Health Care Reform and Potential Opportunities for Professional Counselors

Alicia L. Stanley, Marietta College

Kenneth L. Miller, Youngstown State University

Statement of the Problem: Fragmented Health Care

Delivery in the United States Research has clearly established a link between human physical and mental functioning.

Integrated care suggests a model of health that is more than an absence of disease, but a state of physical and mental wellbeing.

The current health care structure in the United States largely incorporates fragmented care models that treat only parts of the whole. This prac-

tice, coined “silo care,” has negative implications for public health and service delivery (Shallcross, 2013).

“Silo” health care of medical and mental illness is inconsistent with best medical practices.

The adverse effects of silo care on heath outcomes is particularly evident when treating patients with co-occurring medical and mental health

conditions.

Only approximately 10% of those referred by primary care physicians (PCPs) actually follow through with a behavioral health professional

(Shallcross, 2013).

50% to 90% of patients seek treatment for behavioral health issues from their primary care physicians (Aiken & Curtis, 2004).

Research has estimated that the life expectancy of patients receiving behavioral health services in standalone behavioral health settings is

shortened by at least 8 years (Manderscheid & Kathol, 2014).

The adverse effects of silo care on service delivery are particularly evident when treating patients with co-occurring medical and mental health

conditions.

Fragmentation of services further strains the American public health system that is wrought with high costs, problems with managed care,

poor communication between professionals, and billing practices that reward unnecessary medical testing.

Unnecessary services associated with medical and mental health comorbidity costs an estimated $350 billion per year while mental health

conditions are left ineffectively treated (Kathol, deGruy & Rollman, 2014).

The traditional approach to treating comorbid medical and mental health conditions has typically involved referral from one delivery system to

another (Manderscheid & Kathol, 2014).

Section 2703 of the Affordable Care Act

Section 1945 (2703 option) of the Act offers states the option to establish Medicaid Health Homes; integrated health care facilities that provide a

holistic approach to treating chronic medical and behavioral health conditions.

Designed to serve low income patients with chronic medical conditions.

To date, 27 state plan amendments (SPAs) have been approved by the federal government to implement Health Homes in 21 states with

1,282,688 enrollees nationwide.

States are given considerable leverage in defining their state’s Health Home provider infrastructure (i.e., the professionals qualified to pro-

vide Medicaid reimbursed services), target populations, payment methodologies, geographical limitations, and definitions of chronic condi-

tions.

Implications for Professional Counselors

Recognition of the counseling profession by the largest payer for mental health services, Medicaid, is not uniform among states.

Professional associations have been lobbying for more than a decade for Medicaid reimbursement for LPC services.

Federal recognition of professional counselors in legislation (S.3421, the Veterans Benefits, Health Care and Information Technology Act of

2006) came in 2006.

Historically, state and federal legislation have dictated the roles of various health care professionals by defining the scope and breadth of prac-

tice, delineating reimbursement practices, and writing health professionals’ educational and training standards into law (Bergman, 2012).

The newest wave of health care reform focuses heavily on the integration of medical and behavioral health service delivery by requiring the

coordination of care among medical and behavioral health specialists.

In drafting State Plan Amendments (SPAs) for Health Home implementation (e.g., detailing service definitions and selecting provider infra-

structures) states are simultaneously redefining the identities, roles, and functions of Licensed Professional Counselors (LPCs) as behavioral

healthcare providers.

While these changes in federal and state law should be cause for careful scrutiny by the counseling profession, they may also be creating ex-

panded opportunities for LPCs.

Figure B: Provider Infrastructure States may choose to implement one or any combination of the

following three Health Home provider infrastructures: desig-

nated provider, team of health care professionals, and/or

health team. A designated provider (DP) may be a physician,

rural health clinic, community health or mental health center, a

clinical or group practice, home health agency, pediatrician,

OB/GYN, or “other type provider (Medicaid.gov).” A team of

health care professionals (THCP) may include physicians, be-

havioral health professionals, social workers, nurse care coor-

dinators, and nutritionists. These can be, virtual, free-standing,

hospital-based, or a community mental health center. A health

team must consist of the following professionals: medical spe-

cialists, pharmacists, nurses, behavioral health providers, nu-

tritionists, dieticians, social workers, chiropractic's, and

“licensed complementary and alternative practitioners

(Medicaid.gov).” Of the existing twenty SPAs, all have opted for

either the designated provider, team of health care profession-

als or a combination of the two. None have implemented the

health team infrastructure option.

