The Jabberwock by Tenniel
I’ve been on a pretty steady soapbox about video games, and play this past week, and that was not a coincidence. The post I did about HIPAA attracted a lot of positive attention, and some negative. I think the title had something to do with it, in that it was a tongue-in-cheek title. There’s no such thing as a 100% HIPAA compliant practice, and I was poking fun at the fear-based mentality that sometimes consumes us when it comes to our practices and being sued. When my readers poked back, I realized that I needed to explain my perspective, so this post will hopefully clear things up in terms of using technology in therapy and preparing your practice for health care reform. So let me try to do that now:
We live in an era of fear.
That’s it in a nutshell. There is so much change and synergy going on today that it can be overwhelming. Technology, in particular social media, is evolving faster than many of us know how to use it. So we turn away from it in fear and disinterest. The HIPAA issue is in many ways the symptom of that, but it is also a red herring. The way we live and work is changing, and we don’t want to change. We want therapy to begin with the first phone call or the greeting in the waiting room, occur only in the office between two people talking, and end at the 45-50 minute mark. And for many of our patients, that works, and for much of the time, that works. But things are starting to slip, expand. Our potential patients want to know something of us before they even call, so they’re looking for our website. Patients from all over the world are seeking out therapists with particular expertise via Skype rather than the brick and mortar office. And between sessions our patients are following us on Twitter, asking to friend us on Facebook, or reading our blogs. The ability for us to remain as mysterious as we used to be is being challenged. We are googled, and this raises our own ethical concerns about whether we should google our patients. So technology scares us, and we feel it threatens our profession rather than opens new avenues to us to practice our craft.
We are also scared of health care reform, ACOs and global payments. We have grown reliant on the way we have come to do business with health insurances. In the 1980s in Masachusetts, insurers like BCBS offered their subscribers $500 worth of coverage, that was it. There was no parity, and many of our patients paid our full fee out of pocket. Somehow they found the money, sometimes they went without treatment. In the intervening decades many of us made a “deal with the devil,” agreeing to play by insurance companies’ rules in return for the steady fee-for-service reimbursements we got. Sure we sometimes complained about how long it took to get reimbursed, or the clinical reviews we had to do, or the paperwork. But we signed up for the insurances for a reason, we wanted security and steady referrals. And we raised a whole generation of therapists who saw insurance reimbursement as a necessity, not an option.
Worse still, we stopped needing to think with our colleagues and our patients about whether we were doing valuable work. Our patients grew to take it for granted that therapy cost $15, and we grew to think we might only be worth that much. So when insurance companies put incremental demands on us, we acquiesced. When they lowered reimbursement rates, we acquiesced. And we did this, we do this, because we are afraid. And because we are afraid, we keep doing business as usual and rely on the insulation of a third party reimburser to protect us from having the conversations we need to have with our patients on what and why they need to pay for their treatment. We bought into this system because we wanted to avoid those conversations.
Health care reform, if it survives, will be an amazing boon for Americans. Mental health parity has already in MA helped thousands of people get and stay in treatment. As our politicians hammer out the details, our professional organizations are being called on to weigh in on how to move to the new structure of treatment and reimbursement. And to their credit, they are doing what organizations like that need to do, ensuring that they have a place at the table, and speaking out loudly and strongly to advocate for patient care. And yes, they also represent us, but we need to understand that we don’t come first in many ways. The people who need to fight for our businesses are us.
I need to advocate for my own business, make my own business plan, set my own fees, adhere to my own fees, set aside PB+5 or low-cost sessions to have a socially just AND profitable practice. I need to be able to have the difficult conversations, to tell people why I am worth more, why the work we are doing is worth more, than $15. That is my job as a business-owner, even if the business I am in is healing the mind and soul. I need to wean myself off an insurance-only practice, diversify my revenue streams.
In short, I need to become an Epic Therapist.
Epic therapists, don’t play it safe all the time. They know that to get the epic loot they need to try and fail and try and fail again. Epic therapists know they need to network with a group of strong co-players, and learn new strategies to try when the old ones won’t let them down the boss. Epic therapists “learn the fights,” they spend hours learning about how to be the best they can be and let other people know what they are good at.
