Psychologists vs. LCSWs in hospital systems: how do you justify both roles?

[VirginiaIsForLovers]

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With recent budget cuts, our hospital system is taking a hard look at staffing and trying to decide whether to prioritize hiring psychologists or more LCSWs to provide therapy. There’s this push to justify why we would need psychologists when LCSWs are already doing great clinical work, and often at a lower cost.

For context, we are a public hospital system that provides primary, specialty, and tertiary healthcare services. Our psychiatry and psychology services fall under specialty care and are currently structured as multidisciplinary clinics. These include psychiatrists, psychologists, licensed clinical, LCSWs, APRNs, and social work care coordinators. At this time, we do not offer inpatient or higher levels of care; our services are primarily outpatient.

Personally, I believe there is space and a real need for both disciplines. Their roles can complement each other, especially in complex hospital settings. But now we are being asked to clearly define those roles and explain how they differ, both in terms of clinical value and financial impact.

One obvious distinction is assessment. Psychologists can provide psychological and neuropsychological testing and interpretation, though not all of us do that regularly. Beyond that, the overlap in therapy services makes it harder to draw clear lines.

For context, I am specifically talking about LCSWs who are providing therapy, not case management.

I am curious how other systems handle this. How do you make the financial case for having both roles? And when it comes to assigning patients, how does your team decide who sees a psychologist versus a social worker?

Would appreciate any insights.

 

[Sanman]

With recent budget cuts, our hospital system is taking a hard look at staffing and trying to decide whether to prioritize hiring psychologists or more LCSWs to provide therapy. There’s this push to justify why we would need psychologists when LCSWs are already doing great clinical work, and often at a lower cost.

Personally, I believe there is space and a real need for both disciplines. Their roles can complement each other, especially in complex hospital settings. But now we are being asked to clearly define those roles and explain how they differ, both in terms of clinical value and financial impact.

One obvious distinction is assessment. Psychologists can provide psychological and neuropsychological testing and interpretation, though not all of us do that regularly. Beyond that, the overlap in therapy services makes it harder to draw clear lines.

For context, I am specifically talking about LCSWs who are providing therapy, not case management.

I am curious how other systems handle this. How do you make the financial case for having both roles? And when it comes to assigning patients, how does your team decide who sees a psychologist versus a social worker?

Would appreciate any insights.

Without getting into qualifications and mud slinging, you are leaving 20-25% of the reimbursement on the table by hiring a midlevel instead of a psychologist. The question then becomes is a psychologist worth that extra money.

 

[WisNeuro]

Around here. they're not really justifying many different provider types in these roles. In a few of the hospital systems here, almost all OP therapy services, and a good deal of the IP therapy is delivered by midlevels, aside from the VA, anyway.

 

[BuckeyeLove]

Psychologists are in high demand in a few of our hospital systems (I live in Ohio --- obviously). OhioHealth and OSU are always in need. But most of those positions aren't in acute hospital settings. With each passing year I'm becoming more cynical about the midlevels though, especially the newer ones. They're almost all practicing outside of their scope and are incompetent at best.

 

[Sanman]

Psychologists are in high demand in a few of our hospital systems (I live in Ohio --- obviously). OhioHealth and OSU are always in need. But most of those positions aren't in acute hospital settings. With each passing year I'm becoming more cynical about the midlevels though, especially the newer ones. They're almost all practicing outside of their scope and are incompetent at best.

I refuse the let family members see anyone trained during the pandemic as the variability in training during that period was huge.

 

[cara susanna]

Our main hospital systems locally got rid of all the psychologists for therapy years ago. They only hire them for testing now

 

[R. Matey]

I'm really curious how many tiers of midlevel managers there are in this system. My guess is more than three. But anyway....

Our two local non-VA hospital systems hire psychologists into increasing specialty roles (health, pain, peds, neuro mainly) and has midlevel therapists for generalist outpatient psychotherapy and inpatient positions. The arguments I've heard folks make is that psychologists have training and expertise in these areas. Psychologists can also do diagnostic clarification and implement evidenced-based psychotherapy practice with equivalent expertise to psychiatry without the long wait times meaning patients getting quicker expert-level care are likely to be happier with the system as a whole (really twisting the knife on those patient satisfaction scores; "Do you really want to be Kaiser?"). I'm sure to some, this expertise doesn't matter, but then you can ask them what's the difference in blood pressure medicine prescribed by an FNP vs. a cardiologist and then ask them why some of the most disabling conditions in the country do not deserve the same expert-level care.

