AAMFT California Newsletter Fall 2013
Who are the Dual Eligibles
Quiet legislative year comes to a close
Building Couple Connection through Socio-Emotional Relationship Therapy
AAMFT 2013 National Conference
Covered California and MFTs: What are your experiences?
Who are the Dual Eligibles and Why Should I Care?
Olivia Loewy, PhD
Employment. Opportunity. That’s why you should care. A never-before inclusion of MFTs as providers of service within comprehensive public systems of care that will be partially funded through Medicare. It will be a giant step forward in California for individual MFTs and for the profession.
Dual Eligibles are health care beneficiaries who qualify for both Medicare and MediCal public insurance programs. California has about 1.1 million of these beneficiaries, sometimes also referred to as the Medi/Medi population. As many as 7 in 10 are age 65 or older and about 1 in 3 are younger people with disabilities. For more information: http://www.calduals.org/2012/06/13/profile-of-ca-medicare-medi-cal-enrollees/
- Medicare funds are federal and used as the primary payer for most medical services of people who are elderly or disabled.
- MediCal funds come from the state and provide coverage to qualifying people with low incomes.
- For the dual eligible, Medicare is the primary payer of most medical services and MediCal covers related costs, including long-term, home and community based services, as well as other supplementary supports.
Dual Eligible Demonstration Projects
In anticipation of Affordable Care Act (ACA) implementation, the federal government has partnered with several states, including California, in developing demonstration projects to integrate care for Dual Eligible individuals. California’s demonstration is called the Cal MediConnect program, designed to improve health care quality and lower costs by promoting coordinated care. Additionally, in July 2012, the state passed legislation that established the Coordinated Care Initiative (CCI) to improve services and patient satisfaction while achieving savings through maximizing service delivery in beneficiaries’ own homes and communities in lieu of institutional care.
Significance of the Dual Projects
Coordinated Care is the future of healthcare and the Dual Demonstration Projects will be the trail blazers – the first to attempt to navigate through this new, uncharted territory. Healthcare Reform will bring with it massive changes in the way that services are delivered. Systems of the future will be integrated, accountable, and recovery-oriented, driven by the Centers for Medicare and Medicaid Services (CMS) Triple Aim:
- Better Health
- Better Care
- Lower Cost.
While the fundamental concepts and the Triple Aim goals have achieved national widespread acceptance among policy makers, the commensurate guidelines and regulations are still in developmental stages. The goals are clear. The means and methods to achieve them are complex and challenging. The emerging systems are proceeding with great care and scrutiny. Implementation of Cal MediConnect has been delayed, however an inclusive statewide planning process is actively in place and progress is steady.
Significance for MFTs
Early in the developmental process, the California Department of Health Care Services (DHCS) signed a Memorandum of Understanding (MOU) with CMS. This MOU contained the following language:
Participating Plans will have discretion to use the capitated payment to offer behavioral health services, beyond those traditionally reimbursed by Medicare, to help prevent enrollees from needing institutionalized care in a hospital, skilled nursing facility or other setting. This flexibility will enable Participating Plans to address gaps in today’s continuum of care for Medicare-Medicaid enrollees with mental illness.
The MOU statement quoted above allows for MFT provider inclusion. Since the Dual Demonstration projects will be the model for emerging systems of care statewide, this means potential inclusion of MFTs in all future structures. Because California is one of the states that is leading the nation in Healthcare Reform, this inclusion of MFTs could have national implications.
A severe workforce provider shortage is anticipated as healthcare services and coverage expands. Licensed clinicians and post-graduate interns will be in demand; however, a license or an education will not be marketable in these new systems without appropriate preparation. Educators, supervisors and clinicians will need to demonstrate proficiency of the knowledge and training needed to contribute in the new systems, such as: Substance Use Disorder; Working effectively with the seriously mentally ill population; Culture and language of primary care; Evidence-based practice; Recovery-oriented care.
What is AAMFT-CA Doing for You?
AAMFT-CA is working actively to secure a solid place for MFTs within the evolving structures. We are very aware of our responsibility, on behalf of our members and the MFT profession, to A.C.T. Our actions take the form of Advocacy, Connection and Training as follows:
- Advocacy: Through our active participation in relevant policy-making coalitions and meetings, we are continuing to ensure that MFTs are part of the conversation.