Epic therapists aren’t good at working with every single patient problem or person in the world. Those type of therapists, who maintain that they can do equally excellent treatment with anyone for any problem are what I call “Non-Player Character Therapists.” In video games, a NPC is a character in the game like a robot, that anyone can click on and they’ll get the same conversation and quest. NPC therapists have no sense of agency.
This was all a long prelude to what I really wanted to do today, which was to introduce you to some Epic Therapists. These are people doing amazing work in their own unique ways. So here are three epic therapists:
Deb is a social worker in CA with over 25 years of experience working with adolescents and their families. Deb specializes in adolescents whose anger and distress have often landed them in a lot of trouble with the law, schools or their families. Deb is not afraid to fight for the kids she works with, and will often go head-to-head when she is required to testify on their behalf. When I’ve spent time with Deb I’ve been impressed with her energy and authentic cheerfulness. If you are looking for a therapist who “gets” teens and “gets” the technology that is so much a part of their lives, click on the link above and contact Deb.
Also in CA, Brenda is an LMFT who specializes in working with couples. She also specializes in advocating for the voice that may have a hard time speaking up. Brenda may not be the loudest person in the room, but she’s definitely one of the most attentive and thoughtful. In addition to her experience with couples, Brenda has a particular interest in working with couples where one or both partners has been identified as gifted. If you are looking for a therapist but are shy about therapists and therapy in general, Brenda is a good bet. Brenda is also beginning to branch out into online therapy, so you may want to inquire about that as well.
A seasoned clinician with an extensive background in psychodynamic theory and trauma, Carolyn has also been practicing for over 25 years. She has a specialty in evaulations for persons with complex trauma seeking immigrant status, and has testified numerous times as an expert witness. She frequently teaches and lectures on the impact of trauma from a psychodynamic perspective, and in her private practice she has a specialty of working with emergent adults (18-25) who are struggling to maintain their schooling or jobs after having had a psychotic episode or severe depression. Carolyn is not afraid to go to the deep places with her patients, and stay with them through the terror that can exist there.
These are just a few examples of the Epic Therapists I know. Who are some of the Epic Therapists you know? And what makes you an Epic Therapist?
Hi Mike,
Thanks for this very comprehensive post on the key issues/dilemmas facing therapists in today’s environment.
The key take-aways seem to be:
1) Keep your eyes and ears open for change (as change is constantly occurring and you need to be prepared) – there is a good book with a parable that addresses this very important concept: Who Moved My Cheese? by Spencer Johnson.
2) Diversify your income streams (do not have all your eggs on the insurance basket
3) Be prepared to explain your fees (and cease selling yourself short)
4) Figure out which types of therapy or concerns you excel at and focus your work on those areas
5) Re HIPPA and social media, social media is still evolving… NASW’s code of ethics provides some guidelines, HIPPA provides some guidelines and for the gray areas, do what seems to make sense ethically
Thanks again,
Dorlee
This post prompts me to wonder when therapists stopped asking why we do things the way we do them. And maybe as a profession we never had that kind of self reflective / self critical throught process anyway. We challenge our patients’ disempowered constructs all day long, but seem to let our own beliefs about the way things have to be go unquestioned.
I’d include you, Mike, as an epic therapist, for keeping up with the times, and for continually putting the new questions before us.
The so called safeties of the past are crumbling. Therapists have to get our heads out of the sand, stop allowing our work in the world to be dictated and confined by 3rd party interests, and start taking pro-active control of our own self-actualized empowerment.
And yes, we’ll have to take risks, face fears, go out on limbs, and stand apart from the crowd. We have to become advocates for ourselves, as much as, and maybe more than, for our clients.
Keep up the poking. We need it.
Deah
http://www.TheNoHypeMentor.com
Great, as always, Mike. I think, as a profession, we have allowed ourselves to be lulled by “easy” payment (referrals given to us without any marketing and a payment system, that while awkward reimbursed us regardless of quality or outcome.). If we are being very honest, we can all identify colleagues who rely on that system and have not improved their skills, put forth mediocre services and are not epic. Many ARE keeping up and do excellent work, but we all get clumped together by the public who can’t tell the difference between high quality and therapy that is only worth $15.
