Health Insurance Industry: Where is it going?

I receive several healthcare industry newsletters each week. Most of them seem to assume that health insurance companies, as they exist today, are on their way out as the healthcare industry restructures. At the very least, these publications believe that our current ‘fee for service’ model is a dinosaur that will be extinct in the next ten years.

Some people think ACO’s (Affordable Care Organizations) will take the place of the health insurance industry. These are provider groups (including hospitals) who bear the risk for providing all care for a patient for a certain amount of money that is now paid by an insurance company or Medicare. They are expected to use lots of preventive care and to benefit from the large amount of data their electronic health records (EHRs) will gather to provide evidence-based care in a profitable way. Kaiser Permanente is the example of this kind of organization that many people refer to.

The logical extension of these arrangements is that the ACO would contract directly with an employer or group of employers on behalf of their employees cutting out the insurance company. This would be a kind of pre-paid health care where the ACO is on the line for providing best care and keeping members healthy.

Oh, wait….isn’t that what HMO’s were? You remember….Health Maintenance Organizations. In fact, I think Kaiser was long considered an HMO. It has certainly been a most successful one!

For myself, I am a fan of a single payer system… Medicare but for everyone…..with premiums paid by employers or from income taxes or in a variety of ways so everyone can be covered.

What models of funding healthcare do you see as possible and even likely? Do you think insurance companies are with us for the long-term? Where do you think behavioral health will fit in this ever-changing, rapidly evolving arena?

Please share your thoughts and comments below.

Dismantling Habitual Behavior

Since the middle of July, I have been involved in a yoga teacher training program that I have mentioned a few times in blog posts. During that entire process—the 20 days at the yoga institute and the six weeks between the two ten-day sessions—one of the primary focuses has been on our habitual behavior and how it keeps us from being who we really want to be.

The last time I wrote about habits, my article was a review of a book that aims to help us change habits. The methods suggested by the author, Charles Duhigg (The Power of Habit) are very effective at helping us alter habits which are no longer serving us. The approach presented is very logical and behaviorally focused, perfect for individuals and behavioral health professionals to use.

The mode of dismantling habitual behavior in yoga is just a bit different. Yoga practice utilizes the body, the breath, and energy as tools to bring us face-to-face with our habitual reactions, and then uses proper alignment, breath and internal focus (concentration and meditative awareness) to help us react in ways other than our usual, habitual ones.

For many of us, our habits are invisible. Even when others point them out to us, we have a hard time seeing them. We may even become defensive and insist that we do no such thing. For some of us, focusing on the energy tied up in that habit rather than on the habit itself is a more productive path. Becoming aware of our reactive patterns and using that awareness to become mindful of how the habit serves us or does not in our daily lives is one step toward change. Working directly with the energy we have invested in the habit—bypassing our thoughts, rationalizations and justifications for the behavior—can be an effective method of change for those of us who are expert rationalizers and justifiers.

Those of you who are body workers or have had experience with body work (massage, chiropractic, Thai massage, Rolfing, Reiki, Feldenkrais, etc.) know from your personal experience that the body holds a great deal of tension and energy that is connected to emotion. The first time I had a chiropractic adjustment, I cried all the way home—not because it hurt; it did NOT. I cried because I had been in pain for most of a year and the adjustment I received relieved that pain immediately. It also released lots of energy that I had tied up in that pain and in the muscles in my body that were trying to keep it from getting worse and were working hard to protect me from the pain. Releasing that energy makes it available for my use rather than my protection.

The same is true with energy I have tied up maintaining habit patterns that may no longer serve me. That energy can become available for my growth and for improving my health.

What methods have you learned for changing habits…your own or those of your clients? What has the effect been on your energy? Do you have experience with body work or with yoga that has resulted in behavior change?

Please share your experience and comments below.

Managing My Stress: No blog posts until September 30

In an effort to manage my stress levels more effectively, I today made an executive decision—I will take a brief break from blogging. I am getting ready to head to the second half of a yoga teacher training program on Friday. I will not return until September 21. I plan to do my next post on September 30.

