Strengthening the Psychology Workforce to Improve Health Equity

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Advocacy Summit Resources

Legislative Issue(s) and Training Materials

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Request 1: Support the Increasing Mental Health Options Act (S.669) to Improve Access to Psychologists' Services (Factsheet)

Background:

• Although the nation remains in the midst of an unprecedented mental and behavioral health crisis, there are a number of obstacles to evidence-based mental and behavioral health treatment for Medicare beneficiaries.
• One of these barriers involves a requirement that services provided by psychologists in specific care settings—including skilled nursing facilities and outpatient rehabilitation facilities—are subject to oversight and approval by a physician.
• Licensure to provide services as a psychologist generally requires completion of a doctoral-level psychology degree, which requires extensive hours of coursework and in-person training in mental and behavioral health treatment. Physicians, on the other hand, are not required to receive any education or training in mental and behavioral health treatment as a condition of their degree or licensure.
• In practice, imposition of these physician oversight requirements is an unnecessary burden and obstacle to treatment for patients, psychologists, and physicians alike. Patients and psychologists must wait until physician approval is received before services can begin, and creates more paperwork for the supervising physician. In most cases, physicians—especially those with little to no training in mental and behavioral health—will defer to the psychologist’s treatment recommendations anyway.
• Retention of mental and behavioral health professionals in rural and underserved areas remains a challenge. However, many of the current incentives that Medicare offers for treatment in these areas remain exclusively available to those professions within Medicare’s definition of “physician.”

Sample Talking Points:

• Despite having extensive doctoral-level training in mental and behavioral health treatment, services provided by psychologists in many Medicare settings remain subject to oversight requirements by physicians, even where the physician has no prior training or experience in mental or behavioral health treatment.
• These requirements are unique to Medicare. Private sector plans, TRICARE, and services provided through the VA do not impose these requirements on psychologists.
• The Increasing Mental Health Options Act would amend the Medicare statute to:
  • Allow psychologists meeting existing Medicare participation requirements to practice independently in all covered treatment settings, as they are allowed to do under private sector health plans, in TRICARE, and within the Veterans Health Administration. Medicare has for decades allowed psychologists to practice independently, without physician referral or supervision, in office settings;
  • Explicitly maintain long-standing Medicare requirements on psychologists’ consultation with their patients’ physicians in accordance with accepted professional ethical norms; and 
• To incentivize psychologists to continue providing services in rural and underserved areas, the IMHO Act would also make psychologists eligible for Medicare bonus payments for services provided in underserved and rural communities designated as mental health professional shortage areas (MHPSAs).

FAQs: 

How would this change Medicare practice for psychologists?

The legislation amends separate sections of the Medicare statute to extend eligibility for MHPSA bonus payments to psychologists, and to define the descriptions of coverage in certain settings to clarify that psychologists can provide psychological services without physician referral or oversight. This legislation does not alter or expand Medicare’s definition of “physician.”

How would this change the scope of practice for psychologists?

The legislation would in no way change the range of services psychologists are authorized to provide and be reimbursed for within Medicare. Similarly, Medicare requirements regarding psychologists’ consultation with their patients’ physicians would not be changed. The legislation would also incentivize psychologists to increase the number of Medicare patients they see in mental health professional shortage areas by making them eligible for the program’s bonus payment program.

How would this affect Medicare patients’ access to behavioral health services?

Medicare patients in skilled nursing facilities, partial hospitalization programs, outpatient rehabilitation facilities, home health agencies, and hospice programs would no longer need to obtain a physician referral before seeing a psychologist, nor would a physician be required to approve or oversee services furnished by psychologists.

Request 2: Support Reimbursement for Advanced Psychology Trainees in Medicare (Factsheet)

Background:

• A strong mental and behavioral health workforce is critical to combating the long-term impact of the pandemic and remedying longstanding gaps in care. Unfortunately, multiple barriers exist to growing the doctoral psychology workforce.
  • This includes the rising costs associated with pursuing a doctoral degree, which most students are increasingly financing through loans, and lack of robust federal support for advanced psychology trainees (doctoral interns and post-doctoral residents).
• Generally, Medicare generally does not cover services provided by medical trainees (residents), but has carved out an exception to this policy for services provided by primary care residents.
• Although clinical psychology interns typically receive 1,000-2,000 hours of clinical experience prior to beginning their internship, services provided by trainees under the supervision of a licensed psychologist are not reimbursable under Medicare, nor are services provided by psychology residents engaged in post-doctoral degree training.
• This lack of support for psychology interns and residents under the nation’s single largest health insurance program makes it difficult to support training programs, increase the workforce, and has trickle-down effects throughout the rest of the healthcare landscape, as other health insurance programs often look to Medicare coverage policies as a model for revising or updating their own coverage policies.
• CMS has already approved reimbursement for services provided by advanced psychology trainees in Medicaid in several states.

