Graduate debt in Psychology (again)

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Peacemaker36

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I just came across the following fairly recent article about grad school debt across all type of programs.

https://pages.uncc.edu/richard-mcan...ran_Graduate-Debt-in-Psychology_TEPP-2016.pdf

The picture described is not rosy. The article confirms the financial advice we hear often on SDN, and extends the argument to questioning whether even the funded PhD is a viable option. Do folks here find this article credible?

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Breezed through it quick. Tough to say without seeing their advertising materials - if specifically advertised as a study about debt I wouldn't be surprised if that somewhat inflated the numbers (people with debt more likely to respond).

That said, I didn't see anything completely unreasonable that would cause me to question its credibility. I think many take on more than they should. I think even at fully funded programs I see many students take on loans that aren't strictly necessary but allow for a somewhat more comfortable life. That said, I also think the relationship between dollar amount of loans and actual difficulty it causes is exponential and not linear. Small amounts of debt (i.e. an extra 5-10k/year to supplement a stipend) should bemanageable by most, even if not ideal. The relative "burdensomeness" likely accelerates rapidly as the number goes up since it will necessarily start to compete with fixed expenses, versus simply reducing discretionary spending.
 
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I just came across the following fairly recent article about grad school debt across all type of programs.

https://pages.uncc.edu/richard-mcan...ran_Graduate-Debt-in-Psychology_TEPP-2016.pdf

The picture described is not rosy. The article confirms the financial advice we hear often on SDN, and extends the argument to questioning whether even the funded PhD is a viable option. Do folks here find this article credible?
I think this speaks to a much bigger issue in our country

https://www.google.com/amp/s/www.fo.../06/13/student-loan-debt-statistics-2018/amp/

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I disagree with the idea that it is a debt problem. I believe it is an an income problem. Compare the numbers for psychiatry. If you’re making $250k, $62-100k in debt is nothing. If you’re making $60-80k, you’re screwed.

The debt problem cannot be due to poor math. Students can google income. I believe that many students believe they can beat the odds, overestimate their work ethic, and base their opinions off of the lifestyles of established psychologists without taking inflation, changing interest rates, and changing tuition into account.
 
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I disagree with the idea that it is a debt problem. I believe it is an an income problem. Compare the numbers for psychiatry. If you’re making $250k, $62-100k in debt is nothing. If you’re making $60-80k, you’re screwed.

The debt problem cannot be due to poor math. Students can google income. I believe that many students believe they can beat the odds, overestimate their work ethic, and base their opinions off of the lifestyles of established psychologists without taking inflation, changing interest rates, and changing tuition into account.
So why don't we make more in this field? I mean that as a serious question. Is it because we are bad at advocating for ourselves? Is it because we are viewed as the red-headed step-child of the scientific/"real doctors" world? We offer valuable services and train for a very long time. Why do psychiatrists make 250k out of school and we make 60k??

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Are we really supposed to have sympathy for people that take out >$200,000 in student loan debt for grad school, especially when there are debt free paths, and they also expect the public to bail them out of their bad choices?
 
I disagree with the idea that it is a debt problem. I believe it is an an income problem. Compare the numbers for psychiatry. If you’re making $250k, $62-100k in debt is nothing. If you’re making $60-80k, you’re screwed.

The debt problem cannot be due to poor math. Students can google income. I believe that many students believe they can beat the odds, overestimate their work ethic, and base their opinions off of the lifestyles of established psychologists without taking inflation, changing interest rates, and changing tuition into account.
I'm pretty sure I've seen you previously argue that it's at least partially due to poor math, for which I would agree.
 
@psych.meout

I think it’s partially based on ones overestimate of abilities, which is kinda math based, but mostly personality based.

@Magick91683


My opinions:


1) Psychologists have a bad work ethic. If you look at the hourly rate of some physicians, it is not super different than psychologists. The physicians are better at maintaining a stream of business, and actually billing for all of their time. We are not generally paid to write a letter, fill in a form, or return phone calls, but everyone does. A psychologist who actually bills 40hrs/week for psychotherapy to medicare will absolutely make over $150k. But the median salary is like $80k. Don’t you think employers would be lining up to hire a dozen psychologists if they actually brought in this revenue? They don’t though. In my first job, I worked 6 days/week because I was paid for productivity.

2) Psychologists are bad at providing clear results. Most professionals provide clear results. Go to a lawyer, they give advice or draw up a contract. Go to a physician and get a physical and a prescription. Go to a psychologist and it’s not as clear. This makes marketing to the public, insurers, and referral stream hard.

3) Psychologists are difficult. There seems to be a culture of arguing and fighting the power etc that’s inherent in the field. You could invent a cure for mental illness and most psychologists would spend a significant amount of time picking at the bad parts of your study while everyone else is cheering. This makes it hard to unite, and harder to get hired. In that same first job, the other ecp literally complained to the practice owner that it wasn’t fair that I made more money because I worked on the weekend. Seriously.

4) Wardrobe is generally less than business professional. Like it or not, the world respects a certain formality.