In terms of language, I don’t think we need to be ‘epic.’ We need to be relevent, provide high quality services where people can identify real, measurable progress (however you measure it), and have at least rudimentary business/marketing skills.
Anyone can do this with motivation, an open mind and a willingness to take small risks.
You’re right, that many in our profession are running scared. But there isn’t really anything to be scared of (or any more scared than what people felt when the motorized car started to replace horses). Hiding wont’ stop innovation, and in fact, the revolution will pass those by who hide, leaving them worse off than when they started ducking and running.
The only smart direction is forward.
Isn’t that what we try to help our clients do on a daily basis?
We need to walk the talk.
Thanks Susan, I’m glad people like you are able to speak out to our colleagues on the lulling phenomenon of third-party reimbursement.
I think that the language of “epic” is gamer language, but actually for the purpose of our discussion means what you said: highly relevent, high quality service; and that a person can say they excel at something in terms of their specialty or focus. Epic also is intended to embrace the gamer quality of rising to the challenge, trial and failure and retrial until one gets it right, and grouping with other “well-geared” colleagues to strategize and surmount tasks. By that definition I would consider the webinar you are planning to be assembling a group of epic therapists to “gear up” and plan how to down the boss that in this case is the new environment for therapists. But as I write this I realize that I may need to blog more specifically about what makes for epic therapists or epic therapy, which should be fun! 🙂
Well said. Thank you for articulating this so clearly.
Fear is running rampant. Not just in psychotherapy practice, but in our culture as whole. The fear-based mentality in the U.S. has been stoked by popular news for many years, but it was ramped up by geometric levels after 9/11. As I teach my trauma-survivor clients–when our fear schemas are activated we see threat everywhere: research tells us that even neutral stimuli will be perceived as threatening. The problem then is that we can’t figure out if we are seeing something that is truly threatening now, or just a result of my activated schema (the fear from the past).
It’s not that I don’t feel fear about some of the things happening in our world. I do feel afraid. And so I will sit with my fear when I feel it. But I try never to make decisions that are made from fear. Doing so doesn’t result in an increased sense of security (which is what we hope), it just results in restriction of choices and more fear. Like people suffering from agoraphobia, our worlds grow smaller and smaller until we have no space that feels safe and are living in a prison of our own making.
I love the idea of being an “Epic Therapist.” Since I recently closed my therapy practice I don’t think I am allowed to hold up that banner. But I will take on the title of “Epic Social Worker”.
Hi Mike
Are you saying that your total insurance reimbursement is only $15 or is that the amount of the co-pay? If that is the case….yep! you need to do something different!
However, if that amount is the co-pay, and you’re saying that the client is only attaching that “out of pocket” amount as value for therapeutic services, I can say…. yes, I pay a $15 co-pay for any “medical office visit”.
and I do find the statement “patients grew to take it for granted” to be quite a generalization. Some work their jobs in order to maintain insurance benefits for themselves and their families …it is not always “taken for granted”. I pay my copay to the health professional I see, and they are reimbursed by the insurance company according to the contract they entered. The value for me (or the client) comes in a form of “sweat equity” if you will. I work for my insurance benefits! A client can value the service in other ways than financial payout.
(I also noticed that when the health professionals fee was reduced, my co-pay went up. So In my experience the health professional was receiving the same amount of reimbursement.
For example, one professional I worked with received a $10 copay and a $64 insurance reimbusrement….then the insurance company lowered the reimbursement to $59 but my copay became $15.00…either way the total payout was $74.)
I’d love to be able to be able to afford pay “out of pocket” for services! Unfortunately my employer is very unlikely to raise the value of my services in dollars to enable this happen! Don’t forget for quite awhile, employers were offering good benefits to attract quality employees in lieu of higher salaries….that too, over time, became an expectation, and way of life,( taken for granted) for “the workforce” ( non self employed). But as we have seen in the last few years, “the workforce” has also experienced salary and benefit cuts, it’s numbers have been reduced… and no one has had much input about it.
