Pay raise for psychologists?

Psychologists were recently apprised of a “huge win” in advocacy in relation to Medicare, resulting in “rate increases (which) are strong evidence that CMS recognizes the importance of addressing the psychological factors that affect patients’ physical health problems (and) will make it financially more sustainable for psychologists to provide HBAI [health and behavior] services and expand access to psychological care for patients with physical health conditions.”

This will be delightful if true. Consider me skeptical that Medicare, even with the best of advocacy, has had a change in heart (notice the bodily metaphor for emotional intelligence) and truly understands the inextricable nature of mental and physical health (though even the Surgeon General wrote about this ten years ago (i.e.,
https://www.psychosocial.com/policy/satcher.html), and the value of a biopsychosocial model is supported by massive amounts of research. I’m holding my breath, or at least I’ll make some predictions now about what the rate increases would have to look like to really be meaningful.

For the last 10 years, Medicare reimbursement for the “Health and Behavior” (H&B) codes has essentially been flat, and has consistently been substantially below comparable codes for diagnosis and treatment of mental health conditions. Here’s a look, based on Physician Fee Schedule Search data publicly available at
https://www.cms.gov/apps/physician-fee-schedule/search/search-criteria.aspx

Bear in mind that, just to keep up with inflation, 60 minutes of H&B assessment valued at about $91 nationally in 2010 should have been valued at about $106 in 2019 (the actual 2019 national payment amount was $93.72). Sixty minutes of H&B intervention, valued at about $84 in 2010 should have approached $98 this year — just to keep even with inflation (actual value was about $85). Anything less than that and health professionals providing health and behavior services have been losing money the longer they’ve been providing these. Anything less than these values fails to provide sufficient incentive to expand services in these areas.

Which explains why psychologists are providing fewer such services every year in Medicare, at least for the five year look-back I did. It’s important to note that psychologists provide the vast majority of H&B services in Medicare (89% of the basic H&B assessment units provided 2013-2017, 97% of all the basic H&B treatment units) relative to all other provider types. And, except for a 7% increase in the number of H&B assessment units 2016-17 (the first increase seen since 2013), H&B assessment provision has steadily declined among psychologists in Medicare since 2013 (down 26% since 2013).

The pattern of providing these services over time seems to have differed for other health professionals in Medicare relative to psychologists, perhaps reflecting a difference in learning patterns more than anything (or price sensitivity, or other practice demands and billing codes available, or possibly even variation in commitment to a biopsychosocial treatment model). But the outcome has been essentially the same. Other health professionals in Medicare provided about 3% fewer H&B assessment units, and about 6.5% fewer H&B treatment units in 2017 than they did in 2013.

So 2020 could well be a watershed year for psychologists in Medicare for provision of H&B services. If the pay raise truly materializes for these services to a meaningful degree, look for an uptick in the number of these services provided by psychologists in 2020. Given the way data become publicly available though, we probably won’t know until 2022 or so.

Reimbursement for the basic H&B assessment code has increased by about 2.5% since 2010, and for the basic H&B treatment code by a paltry 1.14% since 2010. Remember, these essentially represent losses for those who have persevered providing these services for the last ten years. At a bare minimum, any “meaningful” increases would have to at least meet these increases. That means, in 2020, at a lower end estimate, the H&B assessment code ought to be valued at about $94 for 60 minutes’ activity. The H&B treatment code ought to be valued at about $86 for 60 minutes, just to keep up with the meaningless — below inflation — “increases” seen in the past 10 years. This of course would still keep these rates well below those available for the mental health diagnostic assessment and treatment code values.

One message psychologists received this past week indicated touted “a 30-40% RVU increase for an hour of service in Medicare reimbursement in 2020 (which) will make them essentially equal to psychotherapy code reimbursement.” A 30-40% increase in reimbursement would be all but unprecedented in terms of changes in Medicare reimbursement for services typically provided by psychologists (anomalous and soon-to-be reversed increases greater than these did occur in neuropsychological testing reimbursement 2006-2010). But a change at that level would put the reimbursement for 60 minutes of H&B assessment in the range of $122-$131, and for 60 minutes of H&B treatment in the range of $111-119.

We’ll know soon enough whether the “increases” look more like the typical annual bare minimum increases or are closer to the upper estimates.

More importantly, the upper estimate values would approach national payment values for the mental health assessment and treatment codes. We shall see whether any potential increases are sufficient incentive for psychologists to consider expanding practice in the health and behavior domain. That, after all, should be the goal both in terms of supporting practice, and the needs of the Medicare population.

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