5) because of the low income/poor work ethic, and the fighting the power thing, psychologists are very very very bad at effectively lobbying. Pragmatically, it would be better for the profession if we kept negative things quiet and handled things in house like other professionals. We don’t. We put things into the public and argue about what to do. People freaked out a few years ago about like a $300 increase in apa dues. That’s bonkers. We should be contributing thousands.

6) the fetish with the brain is bad for a profession that mostly deal with behavior.

7) we don’t put money into advertising like we did in the past. Psychotherapy was cool at one point.

8) few innovators. There’s not too many professions that still practice in the same way they did in 1917. Few seem to care about this. We should.

9) ironically, psychologists are bad at direct communication. And passive communication seems more typical. I don’t care about the gender of it all argument. The pragmatics are that direct communication styles are the basis for most professionals.

Imagine going to a CPA because you have a tax problem. You show up, and the cpa is dressed somewhere between jeans and casual Friday at a typical office, tells you a lot of problems are due to systemwide stuff with the irs’s beliefs in something, gives vague advice like “there’s some form we can fill out, but not now.”, he charges $75, tells you to come back in a week and you’ll work on stuff some more, and he doesn’t have a computer, but he only sees 2 people a day because he’s emotionally drained afterwards, and only works tuesdays from 11-2.

You’d run like hell, right?

Now imagine going to a different cpa. They’re dressed in a nice suit, their office is nice, they listen to your problem, tell you a clear plan of action which has worked with others in a similar predicament, with a clear schedule of appointments and end date, politely deflects their personal opinions about stuff, and charges you $400.

You’d feel better about that, right?

Now imagine who you’d hire.

That’s some of the things screwing up psychologists.
 
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@psych.meout

I think it’s partially based on ones overestimate of abilities, which is kinda math based, but mostly personality based.

@Magick91683


My opinions:


1) Psychologists have a bad work ethic. If you look at the hourly rate of some physicians, it is not super different than psychologists. The physicians are better at maintaining a stream of business, and actually billing for all of their time. We are not generally paid to write a letter, fill in a form, or return phone calls, but everyone does. A psychologist who actually bills 40hrs/week for psychotherapy to medicare will absolutely make over $150k. But the median salary is like $80k. Don’t you think employers would be lining up to hire a dozen psychologists if they actually brought in this revenue? They don’t though. In my first job, I worked 6 days/week because I was paid for productivity.

2) Psychologists are bad at providing clear results. Most professionals provide clear results. Go to a lawyer, they give advice or draw up a contract. Go to a physician and get a physical and a prescription. Go to a psychologist and it’s not as clear. This makes marketing to the public, insurers, and referral stream hard.

3) Psychologists are difficult. There seems to be a culture of arguing and fighting the power etc that’s inherent in the field. You could invent a cure for mental illness and most psychologists would spend a significant amount of time picking at the bad parts of your study while everyone else is cheering. This makes it hard to unite, and harder to get hired. In that same first job, the other ecp literally complained to the practice owner that it wasn’t fair that I made more money because I worked on the weekend. Seriously.

4) Wardrobe is generally less than business professional. Like it or not, the world respects a certain formality.

5) because of the low income/poor work ethic, and the fighting the power thing, psychologists are very very very bad at effectively lobbying. Pragmatically, it would be better for the profession if we kept negative things quiet and handled things in house like other professionals. We don’t. We put things into the public and argue about what to do. People freaked out a few years ago about like a $300 increase in apa dues. That’s bonkers. We should be contributing thousands.

6) the fetish with the brain is bad for a profession that mostly deal with behavior.

7) we don’t put money into advertising like we did in the past. Psychotherapy was cool at one point.

8) few innovators. There’s not too many professions that still practice in the same way they did in 1917. Few seem to care about this. We should.

9) ironically, psychologists are bad at direct communication. And passive communication seems more typical. I don’t care about the gender of it all argument. The pragmatics are that direct communication styles are the basis for most professionals.

Imagine going to a CPA because you have a tax problem. You show up, and the cpa is dressed somewhere between jeans and casual Friday at a typical office, tells you a lot of problems are due to systemwide stuff with the irs’s beliefs in something, gives vague advice like “there’s some form we can fill out, but not now.”, he charges $75, tells you to come back in a week and you’ll work on stuff some more, and he doesn’t have a computer, but he only sees 2 people a day because he’s emotionally drained afterwards, and only works tuesdays from 11-2.

You’d run like hell, right?

Now imagine going to a different cpa. They’re dressed in a nice suit, their office is nice, they listen to your problem, tell you a clear plan of action which has worked with others in a similar predicament, with a clear schedule of appointments and end date, politely deflects their personal opinions about stuff, and charges you $400.

You’d feel better about that, right?

Now imagine who you’d hire.

That’s some of the things screwing up psychologists.
Wow. This makes so much sense to me. I especially agree with your point about the number of people we see per day and our field constantly bickering with each other.

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@psych.meout

I think it’s partially based on ones overestimate of abilities, which is kinda math based, but mostly personality based.

