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The Affordable Health Care Act of 2010 passed the United States Congress on March 21, 2010. The act provides for full parity between mental health services and general medical services. This means that the provisions of the new law directly impact your local psychotherapeutic practice. Most provisions of the new law do not go into effect until January 1, 2014.
Background: The new law is designed to reform two main problems with American healthcare: The overuse of high cost interventions and the underuse of prevention strategies. To that end, national health reform has four goals, or "pillars," of which the new law primarily addresses the first two.
Four Pillars of Healthcare Reform
- Insurance Reform
- Coverage Expansion
- Delivery System Redesign
- Payment Reform
According to the National Mental Health Association, 83.1% of Americans currently have some type of insurance coverage. After the provisions of the new law go into effect, this number will rise to 93%. These numbers represent 30 million Americans. Sixty-six percent of the increase will come through an expansion of Medicaid, while the remainder will come from insurance reform and the creation of state insurance exchanges. Medicaid expansion will be accomplished by making the only requirement for coverage set at a household income of 133% of the federal poverty level.
Delivery System Redesign
Previous studies have shown that 29% of those receiving Medicaid had a mental health problem. A new study, based on data gathered about medications prescribed and not based on providers seen, suggests that 49% of those receiving Medicaid have a mental health issue. This means that those extra 20% are receiving psychiatric medications, but are not being seen by a psychiatric specialist.
The new law calls for a closer integration of mental health and general medical services. It remains unclear what this new integration will look like. It may mean local mental health centers entering into contractual relationships with existing medical practitioners, or it could mean local medical clinics hiring mental health staff and local mental health centers hiring general medical staff.
Such a redesigned community mental health center may come to be known as a "federally-qualified behavioral healthcare center." This represents the greatest redesign of public mental health services since the passage of the Community Mental Health Act of 1963 that originally established community mental health centers.
The fee-for-service model is moving toward extinction with the new law. It is being replaced by a "case rate" model. That is, a federally-qualified behavioral healthcare center would receive funds from a payor, say Medicaid, based on the number of Medicaid consumers seen. Moreover, centers with better outcomes would be paid more than centers with worse outcomes, adjusted for number of patients.
For example: Assume the ABC Center for Logotherapy has 200 Medicaid clients in 2014, and the XYZ Center for Logotherapy has 200 Medicaid clients in 2014. If the clients of the ABC Center show more improvement than those of the XYZ Center, then the ABC Center would receive more Medicaid dollars than the XYZ Center, though serving the same number of clients.
Opinion: Opportunities and Challenges for Logotherapy
With an additional 30 million people receiving health care coverage, and with conservative estimates that more than 10 million of them will required mental health treatment, a demand for therapists of all kinds will increase. If we use Frankl's numbers that about 20% of clinical cases are noogenic in origin and suitable for logotherapy, then we have an increase of at least 2 million people likely to respond to logotherapy. How many more logotherapists do we need to treat those 2 millon people?
A closer integration of mental health and general medical care will provide more settings in which logotherapists could be employed. Frankl's concept of a Medical Ministry may become more fully realized, if logotherapists start positioning themselves for it now.
Evidence Based Practices and outcome data will tie into reimbursement. Logotherapy simply must develop more hard data. I encourage you to download and listen to the podcast on Logotherapy and Evidence Based Practices for more information in this area,
There are currently about 4 or 5 outcome measures on the market that are positioning themselves to take advantage of payment redesign. Logotherapy, with its special emphasis on the therapeutic relationship, could and should get on the forefront of that developing research.
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