In a move that could mean millions of dollars to help support psychology internship training, the U.S. Department of Health and Human Services (HHS) has proposed a rule to include the profession in subsidies under Medicare's Graduate Medical Education (GME) program.

Issued in the final days of the Clinton administration, the rule calls for funding psychologists' training, recognizing that "by helping to train more clinical psychologists, we will continue to move toward achieving our goal of providing a comprehensive, multidisciplinary approach to treating Medicare beneficiaries."

HHS estimates that the new rule, when finalized, could mean as much as $200 million over the first five years--$30 million in the first year--will go to hospitals and other health-care facilities for psychology internships.

APA waged a hard-fought battle for inclusion of psychologists in GME for years.

"It appeared to be an impossible task," says Russ Newman, PhD, JD, APA executive director for practice. "Including psychology wasn't an easy sell in a time where the emphasis has been on cutting funds within Medicare."

According to Newman, the rule is a victory for Medicare patients who need the diagnostic and treatment services that well-trained psychologists provide, services that are in jeopardy due to hospitals' increasing fiscal constraints and cost-cutting.

Psychology remains optimistic, however. The new presidential administration--just as with all presidential transitions in recent memory--is reviewing all proposed rules.

There is no binding timetable for producing a final rule. "We hope it will happen this year," says Marilyn Richmond, JD, assistant executive director for government relations. Public comment on the rule will be accepted until mid-March. HHS will then have an open-ended time period to make the rule final.

"This is a tremendous bonus for psychology because it assures that psychology is recognized as one of the critical health professions," says Bob Frank, PhD, professor and dean of the College of Health Professions at the University of Florida, who has been an active advocate of Graduate Medical Education funds for the field. "In the past, the public wasn't investing in us, so we didn't appear to be as important as other disciplines.

"On another level," adds Frank, "in my 20-year career as a psychologist, I can't recall a $50 million [the projected future annual funding] infusion for training. In so many cases, we were looking at decreases, not increases, in training money. This is an extraordinary moment for us."

A long-fought battle

GME is the primary avenue through which the federal government subsidizes training of health professionals in the United States. In order to encourage that training, Medicare reimburses teaching hospitals and other facilities for part of the resources internship programs consume, providing about 30 percent of the costs. In fiscal 1999, the program paid about $6 billion for physician training and about $300 million for training other professionals.

Currently, Medicare does not reimburse for psychology internships due to the fact that psychology education is university-based and, according to Medicare rules, eligible providers must operate both the classroom instruction and clinical training programs.

APA has long asserted that psychology-training programs should be eligible for funding.

"We met the existing criteria as it stood," says Newman, since many of the profession's training sites were clearly separate and independent from the universities where students were receiving their degrees.

Research the association has done in recent years indicates that a significant portion of psychology internship programs would be potentially eligible for GME funding because they are in hospitals or other health-care settings--such as rehabilitation facilities, nursing homes, skilled nursing facilities, home health agencies and hospice programs.

"Medicare perceived us as not having a discrete training component. But we ultimately persuaded them otherwise," Newman says.

In part because of the survey information, Medicare "finally said yes, we can include psychology," he says.

But rather than simply accepting psychology under the old rules, a new regulation was written to include the profession. The new language would expand the rules so that a provider would be eligible if it operates the clinical training portion of a program. Programs that operate the clinical portion of a program must:

  • Directly incur the clinical training costs.

  • Directly control the clinical training curriculum.

  • Control the administration of the clinical training portion, including the collection of tuition, and manage day-to-day operation.

  • Employ the teaching staff of the clinical portion.

APA's battle for the rule change included advocacy within several HHS offices, the Office of Management and Budget and Congress. In 1997, in language attached to the Balanced Budget Act, Congress urged HHS to make the change and since that time HHS has been developing the rule.

Recognizing psychologists' expertise

The rule is particularly good news for hospitals.

"Hospitals have shouldered the costs of psychology internship training without GME funding, but have been less able to do so in recent years," says Cynthia Belar, PhD, APA's executive director for education. "This funding is important to enable training to continue and ensure psychological services are available to Medicare beneficiaries."

In the notice, HHS stated that the change is important because: "Psychologists are exceptionally well qualified to recognize symptoms of depression and provide early intervention services to address mental health problems," says the rule, published in the Jan. 12 Federal Register.

"For example, unlike other groups of mental health providers, in some cases clinical psychologists have hospital admitting privileges, which could potentially increase the accessibility of hospital services to beneficiaries who may need such care."

According to Newman, the bipartisan congressional support really helped push the new rule change. Represen- tatives Ted Strickland (D­Ohio) and Karen Thurman (D­Fla.) were tireless advocates, he notes.

"Strickland was constantly after this issue," he says. "Given the obstacles, he was really persistent and extraordinarily effective."

Several other members of Congress championed GME funding for psychologists in a hard-fought campaign, including Representatives Jim McCrery (R­La.), Clay Shaw (R­Fla.) and John Dingell (D­Mich.) and Senators John Breaux (D­La.), William Roth (R­Del.), Arlen Specter (R­Pa.), Daniel Inouye (D­Hawaii), Kent Conrad (D­N.D.), Bob Graham (D­Fla.), Connie Mack (R­Fla.) and Charles Grassley (R­Iowa).

The new rule underscores the value of psychology in health care, Newman indicates."It's a statement. The largest publicly funded health program recognizes that psychology is a profession worth providing financial support to ensure the quality care psychologists provide. Dr. Pat DeLeon pointed this out years ago when urging us to pursue this agenda," he says.