Considering Medicaid: Unique aspects

The third article in the "Considering Medicaid" six-part series looks at practical aspects in taking on Medicaid clients.

By Rebecca A. Clay

Some psychologists may be afraid of taking on Medicaid patients, says Astrea Greig, PsyD, manager of outreach behavioral health at Boston Health Care for the Homeless, which provides comprehensive health care to 12,000-plus homeless adults and children each year. They shouldn’t be, says Greig. “There’s some stigma against the Medicaid population, but they’re no different than any other clients,” she says. “Medicaid just opens some new doors for people.”

That said, there are a few differences when it comes to working with the Medicaid population. Greig and others offer some tips on how to address those challenges:

Demystify psychotherapy

A large percentage of the clients that Greig sees have never seen a therapist before. “People with lower socioeconomic status may not have been raised in families where therapy was something people did,” says Greig. “When we’re in poverty, we think perhaps these things are unattainable. If I don’t have money for shelter, how am I going to have money for a therapist?” As a result, Greig starts her work with clients by explaining what therapy is and why it can be helpful for anyone. And with all clients, Greig says, it’s important to communicate in clear language that they can understand and avoid complicated clinical terms.

Be prepared to see patients with a wide range of mental health problems

Make sure you get the training you need to work with this vulnerable population, says David Freeman, chief clinical officer at Community Connections Inc., which offers behavioral health, primary care coordination and residential services to marginalized adults and children in Washington, D.C. Most of Community Connections’ clients have major mental illnesses and co-occurring substance use disorders, he points out. “A trauma history is essentially universal” in his urban clinic located in a high-crime area, Freeman says. Of course, people who use Medicaid to access health care also have the same kinds of mental and behavioral health issues other clients have, says Sharon L. Berry, PhD, ABPP, associate clinical director and director of training at Children’s Hospitals and Clinics of Minnesota in Minneapolis, who estimates that at least half of the children seen in her clinic are Medicaid recipients. “You’re going to see the gamut,” she says. In states with Medicaid expansion, which raises the income level for eligibility, psychologists may be seeing more patients who are considered “working poor” and may have less serious mental health conditions, such as attention-deficit/hyperactivity disorder or mild to moderate depression, says Caroline Bergner, JD, an attorney in APA’s Education and Practice Directorates.

Don’t let reimbursement concerns keep you from serving the underserved, especially since rates are rising

“There’s a myth that all Medicaid reimbursement rates for psychological services are low,” says Bergner. “In recent years, we’ve seen increases in reimbursement rates in several states, with New Jersey even doubling some rates.” Because Medicaid expansion has added so many beneficiaries to states’ plans, states need more and more providers to meet new network adequacy requirements from the Centers for Medicare and Medicaid Services (CMS), says Bergner, explaining that states are incentivizing providers to join by raising rates. “We hope this rate increase trend continues across the board,” she says, adding that the APA Practice Organization has shown a commitment to advocacy in this area and hopes to partner with state psychological associations on the issue.

There may be challenges, but for Berry, working with Medicaid clients is its own reward. “It’s meaningful work,” she says. “These are people who are very grateful.”