"The medical society's lock on psychiatric care in this country is starting to break up," says Barbara Alexander, "and they're really hysterical about it."
Alexander is the president of the Illinois Society for Clinical Social Work. Like her colleagues, she is concerned about the issue of "vendorship" for licensed clinical social workers--their right to third-party reimbursement by insurance companies for the mental-health care they provide. At present, insurers are required by law to reimburse PhD psychologists and any MD, whether a psychiatrist, proctologist, or ear, nose, and throat specialist--but not clinical social workers. The social workers want to change that. The insurance industry, assorted business groups, and the medical lobby are fighting them.
The problem is that different people are battling for slices of the same financial pie, a pie that's getting smaller as the federal government cuts its payments for mental-health care and insurance companies cut all the payments they can. The Illinois Psychiatric Society argues that it is fighting to maintain standards in health care. The insurance lobby claims that costs will rise with mandatory vendorship. The social workers respond that this is simply a battle over turf--and money. And there are darker implications about who is being helped by our mental-health dollars: partly because psychiatrists are more expensive, clinical social workers tend to help those who are less well-off.
It's not easy to become a licensed clinical social worker (LCSW) in the state of Illinois. One must have either a master's degree in social work and 3,000 hours of satisfactory supervised clinical professional experience or a doctor's degree in social work and 2,000 hours of such experience. One needs a passing grade on the clinical-social-work examination and good moral character. One must pay a $50 licensing fee to the state, and must have functioned as a clinical social worker or clinical-social-work supervisor for at least two of the last five years.
Clinical social workers are among the major providers of mental-health-care services, along with psychiatrists, psychiatric nurses, and psychologists. Right now, insurance companies that provide reimbursement for outpatient mental-health care are required by law to pay for services only by MDs and PhD psychologists; but many do pay voluntarily for the work of clinical social workers. A bill to make such reimbursement mandatory, Senate Bill 577, recently passed the Illinois senate but was voted down by the house on June 23--by two votes.
Claudia M. Elliott has been a clinical social worker since 1972; she has a private practice, with offices at her home in Bucktown and in Lincoln Park. She gets her clientele largely through references: "From family practitioners, from psychiatrists, from other social workers, from former patients, friends, a priest, a nun," she says. "And sometimes people find me in the phone book.
"Sometimes people come to me because they trust the referral source. If they're referred by former patients, they're going by the word of others who got helped. Sometimes they come to me because they want a woman. Sometimes they come to me because it's cheaper [than going to a psychiatrist]. Sometimes they don't want a doctor. Referrals are most successful when they trust my word, when they think I'm good at [counseling], when they trust my judgment--when we connect."
Elliott charges $60 for an hour--a full 60 minutes--which she calls "pretty reasonable--there are other clinical social workers who charge more. But within a certain range, money is not the issue."
The Illinois Psychiatric Society won't give out information on fees charged by its members; but according to several sources, $100 for an hour of a psychiatrist's time is the average, with a high of $125 in the Chicago area. Clinical social workers, according to a spokesperson for the Illinois Society for Clinical Social Work, average $40 to $70 an hour. Psychiatrists can prescribe medications, hospitalize, and do physical checkups; clinical social workers cannot. But according to Elliott, "There is no difference in terms of the talking treatment. . . . It used to be that a psychoanalyst was concerned only with the mind, and the social worker with the milieu--but that difference does not exist anymore, unless you're dealing with a strict Freudian psychiatrist, and those are probably found only on the east coast now. Psychiatrists now are taking a more interpersonal approach--closer to what a clinical social worker does. The basis of all of it is psychoanalysis."
Elliott says she doesn't really have an average patient; they're all adults who work for a living, but they may be gay, straight, single, or married. She points out that CSWs do most of the less glamorous counseling, such as therapy for alcoholism and other drug-abuse problems. Furthermore, many psychiatrists (who are considerably rarer than CSWs) prefer the more lucrative work to be found in hospitals, where they can see more patients, usually with more severe problems, for shorter sessions and more money. There are often more CSWs available, and they may be more willing to provide garden-variety therapy.