- Connection: Through our recent partnership with the California Council of Community Mental Health Centers (CCCMHA) we are closely connected with the Directors and CEOs of community based organizations throughout the state. These connections provide us with current information about the “real world” of healthcare evolution and the real needs of employers.
- Training: Informed by policy plans and real world needs, we are developing training and resources to prepare you for your changing profession. For more about what we currently offer: http://aamftca.org/preparing-for-healthcare-reform/
Whether or not you will ever want to work in public mental health, you will be professionally impacted by Healthcare Reform implementation. Insurance coverage will change, opportunities will increase. The emerging healthcare systems and structures of reform being developed for the Dual Eligibles will be leading our way. We will continue to ACT, because we know you are going to care.
Image source: Courtesy of Olivia Loewy, PhD
Quiet legislative year comes to a close
Benjamin E. Caldwell, PsyD
Over the past several years, a number of high-profile bills have impacted marriage and family therapists, including bills that dramatically altered our curriculum requirements (SB 33, 2009), changed the rules for minors independently consenting for treatment (SB 543, 2011), and banned reparative or conversion therapy for minors (SB1182, 2012). The 2013 legislative year didn’t have such high-profile bills, but a number of bills were signed into law that will impact MFTs and their clients.
At this point, the legislative year has ended. Governor Brown signed 800 bills passed by the state Legislature and vetoed 96 others this year, according to the Sacramento Bee. Among the bills he signed:
Senate bill 126 extends existing state law requiring health insurance plans to pay for behavioral treatment of autism and related disorders. The requirement had been scheduled to expire in 2014, and this law extends the requirement through the end of 2016. AAMFT-CA supported this bill.
Senate bill 282 will discourage frivolous “shakedown” malpractice lawsuits by requiring that initial settlement offers (essentially, offers to avoid a lengthy court process with an immediate financial payment) be accompanied with permission for a therapist to discuss the case with their liability insurer. This will allow insurers to give therapists legal advice as to whether to accept the settlement offer or fight it. AAMFT-CA supported this CAMFT-sponsored bill.
Senate bill 528 clarifies that minors as young as 12 can consent to their own mental health services even when those minors are wards of the court.
Senate bill 585 places “Laura’s Law,” which allows courts to mandate outpatient mental health treatment in limited circumstances, within the funding stream created by the Mental Health Services Act. This ultimately is likely to improve funding for such services.
Senate bill 821 makes official what had been in the works for some time, pushing back the scheduled exam restructure to January 1, 2016. The restructure was previously planned for January 1 of next year, and the BBS reported that the delay was necessary for them to first finish implementing the new licensing database that will allow for online renewals. Ultimately, the system – called Breeze – will also allow for online applications for licensure.
In addition to these bills, the BBS has also successfully advanced multiple packages of new regulations this year. New advertising rules went into effect in April, and changes in the state’s disciplinary process and guidelines took effect in July. More information on both of these packages can be found on the Board’s web site at www.bbs.ca.gov.
Perhaps the most impactful event of the year was the Department of Consumer Affairs’ legal counsel producing a memo on the reporting of consensual sexual activity among minors. We at AAMFT-CA were moved by the statements of many therapists that current law treated consensual same-sex relationships quite differently from heterosexual relationships, and made resolving this inequity a legislative priority for 2013. In April, in response to our presentation at a BBS meeting, DCA counsel introduced a new interpretation of the law that allows clinicians to use the same standards for same-sex relationships that they do for opposite-sex relationships when considering whether to report consensual sexual activity as child abuse.
Benjamin E. Caldwell, PsyD chairs the AAMFT-California Division Legislative and Advocacy Committee. He can be reached at firstname.lastname@example.org
Image source: Courtesy of Ben Caldwell, PhD
Building Couple Connection through Socio-Emotional Relationship Therapy
By Melissa Wells
Most couples who come to therapy are not aware that invisible gender power processes could very well lie at the root of their problems. But when couples approach their relationship through gender stereotypes, research indicates that many of their problems result from unexamined sociocultural beliefs about how men and women should behave in relationships (McGoldrick, Anderson, & Walsh, 1989). Accordingly, about five years ago ten doctoral students led by two professors at Loma Linda University set out to develop an approach to couple therapy that specifically focuses on the influence of sociocultural context. The clinical research group designated this new approach as Socio-Emotional Relationship Therapy (SERT). Soon, members of the group began writing and publishing articles on their findings, as well as presenting this model at conferences (Knudson-Martin, 2013; Knudson-Martin & Huenergardt, 2010; Williams, Galick, Knudson-Martin, & Huenergardt, 2011).
