The California Association of Marriage and Family Therapists (CAMFT) is a professional association dedicated to representing the interests of Marriage and Family Therapists (MFTs). Membership currently exceeds 32,000 which includes professionals in allied fields as well as students and interns pursuing licensure. Scope of Practice and Expertise Marriage and Family Therapists are trained to assess, diagnose, and treat individuals, couples, families, and groups for a wide variety of mental health issues. The practice includes (but is not limited to) the treatment of personality disorders, post-traumatic stress disorder (PTSD), bipolar disease/depression, substance and alcohol abuse, and anxiety. Marriage and Family Therapists are psychotherapists and healing arts practitioners licensed by the State of California, Board of Behavioral Sciences. Requirements for licensure include a related doctoral or two-year master’s degree, passage of two comprehensive written examinations and completion of at least 3,000 hours of supervised experience. CAMFT establishes and helps maintain high standards of professional ethics and practice for

its members. It supports continuing professional education and works cooperatively with

the licensing board to uphold qualifications for licensure. It has an active legislative program

designed to benefit both the profession and the consumer.

LEGISLATIVE HISTORY 107th Congress (2001-2002) The provision to provide reimbursement for MFTs in the Medicare program was introduced as a standalone bill, S. 1760, by Sen. Craig Thomas (R-WY) and Sen. Blanche Lincoln (D-AR) in 2001. The companion bill, H.R. 3899, was subsequently introduced in the House by Rep. Brad Carson (D-OK). The provision was also included in the House and Senate Medicare mental health modernization bills (S. 690 and H.R. 1522). 108th Congress (2003-2004) Sen. Thomas/Sen. Lincoln reintroduced a standalone bill (S. 310). The language was also included in the Medicare mental health modernization bill (S. 646) and the omnibus Medicare rural access bills (S. 1185 and H.R. 2333). In 2003, the provision passed the Senate in the Medicare prescription drug bill (S. 1), but was not accepted during conference so did not make it into law. 109th Congress (2005-2006) In addition to standalone bills S. 784 and H.R. 5324, introduced by Sens. Thomas/Lincoln and Rep. Barbara Cubin (R-WY), the MFT provision was again included in the omnibus Medicare mental health modernization bills (S. 927 and H.R. 1946) and the Medicare rural access bills (S. 3500 and H.R. 6030). The provision passed the Senate as part of the Deficit Reduction Act of 2005 (S. 1932), but did not make it through conference. 110th Congress (2007-2008) Companion standalone bills S. 921 and H.R. 1588 were reintroduced by Sens. Thomas/Lincoln and Rep. Cubin. Representative Pete Stark (D-CA) included the MHC and MFT language in his omnibus Medicare mental health bill (H.R. 1663). The provision passed the House as part of the SCHIP Reauthorization Act (H.R. 3162). The Senate declined to consider the SCHIP bill. 111th Congress (2009-2010) The provision was reintroduced in companion standalone bills S. 671 and H.R. 1693 by Sens. Blanche Lincoln /John Barrasso (R-WY) and Rep. Bart Gordon (D-TN). The provision passed the House in H.R. 3200, the health reform legislation that passed the Energy and Commerce, Ways and Means, and Education and Labor Committees. The language passed the House as part of the health reform bill (H.R. 3962). The provision was reportedly in the final House-Senate compromise legislation until the election of Sen. Scott Brown (R-MA) changed the Senate balance. 112th Congress (2011-2012)

The provision to provide Medicare reimbursement for MFTs was re-introduced as a stand-alone bill in the Senate, S 604, by Senators Wyden (D-OR) and Barrasso (R-WY). The provision is also included in a Senate bi-partisan rural health bill, S 1680. In the House of Representatives the

provision was included in H.R. 2954. Due to the severe fiscal restraints of this Congress no legislation was considered by either Chamber.

113th Congress (2013-2014)

In the opening months of the first session of this Congress, Sen. Wyden (D-OR) and Sen. Barrasso (R-WY) have re-introduced their stand alone bill, S 562. In the last week of the session in December, 2013, a companion bill, H.R. 3662, was introduced into the House of Representatives by Rep. Gibson (R-NY) and Rep. Mike Thompson (D-CA). Neither bill came up in either chamber nor was passed into law.

