Daniel Michalski, MPA and Jessica Kohout, PhD
APA Center for Workforce Studies
|Module A:||Doctoral Internship|
|Module C:||Client Complexity and Provider Revenue|
|Module D:||Information on Telepsychology, Medication, and Collaboration|
The objective of the 2008 APA Survey of Health Service Providers was to gain a broad understanding of those psychologists providing health services in the United States. Prior research in this area has focused primarily on APA members, which presents problems for generalizability of the data to nonmember providers. This study attempted to address these limitations by including non-APA member participants. Indeed, this was the first major effort undertaken by the APA Center for Workforce Studies (CWS) to include those outside of the association’s membership.
Specifically, this brief report or module focuses on insurance and the ways in which the current health service providers (HSPs) are remunerated for their work. While the vast majority of responses to this particular section of the survey came from APA member psychologists, the data gathered from this effort will be valuable to the association’s planning for the entire psychology workforce. As a whole, it is hoped that by researching financial payments to practitioners and sources of professional revenue, valuable glimpses of issues impacting practitioner income and remuneration may become apparent. Furthermore, these data may indicate future trends of access to psychological services. Unlike previous efforts focusing solely on new doctorates or early career psychologists, the data in this report are drawn from the current population of HSPs across all stages of the psychology career.
We included in the sample 34,289 members of APA identified as working as and/or trained as “health service providers” and holding a doctoral degree in psychology. In other words, the membership sample included members engaged in professional practice or potentially eligible to do so by merit of training or educational background sufficient for licensure in most jurisdictions.
Additionally, a roster of licensed, doctoral-level psychologists in the United States was purchased by CWS in April 2008, from a vendor able to compile a listing of individuals with state-issued professional licenses in psychology. The vendor culled duplicate entries across states and forwarded this list of 99,350 names and mailing addresses on to CWS. This list was then compared against the member sample of HSPs to remove duplicate records.
For the first wave in September 2008, an email invitation was sent to 23,818 members identified as licensed by one or more state licensing agencies/boards and having a valid email address on file with APA. Three follow-up reminders were sent to non-respondents one week apart.
The second email distribution was sent in October to 10,471 members with unconfirmed licensure status (names not appearing on the purchased list) and valid email addresses on file with APA. Non-respondents from this distribution received three follow-up reminders also spaced one week apart.
Third,10,000 randomly selected licensed psychologists (members and nonmembers) were mailed a paper version of the survey along with a URL address to access the online version from an Internet-accessible personal computer. The paper instrument did not include questions pertaining to insurance and methods of client payments. However, 83 of the 5,486 online responses received for this effort were identified as originating from the general survey URL provided to those included in the paper distribution. As such, this small group of respondents consisted of APA members and nonmembers.
Only fully completed and submitted online surveys were included in analysis; data from partial or saved surveys were excluded. Four modules were randomly assigned to the 5,486 members of the sample. Of those, 1,318 participants completed this Insurance module. This brief focuses on the results from those chosen to participate in this section of the survey. Measures of central tendency for values less than 10 in demographic categories were suppressed to protect confidentiality.
Given the exploratory nature of this study, only proportions and frequencies were reported; no distinction between members and non-members is implied beyond descriptive convenience.
Participants answered several questions regarding their participation with various insurance programs and how they were paid for their services. The vast majority of respondents (94 percent) identified that they were licensed for professional practice in psychology by one or more state licensure boards/agencies. Those not licensed to practice predominantly indicated work settings that did not require a license.
Table 1 summarizes general demographic characteristics of those responding to questions in the insurance module. Missing values were excluded prior to analysis. The majority of respondents (94 percent) was licensed for professional practice by at least one state licensing board or agency. The remaining respondents may not be licensed due to a work setting (i.e., consulting) or a position (i.e., faculty or administration) not requiring licensure. Demographic characteristics of respondents were consistent with patterns noted in related CWS and APA databases. As was the case with other CWS studies, more than three fourths (78 percent) of respondents held a PhD degree while one fifth (20 percent) indicated that they held a PsyD degree. Just over 2 percent reported an EdD degree. Women were in the majority (60 percent) and 4 percent of participants identified as Latino/Hispanic. Less than 5 percent reported a disability. Among those that chose to respond to the sexual orientation item, 7 percent identified as gay, lesbian, bisexual or other orientation.
On average, respondents have been licensed for 17 years (SD=10.48) with 20 the most frequent number of years licensed. The longest duration of licensure was 46 years. The median age for participants responding to this insurance module was 54.
Table 2 shows levels of participation in federal programs where services are provided on a contractual basis. Respondents could select multiple options between Tricare, VA, or other governmental program. More than half of those responding to this item (56%) selected Tricare, while just under half (49 percent) participated in an “Other” government program under contract. VA participation was least prevalent at only 12 percent.