Thanks to all of you who read my posts regularly. I appreciate your loyalty!

Fines as Motivators: How do they affect your actions?

I just reviewed two articles that talked about fines against providers for allegedly illegal behavior related to HIPAA and to the False Claims Act. I also just read an exchange of opinions and information on my state psychological association listserv about a Microsoft cloud service product and whether it is HIPAA compliant. As we deal with our customers on a day-to-day basis, I am amazed at the variation in response to possible breach of the law. Some state things like, “Oh HIPAA. I’m not worried about that stuff.” Others indicate opinions such as, “I would never use a Cloud backup program. It cannot possibly be secure!”

The HIPAA article was in an Open Minds newsletter and focused on the money-making potential of HIPAA. The gist of the article is that 2015 is expected to be a very big year for fines for breach of HIPAA requirements. The cases in OCR’s pipeline as well as the plan for HIPAA audits of providers, insurers and clearinghouses are likely to produce record fines. The advice in the article was similar to the advice given by one of the participants in the listserv discussion mentioned above: complete a comprehensive risk assessment for your organization. There are many tools and much guidance available on the CMS web site; the Indian Health Services also have a checklist for what should be in that risk assessment.

The second article I read this morning was about the False Claims Act and how it relates to certain aspects of the Affordable Care Act. The article discusses a Department of Justice and New York Attorney General’s lawsuit against a healthcare organization accused of failing to return Medicaid overpayments the organization allegedly had knowledge of. Apparently, ACA requires return of overpayments by government payers within 60 days of the provider’s awareness that such an overpayment was received. Additionally, the lawsuit is seeking to apply the False Claims Act to this failure to refund. If it is successful, the organization in question could owe treble damages along with the overpayments! That could be lots of money. Large provider organizations are carefully watching this lawsuit as the outcome could have profound and expensive effects on the industry. It could also save us taxpayers lots of money.

Given the wide range of opinions on laws and what they really require of us that we hear every day, I wonder what motivates your organization to get things right. Is it the threat of a fine that could put you out of business? Is it a threat to your license that could keep you from practicing your profession? Is it simply that we owe it to our patients to protect their information? Do you really not worry about such things? What motivates you to meet the requirements of the law? How does that relate to how you provide care?

Please share your comments below.

Perspectives on Stress: Is it all bad?

941737_598275593529458_351690808_n[The following is a guest post by Jeremy Peres. Jeremy is an Applied Biopsychology doctoral student at the University of New Orleans studying stress physiology and emotions. He is also Kathy and Seth’s nephew.]


Hello, SOS readers.  Thanks, Kathy, for giving me the opportunity to write this guest blog post.

I’m writing about something people experience on probably a daily or weekly basis throughout much of their lives: stress. It has shown itself to be a rather hot topic in mental health and medical research and clinical practice over the past 50+ years. From a biological perspective, stress responses (e.g., “fight or flight” responses) typically involve several changes within the body such as increasing heart rate, blood pressure, and the release of the hormone cortisol. The advantage of having such a response that maximizes strength, speed, and awareness is easy to understand when picturing, for example, a human fighting (or more likely running for his life from) a bear that he or she has come across in the forest.

From the psychological side, stress is typically equated with difficult situations that involve discomfort, negative emotions, and anxiety. This makes sense when applied to people in modern society because, though the same physical changes happen as in a fight or flight response, our stress usually does not come from this rare run-in with a bear in the wild that lasts just a few minutes. Rather, modern people experience stress when navigating long work hours, relationship conflicts, financial struggles, etc. and on top of that also experience that same stress just from worrying about work, relationships, finances, etc. even when they are not actually happening.