114th Congress (2015-2016)

In 2015, Sen. Debbie Stabenow (D-MI) and Sen. Barrasso (R-WY) have re-introduced their stand-alone bill, S 1830. A companion bill, H.R. 2759, was introduced into the House of Representatives by Rep. Gibson (R-NY) and Rep. Mike Thompson (D-CA). Neither bill came up in either chamber nor was passed into law.

MEDICARE ISSUE TALKING POINTS FOR 2017

Allowing LMFTs to become Medicare providers will contribute to the financial health of Medicare

Patients lose continuity of care with their existing LMFT when they turn 65 and move into Medicare

Addressing mental health first can alleviate the need for future, more expensive physical health treatments, including emergency room visits

LMFTs have equal qualifications as clinical social workers, who are Medicare providers

Adding LMFTs does not expand the benefits offered by Medicare; LMFTs are qualified to provide the services already covered by Medicare; LMFTs would not be providing marriage counseling to beneficiaries

Inpatient treatment is significantly more expensive to Medicare than outpatient care provided by LMFTs, adding to the overall costs to the Medicare program

Treatment of dual-eligibles is not possible because of the Short Doyle regulation: Medicare

must be billed first and bureaucracy delays the denial statement required before Medi-Cal can be billed

Commissioned by both CAMFT and AAMFT, a study conducted by Applied Policy of VA in 2014 estimated the 10-year (2015-2024) cost at $90.1 million for LMFT participation as a Medicare providers

Given that the study estimates LMFT participation in the Medicare program to be 59.9% in CA and 58.7% in other states, it suggests that CBO’s 2009 10-year estimate of $400 million for both LMFTs and counselors was excessive

Lack of treatment results to expense in backend—homelessness, incarceration and

emergency room care

LMFTs would be less expensive to Medicare than psychologists as the proposal calls for reimbursement rates at 75% of the psychologists’ rate

GENERAL FLOW OF MEETING

1. Introduce yourself and explain what CAMFT is and provide the number of CAMFT members in the district

2. Explain what the Medicare bill would achieve

3. Share personal stories; provide statistics

4. Answer any questions asked by staff/legislator

5. Ask if legislator will co-sponsor Medicare bill a. “Would you co-sponsor this Medicare bill” b. CAMFT will review what to say at meetings if no bill number available at time of

meeting

6. Thank them for their time

7. Ask for business cards

8. Write personal thank you notes

How LMFTs Compare with Other Mental Health Professionals in California Education, Experience, and Training

The attached chart illustrates that the education and training of MFTs and LPCCs receive make them qualified to assist as co-signers of 5150 orders.

CATEGORY LICENSED MARRIAGE & FAMILY THERAPIST

LICENSED CLINICAL SOCIAL WORKER

LICENSED PROFESSIONAL CLINICAL COUNSELOR

PSYCHOLOGIST

Advanced Degree Yes MA, MS, PhD, PsyD, EdD

Yes MSW, DSW

Yes MA, MS, PhD, PsyD, EdD

Yes PhD, PsyD, EdD

Coursework in Counseling and Psychotherapy

Applicable coursework is rich in clinical content

Applicable coursework is rich in social work content

Applicable coursework is rich in clinical content

Applicable coursework can be rich in clinical content

Supervised Experience

3,000 hours 3,200 hours *AB 93 reduces down to 3,000

3,000 hours 3,000 hours

Appropriate Work Settings

While a graduate student and post-graduate but before registration: Governmental entity, school/college/university, nonprofit or licensed health facility Private practice settings for registered marriage and family therapist interns only

While a graduate student and post-graduate but before registration: Governmental entity, school/college/university, nonprofit or licensed health facility Private practice settings for registered social workers only

While a graduate student and post-graduate but before registration: Governmental entity, school/college/university, nonprofit or licensed health facility Private practice settings for registered professional clinical counselor interns only

Pre-doctoral: internship established by doctoral program; employed by an education institution, a school district, or a governmental entity; functioning under a waiver issued by the California Department of Mental Health Post-doctoral: same as pre-doctoral, except that as a registered psychological assistant, the individual may also be employed by a licensed psychologist, licensed physician and surgeon board-certified in psychiatry, by a clinic, by a psychological corporation, by a licensed psychology clinic or by a medical corporation

Licensed by State of California

Yes Yes Yes Yes

Examinations Two written examinations Two written examinations Two written examinations

Two written examinations

Insurance Reimbursement (California)

Private insurance and most government programs

Private insurance and government programs

Private insurance and government programs

Private insurance and government programs

Summary of Services Provided

Counseling and psychotherapy with individuals and groups through diagnosis and treatment.