ETA: APA has some materials on the role of psychology in integrated healthcare that might be helpful.

 

[cara susanna]

Yup, I know a psychologist who does testing within a large healthcare system who is supervised by an LCSW. and it's caused a lot of issues

 

[R. Matey]

Yup, I know a psychologist who does testing within a large healthcare system who is supervised by an LCSW. and it's caused a lot of issues

My question is how social workers were able to sell themselves as the obvious choice for management positions.

 

[WisNeuro]

My question is how social workers were able to sell themselves as the obvious choice for management positions.

They were section heads in my last hospital system job before PP, the positions did not pay well and they operated as meat shields to soak up the discontent from decisions made much higher up the food chain. Their position did nothing to help me run my clinic.

 

[AcronymAllergy]

My question is how social workers were able to sell themselves as the obvious choice for management positions.

I've seen/still see it happen with many nurses as well. I wonder if part of it relates to--the longer you spend training for a specific role (e.g., psychologist, physician), the more wedded you are to doing that job rather than stepping out into other jobs, like management. Also, psychologists have a bad habit of underplaying and underestimating our expertise, deferring to others, and accepting when those others (who may have less knowledge, training, and expertise than us) then tell us what they think we should do.

 

[BuckeyeLove]

My question is how social workers were able to sell themselves as the obvious choice for management positions.

This might come across as denigrative, but here it goes. I've found a good proportion of SWers who end up in administration are a bit characteralogical. And usually when they eff up somehow they still end up in high up admin positions after they get back on their feet. Some may also call that resilient and indicative of grit though i guess.

 

[quickpsych]

My question is how social workers were able to sell themselves as the obvious choice for management positions.

They're cheaper.

Without getting into qualifications and mud slinging, you are leaving 20-25% of the reimbursement on the table by hiring a midlevel instead of a psychologist. The question then becomes is a psychologist worth that extra money.

Yep. Reimbursement rates higher. And since most of these companies and healthcare systems are for profit, well follow the money.

 

[PsyDr]

1) Some states' laws require a psychologist to be in psychiatric hospitals
2) Psychologists can admit in some states, easing call burden (admittedly, there are few states for which this is true).
3) The curriculum for clinical social workers in Virginia are confined to FOUR classes in mental health, followed by clinical work.
4) Broader range of services: While LCSWs can bill for therapy, they do not have any education in psychometric testing, nor are they allowed to admit.
5) 42CFR 482.62 requires that psychiatric hospitals have both psychological services and social services. This is typically interpreted to mean that a psychologist must be on staff.

 

[Sanman]

I'll be curious to see how this plays out. Most administrators seem to have their mind made up before the conversation ever starts.

 

[Therapist4Chnge]

Psychologists are in high demand in a few of our hospital systems (I live in Ohio --- obviously). OhioHealth and OSU are always in need. But most of those positions aren't in acute hospital settings. With each passing year I'm becoming more cynical about the midlevels though, especially the newer ones. They're almost all practicing outside of their scope and are incompetent at best.

This.

SW can’t be all things to all ppl, but that gets magnified when you look at the range of training in SW programs, which licensure does not differentiate between. Some are very case management heavy, while others have more psych/counseling related classes.

They don't know what they don’t know. Diagnostically, they do not live up with even basic competency, and it just gets worse from there. SW, LPCs, and similar bc they frankly don’t get enough training in the meat of the work, let alone have enough experience doing differential diagnosis. I don’t pretend to know case management, but they seem VERY sure that they can diagnose accurately….

 

[R. Matey]

I don’t pretend to know case management, but they seem VERY sure that they can diagnose accurately….

Well, it's all CPTSD, amiright? /s

 

[WisNeuro]

Well, it's all CPTSD, amiright? /s

Just a build up of Little t trauma.

 

[Therapist4Chnge]

SW/Midlevels in leadership positions is whatever, as they are largely administrative. That said, ZERO clinically-related decisions should ever fall to them bc they don’t have the training nor experience to weigh in on clinical decisions and often will do more harm than good.

Admittedly this was a thorn in my side when I was in academic medicine bc there were administrators without clinical training (or were 2 decades away from pt care) who wanted to “weigh in” on clinically-related decisions. I saw it most often in Ethics/Review meetings involving complicated discharges. I handled capacity evals for patients across the various hospitals. Sometimes there would be a disagreement between departments (most often Psychiatry v PM&R, & I was in the latter), and the overly confident administrators would insert themselves into the cases, and it was beyond frustrating bc they’d throw terminology around that made me cringe. Out of touch directors of nursing often did this too, and the politics there were 10x worse.

