lot of that is on the supply side.

 

[WisNeuro]

Of course it is. I still think that there are very big access to care issues, and a lot of that is on the supply side.

Supply of psychologists? Because it's not that low. In fact, our own industry and government projection analyses would argue that we'll be oversupplied soon unless demand increases well beyond expectations. I think those analyses are actually a rosier picture because they don't seem to account much for midlevel encroachment, which many of us see at local levels.

 

[Sanman]

Of course it is. I still think that there are very big access to care issues, and a lot of that is on the supply side.

Lack of supply or a lack of appropriate training opportunities for that supply? While my undergrad alma mater had an ABA training program and early childhood assessment center, my grad program had nothing close to those opportunities. I rotated through peds neuropsych, but nothing related to early childhood assessment. I feel like this is more of an issue related to lack of uniformity in training than lack of graduates.

 

[ClinicalABA]

Supply of psychologists? Because it's not that low. In fact, our own industry and government projection analyses would argue that we'll be oversupplied soon unless demand increases well beyond expectations. I think those analyses are actually a rosier picture because they don't seem to account much for midlevel encroachment, which many of us see at local levels.

Yes- supply of psychologists who provide this specialized service in my region, relative to the demand in my region. I'm talking about psychologists who can provide a specific service that MA level therapist cannot (due to traing or legislative issues)

 

[ClinicalABA]

Lack of supply or a lack of appropriate training opportunities for that supply? While my undergrad alma mater had an ABA training program and early childhood assessment center, my grad program had nothing close to those opportunities. I rotated through peds neuropsych, but nothing related to early childhood assessment. I feel like this is more of an issue related to lack of uniformity in training than lack of graduates.

I don't think you can separate the two (lack of supply and lack of training opportunities). If I had to, I think I'd say lack of training opportunities, as that would temporally proceed lack of trained professionals.

 

[sloh]

Yes- supply of psychologists who provide this specialized service in my region, relative to the demand in my region. I'm talking about psychologists who can provide a specific service that MA level therapist cannot (due to traing or legislative issues)

Could this be more of a practitioner distribution issue?

 

[beginner2011]

Could this be more of a practitioner distribution issue?

Interesting question, and YIKES.

Where are the highest concentrations of licensed psychologists?

There are approximately 106,000 licensed psychologists in the United States, but the distribution of those psychologists is uneven across the country.

www.apa.org

 

[cara susanna]

This map explains why I get so many recruitment emails.

 

[Ollie123]

Would be helpful to see this normed by county population - unless I'm missing something, doesn't look like it was. Some areas surprise me as a result (i.e. unsure how Montana/Wyoming are average). They don't quantify the shading anyways and I don't know for sure, but I'd expect that to pull the tails of the distribution in some.

 

[WisNeuro]

Would be helpful to see this normed by county population - unless I'm missing something, doesn't look like it was. They don't quantify the shading anyways and I don't know for sure, but I'd expect that to pull the tails of the distribution in some.

Yeah, I mean it would make sense that you;d have more providers of every type in population centers. I'd like to see this smoothed out in a per capita basis that would more accurately show over/under saturation.

"2 The map was based on the Getis-Ord statistic generated from county-level hot spot analysis based on the number of licensed psychologists per county. Different concentrations were statistically compared to the national average at the following probability levels: very low concentration (p < .01), low concentration (p < .05), high concentration (p < .05) and very high concentration (p < .01). Counties with no records of licensed psychologists were treated as zeroes. Due to large proportions of records with missing addresses in Hawaii, Oklahoma and Utah, state means of licensed psychologists per county for these three states were used in the analysis.

 

[beginner2011]

Would be helpful to see this normed by county population - unless I'm missing something, doesn't look like it was. Some areas surprise me as a result (i.e. unsure how Montana/Wyoming are average). They don't quantify the shading anyways and I don't know for sure, but I'd expect that to pull the tails of the distribution in some.

Based on the fact that it looks like Cook County (Chicago; pop = ~5 million) is "average concentration" and La Paz County (pop = ~20k) is "very high concentration" I can only assume it has been normed.

 

[WisNeuro]

How Hot Spot Analysis (Getis-Ord Gi*) works—ArcGIS Pro | Documentation

An in-depth discussion of the Gi* statistic is provided.

pro.arcgis.com

 

[ClinicalABA]

I am smack dab in the middle of one of those patches of red. Not all psychologists are created equal. The localish "pay-to-play" institution pumps out dozens of license eligible psyds per year. They typically don't have the combination of interest, training, clinical skills, or professional skills for our needs. The very local phd program (my alma mater) has moved to a clinical scientist model, so grads tend to go academia (and there is no child/ASD focus there). Also- the concentration of licensed psychologists in my area is somewhat inflated by presence of the University (and the several other colleges) and the licensed faculty therein.

So I guess that, yes, it is an issue of distribution to areas of need. That issue does stem from training, though, as well as a relatively newly created need (i.e. state legislation requiring private insurance companies to pay for ASD evals is only about 10 years old, with similar legislation requiring state medicaid to do so only coming around in ~2016.