Rather than escape the bear and move on, our bear prefers to morph into these different modern stressors and follow us around for long periods. Research has shown that this chronic nature of our stress literally makes us sick by weakening our immune system and increases the chances of developing serious conditions such as heart disease and cancer. For a great popular book about this research, check out Robert Sapolsky’s Why Zebras Don’t Get Ulcers.

That’s a lot of bad news about stress. However, as early as the 1970’s, researchers differentiated between distress and eustress which implies a positive perception, such as in being motivated to complete a goal or enjoyable challenge. Regardless, this positive side of stress is often overlooked in large part. In my own reading and conference attendance over the past few years, stress is almost universally presented with a negative connotation, referring solely to the distress side of things. Sometimes research even seems to oversimplify these naturally occurring biological processes (e.g., elevated heart rate) by labeling larger stress responses as being “maladaptive” even if they are not necessarily longer. Additionally, there have been several programs and articles with the phrase “killer stress” (a quick google search shows several examples) in them that, while often showing some great research, tend to be a little overly dramatic and heavily skewed towards the negative.

It is not all bad news though. For one, there are many well-researched ways to reduce stress including meditation, deep-breathing, and relaxation techniques such as progressive muscle relaxation. Secondly, over the past year, I’ve been happy to come across a few different instances showing that there may be some resurgent interest in clarifying that stress is not always a bad thing. This makes me happy because I’m of the opinion that promoting the alarmist “killer stress” viewpoint might have a damaging effect. It not only oversimplifies the biological impact but also promotes an overly negative perspective of a process that is natural and arguably beneficial . . . as long as there is some opportunity for rest and relaxation in between periods of stress or challenge.

This great TED talk by Health Psychologist Kelly McGonigal talks about how she has changed her mind about making stress the enemy. She cites research showing an association between people simply believing that stress is harmful for your health and increased mortality rates. She also cites research by Jeremy Jamieson and colleagues showing that a simple instruction to participants to reframe their body’s arousal during a stressful public speaking task (as being a beneficial and normal process) decreased negative emotions and increased cardiac efficiency. That is, people are better able to overcome the stressful task in a more positive way cognitively and physically. Another study from this group similarly showed that this simple reframing helps socially anxious participants show less anxiety and perform better during the public speaking task.

Another point that Jamieson made at the end of this Psychology Today article talks about the limitations of the typical stress-reduction approach: “Lots of the advice out there for anxious people focuses on promoting relaxation techniques (deep breathing, etc.). These calming techniques are helpful in situations that do not require peak performance, but when gearing up for a speaking engagement reframing how we think about stress may be a better strategy.” Much of this might seem like common sense to behavioral-health professionals, reframing anything in a positive way is good…so what?  I think the important thing here is to just remember that, in light of all the gloomy press that stress receives, there is also a brighter side. And that is important to remember.

In addition to the general point that stress isn’t always bad, I very much like this idea that reframing stress in a positive or adaptive way may be a better strategy for overcoming a challenge (when relaxing and decreasing your heart rate isn’t exactly helpful). I think this perspective might be particularly important in the coming years with the increasing popularity of health-tracking wearable devices such as the Jawbone UP and the Fitbit devices. These types of devices tend to track lots of interesting data about sleep patterns, diet, and “activity” (through movement and/or heart rate). Some devices are now even tracking heart rate, skin temperature, and perspiration, basically acting as simplified and portable biofeedback devices. With more people than ever potentially having access to information showing these markers of physiological stress, it might be more important than ever to educate people that stress is complicated and being “stressed” is not so bad as long as you make stress your friend and find some time to relax now and then.

Please enter your comments below.

ICD-10 Implementation Rule Announced . . . Again

As most of you are aware, Congress this year passed a law which prohibited the Centers for Medicare and Medicaid Services (CMS) from implementing the ICD-10 prior to October 1, 2015. On 7/4/2014, the Office of the Secretary of Health and Human Services (HHS) published a notice in the Federal Register changing the required implementation date from October 1, 2014 to October 1, 2015.

For many of you, this change is of minimal importance. If your software product is ready to go, as is SOS Office Manager, then so are you. For some of you, that is not the case.

