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On Dec. 9, WW first reported that CareOregon, the state’s largest Medicaid provider, would stop reimbursing next year for services provided by associate therapists and social workers who practice independently of an in-network clinic.
The announcement sent shock waves among mental health professionals, some of whom said the policy change would worsen Oregon’s mental health care access crisis. The state has 2,119 associate therapists: mental health practitioners who see clients but are still under supervision by fully licensed clinicians. Most of them care almost exclusively for Medicaid patients. Many of the associates have their own practices and work independently of an in-network clinic.
The policy change would leave thousands of Medicaid patients in need of a new therapist, even as state leaders have made improving access to mental health care a top priority.
In a report released five days after CareOregon’s letter to associates announcing its policy change, Oregon Health Authority director Dr. Sejal Hathi wrote that her agency would engage in rulemaking early next year to do the very same thing: prohibit associate mental health professionals that work independently of an in-network practice from billing Medicaid.
The report suggests that OHA and CareOregon are working in tandem to change the rules—and it offers, for the first time, a justification for the shift.
Hathi wrote that the change would “thereby ensur[e] that this critical workforce pipeline is directed toward our highest-need and highest-acuity settings in the state.”
Hathi’s rationale: that newly trained therapists should be spurred to work for nonprofit and public providers in their first years of work, rather than moving immediately into more lucrative private practice.
“Across the state, partners shared their difficulty recruiting and retaining trained mental health professionals to serve high-acuity patients in community mental health settings,” Hathi wrote. “Partners shared that this shift created a shortage of providers for [community mental health programs] and other nonprofit providers of [behavioral health] services, as newly graduating therapists began moving into private practice while they completed their licensure process, rather than working in a public agency.”
That means that all Medicaid providers across the state, not just CareOregon, will likely be asked to stop reimbursing associate therapists for their work next year.
“It’s important for people to have an established, trusting relationship with a well-trained, highly qualified counselor to get the support they need,” said OHA spokeswoman Amy Bacher. “Access and quality of care need to go hand in hand, and OHA is committed to all members having access to high-quality services.”
Bacher said that the agency “will be eager to receive and consider public input before any changes in current rules are made.”
Hathi’s decision closely mirrors a requested reform that a number of community mental health trade associations have been pushing in recent years, and more aggressively this fall.
Two groups in particular—the Association of Oregon Community Mental Health Programs and the Oregon Council for Behavioral Health—proposed such rules to the state Legislature’s workgroup on community care organizations, the CCO Salon Workgroup.
In rulemaking suggestions submitted to the workgroup in September, the two associations urged the state to prohibit associate therapists from billing Medicaid for appointments.
Their motivations were twofold, they wrote: that associate therapists in search of more money are leaving community health groups to work in private practices, thereby gutting the state of its community mental health workforce, and that a “lack of appropriate training and supervision in these settings increases liability exposure and the risk of bad outcomes.”
“Many providers are leaving the public behavioral health system to go into private practice to serve a lower-acuity population and work fewer hours,” the document read, “leaving huge gaps in the workforce particularly in residential care and outpatient services for people with serious mental health and substance use disorders.”
The two associations wrote that the state should “enforce the existing requirement that unlicensed clinicians cannot bill Medicaid.”
Heather Jefferis, executive director of the Oregon Council for Behavioral Health, says in no other health profession can a person in training work independently of a larger group or clinic.
“I would never recommend to a new grad that they go work alone,” Jefferis says. “We’re providing services that if provided without skill or a low level of skill, people who come to behavioral health care are at risk of death.”
Jefferis concedes that the policy change will create “big disruption” and that associates working for community health groups deserve higher wages, but says that the policy is long overdue for change—both so that community health groups are sufficiently staffed with clinicians and so patients receive high-quality care. “We don’t support habits that put people at risk of not being ready,” Jefferis says.
Cherryl Ramirez, executive director of AOCMHP, says that while associates “are very often skilled, compassionate and competent providers,” until they get fully licensed, “they should be providing that care in a team-based, organizational setting, not as private practitioners, in order to be reimbursed by the Oregon Health Authority and CCOs with public funds.”
Other trade associations disagree.
The Coalition of Oregon Professional Associations for Counseling and Therapy, or COPACT, and the Oregon Counseling Association wrote in a Dec. 12 letter to their members that the policy change gravely concerned them.
“As a State, we are 49th in mental health access, and this decision would only further negatively impact this ranking and the ability of new associates seeking to work independently,” the two associations wrote. “We are aware of and are taking steps to ensure that we advocate to push back against this decision, as the impact would be immensely detrimental to everyone.”
Six licensed and associate therapists who spoke to WW this week said the policy change would worsen the state’s shortage of mental health care, and particularly harm low-income patients that currently work with associates.
Jules Allison, a Portland licensed therapist, calls the OHA’s reasons for changing the policy “baffling.”
“These arguments against associate therapists in private practice are based on flawed assumptions rather than actual evidence—especially when those very policies will harm the clients they claim to protect,” Allison says. “The only thing an agency offers is perhaps some structural advantages; however, these safeguards often falter under systemic issues like burnout and high caseloads. These arguments heavily rely on a very idealized view of agency settings and ignores the significant and pervasive systemic flaws.”
Michelle Sarchiapone, an associate therapist, says the organizations that OHA wants to drive associates toward often have lackluster supervision: “These community mental health organizations will simultaneously tell us we are not competent enough for private practice and, in the same breath, give us a full caseload of high-acuity clients with low-quality supervision. It doesn’t make sense.”
A spokeswoman for Gov. Tina Kotek, Anca Matica, says the governor’s expectation is “that Medicaid members have access to high-quality care; the Oregon Health Authority will continue to monitor the situation to ensure CCOs are meeting their obligations.” Matica adds that Kotek “respects the integrity of the rulemaking as a public process; provider and member input is integral to informing agency decisions.”
Kotek did not comment on whether she’s concerned that the the policy change would reduce the number of therapists that Medicaid patients can access.