Passage of the vendorship bill is important to her, Elliott says, because "every year I lose a couple of people who couldn't be reimbursed if they came to see me. Every year, I have to struggle for reimbursement--sometimes I have to have formal supervision by a psychiatrist, sometimes I have to fight with the insurance companies, sometimes I have to lower my fees. [Passage] would free me to go ahead and do my work without being encumbered with a situation I don't need."
It would also eliminate a common abuse called "signing off," in which a psychiatrist bills insurance companies for work actually done by a CSW, who then splits the fee with the physician. "It's illegal, but it happens. People have to make a living," notes Elliott, who says she rejects all overtures in that direction.
"There's a tremendous amount of opposition from psychiatrists, as there has been in 21 states, because of the fear of competition," says Sheldon Goldstein, executive director of the National Association of Social Workers, which represents 7,500 members in this state. "There's opposition from the insurance industry, which as a kind of knee-jerk response opposes anything new. There's no data that the cost of insurance will rise as a result of adding social workers--in fact, the opposite is true when you add a provider group. Social workers charge 33 percent less on average than psychologists or psychiatrists. The largest corporations in the country are using social workers because they're cost-effective--IBM, Digital Equipment, American Airlines, United Airlines, Honeywell, AT&T--I don't know how long you want me to go on, but there's zillions of them."
Goldstein points out that there are 34 Illinois counties without a single psychiatrist or PhD psychologist; in many areas, the only provider of mental-health care is a social worker. "Seventy percent of all the psychiatrists in the state are in Cook County; probably 90 percent of those are within four blocks of the Tribune Tower. So we're talking about an issue of accessibility to care, as well as lower costs."
So if costs are lower, why do business groups like the Illinois Chamber of Commerce oppose this bill? "Because they want to kill anything that's mandated anything," responds Goldstein. "We have been unable to get their attention and say, 'Why do you think the biggest companies in the country are using social workers? Because they're cheaper, dummy!'
"Twenty-one states have [vendorship], and nothing terrible has happened to the insurance companies or the psychiatrists. The insurance companies can't come up with the data to support their stand--and they're the ones who control the data!" (Although I pressed both sides on this issue, neither could give me any real data on what has happened to costs in states with vendorship.)
According to Goldstein, one primary reason that insurance companies oppose vendorship is that they have many MDs on their boards. These doctors have fought other changes that resemble the proposed addition of LCSWs "tooth and nail," he says. "They fought the chiropractors and the osteopaths and the podiatrists--everything. It really is a situation of pure protectionism on their parts."
Springfield politics have also hindered the provendorship forces, Goldstein says. "We're having trouble because of the business interests [ranging from insurance companies to the Illinois Chamber of Commerce] and the Illinois Medical Society. The IMS gave $275,000 to Illinois legislators last election. Most of the Cook County legislators are for it, but the downstate people are the hardest to reach--they respond to the business interests. We're trying to point out that this means competition, and when we get a level playing field, social workers save money. This really is consumer-choice legislation."
"We're opposed to the bill," says Billie J. Paige of Shea, Rogal & Associates, Ltd., a law/lobbying firm. Paige, an articulate woman, is the lobbyist for the Illinois Psychiatric Society. "The first reason [is that] we believe that, in many instances, psychiatric problems are related to medical problems. Before anyone goes to a mental-health practitioner, they should be diagnosed by a psychiatrist to make sure there's no physical problem.
"Second, it is not the case that a clinical social worker or any other mental-health practitioner will necessarily save money. Just by virtue of adding a new provider you will increase the cost--people will see a psychiatrist and a clinical social worker." Why? "I wouldn't have a clue, but the studies I've seen tell me that would happen. And people see clinical social workers more frequently than psychiatrists.
"Third, the state code now does not prohibit the employer to cover clinical social workers. . . . What we object to is if it would be mandatory. If the bill should become law, it would not cover any of the larger employers in the state who are self-insured--they've got a federal exemption. The burden falls on the small to medium employers."
A fourth reason is not on Paige's list, but she seems to allude to it later. Most insurance policies limit each individual to $10,000 in lifetime mental-health benefits, and if patients are seeing a psychiatrist and a social worker at the same time, they'll use up their benefits more quickly. "Psychiatric benefits are very limited in Illinois," she says. "To try to spread them over more practitioners doesn't serve the public very well." She adds that "the only group we are really talking about [being left out] here is the clinical social worker who is self-employed."
