WASHINGTON — The House Energy & Commerce Health Subcommittee hearing Tuesday on bills to address the mental healthcare crisis was generally very collegial except for a turf war that broke out between the psychiatrist and the psychologist who testified before the subcommittee.
The discord came over H.R. 884, known as the Medicare Mental Health Access Act — a bill sponsored by Reps. Jan Schakowsky (D-Ill.), Judy Chu (D-Calif.) and Markwayne Mullin (R-Okla.) that would treat clinical psychologists as physicians when it came to providing clinical psychology services to Medicare beneficiaries. Currently, psychologist must have a physician’s order if they want to treat and be reimbursed for treating a Medicare patient; the bill would remove that requirement.
“Requiring psychologists to have to go through psychiatrists to provide services is just unconscionable at a time when our seniors are isolated, they’re experiencing anxiety, they need direct services,” said Arthur Evans Jr., PhD, CEO of the American Psychological Association. He added that he heard about one psychologist who was waiting to get a physician’s order for his services “and the psychiatrist said to his face that ‘I don’t believe in psychotherapy; I’m not going to provide that order.’ We cannot allow those barriers in 2020 to continue to exist.”
But Jeffrey Geller, MD, MPH, president of the American Psychiatric Association, argued that the bill went too far. “The goal of H.R. 884 is unclear since Medicare already recognizes and allows psychologists to provide the services they’re trained to perform and to practice independently in Medicare in appropriate settings,” Geller said in his opening testimony. “But psychologists are not physicians. Psychologists do not have medical training. Psychiatrists treat patients with mental illness and co-morbid medical illnesses in inpatient and partial hospital settings. Psychiatrists have to recognize medical disorders masquerading as psychiatric disorders. You cannot be equipped to do this without a medical school background.”
“High-quality care is best provided by a team working together to provide coordinated services, but this legislation would do the opposite — further fragment and create unnecessary and dangerous silos,” said Geller. “Administrative hurdles can be addressed without going to extremes like inappropriately defining psychologists as physicians under Medicare.”
Evans disagreed. “The legislation doesn’t try to redefine psychologists as physicians … What psychologists are interested in is being able to practice to the full extent of their training and their licensure without administrative barriers. I find it ironic that at this hearing where we’ve talked about needless administrative burdens and requiring people to jump through hoops to get services, that we would have this as an issue. The reality is the Medicare program is the only payer that does this — not Medicaid, not Tricare, not the VA, not any private payer.”
Rep. Michael Burgess, MD (R-Texas), the subcommittee’s ranking member, noted that none of the bills being considered addressed the mental illnesses suffered by frontline healthcare workers; he asked Geller for recommendations on how to help them. “A major problem for physicians and nurses and other licensed personnel is the fear they’ll lose their license to practice if they report they’ve had treatment for a mental illness,” Geller said. “I apply for license renewal every few years, and generally I’m asked a question in almost every state, ‘Have I sought psychiatric treatment, and am I mentally impaired or do I believe I’m mentally impaired?’ If Congress would address that problem, I think it would make frontline healthcare workers more willing to seek treatment.”
If there is to be a question on the license renewal application relating to impairment, “it should be a broad question about impairment,” he added. “I could be impaired because I have a medical disorder. The fact that I saw a psychiatrist should not preclude me from being a doctor, an attorney, a school janitor, or anything else.”
Witnesses and subcommittee members also expressed concern that despite Congress’s passing the Mental Health Parity and Addiction Equity Act in 2008, payment for treatment of mental illness is still not on a par with payment for treatment of physical illness. “We all know growing up in families where there is alcoholism, addiction and mental illness, that we don’t like to talk about these things,” said former Rep. Patrick Kennedy (D-R.I.), a mental health advocate, in his opening statement as a witness. “We’re still in deep denial about these illnesses and their pervasiveness … Exhibit A is that Congress never really appropriated the necessary resources for this crisis, and they never enforced the parity Act. Until there’s that same urgency toward enforcing and same money backing up our words that these are equal illnesses, we’re really still in denial as a nation.”
Kennedy noted that currently, the Department of Labor, which oversees compliance with the parity act, has one inspector for every 2,500 health plans. “How are we going to have any accountability if there’s no oversight?” he asked. The committee is considering a bill called the Mental Health Parity Compliance Act that would require plans to provide more information to the government about how they were enforcing parity.
Using telemedicine — including telephone calls — for psychiatric visits was a recurring theme during the hearing. Geller said that the increased ability to get psychiatry services via telephone has made a “tremendous difference” for people who don’t have broadband access. He noted that one of this patients, who “hasn’t bought any new equipment since the Johnson Administration,” only talks to him by phone, “and if he didn’t have that ability, he would be without services and probably be hospitalized.”One bill the committee is considering, the Telemental Health Expansion Act, would allow for continued reimbursement of mental health services furnished through telemedicine, and would allow the patient’s home to be an originating site.
Last Updated July 01, 2020
Joyce Frieden oversees MedPage Today’s Washington coverage, including stories about Congress, the White House, the Supreme Court, healthcare trade associations, and federal agencies. She has 35 years of experience covering health policy. Follow