Three Hopeful Happenings in MH

By E.J. Brown

For OTs, three things may be changing for the better in mental health. How far those changes will take the profession is yet to be seen, and making use of them will be up to individual state organizations and practitioners.

• On Oct. 3, Congress passed the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008, sending it home on the coattails of a $700 billion bail-out package that will try to offset the plunging economy. The law will assure that people in states without parity laws get mental health coverage (from companies that offer it) at a price comparable to their other coverage.

• Occupational therapy is now a graduate-level profession; some states may find that puts them in a much better position to re-qualify OTs as mental health professionals.

• AOTA is willing to put its resources behind any state that, with help, might stand a good chance to getting within reach of qualified mental health practitioner (QMHP) status or an equivalent to it.

Beginning Jan. 1, 2010, group health plans with 50 members or more that are now providing medical/surgical and mental health coverage will have to make deductibles, co-payments and limitations equal in the two areas.

Right now, mental health plans often limit the number of visits beneficiaries may make to their doctors within a year or over a lifetime and charge higher co-pays for mental health treatment. These restrictions have kept poorer people from getting the help they need.

People wonder out loud right now if passage of the bill will blow up in their faces when insurers simply pull out of mental health altogether or employers drop it because it's too expensive. But this law has had input from the industry.

In an online edition of amednews.com, Neil Trautwein, vice president of the National Retail Federation and its employee benefits policy counsel, told reporter Doug Trapp that "business leaders fought mental health parity in the late 1990s, but changed their perspectives after embracing wellness and preventive health care. ÔWe want to be able to identify and manage chronic conditions,' he said. ÔWe want to prevent them when we best can.'

"Trautwein chaired an ad-hoc coalition of business and insurance representatives that participated in the negotiations and helped shape the final compromise between the more sweeping House bill and the more limited Senate measure."

The Government Accountability Office will track the law's impact on coverage, cost and care for 22 months and report to Congress on it by Oct. 2011. The following year, the U.S. Department of Labor will report on group health plans' compliance with the law.

More people using the mental health system will require more mental health professionals. But will OT be one of those?

The best case for OT in mental health is that therapists have long been working there all over the country in inpatient facilities, where OT is lumped into the daily hospital rate; most OT licensure laws identify them as able to do so. The barriers come from state lawmakers who don't see OTs as mental health professionals and won't let them practice in outpatient care.

Mary Hennigan, MOT, MBA, executive director of the Texas Occupational Therapy Association, told ADVANCE, "There isn't a legislator in Texas who has a mental image of OT in mental health."

In 2001, the Texas legislature amended its code of regulations to create a category of non-physician practitioners in mental health, which included nurses, counseling psychologists, social workers and marriage counselors. When TOTA tried to be included, it met fierce resistance from the psychologists.

Another source close to the issue who asked not to be named said, "In Texas, physicians run the show, and they do not support changes in scope of practice, so TOTA backed out. We're too small

to fight these people. We can't afford to have enemies."

But Hennigan believes it's not laws that will keep OTs out of mental health; it's money. In Texas, OT salaries are in the low 60Ks. Counseling psychologists and social workers there make under 40K. And OTs indicate they are not willing to take pay cuts to enter mental health.

In Philadelphia, Nancy Beck, MA, OTR/L, director of rehabilitative services for the Belmont Center for Comprehensive Treatment division of Albert Einstein Medical Center, agreed. "If you're a mental health provider, do you even want to spend the money for an OT when you can get a counseling psychologist for half of that?" she added.

But she said that salaries are very much a product of particular employers. At Einstein, mental health salaries have greatly increased so they are often level with OT.

As administrator of Belmont's partial hospital program, an outpatient program, Beck could not hire OTs at the center. So she trained psychologists in activity.

"They didn't really like it, but I insisted on it," she said. "Activity brings out the issues around functionality. You have to understand not just the psychodynamic, but the physiologic pieces that go into function. It requires all kinds of lifeskills. I know one doctor that actually hired an OT when she was reminded that they existed, and that she had had success with them before."

As in Texas, OTs in Pennsylvania are not on the list of "qualified" practitioners in mental health. But recent changes may make them highly eligible.

Under Title 55, Chapter 1153.2 of the Pennsylvania Code, a mental health professional is "a person trained in a generally recognized clinical discipline including but not limited to psychiatry, social work, psychology, or nursing, rehabilitation or activity therapies who has a graduate degree and clinical experience."

Under the same definition, a mental health worker does not need a graduate degree but training and recognized experience in mental health.

Up until last year, OT education programs were still graduating some bachelor's-level practitioners. But as of 2007, all professional programs have switched to master's-level entry.

Susan Haiman, MPS, CPRP, OTR/L, FAOTA, associate professor in the OT program at Philadelphia University, and past POTA president, is excited about that, and Beck agrees. "The new PA law passed on Highmark/Blue Shield identifies OT as an outpatient [provider] reimbursable in mental health. We could make a good case for it."

AOTA is currently working on mental health initiatives as part of its Centennial Vision effort.

"We wanted three states to do pilot pro-jects to broaden the scope of OT in mental health," said Chuck Willmarth, head of AOTA's State Affairs Group. "These may not all be legislative efforts. We will work with states wherever they are in the process, and we will put a high level of support there."

Right now Texas, Ohio and Minnesota are on the radar, but Pennsylvania could be added, along with one or two other states that have the right profile in mental health.

"One of the challenges here is that on a state-by-state basis, you need to know where mental health is on the priority list. You need a contingent of OTs who work in mental health and a group of people who really want to do this," Willmarth said.

Beck summed up the current mental health picture in Pennsylvania positively.

"If you put that whole matrix together, I feel hope," she said.

E.J. Brown is editor of ADVANCE.