After years of legislative efforts, coalition building and discussions with managed-care officials, psychologists in Rhode Island--and their clients--are seeing the fruits of their labor. In August, they gained major concessions from Blue Cross/Blue Shield in their state. The company increased mental health benefits to 30 visits--an increase of 10 visits--dropped outpatient care management requirements and raised psychologist provider fees. The changes don't just benefit providers; they also assist consumers by giving them more available, accessible, comprehensive psychological services, notes Peter Oppenheimer, PhD, past-president of the Rhode Island Psychological Association (RIPA).

"Some psychologists who were nonparticipating with Blue Cross may choose to become plan providers," he explains. "This should increase access for consumers."

He adds that psychologists may find practice more attractive in the state now that they and other providers will receive fees that are at least equivalent to Medicare reimbursements--they had been approximately 30 percent lower than Medicare's rates before the Blue Cross decision. In fact, a 2002 report by the Massachusetts Medical Society found that Providence doctors were paid 52 percent less than were Boston doctors.

Oppenheimer and other psychologists were part of a multidisciplinary coalition of health-care providers that had been seeking the increase and other concessions from the company for more than 10 years. The coalition argued that Medicare's Relative Value Scale, which weighs three components of health-care providers' work--time, technical skill and mental effort--to set fees, should be the marker for Blue Cross fees. The group was spurred not only by its desire to see fees raised to a reasonable level, but also by its belief that the Relative Value Scale system could shift the health -care culture in its state toward primary care and away from a dominance of specialty medicine, says Peter Erickson, PhD, current RIPA president.

"Blue Cross was about 90 percent specialists," says Erickson. "[Relative Value Scale] is about a shift and a reallocation of resources."

A major shift

Resources at Rhode Island Blue Cross had always been a major issue, says Oppenheimer. In the 1990s, the company suffered severe losses. Under the leadership of Ronald Battista, the president from 1999 until this May, the company reversed its losses and in three years built up reserves of $299 million. Indeed, the health insurance industry in Rhode Island was far more profitable than its counterparts in other states. But providers were paid less than their colleagues around the country, according to a series of articles in the Providence Journal.

"They were basically profiteering on people's premiums," says Mike Sullivan, PhD, assistant executive director for state advocacy in APA's Practice Directorate.

The company's huge reserves--along with corporate abuses such as executive salaries, lavish retreats and loans to the president--eventually came into the public light in 2003 through articles in the Journal and other local and regional newspapers. In addition, two state senators with ties to Blue Cross resigned their senate seats after admitting potential conflicts of interest. Battista's control of Blue Cross began to slip amid accusations of inappropriate professional relationships--he and his family received free medical care from a local acupuncturist--and he quit in May.

During the turbulence, psychologists and other health-care providers gained support from some state leaders in their fight for reasonable rates and accountability--namely, through the Relative Value Scale and timely reimbursement schedules. The legislature appointed a joint task force to examine health-care issues in the state--a major success for providers who had been seeking legislative solutions. Even the governor denounced the company's allocation of resources--specifically, board members' salaries and its $600,000 loan to Battista.

The shake-up at Blue Cross certainly didn't hurt psychologists' cause. On the same night Battista resigned, the Blue Cross board voted to increase reimbursements for providers. The pressure the provider coalition--with support from state leaders--put on the company finally paid off. RIPA past-president Oppenheimer said in the Providence Journal that Battista was the "keystone" in a structure that needed to be dismantled. Since 1998, he says, mental health professionals had no meaningful communication with Blue Cross.

"With [Battista's resignation], doors opened to where for the first time in years, we had meaningful discussions with Blue Cross management," he explains. There is now a tangible feeling of relief among providers in Rhode Island, he says. For many years, reimbursement was so low that many providers decided to leave practice or, in Oppenheimer's case, couldn't afford to expand their practices. "When we were getting 60 percent of Medicare's [Relative Value Scale], it was hard to function. At this level, things should be better," he says.

Looking to the future

The discussions with Blue Cross have led to some very positive changes, in addition to the much-needed provider rate hike, says Erickson. The company has offered to help psychologists meet with benefits managers from different companies in the state. Indeed, he says, RIPA and Blue Cross managers are organizing a conference for the business community on how to integrate primary and behavioral care.

"The situation with Blue Cross illustrates how important it is for psychologists to talk to insurance groups and arm themselves with solid information," says Erickson.

But the work in Rhode Island isn't done. At Monitor press time, psychologists were mounting a similar campaign against United Behavioral Health.

Jennifer Daw Holloway is a writer in Washington, D.C.