20 Jun 2017

Care and Legal Help for Patients in Need

Care and Legal Help for Patients in Need

Medical-legal partnerships are bringing lawyers and paralegals to health-care teams to improve the health and well-being of underserved populations

When Jack Tsai, PhD, treats veterans at the VA Connecticut Healthcare System, they often have problems that go beyond the scope of his work as a psychologist. Many have post-traumatic stress disorder or cognitive disabilities and are fighting for disability benefits. Others are embroiled in housing disputes, are facing eviction or have already become homeless.

While psychologists can treat their mental health concerns, these veterans need legal help, too. "A lot of these patients have never had anyone advocate for them in court," says Tsai, who has dual appointments at the VA and the Yale School of Medicine.

Enter the medical-legal partnership, or MLP, a model that embeds lawyers and paralegals into health-care teams to detect, address and prevent social conditions that harm health. Those legal experts typically work on-site in health-care settings, either part time or full time, where they can access patients' medical records and even sit in on clinical meetings. The legal services are offered at no charge to the patient. Programs are typically funded through a combination of philanthropy, law schools and civil legal aid agencies, with a handful of contributions from health-care partners.

Psychologists are obvious candidates for getting involved in MLPs, Tsai says. They already have long-term relationships with their clients and understand how their legal problems might be interfering with their mental health and well-being. Plus, psychologists are often accustomed to working on interdisciplinary teams.

Unlike sending patients to a legal aid clinic, Tsai adds, the process is streamlined when the legal team is located inside the hospital. "We can walk patients down the hall and do a warm handoff," he says.

Helping underserved populations

The current MLP model was developed at the Boston Medical Center in 1993 but didn't begin to catch on until the late 2000s when it was embraced by the American Medical Association and the American Academy of Pediatrics. To date, nearly 300 hospitals and health centers nationwide have developed MLPs, according to the National Center for Medical-Legal Partnership.

Adding a legal expert to the team helps underserved populations in a variety of ways: They can help patients apply for food stamps and disability benefits; press landlords to improve substandard housing; help tenants avoid eviction; advocate for special education services; fight employment discrimination; and assist with issues related to immigration, child custody and domestic violence—just some of the many factors that can undermine a patient's health.

"I can't imagine what things would be like without having the MLP, because they do so much," says Britt Nielsen, PsyD, an associate professor at Case Western Reserve University and clinical psychologist at MetroHealth Medical Center in Cleveland. In 2015, the MetroHealth MLP provided assistance to 839 people. Of those, 43 percent had mental health disorders.

MetroHealth began its MLP program 14 years ago in the pediatrics department, Nielsen says. Though it has since expanded to assist adult patients as well, advocating for kids is still a focus. "We do a lot of advocacy as psychologists, talking to teachers or writing letters to a patient's school," Nielsen says. "But MLPs have a great working knowledge of the law, and the things they're able to do go beyond what I can do in a phone call or a letter."

Often, families in underserved populations don't understand what rights they have when it comes to education, living arrangements or Supplemental Security Income, she adds. In addition to helping families directly with legal issues, she says, the MLP has also made physicians more aware of patients' rights, helping to ensure more patients get the services and support they need.

In some cases, MLPs highlight a bigger need that goes beyond a single patient. Nielsen points to a case where a local school district wasn't providing students with the special education services required by law. "The MLP was able to take the district to court and get restitution for those families," she says.

Need for data

While anecdotal evidence suggests MLPs are valuable, few studies have assessed their effectiveness. The National Center for Medical-Legal Partnership is developing metrics to systematically measure the effects of MLPs on patient well-being and health-care costs. Meanwhile, some smaller studies have found the partnerships provide benefits.

A study by Mary M. O'Sullivan, MD, at St. Luke's-Roosevelt Hospital Center in New York City, and colleagues found asthma patients had reductions in asthma medications and their hospital admissions and emergency room visits declined after an MLP was put into place (Journal of Asthma, 2012). And a pilot study of a Tucson-based MLP by Anne M. Ryan, JD, and colleagues at the University of Arizona found patients' perceived stress levels decreased and overall well-being increased after receiving help from an MLP (Journal of Health Care for the Poor and Underserved, 2012).