Any behavioral health organization who does not have a clinician or a staff person trained to code using ICD-10 codes rather than ICD-9 codes, should begin to explore what education should occur prior to October 1, 2015. CMS has an entire portion of their web site devoted to information and tools that all organizations may use free of charge to prepare for ICD-10 implementation. There are resources including documents and videos and tools aimed at developing and implementing a plan of action. There are links to the General Equivalency Mappings (GEMs) for 2014 and 2015. There is every bit of information an organization could possibly need to make this transition.

Please don’t be caught off-guard. The new deadline is 14 months away. If your current staff are all trained and prepared, but half of them leave before October 2015, you will need to re-train. If you are now using DSM5 codes and do not understand the relationship between DSM and ICD10, you will need to clarify this information, for yourself and your staff.

Just subscribe to the ICD-10 info notices from CMS and you will be able to stay on top of any information and changes as they occur!

Teleheath, eHealth, and Outsourcing: Where are we going?

When the number of articles coming through my inbox converge on a topic, I usually decide it is time to write about it. Three articles about telehealth and e-health appeared today. Another dropped into my inbox at the beginning of July. What is this about and what does it have to do with behavioral health organizations and practices?

As you are undoubtedly aware, what happens in the broader healthcare community often follows in the behavioral health world. Sometimes behavioral health leads the way with innovations; at other times it merely follows. Telehealth is one arena where I think behavioral health has been in the vanguard.

I would like to start with three simple definitions:

  1. Telehealth is the use of electronic information and telecommunications technologies to support long-distance clinical health care, patient and professional health-related education, public health and health administration. (from
  2. eHealth (also written e-health) is a relatively recent term for healthcare practice supported by electronic processes and communication, dating back to at least 1999.[1] Usage of the term varies: some would argue it is interchangeable with health informatics with a broad definition covering electronic/digital processes in health[2] while others use it in the narrower sense of healthcare practice using the Internet. (from Wikipedia)
  3. In business, outsourcing is the contracting out of a business process to a third-party. The term “outsourcing” became popular in the United States near the turn of the 21st century. . . Outsourcing includes both foreign and domestic contracting,[3] and sometimes includes offshoring or relocating a business function to another country.[4] Financial savings from lower international labor rates is a big motivation for outsourcing/offshoring. (from Wikipedia)


I have included these three terms together because outsourcing often goes with the capability of using electronic devices and various telecommunications methods. Certainly, most of us have some experience of receiving customer service assistance from somewhere half way around the world from our homes. I am wondering if the same will be true as we move toward increasing the use of telehealth and ehealth methods in our healthcare system.

Two of the three articles I saw today related to general healthcare. FierceHealthIT newsletter contained two articles about the potential benefits of electronic doctor visits and telemedicine. With pressure on insurance payers and employers to provide healthcare services at lower cost than currently, we can expect all sorts of innovations. The capability of ‘seeing’ patients remotely is one of those possible innovations.

But what about behavioral health? And what does outsourcing have to do with any of this?

In yesterday’s Open Minds daily briefing, Monica Oss discussed telehealth and how it is beginning to spread in the behavioral health world. With Medicare now willing to pay for telehealth services that meet certain criteria, this possibility has become more likely. In behavioral health, telephone contact with clients has been a long-time staple in helping clients remain stable. Now that Skype and other visual telecommunications capabilities exist, a whole new industry has developed . . . and many existing organizations have added ways to include remote psychotherapy and follow-up sessions in the repertoire of their organizations. SAMHSA and HRSA have pioneered projects and pilot programs to foster such development, especially into rural communities.

Where there is remote capability to provide services, outsourcing is not far behind. If it can be done more cheaply by using resources outside the U.S., businesses will find ways to do it. While licensing and practice laws may currently stand in the way of too much outsourcing, you can be sure that it will come.