@Magick91683


My opinions:


1) Psychologists have a bad work ethic. If you look at the hourly rate of some physicians, it is not super different than psychologists. The physicians are better at maintaining a stream of business, and actually billing for all of their time. We are not generally paid to write a letter, fill in a form, or return phone calls, but everyone does. A psychologist who actually bills 40hrs/week for psychotherapy to medicare will absolutely make over $150k. But the median salary is like $80k. Don’t you think employers would be lining up to hire a dozen psychologists if they actually brought in this revenue? They don’t though. In my first job, I worked 6 days/week because I was paid for productivity.

2) Psychologists are bad at providing clear results. Most professionals provide clear results. Go to a lawyer, they give advice or draw up a contract. Go to a physician and get a physical and a prescription. Go to a psychologist and it’s not as clear. This makes marketing to the public, insurers, and referral stream hard.

3) Psychologists are difficult. There seems to be a culture of arguing and fighting the power etc that’s inherent in the field. You could invent a cure for mental illness and most psychologists would spend a significant amount of time picking at the bad parts of your study while everyone else is cheering. This makes it hard to unite, and harder to get hired. In that same first job, the other ecp literally complained to the practice owner that it wasn’t fair that I made more money because I worked on the weekend. Seriously.

4) Wardrobe is generally less than business professional. Like it or not, the world respects a certain formality.

5) because of the low income/poor work ethic, and the fighting the power thing, psychologists are very very very bad at effectively lobbying. Pragmatically, it would be better for the profession if we kept negative things quiet and handled things in house like other professionals. We don’t. We put things into the public and argue about what to do. People freaked out a few years ago about like a $300 increase in apa dues. That’s bonkers. We should be contributing thousands.

6) the fetish with the brain is bad for a profession that mostly deal with behavior.

7) we don’t put money into advertising like we did in the past. Psychotherapy was cool at one point.

8) few innovators. There’s not too many professions that still practice in the same way they did in 1917. Few seem to care about this. We should.

9) ironically, psychologists are bad at direct communication. And passive communication seems more typical. I don’t care about the gender of it all argument. The pragmatics are that direct communication styles are the basis for most professionals.

Imagine going to a CPA because you have a tax problem. You show up, and the cpa is dressed somewhere between jeans and casual Friday at a typical office, tells you a lot of problems are due to systemwide stuff with the irs’s beliefs in something, gives vague advice like “there’s some form we can fill out, but not now.”, he charges $75, tells you to come back in a week and you’ll work on stuff some more, and he doesn’t have a computer, but he only sees 2 people a day because he’s emotionally drained afterwards, and only works tuesdays from 11-2.

You’d run like hell, right?

Now imagine going to a different cpa. They’re dressed in a nice suit, their office is nice, they listen to your problem, tell you a clear plan of action which has worked with others in a similar predicament, with a clear schedule of appointments and end date, politely deflects their personal opinions about stuff, and charges you $400.

You’d feel better about that, right?

Now imagine who you’d hire.

That’s some of the things screwing up psychologists.


Said another way, I think that many fail to realize that we work in a customer service profession and that the profession is slow to address market changes/demands. Some of this is due to the fact that we are a licensed profession and falling into line is somewhat necessary for CYA. For example, Why is 45-50 min considered the requisite time for a standard session?
 
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Said another way, I think that many fail to realize that we work in a customer service profession and that the profession is slow to address market changes/demands. Some of this is due to the fact that we are a licensed profession and falling into line is somewhat necessary for CYA. For example, Why is 45-50 min considered the requisite time for a standard session?
I get annoyed with this, but maybe in the opposite way you do. One of the Medicaid panels I bill will only cover 90834 and not 90837. Who gets to decide this? I feel like I should because I'm the dr and I'm the one with the training so I should determine how long a patient needs to be seen. Some patients may need only 30 min, but if I'm doing Prolonged Exposure I definitely need that entire hour.

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I get annoyed with this, but maybe in the opposite way you do. One of the Medicaid panels I bill will only cover 90834 and not 90837. Who gets to decide this? I feel like I should because I'm the dr and I'm the one with the training so I should determine how long a patient needs to be seen. Some patients may need only 30 min, but if I'm doing Prolonged Exposure I definitely need that entire hour.

Tip of the iceberg regarding billing codes. Most commercial insurers will deny 90837 without pre-authorization and the completely unqualified person (1st level; 2nd/3rd level insurance treatment auth people are often clinicians) on the phone that wasted your time may or may not approve it for prolonged exposure. Straight medicare is pretty good about 90837. Who decides? The one paying the bill does. You will likely end up doing what most do, which is offer only services that are easily reimbursed for your market or move outside of the insurance system.

To the point, I am not upset about longer or shorter session approvals. Rather, the poor way that it fits many clinical needs. I may need 15 min or 60 min, not just 45 min. Rather I prefer the way in which health & behavior codes are reimbursed ( in 15 min increments), but not the poor level at which they are reimbursed.
 