Evidence also suggests that MLPs make economic sense. In one example, Kerry J. Rodabaugh, MD, at the University of Nebraska Medical Center, and colleagues studied the benefits of an MLP for cancer patients and their health-care institution. Between April 2004 and December 2007, the program assisted terminal patients with legal issues such as guardianship, estate planning and benefits advocacy. During that period, the MLP helped overturn denials of insurance benefits for 17 patients, preventing economic hardship for patients while recovering $923,188 in reimbursements to the hospital (Journal of Palliative Medicine, 2010).

Tsai and his colleagues recently received a grant from the Bristol-Myers Squibb Foundation to evaluate whether the MLP model improves mental health and quality of life for patients at four VA sites in Connecticut and New York over the next two years. Aside from his study, however, little research has been done focusing on the mental health benefits of such programs, he says.

Those data are sorely needed, says Tsai, especially as many MLPs are struggling to find funding through grants and donations. "There's huge potential for mental health researchers to help these legal clinics collect data and evaluate outcomes," he says. "It's an area ripe for psychologists."

For more information on medical-legal partnerships, visit the National Center for Medical-Legal Partnership http://medical-legalpartnership.org.

To watch a video on how medical-legal partnerships work, go to www.youtube.com/watch?v=NdvE5wbumYw.

When Jack Tsai, PhD, treats veterans at the VA Connecticut Healthcare System, they often have problems that go beyond the scope of his work as a psychologist. Many have post-traumatic stress disorder or cognitive disabilities and are fighting for disability benefits. Others are embroiled in housing disputes, are facing eviction or have already become homeless.

While psychologists can treat their mental health concerns, these veterans need legal help, too. "A lot of these patients have never had anyone advocate for them in court," says Tsai, who has dual appointments at the VA and the Yale School of Medicine.

Enter the medical-legal partnership, or MLP, a model that embeds lawyers and paralegals into health-care teams to detect, address and prevent social conditions that harm health. Those legal experts typically work on-site in health-care settings, either part time or full time, where they can access patients' medical records and even sit in on clinical meetings. The legal services are offered at no charge to the patient. Programs are typically funded through a combination of philanthropy, law schools and civil legal aid agencies, with a handful of contributions from health-care partners.

Psychologists are obvious candidates for getting involved in MLPs, Tsai says. They already have long-term relationships with their clients and understand how their legal problems might be interfering with their mental health and well-being. Plus, psychologists are often accustomed to working on interdisciplinary teams.

Unlike sending patients to a legal aid clinic, Tsai adds, the process is streamlined when the legal team is located inside the hospital. "We can walk patients down the hall and do a warm handoff," he says.

Helping underserved populations

The current MLP model was developed at the Boston Medical Center in 1993 but didn't begin to catch on until the late 2000s when it was embraced by the American Medical Association and the American Academy of Pediatrics. To date, nearly 300 hospitals and health centers nationwide have developed MLPs, according to the National Center for Medical-Legal Partnership.

Adding a legal expert to the team helps underserved populations in a variety of ways: They can help patients apply for food stamps and disability benefits; press landlords to improve substandard housing; help tenants avoid eviction; advocate for special education services; fight employment discrimination; and assist with issues related to immigration, child custody and domestic violence—just some of the many factors that can undermine a patient's health.

"I can't imagine what things would be like without having the MLP, because they do so much," says Britt Nielsen, PsyD, an associate professor at Case Western Reserve University and clinical psychologist at MetroHealth Medical Center in Cleveland. In 2015, the MetroHealth MLP provided assistance to 839 people. Of those, 43 percent had mental health disorders.

MetroHealth began its MLP program 14 years ago in the pediatrics department, Nielsen says. Though it has since expanded to assist adult patients as well, advocating for kids is still a focus. "We do a lot of advocacy as psychologists, talking to teachers or writing letters to a patient's school," Nielsen says. "But MLPs have a great working knowledge of the law, and the things they're able to do go beyond what I can do in a phone call or a letter."