SERT therapists work with couples to help partners become more mutually supportive. One way this is done is by examining taken-for-granted assumptions about gender stereotypes and the effects of power processes on couple interactions. A mutually supportive relationship can be recognized as fair give and take between partners (Boszormenyi-Nagy & Krasner, 1986). In SERT this is conceptualized as the Circle of Care, which has four components: mutual vulnerability, shared attunement, mutual influence, and shared relational responsibility. Positive vulnerability in a relationship, for example, creates the possibility for partners to openly disclose each other’s experience without fear of being judged. Attunement is each partner’s ability to be sensitive to the needs of the other and awareness of what is important for the vitality of the relationship. Mutual influence supports each partner in having a voice on matters affecting the couple. Relational responsibility involves each partner sharing the load on the needs of the relationship (Knudson-Martin & Huenergardt, 2010).
A biracial couple wanted an egalitarian relationship, for instance, but experienced significant difficulty in achieving this. The African American husband, Mark, expressed his desire to share parenting and household chores with his Latina wife, Maria, since involvement with their two children was important for him. But Maria’s beliefs about how a woman should manage the family conflicted with her husband’s goals. Both partners were frustrated. Even though Maria admitted that she could use Mark’s help, she felt guilty about not meeting the cultural expectations of the ideal Latina wife and mother. The therapist facilitated examination of these sociocultural influences and their link to the emotions driving the couple’s interactions. In this process the partners agreed that redefining their priorities away from stereotypical roles assigned by gender in the larger society would model a better future not only for themselves, but also for their young son and daughter.
Another couple, Paul and Julie, had a serious problem that threatened to destroy their marriage. Indeed, Paul’s fetish was supported by his cultural beliefs about manhood, and even though this habit posed a significant challenge to the relationship, Paul seemed unable to control the addictive behavior. SERT therapists facilitated a view of this challenge as relational instead of as an individual problem, and worked with Paul to examine his gender socialization and to focus more on Julie’s needs. By becoming sensitive to her emotional bids for connection, the fetish gradually disappeared as Paul intentionally attuned Julie’s and his own relational needs. Both partners experienced a level of closeness that promised a new beginning for their marriage.
These cases involved several important approaches fundamental to SERT. First, SERT therapists work to socioculturally attune to both partners so that they feel understood and validated. SERT therapists do this by appreciating the partners’ contextual identities and the emotions linked to these contexts. Second, therapists interrupt the flow of power stemming from unequal relationship patterns that drive partners’ emotional interactions by examining each partner’s gendered expectations and making visible power differentials. Third, therapists facilitate new couple interactions by encouraging the more powerful partner to initiate connection. This typically involves enactments expressing vulnerability and attunement (Knudson-Martin & Huenergardt, 2010). At first partners may find this new dynamic strange, but they quickly discover their preference for sharing power according to their relational needs. In this way they are able to work together to incorporate a level of mutuality that is uniquely beneficial.
The SERT group continues its research. One dissertation project focuses on the effects of gender power on trust dynamics between adult survivor partners of child abuse. Another will study how vulnerability occurs in relationships. The group also hosts a blog entitled equalcouples.com.
Boszormenyi-Nagy, I., & Krasner, B. R. (1986). Between give and take: A clinical guide to contextual therapy. New York: Bruner/Mazel Publishers.
Knudson-Martin, C. (2013). Why power matters: Creating a foundation of mutual support in couple relationships. Family Process, 52, 5-18.
Knudson-Martin, C., & Huenergardt, D. (2010). A socio-emotional approach to couple therapy: Linking social context and couple interaction. Family Process, 49, 369-386.