We’ve all had acquiesce to a lower reimbursement rate!
I’d like to have “one of those conversations” with my employer ….do you think they’d listen?
Good questions Wisdom! I think this is one reason why psychotherapy does not fit in well or easily with the medical model sometimes. Most specialists you visit you would only see once or twice, and these specialists would charge a lot higher rates.
Yes, you do work for your insurance benefits, I do too, and in fact I have to pay more than many because I am self-employed and have no benefits package! In addition, insurance rembursement rates have decreased steadily over the past 10 years, and most occupations cannot say that they have had un-raises every year for the past decade. If Norma Rae doesn’t want to stand for low-pay or reduction she stands on a table and shouts and she’s a labor heroine. If I speak out against the same issue for my intellectual and emotional labor, I’m considered greedy. Seems unfair. Especially when my debt because of student loans is often disproportionate to the debt of other workers.
The numbers you use are a good example, but they are only half the example. In most cases the full fee for a therapy session is $130-160 in my area for comparable clinicians. So the total payout of $75 is less than half of what my full fee is. You may think that is too expensive, but that is the going rate.
Let me go out on a limb here and say this: Not every course of psychotherapy is medically necessary. If one feels distress to the point of wanting to hurt or kill themselves that is life-threatening and medically necessary. If one feels lonely and disappointed because one cannot find a significant other, therapy can help with that and improve the person’s quality of life, but it is not medically necessary. And in that case, maybe the patient needs to pay for it if they want to improve the quality of their life. Please note that I am speaking from within the context of a capitalist healthcare industry, which like it or not, we have.
Also, not every patient needs to see a therapist in private practice. I don’t have federal grants or fundraising departments to help increase my revenue to offset operating costs. I am also a for-profit business, which is why I don’t get tax breaks that non-profits often get. I have a certain number of hours to see patients and earn money before I collapse, and I would be a poor businessperson if I agreed to cap myself at a certain salary for the next 25 years. Clinics have longer waiting lists, and probably wouldn’t be able to see the non-medically necessary patient quickly or for long, but they are an alternative.
That said, I do want to allow patients to access my services even if they have limited funds. It is why I choose to accept some insurances. It is also why I have a weekly “free” slot for veterans as part of Give An Hour, and why I offer 1-2 PB+5 appointment slots when I don’t. Other clinicians I know have a set number of sliding scale appointments. It is as personal as each person’s finances.
I think that there is no easy answer for these situations, that is the dilemma of our healthcare system. The best we can hope to do at this point is listen to each other’s perspectives and understand how complicated the picture is for everyone.
Interesting points Mike!
The criteria for medical necessity has always been a huge subject for interpretation! A long term “sad and lonely situation” can eventually lead someone into some form of self harm, or a suicidal depression.
How is someone wanting to “hurt themself” defined? There are therapists out there that claim a client who drives (their car) too fast has a unconscious wish to die and/or harm others ….does that client meet medically necessary criteria? Where is the line drawn/ the interpretation made? Or is the therapist trying to get coverage for their client?
And of course there is always an M.D out there waiting to write a presciption to a depre/for depressed client when insurance for talk therapy is rejected. Very complex!
Whether I think $130-$160 is expensive or not isn’t really relevant….for me it wouldn’t be affordable. The rates are about the same if not a bit higher here in Fairfield County Ct..
As you said there are no easy answers! As a society we’ve managed make life very complex just to survive.
Maybe it’s the price we pay for becoming “civilized” and “evolving”
….next headline “Man re-invents the wheel!”
These are the times I’d like to become a towel handler in Tahiti…little stress….nice weather….ocean waves!
Tahiti would be really nice about now! 🙂
You’re right it is very complex, and my examples are oversimplified. I think the hardest thing about our current healthcare debate is to be able to see that every person involved has a context and something to gain and something to lose.
I do think that therapists, however, have an obligation to their patients to try not to make promises they can’t keep. Saying things like “I’ll always be here for you,” “don’t worry about the fee,” things I’ve heard said by the way, sound nice in the moment but are lies that can ultimately be quite devestating to patients. Thanks for the discussion, and thanks for the mental image of Tahiti!!