 

[WisNeuro]

I am smack dab in the middle of one of those patches of red. Not all psychologists are created equal. The localish "pay-to-play" institution pumps out dozens of license eligible psyds per year. They typically don't have the combination of interest, training, clinical skills, or professional skills for our needs. The very local phd program (my alma mater) has moved to a clinical scientist model, so grads tend to go academia (and there is no child/ASD focus there). Also- the concentration of licensed psychologists in my area is somewhat inflated by presence of the University (and the several other colleges) and the licensed faculty therein.

So I guess that, yes, it is an issue of distribution to areas of need. That issue does stem from training, though, as well as a relatively newly created need (i.e. state legislation requiring private insurance companies to pay for ASD evals is only about 10 years old, with similar legislation requiring state medicaid to do so only coming around in ~2016.

I'd agree that the specialists are probably going to be fine for longer than therapy generalists. General therapy is where we have and will continue to cede the most ground to midlevels as well as suffer the consequences of the diploma mills. But, unfortunately, most of our billing codes seem to sink or swim together, so institutional players will continue to get hammered.

 

[ClinicalABA]

How Hot Spot Analysis (Getis-Ord Gi*) works—ArcGIS Pro | Documentation

An in-depth discussion of the Gi* statistic is provided.

pro.arcgis.com

It would seem that those graphs are using overall statistics from across the nation and computing regional z-scores. If that's the case, the big red patch I'm in has as much to do, statistically speaking, with the number of psychologists in the big blue patch as it does with the number of them near me. IThe label of "high concentration" is anchored the population SD and Mean, rather than the actual need. You could could also interpret this graph (probably incorrectly) to mean that there are lower rates of mental illness in the blue areas just a much as you could say there's a "shortage" of psychologists in the blue areas.

 

[Ollie123]

Yeah, that analytic method is a bit funky. There is also clearly a smoothing algorithm I'd need to dig in to understand. I guarantee you there is an urban/rural component to this that from my reading of this isn't getting picked up. No way Oklahoma City, St. Louis, Kansas City, etc. are "as" underserved as rural counties in those states.

Don't get me wrong, still a useful figure. This is just a complicated issue and one that is grown moreso by increasing hyper-specialization. Overall specialization is a good thing, but it can definitely create some geographic oddities in availability of specific services. Some urban areas are otherwise hard-up for neuropsych access. I'm sure somewhere there is a rural area with a weird abundance of child therapists but no one trained in PE, etc.

In a world where I had infinite time/resources (as opposed to my reality of extremely limited resources and negative amounts of time), I'd love to write a web crawler that parsed/aggregated keywords from psychology today pages and PP/hospital websites (e.g. child/adult/gero, CBT/dynamic/ACT/Mindfulness, depression/trauma/addiction, etc.) and plot that over a map like this. Bet you anything we would see some trends that differ dramatically from the overall "# of psychologists" metric.
Retirement project?

 

[R. Matey]

I'd agree that the specialists are probably going to be fine for longer than therapy generalists. General therapy is where we have and will continue to cede the most ground to midlevels as well as suffer the consequences of the diploma mills. But, unfortunately, most of our billing codes seem to sink or swim together, so institutional players will continue to get hammered.

I wonder if that claim is stratified by SES. Working with all income levels in my current position, those with a master's degree and up will wait to see me than be paired with another mid-level peddling mindfulness. Not saying I'm the world's best therapist, but R. Matey, Ph.D. seems to have some market value.

 

[WisNeuro]

I wonder if that claim is stratified by SES. Working with all income levels in my current position, those with a master's degree and up will wait to see me than be paired with another mid-level peddling mindfulness. Not saying I'm the world's best therapist, but R. Matey, Ph.D. seems to have some market value.

I agree that in some settings, and with certain SES, a PhD will always have the prestige factor. But, let's take my former hospital's MH OP clinic. If t he option is to see a midlevel, or go somewhere else, possible OON, doesn't leave a lot of room for choice if there are no doctoral providers even available in some settings.

To your point, I am one of those anecdotes. I will not see an NP/PA for my primary care needs. If I were to need MH tx, I would not go to a midlevel, even if it meant paying OOP. But, I am also someone with fairly considerable means, which is not most of the population.

 

[R. Matey]

I agree that in some settings, and with certain SES, a PhD will always have the prestige factor. But, let's take my former hospital's MH OP clinic. If t he option is to see a midlevel, or go somewhere else, possible OON, doesn't leave a lot of room for choice if there are no doctoral providers even available in some settings.

To your point, I am one of those anecdotes. I will not see an NP/PA for my primary care needs. If I were to need MH tx, I would not go to a midlevel, even if it meant paying OOP. But, I am also someone with fairly considerable means, which is not most of the population.

I'm of less considerable means currently, but would probably make the same decision because I value services provided by experts. But, agree to this, and your point upthread that we probably are talking about smaller segments of the population than many of us would like.