McGoldrick, M., Anderson, C. M., & Walsh, F. (1989). Women in families and in family therapy. In M. McGoldrick, C. M. Anderson, & F. Walsh (Eds.), Women in families: A framework for family therapy (pp. 3-15). New York: W. W. Norton & Co.
Williams, K., Galick, A., Knudson-Martin, C., & Huenergardt, D. (2012). Toward mutual support: A task analysis of the relational justice approach to infidelity. Journal of Marital and Family Therapy. 10.1111/j.1752-0606.2012.00324.
AAMFT 2013 National Conference
By Norma Scarborough
DMFT AAMFT-CA Division President
The 2013 AAMFT Annual Conference on Raising Vibrant Children in Portland, Oregon has come to an end. Portland is a beautiful city which was full of the color of fall as the leaves turned orange, red, and yellow. Inside the huge the convention center, people were gathered in excited groups as they greeted each other for the first time in a year or discussed the merits of the last session they attended. As I looked around, almost everyone seemed to be enjoying the conference. There were some very good workshop presentations and AAMFT really made an effort to bring balance to the keynote addresses.
There were however changes to this conference that were not there last year. First of all, there were no large, colorful programs. They were replaced by a smaller, folded program that still allowed you to find the location of the events easily without having to carry a heavier program. If you lost it, replacements were readily available. Once you were registred, you could easily access your sessions online through the AAMFT website, as well as complete evaluations. Plenary sessions were renamed Keynote Addresses and the evaluations were also done on line. Inside the auditorium, another technological change was added. As an audience we could take surveys based on the presentation. The speaker would reach some critical part of the presentation and then ask for the audience to text their answer to the survey question. We could all watch the screens in front of us as the votes for each item in the survey question was tallied. The numbers appeared in real time as each of us responded to the question. Each of the keynote speakers had a question or questions for us to respond to and it definitely added to the experience.
There were other technological changes that made this conference much easier to enjoy. The presenters of each workshop had their powerpoints posted online and that eliminated having handouts at each session. The presentation rooms were conveniently located to each other and to the Exhibit Hall. Gone were the long hikes between presentations and we did not have to walk the equivalent of several city blocks to return to the Exhibit Halls.
I think the best part of any conference is the ability to get together with friends and colleagues, something that is not always done when we return home because of our incredibly busy schedules. I really enjoyed that aspect of the conference.
The absolute best part of this 2013 conference was watching our own Ben Caldwell accept the Divisions Contribution Award. Many of you know him because of his outstanding work on the Legislative/Advocacy Committee, but he is also the Secretary of the AAMFT-CA Division Board. Ben Caldwell has made many contributions over the years to our division, AAMFT, and the profession. We were very proud that he was honored at the conference and that we could celebrate his achievements, nationally.
If you missed this conference, you may want to plan to attend next year’s annual conference in Minnesota. We would also love to see you at our CA Division events and meetings in 2014 and we would always love to hear your ideas about how the California Division can better serve you.
DMFT President California Division
The Transforming System: A Practical Handbook for Understanding the Changes in California Community Mental Health, American Association of Marriage and Family Therapy California Division, 2012, $42.00 print; $30.00 ebook.
This is a practical handbook for clinical supervisors, interns, and multidisciplinary community practitioners that outline the process and challenges of implementing recovery-oriented care within our current mental health system. This is a refreshing book that looks at recovery within the current system of care, without ignoring institutional and operational issues, such as documentation and billing that pose real problems to implementation. This book details what can be implemented today for both clinical supervisors and practitioners working towards this transformation in service delivery. The information on evidenced-based, substance abuse, trauma-informed, and culturally congruent care, with references for follow up, speaks to the basic skills all clinical staff and supervisors need for informed practice.
This book summarizes the political mandates that led to the transformation in service delivery, provides a historical overview of the mental health services act, and addresses current issues with operationalizing recovery. It is an excellent reference for both clinicians and supervisors as it provides practical information on using strengths based post-modern approaches when working collaboratively with consumers, as well as practical information on using techniques like mapping for case conceptualization and specific advice on dividing goal formation. Service goals are deemed to be the most similar to those of the medical model and most likely to be reimbursed by payers. It’s this type of information, pervasive in this book, which demonstrates its utility for those who want to implement the principles of the recovery model and still need to meet standards within a medical model documentation system.