Counseling and psychotherapy with individuals and groups through diagnosis and treatment.

Counseling and psychotherapy with individuals and groups through diagnosis and treatment.

Counseling and psychotherapy with individuals and groups through diagnosis and treatment.

Emphasis on Primary Service

Counseling and psychotherapy with individuals, families or groups; use of applied psychotherapeutic techniques, to enable individuals to mature and grow within marriage and the family, the provision of explanations and interpretations of the psychosexual and psychosocial aspects of relationships

Counseling and psychotherapy with individuals, families, or groups; provide information and referral services; provide or arrange for the provision of social services; explain or interpret the psychosocial aspects in the situations of individuals, families, or groups; help communities to organize, to provide, or to improve social or health services; perform research related to social work

Counseling interventions and psychotherapeutic techniques to identify and remediate cognitive, mental, and emotional issues, including personal growth, adjustment to disability, crisis intervention, and psychosocial and environmental problems; counseling interventions and psychotherapeutic techniques for the purposes of improving mental health

Diagnosis, prevention, treatment, and amelioration of psychological problems and emotional and mental disorders of individuals and groups

Federal Recognition

Recognized as a Core Mental Health Discipline by the Public Health Services Act and as a Behavioral and Mental Health Professional by the National Health Service Corps

Recognized as a Core Mental Health Discipline by the Public Health Services Act and as a Behavioral and Mental Health Professional by the National Health Service Corps

Recognized as a Behavioral and Mental Health Professional by the National Health Service Corps

Recognized as a Core Mental Health Discipline by the Public Health Services Act and as a Behavioral and Mental Health Professional by the National Health Service Corps

5

9

10

11

12

13

Q&A on AAMFT/CAMFT Medicare MFT Cost Study

Q1: What is the AAMFT/CAMFT Medicare MFT Cost Study?

A: It is a report estimating the 10-year (2014-2023) cost of adding independent-practice MFTs as Medicare Part B (office-based) practitioners. It was prepared by Applied Policy, Inc., with assistance of Dobson/DaVanzo Inc., and funded jointly by AAMFT and the California Association of Marriage and Family Therapists (CAMFT). Q2: What is this study’s key finding? A: The study estimated the 10-year (2014-2023) cost to Medicare of adding independent-practice MFTs as Medicare Part B (office-based) practitioners would be $90.1 million. Q3: Why was this study done?

A: Medicare coverage of independent-practice MFTs has long been the top federal advocacy goal of AAMFT and CAMFT because many elderly and disabled Medicare beneficiaries have unmet behavioral-health needs, and adding MFTs would increase those beneficiaries’ access to covered behavioral practitioners, who now include psychiatrists, clinical psychologists, and clinical social workers. Adding MFTs requires enactment of Congressional legislation, and bills adding MFTs passed the US Senate in 2003 and 2005, and the US House of Representatives in 2007 and 2009. But in each case the other Congressional chamber did not concur, arguably due to this change’s cost as estimated by the Congressional Budget Office (CBO). CBO’s most recently (in 2009) estimated the 10-year (2010-2019) net cost to Medicare of adding both MFTs and Professional Counselors (LPCs) at $400 million. CBO did not estimate MFTs’ costs separately from those of LPCs, although the number of LPCs comprises two-thirds of the cumulative number of both professions. In the subsequent five years since CBO’s estimate, the numbers of beneficiaries and of covered behavioral services have grown, and Medicare’s share of total payments (Medicare + Client co-pays) has increased (from the prior 50%) to 80% in order to achieve Parity with Medicare Part B’s physical-health payments. This implies that MFTs’ cost have risen recently, but CBO’s undivulged (“black box”) estimation process, and its inclusion of LPCs as well as MFTs, suggest that CBO may have over-estimated MFTs’ costs. Q4: What are Applied Policy, Inc’s, and Dobson/DaVanzo Inc’s, qualifications for this study? A: Applied Policy’s principal, James Scott, JD, was the Senate legal drafter (legislative counsel) for the Medicare MFT and LPC bill (currently S 562/HR 3662), and also formerly worked for the HHS Centers for Medicare and Medicaid Services (CMS). Dobson/DaVanzo’s principals are health economist Alan Dobson, PhD, who formerly was Research Director for CMS (then called the Health Care Financing Administration), and Joan DaVanzo, MSW, who formerly was a clinical social worker

