Psychologist Sara Schneidmiller, PhD, should be paid $89.35 for her 50-minute psychotherapy session with "Alice," a 70-year-old woman who became depressed after hip-replacement surgery forced her into a North Carolina nursing home.

But Schneidmiller will receive only $44.67. That's because, by statute, the Medicare program limits reimbursement for psychotherapy and other outpatient mental health services to 50 percent of the amount that Medicare allows a provider to collect. By contrast, medical services are compensated at 80 percent.

In some states, Medicaid may pay the remaining 50 percent for Medicare beneficiaries who are also eligible for Medicaid.

Yet, the number of state Medicaid systems picking up the remaining 50 percent has dropped in the last three years because the 1997 Balanced Budget Act contained a provision allowing states to pay less than the full 50 percent outpatient mental health services co-payment. Indeed, between 1997 and 1999 the number of states making payments at the full rate dropped from 31 to 16, according to a Kaiser Family Foundation report.

Consequently, many states including North Carolina now provide little or no co-payment for psychotherapy and other outpatient mental health services. That leaves the patient responsible for any remaining charges. But, Alice, like many other older adults, cannot afford it.

"There's no way to collect any co-payment from a large number of elderly patients," says Schneidmiller, director of behavioral health services for ProActive Health Services in Winston-Salem, N.C., a provider of specialty services for long-term care patients.

The result?

"These low reimbursement rates and restrictions effectively become barriers for mental health services for older adults," says Margaret P. Norris, PhD, an associate professor of psychology at Texas A&M University and chair of public policy for APA's Div. 12 (Society of Clinical Psychology), Section II (Clinical Geropsychology).

And demand for psychological services in long-term care isn't, of course, confined to the elderly. About 20 percent of nursing-home residents are younger adults with chronic illnesses and disabilities who require long-term assistance with daily care.

Recognizing the critical need for psychological services in nursing homes, a network of 150 psychologists called Psychologists in Long-Term Care (PLTC) has launched a campaign to convince state and federal legislators that psychologists should be reimbursed for individual psychotherapy for patients with mild dementia and behavioral management services.

"We're trying to highlight reimbursement problems, become a stronger voice and hopefully get more support for psychologists working in all areas of long-term care," says member Mary Davis, PhD, a geropsychology fellow at the Brockton/West Roxbury Veterans Affairs Medical Center.

Many PTLC members are also APA members; most are practitioners but some are researchers and academicians. The group plans to meet with members of Congress during APA's Annual Convention, Aug. 4-­8, in Washington, D.C.

PTLC members have also been petitioning their state legislatures to change their Medicaid reimbursement rates by educating them about the need for psychological services in long-term care.

Demand exceeds resources

Studies on older Americans show that about 60 percent of the people in long-term care suffer from depression and 45 percent to 75 percent of nursing home residents have mental health problems.

"Generally, people in nursing homes are unserved or underserved," says David Hunt, an administrator at Mountain Trace Nursing Center in Sylvia, N.C.

Medicaid policies discourage nursing homes from providing specialized mental health services, and Medicaid reimbursement for long-term care patients has been too low to provide incentive for highly trained mental health practitioners to provide treatment, finds the U.S. Surgeon General report on mental illness released last December.

Indeed, if it weren't for the public policy barriers, long-term care could be a growth area for psychology as baby boomers age and life expectancy continues to increase, says PLTC coordinator Victor Molinari, PhD, staff psychologist for the geropsychological inpatient unit at the Houston Veterans Affairs Medical Center.

A recent report finds that 15 million elderly people are expected to suffer from some kind of psychiatric illness by the year 2030. But current research efforts, funding levels and the number of geriatric-trained mental health personnel cannot meet the future demands of this growing population, according to the report, "Consensus Statement on the Upcoming Report in Geriatric Mental Health: Research Agenda for the Next Two Decades."

In addition, demand for long-term care will increase as medical advances continue to help people with spinal cord injuries and AIDS live longer.

"We have to start now to train psychologists and provide incentives for them to work in long-term care," says Molinari.

Further Reading

For more information about Psychologists in Long-Term Care, contact Margaret P. Norris at (409) 845-2507 or mpn@psyc.tamu.edu.

Further reading

  • Molinari, V. (Ed.). (2000). Professional Psychology in Long-Term Care. New York: Hatherleigh.

  • Norris, M., Molinari, V., & Rosowsky, E. (1998). Providing mental health care to older adults: Unraveling the maze of Medicare and managed care. Psychotherapy, 35 (4), 490­497.