 

[quickpsych]

SW/Midlevels in leadership positions is whatever, as they are largely administrative. That said, ZERO clinically-related decisions should ever fall to them bc they don’t have the training nor experience to weigh in on clinical decisions and often will do more harm than good.

Especially fun when they review documents and notes as "quality assurance" and then tell providers "well it looks like based on the eval or progress note they should be seen X times a month or "should be seen again because you used the word "sad" in a note." Or the ones that go further and say they just review for quality assurance "but as a clinical person just like you; I think you should do XYZ instead and we'll let your direct manager know so they can help you do what I think you should do." These people , in my experience, exist in so many different settings too.

They're almost like the quacks that work for insurance companies and approve or deny claims based on their "clinical knowledge" without having ever laid eye on the patient. But least leadership midlevels by and large are too busy in spreadsheets and meetings to bother providers most of the time lol. But I suppose unlike the insurance ones, they at least sometimes have good intentions just lack of knowledge or clinical skills.

Admittedly this was a thorn in my side when I was in academic medicine bc there were administrators without clinical training (or were 2 decades away from pt care) who wanted to “weigh in” on clinically-related decisions. I saw it most often in Ethics/Review meetings involving complicated discharges. I handled capacity evals for patients across the various hospitals. Sometimes there would be a disagreement between departments (most often Psychiatry v PM&R, & I was in the latter), and the overly confident administrators would insert themselves into the cases, and it was beyond frustrating bc they’d throw terminology around that made me cringe. Out of touch directors of nursing often did this too, and the politics there were 10x worse.

The terminology lets others know they must know what they're talking about 😆

 

[psych.meout]

Psychologists are in high demand in a few of our hospital systems (I live in Ohio --- obviously). OhioHealth and OSU are always in need. But most of those positions aren't in acute hospital settings. With each passing year I'm becoming more cynical about the midlevels though, especially the newer ones. They're almost all practicing outside of their scope and are incompetent at best.

This.

SW can’t be all things to all ppl, but that gets magnified when you look at the range of training in SW programs, which licensure does not differentiate between. Some are very case management heavy, while others have more psych/counseling related classes.

They don't know what they don’t know. Diagnostically, they do not live up with even basic competency, and it just gets worse from there. SW, LPCs, and similar bc they frankly don’t get enough training in the meat of the work, let alone have enough experience doing differential diagnosis. I don’t pretend to know case management, but they seem VERY sure that they can diagnose accurately….

This has been my experience as well. I know a few who seem quite good at what they do and, most importantly, appear very self-aware and cognizant of what is in their scope and what isn't, and they now when to refer out or consult with psychiatry and psychology.

Speaking of psychiatry, I'd add that my experiences throughout practicum, internship, and post doc (as well as my work prior to grad school) have significantly lowered my opinion of psychiatrists. Seeing what they consider to be assessment and therapy ranges from laughable to scary. Yes, this is purely anecdotal, but the ones I've come across in multiple health systems and settings are clueless when it comes to assessment and conceptualization. Such garbage diff dx and the overall conceptualization is amateur, at best. I've known psychology grad students who were better than mid- or late-career psychiatrists. The therapy and bedside manner aren't much better.

 

[BuckeyeLove]

This has been my experience as well. I know a few who seem quite good at what they do and, most importantly, appear very self-aware and cognizant of what is in their scope and what isn't, and they now when to refer out or consult with psychiatry and psychology.

Speaking of psychiatry, I'd add that my experiences throughout practicum, internship, and post doc (as well as my work prior to grad school) have significantly lowered my opinion of psychiatrists. Seeing what they consider to be assessment and therapy ranges from laughable to scary. Yes, this is purely anecdotal, but the ones I've come across in multiple health systems and settings are clueless when it comes to assessment and conceptualization. Such garbage diff dx and the overall conceptualization is amateur, at best. I've known psychology grad students who were better than mid- or late-career psychiatrists. The therapy and bedside manner aren't much better.

“It’s probably bipolar.” - every psychiatrist licensed between 1965-2010.

 

[Sanman]

SW/Midlevels in leadership positions is whatever, as they are largely administrative. That said, ZERO clinically-related decisions should ever fall to them bc they don’t have the training nor experience to weigh in on clinical decisions and often will do more harm than good.