How does any of this affect your behavioral health organization? Our experience with our customers suggests that change occurs very slowly within their organizations.

As those of us who are more senior slow down our participation and eventually retire, resistance to paradigmatic change reduces. As younger people who are perfectly comfortable with all things electronic move into the professional arena, newer technologies are successfully introduced. Where is your organization in this process? Do you see groundbreaking changes ready to happen? Or is your organization one of those holding onto the older ways at all costs?

Please share your opinions and experience with telehealth services and where you see it going. And what about outsourcing? Just click in the Comment box below to share your thinking.

Brain Training: What is it and does it work?

In July, I spent ten days at an ashram taking an immersion program in preparation for yoga teacher training. In this particular tradition, the teacher is provided with a script that must be memorized prior to certification. The program is structured to maximize learning the script, but I have found myself stressed to my utmost in my efforts to memorize this sequence of 29 postures and the two paragraphs of instructions that go with each one.

Memorization has never been my favorite type of learning. It is good that I did not need to memorize too much to complete my Ph.D. Comprehension is my strong suit. I am great with concepts…learning and expressing them. I am not so good with word-for-word memorization. As a student, I did this by repetition and rehearsal. I did oratory and debate in high school and, with lots of work, I was able to memorize my speeches when appropriate. Besides, I had written them, so they were my thoughts and words. Memorizing my lines in a play was always harder. Memorizing lists of terms and their definitions was my least favorite, but usually successfully done task.

Then my brain aged. Thank goodness for that; it certainly beats the alternative. However, the aging of my brain has manifested itself most obviously in struggles with remembering things. I use a reminder app on my telephone for day-to-day things, and it is very effective. I use a calendar with alarms for appointments. I do not usually miss things I have scheduled or reminded myself to do. But memorizing a large number of someone else’s words is proving to be very difficult for me.

In June, Monica Oss of Open Minds wrote an article summarizing some of the presentations and discussion at their June 2014 conference Technology for Better Brains: The Rise of New Treatments Based on Brain Science Innovation. The presenters were from Neuronetics, providers of Neurostar TMS Therapy® (Transcranial Magnetic Stimulation) and the Center for Life Management, an organization that uses this system; Brain Resources, Inc., a company that markets assessments and brain training tools; and Posit Science, the developers of brainHQ. Obviously, these individuals are all selling something, so I would want to know a bit more about the science before I buy.

In February, we had a visitor who had a concussion last Fall. She is a physician in her late 50’s who was told to rest her brain entirely to allow it to heal and recover. After a couple of months of rest, she was allowed to begin some brain rehabilitation. Now, she does brain exercises daily at a website called She has found them to be most helpful. I take this first hand experience seriously coming from a physician who does not have a vested interest in the process.

I have not yet signed up for their program or any of the others, but I am very curious. I wonder what experience and information any of you have about these systems. I know we have neuropsychologists who read this blog. What is your take on brain training? Does the science support the sales? My ailing memory wants to know!

Please share any information or experience you might have with any brain training systems or with Transcranial Magnetic Stimulation. Just enter your comments below.


SAMHSA Listening Session Important for SA Providers

The Substance Abuse and Mental Health Services Administration (SAMHSA) will be holding an all-day listening session on June 11, 2014. During that session, they will hear input from stakeholders about possible changes to the regulations that govern 42 CFR Part 2 controlled organizations. If your organization provides services to chemically dependent and recovering individuals, it might be useful for you to listen in on this session.

Event Details

The Substance Abuse and Mental Health Services Administration (SAMHSA) announces that it will hold a public listening session to solicit information concerning the Confidentiality of Alcohol and Drug Abuse Patient Records Regulation, 42 CFR Part 2. These sessions will be held in Rockville, MD to obtain direct input from stakeholders on updating the regulations. The scheduled listening session provides an opportunity for SAMHSA to seek public input on potential changes to the regulations.