Often, families in underserved populations don't understand what rights they have when it comes to education, living arrangements or Supplemental Security Income, she adds. In addition to helping families directly with legal issues, she says, the MLP has also made physicians more aware of patients' rights, helping to ensure more patients get the services and support they need.

In some cases, MLPs highlight a bigger need that goes beyond a single patient. Nielsen points to a case where a local school district wasn't providing students with the special education services required by law. "The MLP was able to take the district to court and get restitution for those families," she says.

Need for data

While anecdotal evidence suggests MLPs are valuable, few studies have assessed their effectiveness. The National Center for Medical-Legal Partnership is developing metrics to systematically measure the effects of MLPs on patient well-being and health-care costs. Meanwhile, some smaller studies have found the partnerships provide benefits.

A study by Mary M. O'Sullivan, MD, at St. Luke's-Roosevelt Hospital Center in New York City, and colleagues found asthma patients had reductions in asthma medications and their hospital admissions and emergency room visits declined after an MLP was put into place (Journal of Asthma, 2012). And a pilot study of a Tucson-based MLP by Anne M. Ryan, JD, and colleagues at the University of Arizona found patients' perceived stress levels decreased and overall well-being increased after receiving help from an MLP (Journal of Health Care for the Poor and Underserved, 2012).

Evidence also suggests that MLPs make economic sense. In one example, Kerry J. Rodabaugh, MD, at the University of Nebraska Medical Center, and colleagues studied the benefits of an MLP for cancer patients and their health-care institution. Between April 2004 and December 2007, the program assisted terminal patients with legal issues such as guardianship, estate planning and benefits advocacy. During that period, the MLP helped overturn denials of insurance benefits for 17 patients, preventing economic hardship for patients while recovering $923,188 in reimbursements to the hospital (Journal of Palliative Medicine, 2010).

Tsai and his colleagues recently received a grant from the Bristol-Myers Squibb Foundation to evaluate whether the MLP model improves mental health and quality of life for patients at four VA sites in Connecticut and New York over the next two years. Aside from his study, however, little research has been done focusing on the mental health benefits of such programs, he says.

Those data are sorely needed, says Tsai, especially as many MLPs are struggling to find funding through grants and donations. "There's huge potential for mental health researchers to help these legal clinics collect data and evaluate outcomes," he says. "It's an area ripe for psychologists."

For more information on medical-legal partnerships, visit the National Center for Medical-Legal Partnership http://medical-legalpartnership.org.

To watch a video on how medical-legal partnerships work, go to www.youtube.com/watch?v=NdvE5wbumYw.

Additional reading

  • Medical-Legal Partnerships: Transforming Primary Care by Addressing the Legal Needs of Vulnerable Populations, Sandel, M., Hansen, M., Kahn, R., Lawton, E., Paul, E., Parker, V., Morton, S., and Zuckerman, B. Health Affairs, 2010
  • The State of the Medical-Legal Partnership Field: Findings from the 2015 National Center for Medical-Legal Partnership Surveys, Regenstein, M., Sharac, J., and Trott, J.

By Kirsten Weir 


This article was originally published in the November 2016 Monitor on Psychology

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06 Jun 2017

Reimbursing Interns, Increasing Care

Reimbursing Interns, Increasing Care

When Medicaid pays for psychology interns' services, more people get care

It is already hard for many psychology graduate students to find high-quality internships. The fact that training programs in 34 states cannot be reimbursed by Medicaid—the government insurance program for those with low incomes and limited resources—for the work of their highly skilled interns makes it even harder. The result? Less access to care for vulnerable patients who are already among the most underserved in the nation.

At least one North Carolina internship site, for example, has already closed partly because it couldn't get Medicaid reimbursement for the services its interns provided. In states that allow Medicaid reimbursement for interns, internship sites use that money to help finance their internship programs.