in private practice. These principals were assisted by an extensive team of researchers within their firms. Q5: How was the study conducted? A: Applied Policy and Dobson/DaVanzo: 1) reviewed the relevant professional literature, 2) conducted AAMFT and CAMFT member surveys regarding the extent of members’ worksites in private offices (as opposed to other settings) and, for the private-office subset, the extent of interest in Medicare participation (yes/no, and (if yes) average estimated appointments’ availability), 3) performed multivariate analyses of national Medicare Part B (PSPS) data that trended-forward the number and service-mix of covered behavioral services, and 4) estimated the net savings that would result from the partial substitution of MFTs for services of clinical psychologists (paid at higher rates) and clinical social workers, which savings would reduce the cost of treating beneficiaries who otherwise would not access those services. This method is the standard one used by these contractors and other researchers to address such policy questions. CBO does not divulge its research methods, but the current study’s detailed method is believed similar to CBO’s general approach. Q6: The study estimates the direct costs to Medicare for covering MFTs (i.e. payments for aggregate increase in covered behavioral services), but does it also estimate the indirect savings that would accrue to Medicare? A: No. Researchers believe Medicare MFT coverage would yield two types of indirect savings to Medicare: 1) many beneficiaries’ avoidance of clinical deterioration that increases later outpatient treatment costs or even requires costly hospitalizations, and 2) savings from the so-called “Mental Health Offset,” a holistic effect in which improved mental health (e.g. reduced clinical depression) also increases physical health (e.g. greater compliance with clinical and healthy-lifestyle regimens), thus reducing subsequent physical health costs. CBO classes such indirect savings as “dynamic” and because they depend on behavioral changes, declines to count such savings in any of its estimates. Because such indirect savings would depend on individual behavioral changes of many beneficiaries, an estimate of such savings would be relatively speculative and expensive to derive. Q7: Does the absence of a new cost estimate for LPCs indicate AAMFT and CAMFT believe Congress should simply pass a Medicare MFT provision without a parallel provision for LPCs? A: No. AAMFT and CAMFT work together with all three LPC associations to urge joint legislation to be enacted. Had this study included LPCs as well as MFTs, its cost would have been prohibitive. The American Counseling Association funded an LPC-only Medicare cost study in 2002. Q8: Would Medicare Part B eligibility of office-based MFTs change Medicare’s behavioral services coverages?

A: No. As with currently-eligible practitioner types, a clinical diagnosis (DSM-5) would be required. Medicare would NOT cover marital counseling or other conditions that do not meet this diagnostic standard. Q9: Will CBO re-estimate the direct cost of Medicare MFT coverage in view of the AAMFT/CAMFT study? A: This study has been shared with relevant CBO staff. CBO receives many such requests, so it is unclear when it would conduct a re-score.

Bending the Cost Curve: Increasing Medicare’s Outpatient Spending to

Decrease its Inpatient Spending

There is significant evidence to support the conclusion that by shifting Medicare’s mental health

spending from inpatient to outpatient services, Congress could save significant funds. An

immediate investment of $200 million over five years to cover services provided by licensed

professional counselors and marriage and family therapists would grant beneficiaries access to

over 160,000 mental health providers and decrease inpatient spending in the future.

Older Americans (65+) have higher rates of mental illness and suicide than any other

demographic, but they are also the least likely to seek services, with only one in five receiving

needed therapy from a mental health professional. Older Americans also have the highest rates

of mental-health related hospitalizations (Health Affairs, May-June 2009). Finally, mental

illness is the most common (35%) qualification for individuals with disabilities—the other

Medicare-eligible population.

This all leads to higher inpatient spending under Medicare than any other health care provider.