The session is open to the public and the entire day’s proceedings will be webcast, recorded, and made publicly available. Interested parties may participate in person or via webcast. Capacity is limited and registration is required. Registration will be open until we meet maximum capacity. The forum will begin with opening remarks from the SAMHSA official charged with moderating the session. The session location is accessible to persons with disabilities.


Do register if you have concern about confidentiality and 42 CFR Part 2, or just want to learn more.

Vacation Time: Storm before the calm

It is time for a vacation. I feel like I have been racing around for the past year. I am not sure why things got even more hectic once I no longer had caregiver responsibilities, but they did. Perhaps I have spent the year trying to catch up and get back to being productive. Now I am beat!

I have never learned the skill of getting away for vacation without working lots more before and after the trip. Especially as I get older, I think about things that really should be taken care of before I leave…just in case. Perhaps some of you have suggestions for me. I would love to be able to get away without so much stress! Please share your ideas. My mental health is at stake.

In any case, this blog will be on hiatus for the rest of May while I try to reinvigorate myself. Please enter your comments below.


Single Payer Systems: U.S. Medicare and Canadian Medicare

I don’t know about you, but I often read a brief article that draws upon another. Sometimes those secondary articles are excellent in their own right. Sometimes, going to the original is the only way to actually get the original author’s slant.

Wendell Potter is a former Cigna executive turned whistle-blower on the private insurance industry in general and HMO’s in particular. In his position as Vice President of Corporate Communications, he participated in what he now considers disinformation about healthcare single payer systems and the U.S. insurance industry. He now works for the Center for Public Integrity, speaking and writing extensively.

An article Potter recently wrote, The Canadian health care system I disparaged, was cited in FierceHealthPayer, a newsletter I read regularly. Single-payer traits worth emulating found two such qualities the Canadian system would benefit from:

  1. Make their system more consistent across provinces, as does the U.S. Medicare system. Currently, Canadian Medicare operates like U.S. Medicaid in that the province has great discretion about the benefits provided, just as the states do with Medicaid.
  2. Provide prescription medication coverage like Medicare Part D. At present, Canadians must purchase separate insurance if they do not want to pay the entire cost of prescriptions out of pocket.

The Canadian system covers everyone; U.S. Medicare only covers those 65 and over, and some disabled individuals. In his article, Mr. Potter apologized to Canadians for his years of disparagement of their system. He noted that he and other insurance industry representatives routinely presented exceptional cases as the norm, denigrating the Canadian system. In his travels and speaking in Canada, he “didn’t encounter a single Canadian who didn’t talk about their Medicare program with pride”.

Over the course of a two-decade career as a health insurance executive, I spent hours and hours implementing my industry’s ongoing propaganda campaign to mislead people about the Canadian health care system. We spread horror stories about “rationed care” and long waiting times for medically necessary care. Our anecdotes were not at all representative of most Canadians’ experiences, but we spent millions of dollars to persuade Americans that they were.

FierceHealthPayer indicates that

Experts from Canada, Denmark and other countries have maintained that a U.S. Medicare-for-all system would alleviate high administrative cost. In Canada, administrative costs average 1.3 percent, well below the average 31 percent for the U.S. healthcare system, Danielle Martin, M.D., vice president of medical affairs and health system solutions at Women’s College Hospital in Toronto, Canada, told the Subcommittee on Primary Health and Aging last month. Martin also addressed U.S. concerns about socialized medicine, explaining that in Canada, insurance is public and hospitals and providers are private entities.

How would your organization function differently if there were a single payer for all services, covering your behavioral health services at the same level they are covered now (averaging across your current payers)? Would such a system work better or worse for you? I know what my answers are to those questions. I wonder what yours are. Please enter your comments below.


Anxiety, Anticipation, Excitement: Prelude to . . .

Have you ever found yourself anxious prior to an event to which you have been looking forward? Do excitement and anticipation blend into anxiety for you? Or vice versa? Can you shape anxiety into a more positive anticipation and even excitement?