"My concern is that as there is more and more pressure on internship programs to support themselves, we could be in danger of losing more," says Sally Cameron, executive director of the North Carolina Psychological Association. Traditionally, she says, clinicians did not have to worry about billing enough services to cover their salaries. But with health-care institutions facing mounting financial pressures, that has changed—in a way that could be bad news for internship programs and Medicaid patients alike.

"Not being able to bill for a qualified service by a highly trained, supervised intern could result in further losses," says Cameron.

The lack of reimbursement for interns is also bad for consumers, because fewer internship slots mean fewer providers and thus gaps in mental health care for people who rely on Medicaid, Cameron points out. The 60 or so North Carolina internship slots at sites that now see Medicaid patients—the state's 20 other internship slots are in the federal prison system, where Medicaid reimbursement is not an issue—may not be allowed to see Medicaid patients because they cannot be reimbursed for their services. There is also a quality of care issue, adds Cameron, noting that the interns who see Medicaid patients are better equipped to serve Medicaid patients well once they become full-fledged psychologists.

The North Carolina Psychological Association is just one of many state, provincial and territorial psychological associations (SPTAs) working alongside APA to push for new legislation or regulatory fixes. "Our goal is full reimbursement for interns' services, without any strings attached," says Cameron. "We want interns to be full partners in providing services under supervision."

What is at stake is access to high-quality psychological services for the more than one in five Americans who rely on Medicaid for their health care. And with the Medicaid expansion in many states as a result of the Affordable Care Act, the demand for psychological services will only grow. "In some places, clients are already waiting weeks or months to be seen," says Eddy Ameen, PhD, who directs APA's Office on Early Career Psychologists.

Meeting a growing need

Because Medicaid is a joint federal/state program, each state runs its own program, within broad parameters set by the federal government. "Programs vary tremendously from state to state," says Shirley Ann Higuchi, JD, associate executive director for legal and regulatory affairs in APA's Practice Directorate. The managed-care companies that run many state Medicaid programs—and provide services to 80 percent of Medicaid beneficiaries—may also have their own reimbursement rules.

Only 16 states currently allow reimbursement for interns in some capacity; Nevada and Texas have rule changes pending that would allow for intern reimbursement. Of those 16 states, some limit intern reimbursement to certain settings or services. In Oregon, for instance, interns can be reimbursed only for services provided in coordinated care organizations. In Colorado, interns can bill for Medicaid services provided in residential facilities and a few other settings.

APA's Practice and Education Directorates are working to increase the number of states that allow Medicaid reimbursement for interns. APA is researching state programs to determine how they function and to identify barriers, investigating possible legislative or regulatory fixes and trying to come up with a national strategy that could be used as a template for advising state Medicaid agencies considering changes. APA is also tackling the problem of the six states, plus the District of Columbia, that don't even reimburse independently practicing psychologists for services provided to Medicaid patients—a situation that also limits patients' access to mental health care.

One significant barrier that has to be overcome is the concern among some state Medicaid agencies that interns aren't competent to provide services because they aren't yet licensed. "People outside the psychology training community assume that because doctoral psychology students take their licensing exams after their internship years, these unlicensed practitioners aren't as qualified as their licensed supervisors," says Caroline Bergner, JD, a policy and advocacy fellow in APA's Education Directorate. "But interns have so much experience by the time they start their internships—between 1,500 and 2,000 hours of patient care—that they're very well-equipped to provide psychotherapy and a host of other services."

Bergner and others encourage psychologists and trainees to reach out to APA for help if they're interested in fixing the intern reimbursement problem in their states. They should also collaborate with their SPTAs, training directors, state psychology licensing boards, students and others as they begin exploring legislative or regulatory possibilities. In states that have already won the fight, the psychology community should share that story and help those in other states achieve success, too. Says Ameen, "We need champions in more states."

For more information about Medicaid reimbursement, tips on how you can help and resources, check out the Advocacy Toolkit at www.apa.org/ed/graduate/about/reimbursement/index.aspx.

By Rebecca A. Clay


This article was originally published in the September 2016 Monitor on Psychology

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01 Jun 2017

Working with an Accountable Care Organization

Working with an Accountable Care Organization

Arnold D. Holzman and his practice are joining forces with hundreds of physicians.

