Government health care changes have wins, losses for psychology

The National Psychologist January/February 2014, Vol 23, 1, pp 6-7.

Government health care changes have wins, losses for psychology

By Paula E. Hartman-Stein, Ph.D.

Medicare changes in 2014 that impact reimbursement and new government reporting requirements are good, bad and ugly for psychology.

First the good news: in the over 1,369-page 2014 Medicare Physician Fee Schedule final rule published Dec. 10 in The Federal Register, the Center for Medicare and Medicaid Services (CMS) accepted recommendations of the Relative Update Committee (RUC) that will improve Medicare payment for mental health services. On average psychologists will see an 8 percent increase in reimbursement.

Just before the holiday break, the sustainable growth rate (SGR) payment adjustment for 2014 that would have been 23.7 percent was blocked by the U.S. Senate.

Back to the good news: According to James Georgoulakis, Ph.D., JD., advisor to the RUC for APA and the APA Practice Organization and member of the Health Care Professionals Advisory Committee to the RUC Research Subcommittee, “CMS accepted 100 percent of the RUC’s recommendations following a review of survey data regarding the work values of the psychotherapy codes. CMS accepted only 76 percent of the RUC’s recommendations for all medical specialties for 2014.”

Despite recent criticisms of the RUC in news outlets alleging bias toward higher paying medical specialties rather than primary care, Georgoulakis said, “The American Medical Association (AMA) and RUC understand the amount of cognitive work involved in working with patients that require mental health services.” He added that the RUC has policies that safeguard members from lobbyists. “RUC members are prohibited from representing positions advocated by special interest groups,” he said.

Georgoulakis said, “The increase of work values could not be achieved without the support and partnership with our colleagues in psychiatry and social work.”

The Federal Register on Nov. 27 indicated that clinical social work averaged a positive impact of 8 percent and psychiatry received a 6 percent increase overall. The change comes from the combined impact of work, practice expense and malpractice costs.

Compared to 2013 rates, examples of changes in psychotherapy reimbursement are in family psychotherapy (code 90847) with a boost on average of 15.5 percent, psychoanalysis (code 90845) with a substantial increase of 17 percent, the 60 minute psychotherapy (code 90837) payment increased 3.5 percent and the 45-minute psychotherapy (code 90834) went up 1.5 percent. Reimbursement for 30-minute psychotherapy (code 90832) decreased by 1.5 percent.

When asked why psychoanalysis and family psychotherapy received such significant increases, Georgoulakis said, “Two reasons, first, the relative work values as generated from the survey data and second, the value maintains the relationship within the family of codes.”

Antonio Puente, Ph.D., APA’s representative and voting member of the AMA’s CPT committee, said, “The numbers overall are generally very good, given the state of health care.”

The bad news is reimbursement for the initial psychiatric diagnostic interview (CPT 90791) went down 15 percent on average for psychologists.

Puente said the practice expense has been reviewed and substantially changed for this service because in the original valuing of the psychiatric interview code there were additional personnel involved with the intake.

In a previous article in The National Psychologist (September/October 2013), Georgoulakis said that for about 20 years practice expenses for mental health practitioners, including psychologists, benefited from inpatient costs that included nursing labor costs. This has now been removed.

This disproportionately affected the diagnostic interview and time psychotherapy codes but not others.

The work values of the testing codes and the Health and Behavior (H and B) codes were not reviewed in 2013 but their reimbursement for 2014 increased approximately 1.5 percent.

Neuropsychological testing (code 96118) increased by 3 percent with neuropsychological testing by a technician (96119) increasing by 4 percent. The largest decreases are in the testing codes by a computer, reduced by 38 percent (code 96103) and 55 percent for (code 96120).

Psychological testing by a technician decreased by 28 percent (code 96102) and psychological testing (code 96101) decreased by 7 percent. According to the APA Practice Organization newsletter released on Dec. 3, losses of reimbursement to the testing codes are largely due to the change in the practice expense.


New methodologies considered

According to Georgoulakis, “The RUC is aware of the problems with the practice expense issue. We are not just sitting on it. The AMA has already put proposals in front of CMS.”

He said the AMA will ultimately accept a methodology that will apply across the board to all specialties. “The present formula for calculating practice expenses is more beneficial for the surgical area than for the cognitive procedures, but the AMA is looking at three methodologies to try to make the way practice expense is calculated more equitable, which will benefit psychology greatly,” said Georgoulakis.

According to Puente, “This is a work in progress. Today’s numbers may not be tomorrow’s.”


Bad news for RxP psychologists

Georgoulakis said the section on medication prescription codes in the December 10 Federal Register is clear: CMS will not be reimbursing for psychologists who prescribe medications. “The language in the Federal Register is new, but the position of CMS is not.”


Increases in work values increase opportunities for psychology

Georgoulakis said the work values recently set for psychotherapy services have impact beyond Medicare with more than 90 percent of the payers in the country using the relative work values (RVUs) to determine their fee structure. Georgoulakis said, “Other arenas that use RVUs are managed care, the Veterans Administration and the US military. The RVUs go far beyond Medicare.”

According to Georgoulakis, RVUs will tie into salary structures for clinicians who will have salaried positions from integrated health care systems that are being created as a result of the Affordable Care Act (ACA). “In order to pay each of the specialties, we go back to work values, as it is the only thing we can do. We are going to see more bundled reimbursement that will go to teams.”

Some more good news: “As the RVUs increase for mental health, we will likely get more dollars allocated to mental health professionals, and this will lead to greater opportunities for psychology,” said Georgoulakis.


Physicians Quality Reporting System (PQRS) changes in 2014

Based on the Dec. 10 Federal Register, 2014 is the last year providers can qualify for an incentive payment of 0.5 percent under PQRS. Beginning in 2015 there will only be penalties for failure to report satisfactorily.

Individual clinicians must report on at least nine measures to receive incentives and must report on three measures for 50 percent of applicable patients to avoid 2016 PQRS penalties. At press time the complete list of 284 quality measures was not available.

Of uncertain impact is the elimination of the option to report on claims-based measures groups.

Dori Bischmann, Ph.D., of Waukesha, Wisc., a new representative for APA at the Physician Consortium of Performance Improvement (PCPI), an AMA committee with the goal of improving patient health and safety, said APA opposed the requirement of increasing the number of quality measures from three to nine. “APA thought it would be too much for psychology. The final rule is disappointing.”

According to Puente, “PQRS is the evolution of the Medicare system from fee for service to pay for performance. At present time PQRS is documentation-based, but not for long. PQRS is here to stay.”

Bischmann said there is a website that is part of the ACA to develop a transparent mechanism to compare physicians and all providers called Physician Compare. She looked up her own name and found data such as her office address, gender and whether she participated in PQRS and accepted Medicare assignments. “This is just the beginning of reporting information to the public about the quality of the physician,” she said.


Psychology volunteers impact future of health care

According to Puente, an untold amount of effort has been exerted from the psychologists who participate on the AMA committees. “It is an untold story to understand how much time, networking, diplomacy and effort go into the work throughout the year from psychology volunteers on the various AMA health care committees. It really takes some blood, sweat and tears.”


Paula Hartman-Stein, Ph.D., offers workshops for professionals on optimal aging and geropsychology practice issues, including PQRS. She is a faculty associate at Arizona State University for a course on integrated geriatric behavioral health. She is a member of the Medicare Evidence Development and Coverage Advisory Committee to CMS and former chair of the psychology work group to develop measures for PQRS. She can be reached through