She brushes aside the argument that 34 Illinois counties have no shrink: "There is no county in the state where there is not a physician. There is no county in the state that is not contiguous to a county that has a psychiatrist.
"The capacities of a clinical social worker to be the first contact are not those of a physician. It has more to do with the quality of care than it does with the third-party-reimbursement issue. Our major concern is that they see an MD first.
"I guess I'm saying that if it ain't broke, don't fix it. And from our perspective at least, it ain't broke."
Elliott snorts at the "every county has a physician" argument: "That's ridiculous! It's just a way for them to keep control over the psychiatric dollar. Most of us have a pretty good idea if someone needs to see a doctor--and most psychiatrists, if they're honest about it, will admit they've been out of medical school so long they wouldn't recognize the flu if they saw it. I was trained to err on the side of caution--if I suspect a medical problem, I send that person to a physician.
"I had five years of weekly supervision with an analyst, learning to keep my eyes open for all aspects. . . . And why is it that a doctor should see the patients of a social worker when a doctor does not see the patients of a psychologist?"
Dick Lockhart thinks it is broke. Lockhart is Paige's opposite number, the lobbyist for the Illinois Society for Clinical Social Work, and he's been getting a "mixed reaction" from legislators to his work for the vendorship bill.
"I do think, personally, that there's an element of competition that concerns the psychiatric society, although I don't think they'll say that for the record. But I do think that there's a turf question here. The physician--he may be a radiologist, or an orthopedist, with no training in mental-health care. Why should he be qualified for reimbursement when a licensed clinical social worker is not?
"The coverage is not changed; it will simply add clinical social workers to the coverage list. . . . I think it's economic, I really do; and I think if you pressed them on it, that's what would surface."
Jerome Beigler, MD, is chairman of the committee on government affairs for the Illinois Psychiatric Society. He has a private psychiatric practice in the Prudential Building in downtown Chicago. He believes it's important to have medical screening first, and he shrugs off the issue of inaccessibility: "They make a big point that many counties in Illinois do not have psychiatrists available. But 90 percent of the population have access to a psychiatrist in their county or an adjacent county. So on a statistical basis, the care situation is well taken care of."
As to costs, "Fifteen states have vendorship statistics," he says, "only five of which are comparable to the situation in Illinois. Costs do go up; and when a new category of provider is authorized, the old patients stay with their old providers, but new patients come and utilize the new ones. Studies show that social workers see patients more often and for a longer time [than psychiatrists]."
Beigler says he thinks highly of the abilities of social workers: "Social workers are a very important part of a team. We all refer [cases] to social workers--there's no substitute for them." He also admits that there's something to the "turf battle" argument. "If there were an infinite availability of resources," he says, "there would be no problem."
Goldstein denies that most patients see a social worker more frequently than they might a psychiatrist. That conclusion, he says, is based on mismanaged statistics; physicians and psychiatrists are lumped together in the same stats. "You go to see a doctor once for a cold, and that's it. That brings down the overall statistics. But you can go to see a psychoanalyst five times in a week! That's not unusual at all. Clinical social workers have been trained in what is called 'brief therapy'--very often, ten sessions and it's done with." He says that Beigler's statistics are outdated and inapplicable.
"We oppose all mandates," says Larry Barry, president of the Illinois Life Insurance Council. "When we're told we must cover certain types of provider, it just increases our cost. They may argue that one particular type is cheaper than another, but our experience is that you add one, you increase the cost."
Barry repeats lobbyist Paige's argument that the new law would be discriminatory: "Mandates such as this cannot be enforced on employers who are self-insured. Self-insurers make up about 50 percent of all the insurance written, and they're mostly big companies. It's unfair to mandate only on the medium to small employer.
"Social workers deliver over 60 percent of the mental-health care in the United States. It doesn't take a mathematician to see that you don't take someone who's delivering 60 percent of the mental-health care in the United States, add them to your coverage, and save money. People don't leave a psychiatrist or a psychologist to go to a clinical social worker. Our experience is you have more people utilizing more coverage."
