Legislative Report
By: Alexandra Forbes, M.A., Legislative Chair
With complex healthcare reform process unfolding here in Vermont, a number of opportunities and challenges face the psychological community and advocates seeking to improve access to appropriate care.
Partly because there is an assumption that “Parity” between medical and mental health care has already been addressed in past legislation, it can be an uphill battle to bring attention to the access problems facing patients seeking care and psychologists trying to survive financially. This last year's legislative advocacy work encountered a roller coaster of inclusion then and exclusion of important mental health informed legislative language to help guide healthcare policy decisions. (See the spring 2011 VPA Legislative Report)
Currently this process has many dimensions because the administration has 10 different work/ advisory task forces working on aspects of building and financing first the mandated insurance exchange and then single payer model system for Vermont. The challenge for the profession is to keep up and informed with all the different initiatives.
To read more, visit:
http://dvha.vermont.gov/advisory-boards

Several important task forces:
Information technology initiatives are underway that will have a direct impact on how sensitive clinical information is shared or protected for patients who are receiving psychological services. Currently the committee addressing this project did not include any mental health consumer or professional mental health input. It is unclear whether there will be professional mental health guidance available for this committee.
Blueprint initiatives across the state so far include local attempts to integrate mental health services into primary care settings. There continue to be difficulty creating efficient referral processes as the process has been dependent on local networking and lacks statewide I.T. infrastructure connecting doctor’s offices with clinicians who have openings for new patients.
There is a payment reform project that will impact how psychological services will be paid for and at what level. Currently, there is tremendous political pressure to create a model that will reduce the cost of healthcare across the board as the state formulates a single payer system. Models that include capitation with shared risk for primary care are being designed for three different geographical locations: Burlington, St Johnsbury and Rutland. This raises the possibility that there will be additional gatekeepers, requiring even more expensive and unnecessary reviews of outpatient mental health services as well as even more restrictive guidelines for intensive services. It is essential that the needs and concerns of Psychologists are being represented at these formative meetings. Currently, the Psychological Association has minimal active representation in these discussions.
In the 2011 spring legislative session, the Vermont Senate Health Care committee with heavy insurance lobbying, passed a bill relegating payments for all medical care including psychological services to the lowest contracted fee, complicating financial gains from the federal out of network parity provision. This state provision passed without any testimony from any mental health advocacy group or association.
During a recent Council meeting with Robin Lunge, (9/1/2011) the Director of Healthcare Reform, the clinicians present were impressed with Robin's expression of sincere interest in helping overcome the difficulties that both professionals and consumers are encountering in the delivery of mental health services (particularly outpatient services). She expressed concern with the descriptions of workforce shortages, access problems and the impact of current under-funding of mental health services in both private and public systems. She encouraged the Council (of mental health and substance abuse treatment professionals) create a vision statement for policy makers to refer to for guidance. She suggested we address the problems of cost-containment, access and quality care in our document. A sub group from the Council agreed to draft a joint statement that will be reviewed by the VPA executive board.
Hopefully the VPA legislative committee activities will attract new members who are interested in helping advocate for psychology and help policy makers be informed about the important central role mental health treatment has in cost-effective, accessible healthcare.

