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