The nature of clinical supervision itself changes when implementing recovery principles of collaboration, and the section on parallel process specifically provides plenty of thought provoking issues for clinical supervisors. We ask clinicians to meet individuals where they are at and be an equal partner in treatment decisions yet we still operate according to hierarchy in supervision. The sections dealing with parallel process raise ethical questions for supervisors and challenge the traditional clinical supervision process.
The section that covers what employers expect from interns, trainees, and any clinical candidates is refreshing in its honesty. Recovery model does not mean professionalism; dress, speech, interpersonal skills, etc. cease to matter. It does mean that the specific recovery language and additional knowledge has been added. This section provides helpful, practical feedback from diverse community agencies in California.
This book is a must have for clinical supervisors and highly recommended for anyone wanting to learn more about the transforming mental health system within California, the challenges of recovery model implementation in the CA mental health system, information on training issues, and practical information on bridging concepts from practitioners and professors working with students and clinical staff during this formative period in mental health.
Reviewed by Sherine Costa, LMFT, LPC, CCMHC (email:email@example.com)
This book is available on Lulu.com: http://www.lulu.com/spotlight/aamftca
Covered California and MFTs: What are your experiences?
Covered California will be enrolling beneficiaries in new, federally directed health plans that are required to include Mental Health and Substance abuse treatment. AAMFT is interested in hearing of all CA Division members’ experiences with the Covered California Qualified Health Plans (QHPs). AAMFT is tracking the experiences of MFTs nationally and appreciate we want to know about your related experiences. On this topic, here’s what initial reports are nationally:
1. Most private MFTs (as well as apparently most tertiary-care hospitals/clinics and typically 1/3rd of community hospitals) are NOT in Exchange plans’ (QHPs) provider networks, a pattern called “narrow” networks. Although ACA requires “adequate” provider networks, there is no operational definition of this, nor any widespread empirical data.
2. QHP enrollees in all but 3 States (MD, MN, OR) cannot easily determine which MFTs (or other providers) are in each QHP, largely due to the problems and structures of the federal and State websites. This is a problem both for private MFTs’ current clients who will transition to QHPs, and for potential clients. . (It would be preferable to have a spreadsheet for each QHP in a State, as in MN, with hotlinks to each QHP’s provider directories. It appears that most, if not all, insurers offering QHPs use the same providers for their Bronze thru Platinum QHP plans.)
3. Where provider lists are available, in ~40% of cases, QHP-contracted providers are listed erroneously (either listed without their knowledge [although they may previously have signed contracts for “all” of an insurer’s plans], or not listed despite having contracts).
4. Few providers who participate in a QHP insurer’s other products are given the opportunity to opt-out of QHP products, despite this absence arguably comprising an unlawful “tying arrangement.”
5. QHP pay rates (for both MFTs and other providers) are typically lower than those a QHP insurer offers for its other plans, and in at least one case, the lower rates now apply to an MFT (for the insurer’s other plans) even if she declines QHP participation.
6. Despite the requirement for Health and Human Services (HHS) (for the 36 federally-run states) and the 14 States and DC running their own Exchanges to certify that all QHPs meet the Essential Benefit Standard of MH/SA coverage at Parity, there are questions on QHP compliance (in e.g. NY), due in part from HHS’s 5-year-long failure to issue Parity rules for non-quantitative issues such as for specific Tx regimens and psychoactive-drug Formularies.
7. While good data on enrollee composition (e.g. Mental Health/Substance Abuse needs) does not exist, early reports are that enrollees are disproportionately relatively old. In some locales, Mental Health America affiliates have been certified as Navigators in order to get persons with Serious Mental Illnesses enrolled in QHPs. In a similar population (Medicaid expansion in WI), large upticks occurred in MH and SA treatments soon after enrollments. Due to relatively high premiums and a low non-compliance penalty (in 2014, greater of $95 or 1% of MAGI), enrollments likely will include relatively few young adults (esp. aged 27-40). This last point raises concerns about the long-term actuarial viability of the Exchanges, and of insuring young adults at high risk for schizophrenia onset.
Please contact us to share your experiences: firstname.lastname@example.org.