Outliers in Psychotherapy Revisited

ProPublica named names in its recent analysis of “highly unusual billing patterns” for office visits to MDs within Medicare. This reminded me of the 2016 analysis I conducted of billing patterns for 53+ minute psychotherapy sessions. I thought it was time to provide an updated analysis for the most recent data available, 2015. I won’t name names, but the point is, the names and the data are readily available, to the public, to journalists, to competitors. Proactive psychologists and other health care professionals should know our own numbers, and ask, “What do the numbers show about my practice relative to my peers?” and, “What would a payer think looking at my numbers?”.

I’d previously written that the number of 53+ minute sessions provided to Medicare beneficiaries increased by 48% from 2013 to 2015, to nearly 3.2 million of these sessions provided in 2015. Reasons for the growth in utilization may be debatable, but increased use since this treatment code first became available is undeniable. From 2013 to 2015, there was a 57% increase in use among LCSWs, 51% increase among psychologists, 5% increase in psychiatry, and 27% increase in use among other health care providers in Medicare. Utilization patterns remain obscure in non-Medicare systems.

The following is based on 2015 “Medicare Provider Utilization and Payment Data.” All of the clinicians in the database are listed as “individual” providers, i.e., these are not clinic or other organization entities billing these therapy services.

In 2015, 14502 clinicians billed Medicare a total of 3,190,518 90837s (255 billed in more than one location). The distribution of number of sessions billed by clinicians is shown in the following.

Clinicians billed an average of 216 90837s (SD = 243), The number and percent of clinicians billing within 1, 2, and 3 SDs of the average number is shown below.

The vast majority (91%) of clinicians billed a number of 90837s within 1 SD of the number billed by clinicians submitting this charge to Medicare. But, nearly 10% of clinicians billed greater than 1SD more than their peers, and 196 clinicians (1.33%) billed greater than 3 SD more than their peers, i.e., at the 99.9th percentile.

Use your judgment to determine how you might define “outlier” practice, at least in terms of the number of 53+ minute sessions billed. Then think how Medicare might define outlier practice. Or another payer, looking at similar data. Or a curious and capable prospective client.

Beyond the numbers, a functional way to think about this might be the following. A clinician working 261 days a year (taking weekends off), seeing 8 patients a day for 53+ minutes, would be able to provide 2088 such visits at most. With no vacations, no sick days, no continuing education, and with documentation and necessary coordination of care being done perhaps within the 7 minutes between sessions. In 2015, twenty-one clinicians represented to Medicare this was the nature of their practice.

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