Legislator Anne Donahue speaks about her perspective on the state of Parity in Vermont.
As Submitted by Alexandra Forbes:
"Mental Health) Budget, rate setting, reimbursement and cost sharing inequities in both public and private systems.
The administration’s proposed budget this past year is another example (of the lack of leadership and commitment to mental health). As a result of the bifurcation between Department of Health Access Medicaid reimbursement of care (inpatient and outpatient) and Department of Mental Health contracts with designated agencies for care, there was no budget consistency in how cuts might impact integrated health care. The indiscriminate percentage-based proposed five percent cut to community mental health agencies bore no relationship to specific and systemic cost savings approaches in Medicaid. In fact, data in a Joint Fiscal Office analysis I requested suggests that if one combined all three major areas of public health funding for mental health [Medicaid providers, inpatient, and the mental health share of designated agency contracts] and contrasted it to public health funding for all other general health care, the support for mental health care has been dropping as a proportion.
There have also been apparent disproportionate rate reductions for private community providers (continuing to reduce access, ironically at the same time as designated agencies are told that lack of funding for adult outpatient services can be made up through referrals to community Medicaid providers), and the disproportionate impact of DRGs for inpatient psychiatric care. The DRG issue has directly affected the ability of designated hospitals to help relieve the pressure on the Vermont State Hospital through admission of court-referred patients who require both a forensic evaluation and inpatient care. Only a year ago, as a part of the Challenges for Change savings initiatives, legislation was passed that specifically addressed legal barriers to such admissions, but the DRG impact has blocked implementation.
Ironically, this also works directly counter to the state’s overall interest in seeking to have inpatient access for patients in its own legal care and custody. The intensive care services needed by such patients include additional staff and other resources, as well as a longer average length of stay. Instead of a supplemented reimbursement for these costs (which create significant health cost savings to the state as an alternative to the state hospital), the DRG creates a fiscal disincentive through its mechanism of placing a premium on shorter stays. The medical norm is to recognize the higher cost of intensive care services; there is no such recognition here. [Note that the VSH budget does not differentiate between cost of days in length of stay.]
Medicaid payment reforms, as well as future ones, are appropriately targeting services that may be being over-charged. If this occurs in a vacuum, it will fail to address the fact that inpatient psychiatry is sustained through internal hospital cost shifting, based upon hospitals’ commitments to provide this service. The psychiatric inpatient payer mix is disproportionately uninsured or Medicaid-reimbursed, meaning such services either lose money or barely break even. This reflects an historic inequity in support for mental health. Inpatient mental health care will be at significant jeopardy if there is not awareness of this context.
If current budget and reimbursement inequities are not being recognized and addressed, what statement does this make about the recognition and proactive addressing of these inequities in a reformed system?
The private insurance system remains heavily discriminatory as well. Vermont law, progressive as it may be, continues to allow “carve-outs” (providing subcontracted insurance products for mental health coverage), which blocks full health care integration on the most fundamental level and perpetuates the message that mental health is different from other health care. They help to enable disparities in provider reimbursements that limit access, and divert resources to administrative costs. In addition, despite a higher standard under federal law, Vermont continues to permit cost sharing discrimination for products sold to employers with fewer than 50 employees – covered under Vermont parity law, but not by federal law. Thus small group policies continue to be permitted to charge “specialist” co-pays for access to mental health providers, while under federal law, co-pays for mental health care must be equivalent to primary care. [An example of the impact in one product is a primary care co-pay of $20, or roughly 20% of the reimbursement allowed to the provider; a specialist co-pay of $30, perhaps 10 to 15% of the higher reimbursement for the specialty physician; and a mental health provider “specialist” co-pay of $30, more than 50% of the $57 total reimbursement.]”

2011 Federal Advocacy Coordinator Report
By: Milton J. Marasch, Ph.D.
I have had the pleasure of serving VPA in the capacity of Federal Advocacy Coordinator (FAC) by participating in the March, 2011 Washington, DC Hill visit and coordinating the American Psychological Association Practice Organization (APAPO) email action and information alerts to those on the FAC alert list. Issues on the federal level for 2011 include Medicare payments, Medicare physician definition, and mental health inclusion in health information technology programs. Additionally, I note the issue of retroactive Medicare payment increases from 2010.
In regard to Medicare payments, there is the issue of protecting the Medicare mental health payment. Essentially this is a the maintenance of a booster to replace the previous 5% cut from psychotherapy reimbursements. Similarly, there is advocacy for changing the sustainable growth rate (SGR) formula that would otherwise cut Medicare Part B payments by 25%. Since the last FAC annual report, President Obama signed the Medicare and Medicaid Extenders Act of 2010. This continued the 5% psychotherapy payment restoration and halted the SGR.
In regard to the Medicare physician definition doctorate psychologists are among the only doctoral providers who participate in Medicare who are not included under this definition. The definition presently includes chiropractors, optometrists, dentists, and podiatrists. Note that inclusion would not expand scope of practice, but would allow for a reassessment of psychologist services being able to be provided without requiring medical sign-off.
In regard to health information technology, there is the Behavioral Health Information Technology Act of 2011. This act would expand to psychologists the ability to participate in the electronic health record Medicare and Medicaid incentives. On a positive note, we have late-breaking news that Senator Sanders has now signed on as a cosponsor.
Then there is the long-promised retroactive Medicare payment increase for the first part of 2010. I notice an APA Practice Organization online update, dated February, 2011, mention that the Centers for Medicare & Medicaid Services (CMS) promising retroactive restoration services for the months between January 1 and July 1, 2010 “soon.” Interestingly, I am only now receiving those payments myself (without interest). Of remaining concern for participating Vermont psychologists are the headaches with managing to collect the couple dollars per hour of service on the secondary insurances. Medicaid crossover problems are already appearing for some (see Insurance Committee report).
In addition to following and coordinating regarding the aforementioned issues, the position also involves monitoring federal legislative and rules proposals that might be positive to psychology on a nationwide basis, but that could negatively impact all or part of Vermont's practicing psychologists. None of the legislative proposals addressed this year appear to produce a negative impact for psychologist-masters or psychologist-doctorates practicing in Vermont. I refer you to the “Medicare Task Force” Ad-Hoc Committee for any updates on the prospects of bringing psychologist-masters to the Medicare table (as is already the case for social workers). In the meantime, I continue to coordinate on federal matters – including those that help keep the Medicare table intact for both those presently seated and those who may join the table in the future.