Small Steps and Lost Opportunities

Through Health Home legislation, states have defined which mental health disorders are to be treated as chronic medical conditions. By amending

state constitutions, states have identified eligible mental health providers to provide treatment for such conditions and to receive Medicaid reim-

bursement for their services. For states whose state plan amendments cite Licensed Professional Counselors in their provider infrastructure (as des-

ignated providers or members of the team of healthcare professionals), this legislation not only delineates their scope of practice (definition of

chronic conditions) for LPC’s, but also stipulates their eligibility for Medicaid reimbursement. This is a step forward for the three states whose Health

Home legislation cites Licensed Professional Counselors as service providers (see Figure A). However, for the remaining 18 states in which legisla-

tion cites generic professional titles (e.g., behavioral health professional, substance abuse specialist) or simply behavioral health agencies as the

Medicaid reimbursement recipients, LPCs may have missed critical opportunities to have the breadth and scope of their practice written into law as

Medicaid reimbursable mental health professionals. These missed opportunities serve to further confound the professional identity of LPCs: Who are

we? What is our scope of practice? What are our educational standards? Why don’t our legislators know who we are?

Figure C: Definition of Chronic

Conditions

States have been given considerable leverage in delineating

the chronic conditions eligible for Health Home services. All

states were federally required to consult with SAMHSA as

they drafted State Plan Amendments, each state was given

the opportunity to choose which conditions qualified for

Health Home service coverage. For example, in Ohio severe

and persistent mental illness is cited in legislation simply as

“Mental Health Condition.” Whereas definitions of chronic

conditions in Kansas and Vermont (schizophrenia, bipolar

disorder, depressive disorder, obsessive compulsives disor-

der, PTSD, personality disorder, psychosis NOS, and delu-

sional disorders, and opioid addiction, respectively) are de-

tailed to a greater or lesser degree.

Figure A: Eligible Behavioral Health

Providers

Vermont, Michigan and Kansas are the only 3 states to cite

Licensed Professional Counselors as eligible, Medicaid-

reimbursable, mental health service providers in Health

Homes. In the remaining states, it may be possible for LPCs

to provide Medicaid-billable services as employees of an

agency (i.e., the agency is reimbursed then reimburses the

LPC) or because they have the credentials to satisfy provid-

er requirements for generic mental health professional titles

identified in the state’s amendment (i.e., behavioral health

professional, substance abuse specialist).

Generic

Agency

LPC

The Path Ahead

Perhaps the most powerful lesson that the counseling profession (ACA [Divisions, and Affiliates], CACREP, NBCC, State Licensing Boards) can take

away from the Health Home experience is self-evident, yet largely unlearned.

If the counseling profession is to enjoy full membership in the league of legally-recognized, high status, mental health professions, it must develop a co-

herent and consistent professional identify based on: (a) a comprehensive, vigilantly monitored, and enforced code of ethical practice (met); (b) con-

sistent definitions of legally sanctioned professional roles and responsibilities in all states (unmet); (c) clearly-defined professional training standards

(partially met); (d) requirement for a “terminal degree” commensurate with the complexities of professional practice (unmet); and, (e) a clear statement

of the unique contribution of Professional Counseling to human health and wellness (unmet).

In the absence of achieving these goals, it seems likely that the counseling profession will continue to be marginalized and disenfranchised, that counse-

lors will continue to be regarded as “second class paraprofessionals,” and that they will be consistently denied opportunities for equal compensation

and status in federal and state health initiatives.

Provider Infrastructure

Chronic Conditions

Eligible Mental Health

Service Providers

Designated Provider

Team of Health Care Professionals

Both

SPMI Only

SPMI and Medical Condition

Medical Condition Only

Figure A

Figure B

Figure C