Admittedly this was a thorn in my side when I was in academic medicine bc there were administrators without clinical training (or were 2 decades away from pt care) who wanted to “weigh in” on clinically-related decisions. I saw it most often in Ethics/Review meetings involving complicated discharges. I handled capacity evals for patients across the various hospitals. Sometimes there would be a disagreement between departments (most often Psychiatry v PM&R, & I was in the latter), and the overly confident administrators would insert themselves into the cases, and it was beyond frustrating bc they’d throw terminology around that made me cringe. Out of touch directors of nursing often did this too, and the politics there were 10x worse.

I feel you on this one. I handle capacity evaluations as well and they are an enormous headache due to the "administrators" that want to second guess me with less experience in this than I have and just have multiple rounds of meetings. Why hire someone with years of expertise in this area and then second guess them?

 

[Sanman]

This has been my experience as well. I know a few who seem quite good at what they do and, most importantly, appear very self-aware and cognizant of what is in their scope and what isn't, and they now when to refer out or consult with psychiatry and psychology.

Speaking of psychiatry, I'd add that my experiences throughout practicum, internship, and post doc (as well as my work prior to grad school) have significantly lowered my opinion of psychiatrists. Seeing what they consider to be assessment and therapy ranges from laughable to scary. Yes, this is purely anecdotal, but the ones I've come across in multiple health systems and settings are clueless when it comes to assessment and conceptualization. Such garbage diff dx and the overall conceptualization is amateur, at best. I've known psychology grad students who were better than mid- or late-career psychiatrists. The therapy and bedside manner aren't much better.

I mean, late career psychiatrists were those who went to med school when psychiatry residency was where your career went to die. Lots of barely graduated folks and mid-career burnouts.

 

[WisNeuro]

I feel you on this one. I handle capacity evaluations as well and they are an enormous headache due to the "administrators" that want to second guess me with less experience in this than I have and just have multiple rounds of meetings. Why hire someone with years of expertise in this area and then second guess them?

Much more often than not, in my hospital experience, treating physicians are questioning capacity solely on the basis of the patient not agreeing to the physicians recommended plan of action. In the majority of cases I was consulted on, the patient very clearly had medical decision making capacity. Like not even close. Maybe 10% of the time they clearly did not have capacity, and maybe 10% were actual grey area/difficult cases in which a consult to me was actually appropriate.

 

[Therapist4Chnge]

I feel you on this one. I handle capacity evaluations as well and they are an enormous headache due to the "administrators" that want to second guess me with less experience in this than I have and just have multiple rounds of meetings. Why hire someone with years of expertise in this area and then second guess them?

Bingo!!

I literally gave a talk once a year on Capacity v Competency, and it was always SLAMMED w providers and administrators….yet I’d still end up arguing w many of those same providers/administrators in the meetings later.

 

[Therapist4Chnge]

Much more often than not, in my hospital experience, treating physicians are questioning capacity solely on the basis of the patient not agreeing to the physicians recommended plan of action. In the majority of cases I was consulted on, the patient very clearly had medical decision making capacity. Like not even close. Maybe 10% of the time they clearly did not have capacity, and maybe 10% were actual grey area/difficult cases in which a consult to me was actually appropriate.

This.

I’d get repeated referrals on the same patients bc they just wanted me to agree with them, whether it was to hold/boot a patient. My professional opinion doesn’t change just bc the result is “inconvenient” to the staff member.

 

[Sanman]

Much more often than not, in my hospital experience, treating physicians are questioning capacity solely on the basis of the patient not agreeing to the physicians recommended plan of action. In the majority of cases I was consulted on, the patient very clearly had medical decision making capacity. Like not even close. Maybe 10% of the time they clearly did not have capacity, and maybe 10% were actual grey area/difficult cases in which a consult to me was actually appropriate.

I get a lot of the opposite actually. Old folks that are rarely seen and unsafe until someone finally asks whether they are actually safe to live independently. Then you have adult protective services, capacity evaluations, etc.

 

[WisNeuro]

I get a lot of the opposite actually. Old folks that are rarely seen and unsafe until someone finally asks whether they are actually safe to live independently. Then you have adult protective services, capacity evaluations, etc.

I see that out in the community, but all of my capacity consults at my old position were inpatient medical decision making consults.

 

[cara susanna]

We automatically refer capacity evals out because everyone here thinks they require neuropsych testing and we don't offer that. Don't get me started, lol

 

[WisNeuro]

We automatically refer capacity evals out because everyone here thinks they require neuropsych testing and we don't offer that. Don't get me started, lol

Ugh, it is definitely not needed, though knowledge of neuropathology can be helpful.