Tip of the iceberg regarding billing codes. Most commercial insurers will deny 90837 without pre-authorization and the completely unqualified person (1st level; 2nd/3rd level insurance treatment auth people are often clinicians) on the phone that wasted your time may or may not approve it for prolonged exposure. Straight medicare is pretty good about 90837. Who decides? The one paying the bill does. You will likely end up doing what most do, which is offer only services that are easily reimbursed for your market or move outside of the insurance system.

To the point, I am not upset about longer or shorter session approvals. Rather, the poor way that it fits many clinical needs. I may need 15 min or 60 min, not just 45 min. Rather I prefer the way in which health & behavior codes are reimbursed ( in 15 min increments), but not the poor level at which they are reimbursed.

If only there was a set of codes that would reimburse you for the time and complexity, for the evaluation and management of your patients...

E/M codes are one of the keys to our professional longevity
 
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Tip of the iceberg regarding billing codes. Most commercial insurers will deny 90837 without pre-authorization and the completely unqualified person (1st level; 2nd/3rd level insurance treatment auth people are often clinicians) on the phone that wasted your time may or may not approve it for prolonged exposure. Straight medicare is pretty good about 90837. Who decides? The one paying the bill does. You will likely end up doing what most do, which is offer only services that are easily reimbursed for your market or move outside of the insurance system.

To the point, I am not upset about longer or shorter session approvals. Rather, the poor way that it fits many clinical needs. I may need 15 min or 60 min, not just 45 min. Rather I prefer the way in which health & behavior codes are reimbursed ( in 15 min increments), but not the poor level at which they are reimbursed.
That makes sense. I have only had one panel that has a problem with 90837. But we do get a before PA (I think it's called that-this is all new to me). Medicare has definitely been easier to deal with-better reimbursement rates for sure. I just wish our system worked more like that of an attorney where would could bill for EVERYTHING. Is there really no way to get paid for non face to face time through any insurance (whether private or Medicaid/medicate)?

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You mean like interactive complexity?
If only there was a set of codes that would reimburse you for the time and complexity, for the evaluation and management of your patients...

E/M codes are one of the keys to our professional longevity

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Is there really no way to get paid for non face to face time through any insurance (whether private or Medicaid/medicate)?

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I can only speak to my state (MA) but Medicaid allows states to create waiver/demonstration projects for Home and community based supports. For children and adolescents under 21, who were provided these HCB services, a provider could bill for phone calls, documenting etc. I used to provide intensive family therapy in the home, and could bill for the direct time with the family/youth, time spent documenting the comprehensive assessment in the EHR, time spent documenting the session, developing the treatment plan, attending meetings with other providers or schools, phone calls with parents etc. all billed in 15 min increments. It’s annoying that outpatient providers can’t do the same, as it all benefits the client. Not sure how other states handle this.
 
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I can only speak to my state (MA) but Medicaid allows states to create waiver/demonstration projects for Home and community based supports. For children and adolescents under 21, who were provided these HCB services, a provider could bill for phone calls, documenting etc. I used to provide intensive family therapy in the home, and could bill for the direct time with the family/youth, time spent documenting the comprehensive assessment in the EHR, time spent documenting the session, developing the treatment plan, attending meetings with other providers or schools, phone calls with parents etc. all billed in 15 min increments. It’s annoying that outpatient providers can’t do the same, as it all benefits the client. Not sure how other states handle this.
Thanks for that information. I completely agree that outpatient providers can't do the same. Im not sure I could see more than 7 clients per day. And that would get old pretty quickly if it were the only thing I were doing 5 days per week. The place where I am working does have contracts with home and school based services but I'm not exactly sure how their billing works.

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E/M codes are one of the keys to our professional longevity

Psychologists had their shot at this. I worry we're not getting any closer.

One of the Medicaid panels I bill will only cover 90834 and not 90837. Who gets to decide this?

I'd wager that the vast majority of early career psychologists cannot answer this question in a coherent way. But they should be able to by the time they graduate. As a health service profession I think we are unique in our degree of tunnel vision.
 
Psychologists had their shot at this. I worry we're not getting any closer.



I'd wager that the vast majority of early career psychologists cannot answer this question in a coherent way. But they should be able to by the time they graduate. As a health service profession I think we are unique in our degree of tunnel vision.
I completely agree. I'm about a month into my postdoc and trying to figure this out. Obviously I have some guidance but I really would like to have a better understanding for myself about how all of this works. This was never discussed in my graduate program, my prac sites, or my internship.

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I'd wager that the vast majority of early career psychologists cannot answer this question in a coherent way. But they should be able to by the time they graduate. As a health service profession I think we are unique in our degree of tunnel vision.

Ha, I know a good number of psychologists that could not only not answer this, but did not know the basic time requirements for the major CPT codes. The social workers were worse than the psychologists overall, but the amount to accidental billing fraud occurring kept my job quite secure.
 
You mean like interactive complexity?

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Yes, but much more useful. Psychologists get a single interactive complexity code that adds something like $4 to a session fee. E/M codes are all billed on time and complexity. So you have time it took, the level of history, the extent of examination, and the level of decision-making.

