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By JON KOLE
Nearly 66 million Americans are currently enrolled in Medicare, a number that will likely swell towards 80 million Americans within the next seven years. These are our mothers, fathers, aunts, uncles, grandparents and friends – and, maybe, you.
A significant portion of these millions of people need mental health services – and, yet, many face long wait times or aren’t able to find a therapist at all. On average, Americans have a waiting period of 48 days before receiving mental health care. At present, two notable provider groups – Marriage and Family Therapists (MFTs) and Mental Health Counselors (MHCs), which summed to approximately 415,000 in 2021 – have not been eligible to provide psychotherapy for people with Medicare.
Currently, Medicare only approves psychologists and masters-level Licensed Clinical Social Workers (LCSWs) to provide therapy to Medicare recipients. In July, CMS proposed policies that would significantly increase access to mental health services by adding MFTs and MHCs into the ranks of Medicare-eligible providers. At a time where access to mental health services is acutely limited, it is startling that such a large pool of providers with advanced specialized degrees are not allowed to provide care.
There are many similarities between LCSWs and MFT/MHC training. In addition to an undergraduate degree, LCSWs, MFTs and MHCs have completed a two-year Master’s program, which is then followed by two years of supervised clinical practice prior to taking a licensure exam in their relevant discipline. Once they pass that test, they are able to practice independently in a wide range of settings.
Adding these trained professionals to the roster of available providers is a meaningful step to improve access to mental health services for Medicare members.
Improving access is not just about getting to a provider, though, t’s also about getting connected to one that a patient can feel safe with, connected to, and build a strong working rapport with. According to AAMFT, the satisfaction rate among patients engaged in care with a MFT is exceptionally high, with nearly 90% reporting an improvement in their emotional health after receiving treatment.
One key element in patient-provider connection is allowing options for demographic matching. Studies have shown that when patients from ethnic/racial minority backgrounds are able to connect with providers who share similar demographics, they report better health outcomes and increased satisfaction with the care provided. In one analysis, data gathered from Black caregivers showed 83 percent felt that having a mental health provider of the same race and ethnicity was important, citing themes like relatability, diversity in cultural experiences and the overall patient experience.Adding MFTs and MHCs has the potential to improve demographic matching, given that these are more diverse groups than PhDs or LCSWs.
Given the overall supply-demand imbalance, which is only predicted to get worse, the time is now to ensure that the entire qualified mental health labor force is able to work with Medicare recipients. The CMS proposal would do that.
It is often said in health care economics that there is an “iron triangle” of quality, access, and cost. When trying to improve any of these domains, you always risk worsening one of the other two. With MFTs/MHCs typically collecting lower salary averages than LCSW and PhDs, this addition will likely generate cost savings for Medicare, leaving a question of quality. Will a Medicare member get the same quality of care with a MFT or MHC that I would get with an MSW or PhD?
The reality is for many conditions, including some of the most common depressive and anxiety disorders, we know confidently there are a variety of therapeutic approaches that are effective. In fact, there is strong evidence that quality of the client–therapist alliance is a reliable predictor of positive clinical outcome independent of the variety of psychotherapy approaches and outcome measures. This means for many of the most common conditions affecting Medicare recipients, the most important aspect of their therapy is not the letters listed after their provider’s name, but instead their provider’s ability to make them feel seen, validated, and encouraged to share and engage with the treatment recommendations made.
Finally, and most importantly, schools educating therapy trainees of all types historically have not emphasized the most evidence-based treatments. First published in Myrna Weissmans’ “National Survey of Psychotherapy Training” and outlined in Dr. Thomas Insel’s book Healing, “over 60 percent of professional schools of psychology and master’s of social work did not include any supervised training for any scientifically based therapy.” These numbers are only slightly better than those in MFT/MHC schooling. This is not a concern to be taken lightly. For conditions like post traumatic stress disorder, obsessive compulsive disorder, and eating disorders, offering evidence-based therapies can be the difference between meaningful recovery and persistent struggling. Ensuring patients are getting high quality evidence therapy is an issue not limited to MFT/MHCs and will require commitment across professional schools.
Fortunately, for all mental health providers, education does not conclude with their professional schooling. MFTs and MHCs, like social workers and psychologists, are required to complete yearly continuing education to maintain their licensure. There is great research interest in disseminating evidence-based training to therapists of all backgrounds as this is a demonstrated need across licensure. With greater focus from insurers, employers and clinical leaders on measurement-based care and evidence-based practices, MFTs and MHCs are increasingly required to document and demonstrate the evidence-based elements of their therapy work.
As our population ages and our mental health utilization reaches all time highs, opening the door by adding over 400,000 additional therapists to support Americans depending on Medicare is a reason to rejoice. We have a real potential to reduce costs and improve access to mental health services to this population. And as to questions of ensuring high quality, all of us in mental health care, regardless of the letters after our name, have to own this challenge with commitment to continued education in service of those we treat.
Dr. Jon Kole is Medical Director and Senior Director of Psychiatry at Headspace
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