Ask Arnold D. Holzman, PhD, how he sees the future of psychology, and he lays out a vision of psychologists working side by side with physicians in accountable care organizations — groups of health-care providers who come together to provide care for a particular patient population and enjoy bonuses for keeping their patients healthy. That's why Holzman quickly agreed when an accountable care organization called the Community Medical Group asked his practice for help last year.

The idea behind the accountable care organization was to better serve patients in Connecticut's New Haven and Fairfield counties. But the several hundred physicians involved soon realized they couldn't go it alone.

"They kept coming back to the need for high-quality psychological intervention," says Holzman, co-founder and managing partner of Behavioral Health Consultants, LLC, in Hamden, Connecticut. "Many of the problems that bring individuals to physicians' offices, particularly primary-care offices, are psychologically based."

As a result, the accountable care organization turned for help to Behavioral Health Consultants, which has 11 psychologists and three master's-level clinicians on staff and subcontracts with other mental health professionals — about half of them psychologists — as needed.

Accountable care organizations are springing up in response to the Affordable Care Act, which is intended to improve care and reduce costs by encouraging reimbursement focused on the quality — not the number — of services provided. Physicians share accountability for the cost and quality of care delivered to a patient population, with insurers rewarding improved outcomes and lower costs. The organizations can not only develop their own treatment protocols but also share electronic medical records and back-office functions, such as billing and appointments.

Realizing that integrating medical and psychological services was key, Community Medical Group recruited Behavioral Health Consultants, whose providers already had relationships with many of the physicians in the organization, to provide the psychological services its patients need.

Behavioral Health Consultants and the accountable care organization are currently separate entities, but the two are discussing the possibility of co-located services. That way, says Holzman, patients will see psychologists as "a routine extension of their work with a doctor as opposed to something separate." He hopes that eventually his practice will be able to enjoy such benefits of integration as shared administrative and support services and electronic medical records, joint negotiations with payers, even profit-sharing. "This is a process that will take years," he predicts.

So far, the relationship consists of referrals.

"The problem with more traditional relationships, as many physicians have told us, is they'll often tell patients they should go see someone, but they don't know whom to refer them to," says Holzman. "And they don't know if they got there because there's no [follow-up] communication."

The physicians now tap Holzman and his colleagues when they suspect patients have emotional or behavioral problems that are impairing their health. One young man, for example, came to Holzman after tests could find no medical reason for his chest pain and other symptoms of a possible heart problem. The real issue turned out to be anxiety. "Once we reframed his symptoms as anxiety, we could approach the problem as a psychological one, not a medical one," says Holzman, who used cognitive-behavioral therapy to teach the man how to better manage the stressors in his life and the resulting anxiety.

But Holzman and his colleagues also assist patients with medical problems. In fact, they are developing the accountable care organization's protocol for treating patients who have diabetes along with depression, obesity or other problems, yet aren't following their physicians' recommendations. The protocol will lay out how referrals will be made, as well as guidelines for individual and group treatment and outcome measures so all of the providers can determine whether treatment is successful.

Holzman is also in discussions with insurers who may provide seed money for demonstration projects to show that adding psychologists' interventions keeps patients healthier. "They see our work as potentially reducing their financial exposure if patients get better sooner," he says.

He encourages other psychologists to get involved with accountable care organizations, either by developing relationships with physicians who are members of one or more organizations or by joining practices like his own that have already developed those relationships.

Holzman's background in pain management and health psychology prepared him well for working with an accountable care organization, he says. "When you're trained in pain management, communicating with physician referral sources is second nature," says Holzman, who earned a doctorate in clinical psychology from the State University of New York at Binghamton in 1981.

Such integrated care, he adds, is not only good for patients. It's also good for the bottom line. Because of the new relationship with the accountable care organization, Holzman anticipates substantial growth and expects to bring on many more clinicians and subcontractors.

"That's really the motivation here: to provide high quality service and be successful at the same time," he says.

By Rebecca A. Clay 


This article was originally published in the May 2016 Monitor on Psychology

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