So , treating a young person with a single issue or a well-check on an existing patient might be complexity level 1 office visit.
Treating an older complex patient with multiple medical and psychiatric issues might be coded as a complexity level 4 office visit.

So, physicians make more money treating complex patients while psychologists are better off treating the easiest patient possible.
 
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Yes, but much more useful. Psychologists get a single interactive complexity code that adds something like $4 to a session fee. E/M codes are all billed on time and complexity. So you have time it took, the level of history, the extent of examination, and the level of decision-making.

So , treating a young person with a single issue or a well-check on an existing patient might be complexity level 1 office visit.
Treating an older complex patient with multiple medical and psychiatric issues might be coded as a complexity level 4 office visit.

So, physicians make more money treating complex patients while psychologists are better off treating the easiest patient possible.
But that's not fair I sound like my 10 year old.

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I don't know if I agree on all that. I think many of the points you make are a byproduct of the current situation. I think the answer is much simpler. Providing therapy is not as lucrative as writing prescriptions. There are numerous mid-level provider that can do it and doing therapy is costlier for patients (time, resources, understanding). RxP are much more inclusive, less providers can do it and less costly for patients.

The best comparison is likely psychiatry since we deal with the same problems (as opposed to lawyers and CPAs). My anecdotal experiences with psychiatrist, they don't seem less difficult, don't dress better, and don't have a better work ethic. Psychiatry takes an even greater bio-based approach. I don't know if there has been much innovation since Prozac. Psychiatry does seem to be clearer and direct: take this pill and come back in 1-6 months.

These questions can be answered empirically, so all this is just hot air. I would bet the evidence supports my hypothesis and we would only need to compare typical psychologists, RxP psychologists, and psychiatrists.

Of course, what I am doing right now supports your point #3 :)

@psych.meout

I think it’s partially based on ones overestimate of abilities, which is kinda math based, but mostly personality based.

@Magick91683


My opinions:


1) Psychologists have a bad work ethic. If you look at the hourly rate of some physicians, it is not super different than psychologists. The physicians are better at maintaining a stream of business, and actually billing for all of their time. We are not generally paid to write a letter, fill in a form, or return phone calls, but everyone does. A psychologist who actually bills 40hrs/week for psychotherapy to medicare will absolutely make over $150k. But the median salary is like $80k. Don’t you think employers would be lining up to hire a dozen psychologists if they actually brought in this revenue? They don’t though. In my first job, I worked 6 days/week because I was paid for productivity.

2) Psychologists are bad at providing clear results. Most professionals provide clear results. Go to a lawyer, they give advice or draw up a contract. Go to a physician and get a physical and a prescription. Go to a psychologist and it’s not as clear. This makes marketing to the public, insurers, and referral stream hard.

3) Psychologists are difficult. There seems to be a culture of arguing and fighting the power etc that’s inherent in the field. You could invent a cure for mental illness and most psychologists would spend a significant amount of time picking at the bad parts of your study while everyone else is cheering. This makes it hard to unite, and harder to get hired. In that same first job, the other ecp literally complained to the practice owner that it wasn’t fair that I made more money because I worked on the weekend. Seriously.

4) Wardrobe is generally less than business professional. Like it or not, the world respects a certain formality.

5) because of the low income/poor work ethic, and the fighting the power thing, psychologists are very very very bad at effectively lobbying. Pragmatically, it would be better for the profession if we kept negative things quiet and handled things in house like other professionals. We don’t. We put things into the public and argue about what to do. People freaked out a few years ago about like a $300 increase in apa dues. That’s bonkers. We should be contributing thousands.

6) the fetish with the brain is bad for a profession that mostly deal with behavior.

7) we don’t put money into advertising like we did in the past. Psychotherapy was cool at one point.

8) few innovators. There’s not too many professions that still practice in the same way they did in 1917. Few seem to care about this. We should.

9) ironically, psychologists are bad at direct communication. And passive communication seems more typical. I don’t care about the gender of it all argument. The pragmatics are that direct communication styles are the basis for most professionals.

Imagine going to a CPA because you have a tax problem. You show up, and the cpa is dressed somewhere between jeans and casual Friday at a typical office, tells you a lot of problems are due to systemwide stuff with the irs’s beliefs in something, gives vague advice like “there’s some form we can fill out, but not now.”, he charges $75, tells you to come back in a week and you’ll work on stuff some more, and he doesn’t have a computer, but he only sees 2 people a day because he’s emotionally drained afterwards, and only works tuesdays from 11-2.

You’d run like hell, right?

Now imagine going to a different cpa. They’re dressed in a nice suit, their office is nice, they listen to your problem, tell you a clear plan of action which has worked with others in a similar predicament, with a clear schedule of appointments and end date, politely deflects their personal opinions about stuff, and charges you $400.

You’d feel better about that, right?

Now imagine who you’d hire.

That’s some of the things screwing up psychologists.
 