 

[AcronymAllergy]

I am smack dab in the middle of one of those patches of red. Not all psychologists are created equal. The localish "pay-to-play" institution pumps out dozens of license eligible psyds per year. They typically don't have the combination of interest, training, clinical skills, or professional skills for our needs. The very local phd program (my alma mater) has moved to a clinical scientist model, so grads tend to go academia (and there is no child/ASD focus there). Also- the concentration of licensed psychologists in my area is somewhat inflated by presence of the University (and the several other colleges) and the licensed faculty therein.

So I guess that, yes, it is an issue of distribution to areas of need. That issue does stem from training, though, as well as a relatively newly created need (i.e. state legislation requiring private insurance companies to pay for ASD evals is only about 10 years old, with similar legislation requiring state medicaid to do so only coming around in ~2016.

This applies to my area of the map as well, although in the opposite direction--I'm in a low/very low area, but there are probably more neuropsychologists per capita here than many other small or medium-sized cities, at least from what I know. It's definitely still an interesting map.

 

[thebalmofhurtminds]

I agree that in some settings, and with certain SES, a PhD will always have the prestige factor. But, let's take my former hospital's MH OP clinic. If t he option is to see a midlevel, or go somewhere else, possible OON, doesn't leave a lot of room for choice if there are no doctoral providers even available in some settings.

To your point, I am one of those anecdotes. I will not see an NP/PA for my primary care needs. If I were to need MH tx, I would not go to a midlevel, even if it meant paying OOP. But, I am also someone with fairly considerable means, which is not most of the population.

This is my preference as well, and piggybacking off of why that might be difficult to find alternatives - at my hospital (biggest hospital in the city, blah blah) they specifically told me that their MD OB/GYNs are not even taking "healthy" patients at this time, even for 1 year+ wait list. It was NP/PA or nothing.

 

[watchfulwaiting1957]

Supply of psychologists? Because it's not that low. In fact, our own industry and government projection analyses would argue that we'll be oversupplied soon unless demand increases well beyond expectations. I think those analyses are actually a rosier picture because they don't seem to account much for midlevel encroachment, which many of us see at local levels.

I just saw this article today in the WSJ CVS Wants to Be Your Therapist, Too

I don't know if CVS will be having midlevels or hire MDs to do the psy counseling at the pharmacies and then subsequent script generation for the pharmacy to fill. Either way I think this will change the landscape for psychiatrists and maybe psyDs as well. Think about what Walmart did to optometrists and what the corps (Aspen and Heartland) have done to dentistry recently.

 

[WisNeuro]

I just saw this article today in the WSJ CVS Wants to Be Your Therapist, Too

I don't know if CVS will be having midlevels or hire MDs to do the psy counseling at the pharmacies and then subsequent script generation for the pharmacy to fill. Either way I think this will change the landscape for psychiatrists and maybe psyDs as well. Think about what Walmart did to optometrists and what the corps (Aspen and Heartland) have done to dentistry recently.

The therapy will definitely be done by midlevels and/or diploma mill grads. They'd have trouble findings MD/DOs to do therapy at the reimbursement that they are likely going to offer.

 

[AcronymAllergy]

The therapy will definitely be done by midlevels and/or diploma mill grads. They'd have trouble findings MD/DOs to do therapy at the reimbursement that they are likely going to offer.

Agreed that it'll likely be midlevels. If they're already staffing their urgent care clinics with NPs instead of physicians, I don't foresee them staffing their MH clinics with psychologists or psychiatrists, unless the psychologists are willing to accept the offered reimbursement.

 

[WisNeuro]

Agreed that it'll likely be midlevels. If they're already staffing their urgent care clinics with NPs instead of physicians, I don't foresee them staffing their MH clinics with psychologists or psychiatrists, unless the psychologists are willing to accept the offered reimbursement.

Yeah, every minute clinic or similar around here is staffed with NP/PA. I'm sure in states without independent practicing, they'll just hire a physician regionally who is pretty much just there to rubber stamp notes for like 10 stores.

 

[AcronymAllergy]

Yeah, every minute clinic or similar around here is staffed with NP/PA. I'm sure in states without independent practicing, they'll just hire a physician regionally who is pretty much just there to rubber stamp notes for like 10 stores.

I've also never seen a physician in a CVS or Walgreens clinic. I have seen some physicians in some of the stand-alone urgent care centers (some of which I suspect are probably physician-owned) or those affiliated with a hospital.

 

[watchfulwaiting1957]

The therapy will definitely be done by midlevels and/or diploma mill grads. They'd have trouble findings MD/DOs to do therapy at the reimbursement that they are likely going to offer.

what if they try to make up the low reimbursement with volume?

 

[psych.meout]

what if they try to make up the low reimbursement with volume?

 

[WisNeuro]

what if they try to make up the low reimbursement with volume?

Well, yeah, that's what every hospital system has been doing for years now, only those systems will be paying a lot more for it than pharmacies. Also, these "one-stop" pharmacies are already keyed in to the midlevel business model. They're not going to pivot in the direction of increasing their overhead.