But will costs really rise? Says Barry, "There's no accurate information [on costs] from our side or theirs."
From a letter from William R. Schleicher, regional manager of AT&T's employee-assistance program, to state senator Emil Jones, sponsor of Senate Bill 577:
"AT&T's experience in utilizing social workers to treat employees and families has been most positive and beneficial. In using reimbursement for social workers through our insurance plans we have not found our costs rising. . . . In many areas of Chicago social work services are close by, whereas other reimbursable counseling is located some distance away for the consumer."
Barbara Alexander argues that it doesn't matter that self-insured companies are excluded from the proposed legislation--because they are already using social workers. "It's called managed health care, and all the big companies are doing it," she says. "Our training is better, we're more efficient, we cost less, and so they use us."
"I've never seen a study that proves out the contention that [adding clinical social workers to reimbursement plans] saves money," says Pamela Mitroff, health-care cost manager for the Illinois chamber of commerce. "You have to wonder if this type of legislation is not to make up for failed marketing objectives. If you can't go out there and sell it one-on-one to employers and insurers, then what better way than to have a government fiat?"
Mitroff stresses that the chamber of commerce does not object to social workers per se--"[Nonmedical reimbursement] is a generic concern." She seems taken aback when it's pointed out to her that radiologists can legally prescribe psychoactive drugs and be reimbursed for mental-health care. She says, "If we had our druthers, we wouldn't have any of these [mandates] on the books. Unfortunately, we can't go backward. . . . [But in this case] we've got to let those decisions be made in the marketplace."
"It's not that there's been a failure in marketing--it's that we're new to marketing, because of this helper/server mentality," says Alexander. "It's just in the last few years that we've stopped seeing ourselves as handmaidens to physicians. 'Oh, yes, you are all-knowing and all-powerful, doctor; please sign this for me.'
"I think that there's a big faction in social work that views itself as helpers and servers; this dates back to the founding of the field. . . . We're seeing the changing in identity of a profession. Maybe it's because of more men going into the field; maybe it's an overall change in identity.
"Social workers have always worked with alcoholism problems, with emotional problems, with psychiatric problems. It has only been in the last 10 to 15 years that mental-health coverage has existed in this country; you know the tremendous stigma that mental illness has in this country."
Alexander admits that "we haven't really gone out and made an all-out effort" to sell employers and insurers on an individual basis. But she also suggests that this may not be worth the effort, pointing out that a mega-insurer like Blue Cross, which does not directly reimburse CSWs, was founded by doctors, the group fighting vendorship the most vigorously.
Elliott suggests two additional subtle--perhaps unconscious--reasons for the medical establishment to resist reimbursement for social workers. Sexism is one--most psychiatrists are male, most social workers are female. The other is a lack of caring for the poorer strata of society, most of whom turn to social workers rather than psychiatrists. Most elderly people, too, resist seeing a psychiatrist but will see a social worker.
Paige dismisses the first charge: "I don't believe that for a moment, or I wouldn't be talking to you--they wouldn't have hired a woman. I've been working [for the IPS] for over six years, and I have detected none of that at all. In fact, the current president of the Illinois Psychiatric Society is a woman."
The IPS's Beigler concurs: "That's an opportunistic argument." But he admits that the question of who's providing mental-health care to the poor "has some validity. But when poor people require treatment, they come to a clinic, to a hospital clinic, where they're screened by a physician first. . . . There's a stigma, a prejudice about mental-health care; psychiatric patients do not have much voice in the distribution of funds. The health-care industry is under financial pressure. The budgetary aspects of this have gotten out of hand, according to the people who run our government."
"I was talking to someone the other day who in one week had six patients referred to her, and had to turn them all down because she couldn't get reimbursement," says Alexander. "They probably went to someone who charged more."
"If the truth be known," says Elliott, "I have a feeling that our service populations don't really conflict. If people need a psychiatrist, they find one. Others want nonmedical help.
"What I want to be able to do is to practice my art and my skill to the best of my ability without specious control. I take my work very seriously, and I know what to do."
Art accompanying story in printed newspaper (not available in this archive): photos/Loren Santow.