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At least in the clinical realm, I'll add on to what others have said. Much of what is done, namely therapy, is also done by midlevels, as has been mentioned. Yes, many of us probably do it better since we received adequate training, but we have not empirically demonstrated that in any meaningful way. Why would CMS/insurance pay us significantly more for that billing code than a midlevel when we have given them no reason to do such? And honestly, with the proliferation of diploma mills, we are pumping out way too many "doctors" who are actually at the competency levels, or in some cases below, those same mid-level providers.

And, as others have mentioned in some capacity, our advocacy has lagged other professional bodies. Both at the local and national level. As a whole, we don't contribute very much to our national advocacy bodies (e.g., APAPO). Either because many have crippling levels of debt that they brought upon themselves and feel justified in not contributing, or because they are taking some kind of stance against the APA because of some tangentially related issue. Either way, the end result is the same, our advocates at the national level, who are currently in negotiations with the new CMS billing guidelines for 2019, have limited funds of which to spend on lobbying efforts, especially compared with other doctoral level professions. At the local level, I see far too many of us avoiding leadership input. In the several hospitals in proximity within my system, I am the only psychologist that regularly shows up to the mental health council meetings, of which we all hold voting seats on. And, they wonder why the presence of psychology has been waning over the years.
 
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many of us probably do it better since we received adequate training, but we have not empirically demonstrated that in any meaningful way
probably b/c there is no financial incentive to demonstrate an effect. Who would gain from empirical evidence that doctoral trained clinicians lead to better outcomes? Not the insurance companies, not Big Pharma, and definitely not traditional PhD programs that are fighting off high caliber applicants annually.

or because they are taking some kind of stance against the APA because of some tangentially related
I think the problem is we are plumbers with a traditional learned background. So, while we apply services (practice) we also have to make sure its true (science). And it becomes very difficult for some to contribute to unsupported or pseudoscientific advocacy.
 
probably b/c there is no financial incentive to demonstrate an effect. Who would gain from empirical evidence that doctoral trained clinicians lead to better outcomes? Not the insurance companies, not Big Pharma, and definitely not traditional PhD programs that are fighting off high caliber applicants annually.

Well, we as a profession stand to gain financially is there was a demonstrable effect. The study would just have to be conducted independently for political reasons. It could be the most well-designed outcome study in the world, but if it were conducted by the APA, it would be dismissed by most parties as biased and invalid.
 
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Since it hasn't come up yet - for those who aren't following there ARE major changes to billing in the pipeline. CMS is rolling out changes that will impact Medicare, but it is expected other payers will follow suit in short order.

MACRA: MIPS & APMs - Centers for Medicare & Medicaid Services

Short version - beginning the gradual process of shifting towards a "fee for value" model and population health. Has the potential to curb costs and better incentivize cost control. As with most system changes, it is likely to be a train wreck for a few years. The good news is that I think this framework has the potential to benefit us tremendously in the long run, assuming we adapt. Our patients are typically higher utilizers than average. We bring value, but the broader system is not designed in a way that properly captures that value and I think this is a step in the right direction. What it will really mean in the end and whether we will be able to capture that value into increased reimbursement is a separate question, but its changing how I think about my clinical effort

Especially for folks in private practice who take insurance - you need to be preparing for this. I imagine most/all hospital systems are aware and working to address, but I know a few people in practice who were completely unaware this was even a thing. Tons of articles (both news and scientific) out there already, so read up.
 
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To follow up with Ollie, there are actually huge changes coming to assessment. For those of you who are used to/like to do lengthy evals, get ready for a pay cut.
Yup.

More and more, there is going to be a need for brief, validated, and highly effective instruments that measure more in less time. For instance, the RBANS seems great in theory until you look and find zero support for its interpretive factor structure. Yet I still see people treating them like they are... *I'll rant about this to myself in person* Thats going to pose an increasing problem in the coming years since folks are likely to continue relying on measures that fall into that group to make conclusions during briefer assessment procedures. And that, my friends, is how we look to underscore the thing we bring to the healthcare table.
 
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Yup.

More and more, there is going to be a need for brief, validated, and highly effective instruments that measure more in less time. For instance, the RBANS seems great in theory until you look and find zero support for its interpretive factor structure. Yet I still see people treating them like they are... *I'll rant about this to myself in person* Thats going to pose an increasing problem in the coming years since folks are likely to continue relying on measures that fall into that group to make conclusions during briefer assessment procedures. And that, my friends, is how we look to underscore the thing we bring to the healthcare table.

Yeah, the RBANS is ok for inpatient assessments with individuals currently exhibiting a fairly low cognitive ceiling. I see OTs giving it like it's a comprehensive outpatient eval, though.
 
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Yeah, the RBANS is ok for inpatient assessments with individuals currently exhibiting a fairly low cognitive ceiling. I see OTs giving it like it's a comprehensive outpatient eval, though.
Yeh, it's an 'ok' measure of general function in some contexts but I've seen a number of neuropsychs giving it outpatient as well, and more often than not they interpret factor scores. Why? I don't know.
 