Medicare spends approximately four times as much on inpatient and institutional outpatient

services ($4.5 billion in 2002) as on physician/supplier services ($1.2 billion in 2002) for its

mental health claimants. Inpatient services constitutes 73% of total spending for mental health

claimants, but serve just 10% of claimants, while outpatient spending constitutes just 19% of

spending and serves 92% of claimants. In 2002, this resulted in a cost of $9,660 per inpatient

claimant versus just $342 per outpatient claimant.

Mental illnesses also result in increased spending for physical ailments. In 2004, Medicare spent

a total of $62.8 billion for services to mental health claimants, of which less than $10 billion was

for MH/SA services. Not surprisingly, a January 2009 study in the Journal of the American

Geriatric Society found that Medicare beneficiaries with a diagnosis of depression in addition to

a chronic physical illness cost the program nearly twice as much as beneficiaries with a chronic

illness but no depression. One epidemiological study found that chronic depression increases the

risk of cancer by 88% in older Americans (Mental Health: A Report of the Surgeon General,

1999).

Congress can “bend the cost curve” by spending money the right services. A study of private

insurance recipients’ mental health care purchases found that increased availability of outpatient

treatment for mild or moderate mental health disorders, such as depression, resulted in a $2307

per patient (30 percent) decrease in mental health care costs (American Journal of Psychiatry,

1999). By covering professional counselors and marriage and family therapists, Medicare can

take advantage of those savings—increasing availability of outpatient treatment and cutting

spending at the same time.

“LMFTs as Medicare Providers: The Long and Winding Road”

Jill Epstein, JD

Executive Director

CAMFT has partnered with AAMFT, American Counseling Association (ACA), American

Mental Health Counselors Association (AMHCA), and the National Board for Certified

Counselors to lobby federal legislators as the “Medicare Access Coalition”. While the pursuit

of Medicare reimbursement for LMFTs has been a long and winding road (legislation has nearly

passed several times in the past 11 years), it is the requisite process for getting a non-physician

provider added into Medicare. The psychologists lobbied for 13 years before they were

accepted as Medicare providers (with the social workers tacking on to that legislation at the same

time). This demonstrates that LMFTs have laid the proper groundwork, and invested the

requisite amount of years, to hopefully become Medicare providers in the not-too-distant future.

The Creation of Medicare

Social Security officials had long been troubled by the fact that, as long as the Social Security

system failed to protect against the greatest single cause of economic dependency in old age--the

high cost of medical care--it could not really fulfill its basic objective. In 1950, the Federal

Government took a significant first step in the direction of providing medical care for the aged,

when it enacted a program of direct payments to "medical vendors" for the treatment of welfare

clients, including the elderly. See “The Evolution of Medicare . . . from Idea to Law” by Peter

A. Corning (http://www.ssa.gov/history/corningchap4.html).

Medicare was created when the Social Security Act of 1965 was signed into law on July 30,

1965 by President Johnson. Medicare has since evolved to providing health insurance coverage

to people who are aged 65 and over; to those who are under 65 and are permanently physically

disabled or who have a congenital physical disability; or to those who meet other special criteria

like the End Stage Renal Disease program (ESRD).

While Medicare originally covered only medical and hospital services, groups of non-physician

providers have successfully lobbied to be included as reimbursed providers. Examples of non-

physician Medicare providers are: nurse practitioners, certified nurse midwives, certified

registered nurse anesthetists, clinical nurse specialists, physician assistants, clinical social

workers, clinical psychologists, non-clinical psychologists, physical therapist, occupational

therapists and speech pathologists.

“Medicare Access Coalition” Legislative History: 2001-Today

107th Congress (2001-2003): The provision to provide Medicare reimbursement for LMFTs and

LPCCs was introduced as stand-alone bills in the House and the Senate. The provision was also

included in the House and Senate Medicare mental health modernization bills. There were no

hearings, nor votes, on any of these bills.

108th Congress (2003-2005): The provision to provide Medicare reimbursement for LMFTs and

LPCCs was re-introduced in the Senate as a stand-alone provision and was also included in a

new Medicare mental health modernization bill and in the omnibus Medicare rural access bills.

The provision actually passed the Senate in the Medicare prescription drug bill, but was not

accepted during conference committee. (A conference committee is a committee of the Congress

appointed by the House of Representatives and Senate to resolve disagreements on a particular bill.)