Table 3 reports the extent to which the respondents contracted with behavioral health carve-out plans. With the exception of EdDs, slight majorities or greater of HSPs reported that they do not participate in carve-out plans across nearly every listed characteristic. The small cohort of EdDs in this study was insufficient as a basis for analysis and presentation of data. Also, EdDs may work in professional settings where contracting with carve-out plans is uncommon. Blacks/African Americans reported the highest percentage of nonparticipation in carve-out plans (88 percent) except for Native Americans (100 percent). Yet, the small population of Native American participants does not allow for inferences to the general population of these psychologists.
Table 4 breaks out the proportion of payments that are paid directly by clients or for whom HSPs bill insurance companies. In aggregate, respondents indicated that 33 percent of their clients’ payments were paid directly, while the remaining two thirds (67 percent) of payments were obtained by billing insurance plans.
Table 5 analyzes Medicare participation by demographic characteristics. One hundred and thirty-six respondents reported that they had previously participated in Medicare but do so no longer. EdDs reported the highest proportion of participation in Medicare (82 percent) with nearly half of PhDs and PsyDs participating (49 and 48 percent respectively). As previously mentioned the small cohort of EdDs (N=27 for this item), does not allow for meaningful analysis. Nearly half of women (47 percent) and 52 percent of men participated. Ethnic minority psychologists reported the lowest proportion of Medicare participation, ranging from 16 percent for Latinos to 35 percent for Asians. White/Caucasians held the greatest level of participation at 51 percent as did those identifying a disability (50 percent). For those not currently participating in Medicare, the majority had never participated.
Table 5a highlights the reasons that respondents were not participating in Medicare. Just under one third (31 percent) stated an “Other” reason for non-participation in Medicare. Many respondents do not participate in Medicare by virtue of their client case-mix (30 percent). Yet nearly one quarter (23 percent) chose to not participate or discontinue participation due to reimbursement rates.
Table 5b explores the other reasons that respondents do not or no longer participate in Medicare beyond the options provided in Table 5a. While more than one quarter (27 percent) of responses did not fit a discernable category, nearly one fifth (19 percent) stated that inconvenient or burdensome paperwork and administration as contributing to their nonparticipation. Work setting also determined Medicare participation, as those working in organized health care settings (such as prisons, VA and schools) or other work settings not eligible for Medicare (including retirees) accounted for 41 percent. Also, new doctorates providing services under supervision provided non-licensure as a reason for not participating in Medicare (6 percent). A small proportion of respondents received funding through grants or offered their services pro bono (5 percent).
Table 6 analyzes Medicaid participation by demographic characteristics. When compared to the level of participation in Medicare, a smaller proportion of psychologists reported participation in Medicaid, 32 percent versus 49 percent. By characteristic, smaller proportions were reported for each category; at or less than 34 percent. As was evident in Table 5, for those not participating, the majority never participated.
Table 6a highlights the reasons why respondents were not participating in Medicaid. Slightly more than one quarter (28 percent) of psychologists selected an “Other” reason for not participating. As was discovered in Table 5a for Medicare, respondents felt that issues concerning reimbursement rates contributed to their nonparticipation, but at a higher proportion (32 percent compared to 23 percent for Medicare).
Table 6b examines more specific “Other” reasons that respondents no longer participated or do not participate in Medicaid. Many of the reasons for not participating in Medicaid are similar to those offered by respondents in Table 5b (Other Reasons for Not Participating in Medicare). Similarly, paperwork burdens were a primary reason for nearly one fifth of respondents (19 percent). Yet, the most common reason was that psychology is not included in some states’ Medicaid programs (20 percent). Work setting also determined participation in Medicaid, with 16 percent stating that their current employment (including retirement) doesn’t necessitate Medicaid participation. A small proportion of respondents received funding through grants or provided services pro bono (3 percent). As found in Table 5b, 5 percent of respondents are not yet licensed and as such unable to participate in Medicaid.
Table 7 breaks out the methods by which patient services were covered financially across various private, public and personal sources. Across all respondents, 43% of revenue from clients came from private insurance payments. Self-pay by clients accounted for 21 percent of financial remuneration to psychologists for health care services. At 2 percent, Tricare accounted for the smallest proportion of revenue.
The reasons respondents were not participating or discontinued participation in federal programs such as Medicare and Medicaid suggest that the complexities and administrative procedures of these programs discourage HSPs in independent settings from participating. Those working in organized settings such as schools, VA facilities or hospitals do not encounter these issues but may be providing services to focused subgroups of the broader population. Although the majority of respondents reported that their clients pay by private insurance and/or through a government program, a significant number of these psychologists do rely on clients able to pay directly. It may be the case, that a client’s method of payment or type of insurance is correlated with access to psychological care. As increasing numbers of health service provider psychologists enter the workforce each year, policymakers should be aware of challenges faced by those HSPs currently in the workforce and how their participation in public and private insurance programs may affect access to mental health services for underserved populations.