Yeh, it's an 'ok' measure of general function in some contexts but I've seen a number of neuropsychs giving it outpatient as well, and more often than not they interpret factor scores. Why? I don't know.

I wonder if we looked at the training background of these "neuropsychologists" if we'd see a trend? I will check down to the RBANS in an outpatient setting in some circumstances. 1.) the patient is way more impaired than I thought after interview and a few of my usual measures, and 2) they failed validity measures in a big way.
 
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@DynamicDidactic


To be fair, I am only voicing my opinions just like you. It's not like either of us have the answer to all this, unless you're holding back on us. I don't think my opinions are better than your anecdotes.

There is absolutely a financial incentive. If the product had a high popular demand, it would be expensive as a luxury item. If the product which was paid for by a third party, was cheaper and longer lasting, it would be highly sought after as a cost reduction strategy.

@Sanman

Bet you didn't know psychologist had the ability to use E/M codes way back when. We gave them away.

@Justanothergrad

I believe this is the effect of neuropsych moving from a diagnostic procedure to a descriptive procedure. Keep in mind that diagnosis comes from the psychologist's judgement, not the test. We're just awful at calling it without backing it up with 900 pages of support. I believe this to be due to the educational model. Ever been referred someone whose diagnosis you know within 15 minutes, but have to test for another 4 hours to support your diagnosis?

@WisNeuro

One of the former officers of AACN uses the RBANs in HUGE legal proceedings.
 
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Let's get Wis some extra RBANS Update forms for his birthday. You really want that downward age extension so that you can test the 12-year olds as outpatients, too!

I've already got A and B. Can you send me C and D? That way I can set up my "mTBI" clinic and do some serial testing over a few months.
 
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I've already got A and B. Can you send me C and D? That way I can set up my "mTBI" clinic and do some serial testing over a few months.
Everyone knows that only works if the patient has intensive OT/PT/SLP...add in some vestibular therapy, prism glasses, and maybe some “brain games”....
 
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Everyone knows that only works if the patient has intensive OT/PT/SLP...add in some vestibular therapy, prism glasses, and maybe some “brain games”....

I was going to offer those things too. I figure if they can practice well out of their scope and upward, I can practice outside of mine and downward.
 
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I believe this is the effect of neuropsych moving from a diagnostic procedure to a descriptive procedure. Keep in mind that diagnosis comes from the psychologist's judgement, not the test. We're just awful at calling it without backing it up with 900 pages of support. I believe this to be due to the educational model. Ever been referred someone whose diagnosis you know within 15 minutes, but have to test for another 4 hours to support your diagnosis?
I'm sure that is part of the issue, but why are they performing tests to backup their diagnostic impression that don't do those things. Sure, I've continued doing testing when it isn't needed for me to inform my impression, but those tests at least add to it/can offer support for my position. It's more than a bit ethically questionable to bill/provide a service that offers no utility because the test doesn't work, just to say you did a test. It's part of why I question 'neuropsych' evals for ADHD with a heavy testing component.

Of course, we should have diagnostic procedures, bu that's another issue. I mean, we know that interpretation of standardized test results in dubious at best (e.g., Cook et al., 2017)Cox, Cox, & Caplan, 2013; Guilmette, Hagan, &Giuliano, 2008). The Guilmette article is probably my favorite cause of the degree to which it shows how problematic this is even among experts, and neuropsych is a lot better in producing consistent testing interpretation than other assessment subdisciplines. This shouldn't be a surprise though.... *cue Paul Meehl*
 
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I think the managed behavioral healthcare system in this country is largely a checklist model at this point, sans some cases. Your psychometric issues/concerns mean nothing to managed care companies. Nor does how the fact some of our psychometric tests/rating scales might inform treatment planning... rather than just the diagnosis per se and are thus medically justified/necessary.

These decisions are ultimately being dictated by people who make more money than you and don't care about your profession or the tests.
 
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I think the managed behavioral healthcare system in this country is largely a checklist model at this point, sans some cases. Your psychometric issues/concerns mean nothing to managed care companies. Nor does how the fact some of our psychometric tests/rating scales might inform treatment planning... rather than just the diagnosis per se and are thus medically justified/necessary.

These decisions are ultimately being dictated by people who make more money than you and don't care about your profession or the tests.
Sad but true.
 
I'm sure that is part of the issue, but why are they performing tests to backup their diagnostic impression that don't do those things. Sure, I've continued doing testing when it isn't needed for me to inform my impression, but those tests at least add to it/can offer support for my position. It's more than a bit ethically questionable to bill/provide a service that offers no utility because the test doesn't work, just to say you did a test. It's part of why I question 'neuropsych' evals for ADHD with a heavy testing component.