109th Congress (2005-2007): The provision to provide Medicare reimbursement for LMFTs and

LPCCs was introduced as stand-alone bills in the House and the Senate. The provision was,

again, included in the omnibus Medicare mental health modernization bills and the Medicare

rural access bills. The provision ultimately passed the Senate as part of the Deficit Reduction

Act of 2005, but did was not accepted during conference committee.

110th Congress (2007-2009): The provision to provide Medicare reimbursement for LMFTs and

LPCCs was re-introduced as stand-alone bills in the House and the Senate. The provision was

also included in the House omnibus Medicare mental health bill. The provision passed the

House as part of the SCHIP Reauthorization Act, but the Senate declined to consider the SCHIP

bill.

111th Congress (2009-2011): The provision to provide Medicare reimbursement for LMFTs and

LPCCs was re-introduced as stand-alone bills in the House and the Senate. The provision

passed the House as part of the health reform bill. The provision was reportedly in the final

House-Senate compromise legislation until the election of Senator Scott Brown (R-MA) changed

the Senate balance. In response to this situation, there was no formal conference between the

House and Senate. Instead, the House passed the Senate bill which did not include the provision

to provide Medicare reimbursement for LMFTs and LPCCs.

112th Congress (2011-2013): The provision to provide Medicare reimbursement for LMFTs and

LPCCs was re-introduced as a stand-alone bill in the Senate. As of this writing, there is not a

House Republican willing to co-sponsor a companion, stand-alone bill. The provision is also

included in the rural health bill.

Why Medicare Reimbursement is good for YOU

Members are often perplexed about why they should care about, or advocate for, LMFTs as

Medicare providers. The truth is, however, that inclusion in the Medicare program has vast

implications for LMFTs in a number of different settings.

Aging Clients: LMFTs in private practice are reporting instances when a client ages and no

longer receives primary health insurance from a private insurer. At age 65, most clients transfer

over to Medicare, which does not cover the services provided by an LMFT. Clients often

discontinue treatment since they cannot afford to pay out-of-pocket. This is not only a

troubling outcome for the patient, but also impacts the LMFT’s practice. If LMFTs are Medicare

providers, this would provide continuity of care for patients and increase the pool of potential

clients for LMFTs.

Agencies/Hospitals: Many agencies and hospitals shy away from hiring LMFTs because LMFT

services cannot be directly billed to Medicare and many clients served in these settings are from

the Medicare population. While an agency or hospital may potentially bill Medicare for an

LMFT’s services if the services are “incident to” a treatment prescribed by a Medicare provider

(i.e. physician), the reality is that most agencies and hospitals do not want the added bureaucracy

and, instead, favor Medicare providers as employees. If LMFTs become Medicare providers,

additional job opportunities will become available.

Short-Doyle II: In 2010, state legislation was passed that requires all providers who bill for

services rendered to “dual eligibles” (Medicare and Medi-Cal eligible) to submit for

reimbursement first to Medicare. Upon denial of the Medicare claim, the state Medi-Cal can be

billed. However, it often takes months to receive a Medicare denial and sometimes denials are

not issued at all. (See The Therapist, November/December 2010, “Medicare Inclusion for

MFTs: Another Reason it is Critical for the Profession” by Mary Riemersma.) As the “dual

eligible” population increases and as health reform is implemented to expand Medi-Cal, LMFTs

would greatly benefit to be reimbursed by Medicare and avoid the bureaucratic paperwork of

billing two government entities.

Federal Agencies: Since federal departments and agencies often default to the list of non-

physicians Medicare providers for employment, they are hesitant to employ LMFTs. CAMFT

must lobby each department to explain the services provided and how these services would

benefit the people served by that department (i.e. Department of Veterans Affairs, Department of

Defense). If LMFTs were reimbursed by Medicare, it is likely that job opportunities at federal

departments and agencies would be more readily open to LMFTs.

Next Steps

CAMFT and the Medicare Access Coalition will continue to vigorously pursue Medicare

reimbursement for LMFTs and LPCCs. As Medicare-related bills come up for votes, CAMFT

will be using new grassroots advocacy technology to engage our membership to speak out in

support of Medicare reimbursement. Together, we will successfully get to the end of this long

and winding road!

Æ