Sample Talking Points:

• Reimbursement for services provided by psychology interns and residents under Medicare would create more opportunities for trainees to gain experience working with this population, providing more incentive for psychologists to participate in Medicare once independently licensed.
• Medicare coverage of trainee services would help support training programs and their growth and provide more equitable reimbursement of mental and behavioral health services.
• Coverage of services provided by psychology trainees and residents would benefit both Medicare beneficiaries and the broader population covered by other forms of insurance in the long-term.
• CMS already permits many state Medicaid programs to cover services provided by psychology interns and residents. However, this is currently a very patchwork solution, as different state Medicaid programs impose different limitations on coverage of these services.
• Many primary care medical practitioners are seeking out models of integrating mental health services with primary care practices. Both the medical trainee and doctoral-level psychology trainee involved in integrated care programs should have equal degrees of support.

FAQs: 

Has legislation been introduced on this?

This legislation is being championed by Senators Bennet (D-CO) and Barasso (R-WY), and is expected to be introduced in the coming weeks. APA is working on identifying co-leads for companion House legislation.

How many State Medicaid Programs have cover services provided by psychology interns and/or residents?  

With CMS’ approval, 28 state Medicaid programs provide at least some degree of coverage to psychology interns or post-docs for their services.  

Those states are AL, AK, AR, DE, GA, ID, IN, IA, KY, MA, MI, MN, MO, NV, NH, NM, ND, OH, OK, OR, SC, TX, UT, VT, VA, WV, WI, and WY.  

However, there are a lot of variations and limitations amongst these coverage policies.  For example, some limit coverage to services provided by post-docs OR interns (sometimes referring to them under a different classification, i.e. “psychology associate”), while others limit coverage only to specific services or only to services provided in specific settings. 

My clinic does not use the terms “residents” or “interns” to refer to their psychology trainees. Should I relay this information during our meetings?  

These materials are intended to utilize terminology with which Congressional staff are most likely to be familiar. You are welcome to provide staff with a very brief and basic overview of training requirements for psychologists without getting bogged down in the nuances of different terminology. 

Does Medicare reimburse for supervised services provided by medical residents?  

Medicare generally does not allow reimbursement for services provided by medical trainees, with the exception of supervised services provided by medical residents in primary care. This is known as the “primary care exception.” 

How might this change in Medicare impact other forms of insurance? 

Currently, very little coverage of services provided by psychology trainees is allowed through private plans. However, other health care insurers often look to Medicare coverage policies as a model in revising or updating their own policies. 

Request 3: Increase FY24 Appropriations for the Graduate Psychology Education (GPE) Program and Minority Fellowship Program (MFP) (Factsheet)

Background:

The Graduate Psychology Education (GPE) Program is the nation’s primary federal program dedicated to the interprofessional education and training of doctoral-level health service psychologists. Established in 2002, GPE has the “two-for-one” benefit of supporting the interprofessional training of psychology graduate students and interns, while also expanding access to mental and behavioral health services for underserved populations in rural and urban communities. 

The Minority Fellowship Program (MFP) provides funding for training, career development and mentoring for mental and behavioral health professionals to work with individuals of color. The program focuses on training students, postdoctoral fellows and residents to be culturally and linguistically competent in addressing the needs of underserved areas. The program supports the trainees in psychology, nursing, social work, psychiatry, addiction counseling, professional counseling, and marriage and family therapy.

Sample Talking Points for States with GPE Grants: 

• Increased investments to support our nation’s psychological health and emotional well-being are needed now more than ever, as current data shows that Americans are experiencing a surge in COVID-related mental and behavioral health problems, including increases in anxiety, depression, and post-traumatic stress disorder.
• Our state currently has [number] GPE grant(s) at [institution], which is supporting integrated training for psychology doctoral students and expanding access to mental and behavioral health services for underserved populations in [region of state].
• As you may know, there is a shortage of qualified mental health providers in our state, particularly in [rural/urban] areas. GPE funding is critical to increasing our state’s capacity to reduce health disparities and improve health care outcomes for high-need, underserved populations (e.g. older adults, children, individuals with chronic illness, veterans, victims of abuse, ethnic minority populations, and victims of natural disasters).
• The GPE program is currently funded at $25 million. Increased funding for GPE to $30 million in FY24 would strengthen current efforts to expand the psychology workforce.