Of course, we should have diagnostic procedures, bu that's another issue. I mean, we know that interpretation of standardized test results in dubious at best (e.g., Cook et al., 2017)Cox, Cox, & Caplan, 2013; Guilmette, Hagan, &Giuliano, 2008). The Guilmette article is probably my favorite cause of the degree to which it shows how problematic this is even among experts, and neuropsych is a lot better in producing consistent testing interpretation than other assessment subdisciplines. This shouldn't be a surprise though.... *cue Paul Meehl*


I think the other issue is that as mentioned above, there is a lot of utility in a test the length of an RBANS or Cognistat for many patients as compared to a full battery in the current environment. I think that people make do with what they have often. I know that I am constrained to MOCA and RBANS due to a number of non-clinical factors. If not the RBANS, what is your choice of test give similar administration time constraints?
 
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I think the other issue is that as mentioned above, there is a lot of utility in a test the length of an RBANS or Cognistat for many patients as compared to a full battery in the current environment. I think that people make do with what they have often. I know that I am constrained to MOCA and RBANS due to a number of non-clinical factors. If not the RBANS, what is your choice of test give similar administration time constraints?
I love the RBANS... but as a screener. Isn't that its intended purpose?

Sent from my SM-G950U using SDN mobile
 
I think the other issue is that as mentioned above, there is a lot of utility in a test the length of an RBANS or Cognistat for many patients as compared to a full battery in the current environment. I think that people make do with what they have often. I know that I am constrained to MOCA and RBANS due to a number of non-clinical factors. If not the RBANS, what is your choice of test give similar administration time constraints?

Depends on what the referral question is and how much time you have.
 
Depends on what the referral question is and how much time you have.

In my case, brief evaluation of cog status in dementia patients in their homes for the purpose of general treatment planning. I mostly use MOCA as an initial screener for gen pop with the rare RBANS as necessary for the lower functioning dementia patients or a referral to neuropsych if transport is possible. The RBANS suits my needs fairly well, but I am always curious about differing opinions. Regarding time, I try to limit testing to one hour as I that is about how long I am likely to have in private without various interruptions.
 
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In my case, brief evaluation of cog status in dementia patients in their homes for the purpose of general treatment planning. I mostly use MOCA as an initial screener for gen pop with the rare RBANS as necessary for the lower functioning dementia patients or a referral to neuropsych if transport is possible. The RBANS suits my needs fairly well, but I am always curious about differing opinions. Regarding time, I try to limit testing to one hour as I that is about how long I am likely to have in private without various interruptions.

I'd just go with the HVLT, BVMT, trails, Rey Copy, Digit Span, COWA/Animals, and BNT (short form if need be). Honestly, the RBANS is terrible at picking up MCI/early dementia. If they are likely to be getting a full neuropsych, the RBANS could be fine. But, in the case of a future full eval, the MoCA is sufficient. I'd focus my time on the MoCA and a good assessment of their i/ADL function in home as the biggest bang for your buck, really.
 
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I'd just go with the HVLT, BVMT, trails, Rey Copy, Digit Span, COWA/Animals, and BNT (short form if need be). Honestly, the RBANS is terrible at picking up MCI/early dementia. If they are likely to be getting a full neuropsych, the RBANS could be fine. But, in the case of a future full eval, the MoCA is sufficient. I'd focus my time on the MoCA and a good assessment of their i/ADL function in home as the biggest bang for your buck, really.

Thanks for the reply. I mostly do MOCA and a general report of ADL and IADL functioning. The RBANS is used if we need more info and my rural clients cannot make it up to the medical center. Usually this is on lower functioning patients (moderate to severe dementia) or those with other limitations. At the moment it is the only other assessment I have access to and even then it is a pain to get as I have to drive to the main medical center and not my CBOC and sign it out of the HBPC office. All other testing materials need to borrowed from neuropsych . Frankly, both are a giant pain in the a**. However, you never know what the future holds.
 
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Thanks for the reply. I mostly do MOCA and a general report of ADL and IADL functioning. The RBANS is used if we need more info and my rural clients cannot make it up to the medical center. Usually this is on lower functioning patients (moderate to severe dementia) or those with other limitations. At the moment it is the only other assessment I have access to and even then it is a pain to get as I have to drive to the main medical center and not my CBOC and sign it out of the HBPC office. All other testing materials need to borrowed from neuropsych . Frankly, both are a giant pain in the a**. However, you never know what the future holds.

If these are mostly moderate-ish people, will they train you on and give you a copy of the DRS-2? I'd rather have that and some info on I/ADLs than an RBANS.
 
I agree about it being an income problem.

But, psychology also has a ****ty image right now.

There are people who refuse to adjust to a modern, more scientifically informed, evidence based treatment style.

For example, people out there are still giving projectives and asking $125 an hour for play therapy.

If we want to make money, we need to embrace clinical science. I also think psychology is shooting itself in the foot by not focusing on individual outcomes as much. The field is becoming an activist discipline that rejects capitalism.
It's good for us to be activist (I think that makes sense when it comes to all sorts of issues that we have knowledge of- such as trauma, victim needs, and the impacts of victimization ... for a timely example). For some reason we're choosing to that advocacy and not the step that goes along with it and might actually enable us to be successful (i.e., policy advocacy and focus on reimbursement / greater equitable incorporation into managed care).

It's like being an advocate for a road trip but not doing anything to put gas in the car. There is no road trip happening.
 
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