Sample Talking Points for States without GPE Grants: 

• Increased investments to support our nation’s psychological health and emotional well-being are needed now more than ever, as current data shows that Americans are experiencing a surge in COVID-related mental and behavioral health problems, including increases in anxiety, depression, and post-traumatic stress disorder.
• As you may know, there is a shortage of qualified mental health providers in our state, particularly in [rural/urban] areas. Funding for GPE provides a critical mechanism that could help increase our state’s capacity to reduce health disparities and improve health care outcomes for high-need, underserved populations (e.g. older adults, children, individuals with chronic illness, veterans, victims of abuse, ethnic minority populations, and victims of natural disasters).
• Currently funded at $25 million, increased funding for GPE to $30 million in FY24 would strengthen current efforts to expand the psychology workforce by increasing opportunities for our state to apply for GPE funding.

Sample Talking Points for MFP:

• The Minority Fellowship Program (MFP) aims to reduce health disparities and improve behavioral health care outcomes for racial and ethnic populations.
• MFP supports the training, mentoring and career development for psychologists and other mental health professionals to provide culturally competent, mental and behavioral health services to diverse populations. 
• As you may know, there is a need to increase the number of culturally competent mental health professionals in our community. Culturally competent mental health professionals are important because (offer your own example or personal story). 
• The Minority Fellowship Program is currently funded at $19.4 million. Increasing funding to $36.7 million in FY24 would allow more psychologists to work with diverse populations in what are often underserved areas.

FAQs:  

What’s the difference between GPE and MFP?

GPE is administered by the Health Resources and Services Administration (HRSA) and provides grants to accredited psychology doctoral, internship, and postdoctoral training programs. The purpose of this program is to expand the capacity of clinical training programs to prepare doctoral-level psychologists to deliver mental and behavioral health care in settings that provide integrated primary and behavioral health services to underserved and/or rural populations. There are currently 57 grantees. 

MFP is administered by the Substance Abuse and Mental Health Services Administration (SAMHSA), and provides grants to professional associations that represent mental/behavioral health providers. APA is one of seven grantee organizations that administers the program. The overarching purpose of MFP is to improve behavioral health care outcomes for racial and ethnic populations. APA’s MFP seeks to accomplish this by increasing the number of racial/ethnic minority psychologists, as well as the number of psychologists with expertise in racial/ethnic minority behavioral health. Individuals also apply individually to be accepted to MFP programs. This differs from the GPE programs.

A Congressional Office has asked us to fill out an FY24 Appropriations Request Form. Do I need to submit a form for both GPE and MFP?

No. We are only submitting FY24 Appropriations Request forms for GPE for the March Advocacy Summit. There is a separate coalition that will submit all Appropriations Request forms for MFP.

Who should submit our Appropriations Request Form for GPE? 

FACs should take the lead on submitting appropriations request forms for the delegation. For large states, the FAC may designate other members of the state delegation to help submit forms. 

Where can I find the information I need to fill out an Appropriations Request Form for GPE? 

Please click here. If you have any questions, please contact Raegina Likewise.

How can I tell if APA has already filled out an Appropriations Request Form for GPE? 

Please click here. If you have any questions, please contact Raegina Likewise.

What have MFP and GPE been funded at historically?

MFP was funded at the following levels for the last few years: FY 21-$16.2 million, FY22-$16.2 million. FY23- $19.4 million. Historical funding for GPE can be found at the bottom of this page. 

What level of funding was requested for GPE and MFP in the President's FY24 Budget Request? 

$25 million for GPE and $36.7 million for MFP.

Frequently Asked Questions

How can I prepare for the Summit?

All information for the Summit, including our legislative requests, fact sheets, agenda, and participant list can be found on this Summit action center. If you are not seeing the information you are looking for, please check back later - this page will be updated as we receive more information. 

If you are new to advocacy or would like a refresher, please watch APA’s Federal Advocacy for Psychology video.

Do I have to schedule my Hill visits for March 27?

No. Our partner, Soapbox Consulting, is handling all scheduling for legislative hill visits for March 27.

When will I get by schedule from Soapbox?

All Hill Day schedules will be emailed to you by Soapbox at the latest 12pm EDT on Thursday, March 23. On the “Meeting Roster” button next to each meeting, you can find the names and email addresses of your fellow advocates for each meeting so you can reach out in advance to introduce yourselves.

What if I can no longer make the March 27 Hill visits?

Please contact us at advocacy@apa.org as soon as possible so we may remove you from the congressional meeting schedule.

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How can I attend the Summit?

All participants may join the Advocacy Summit via zoom at 11am EDT on March 26 by clicking this link. 

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All participants may join the Summit’s debriefing session on Monday, March 27, between 3:00pm and 5:00pm EDT via Zoom by clicking this link.