I find myself approaching a vacation that I have been planning and looking forward to for months. We are doing the trip as I would prefer…without bicycles. We are going to the cities I have wanted to visit and engaging in many of the activities I choose.

That is not to say that the inclinations of those with whom I am traveling have been ignored. They would prefer not to be in museums all the time, and not to be scheduled every moment of every day. There are so many things that I want to do and see that I could happily go from one to the next to the next if I were on my own (and if my feet held out). Since I am with others, I have scheduled us for things that require it and generated possibilities for the rest of the time.

This has caused lots of anxiety for me. I am a people-pleaser in my core makeup. I work to assert my needs and desires, but I also want those around me to be happy. Needless to say, this causes anxiety, ambivalence, frustration. The planning process has been a stressful one.

I am always fascinated by the internal experience of a set of emotions. Like many people, I have been very anxious since I was a child. Research on DSM diagnostic categories indicates that Anxiety is easily the most common of emotional difficulties experienced by the U.S. population. I fit right in there.

As a child and teenager, I just pushed through the anxiety in order to accomplish the goals I had set for myself. As a young woman, I learned that I could reinterpret my anxiety, choosing to see the physical agitation, increased heart rate, sleeplessness and other physiological signs of arousal as excitement, thereby giving it a positive meaning rather than the negative connotations of anxiety.

As an older adult, I find it harder to manage the experience of anxiety. My yoga practice helps me feel better at the time, but I have not been successful at carrying the relaxation and positive mental state over into the rest of my day. The agitation causes stress in my relationships. I have a harder time not snapping at those closest to me. Sleep disturbance makes that even worse.

I certainly need to get this in check or I risk messing up my enjoyment of my vacation!

How do you deal with anxiety? Is medication your route? Or meditation? Go for a run? Do you have methods that I might learn…quick? Please share your comments below.

Turbulence Ahead in the Behavioral Health Marketplace

I recently found myself thinking . . . again . . . about changes in the behavioral healthcare marketplace and wondering how our customers are doing. A couple of weeks ago, Monica Oss of Open Minds wrote about dramatic changes in reimbursement methods in the public behavioral health sector in New Jersey and how organizations there are adapting and positioning themselves. We have been watching our larger customers go through multiple changes in how they are structured and how they serve clients over the past five or more years; simultaneously, most of our smaller, private practitioners seem to have made few changes in how they provide services.

Ms. Oss lays out some of the payment issues very clearly:

The reasons for the shift away from fee-for-service (FFS) reimbursement are many and the emerging value-based payment and pay-for-performance (P4P) payment models are many and complex. But the challenges for executive teams, regardless of the emerging payment model in their market, fall in two categories — market positioning for future sustainability and competitive organizational performance.


At the front end, a focus on markets and business approaches to practice turns many small providers off. They do not want to recognize or address the fact that they are running a business and that doing so takes thought and consideration about their market and about how they measure up compared to others who provide the same services. They see themselves as helpers, not as business persons. On the other hand, failure to be informed about transformations that are rapidly occurring and where they will fit into the altered professional environment, will likely leave them stranded in a practice that is slowly dying.

One of the most profound of the emerging changes is the integration of behavioral health and physical health services into one setting.

Since my own training is as a psychologist, I decided to take a quick look at what American Psychological Association (APA) is promoting to its members to help them prepare for and address the dramatic modifications that are likely coming in mental health service delivery. At first glance, I was pleased to see that the organization has developed a Center for Psychology and Health. I do recall that this was a major push of my friend and colleague Suzanne B. Johnson, Ph.D. when she was APA President. But it took some patience and searching to find any meaningful information.

I visited the APA website, but had to read the small print three-quarters of the way down the page to get to the first mention of the Center for Psychology and Health. Once I navigated to that page, the first thing I saw there was ‘Health Psychology CE Programs.’ I had to push past my hesitation (because I am not a ‘health psychologist’); I read around the rest of the page and found a few things that looked hopeful, but only found those under the headers ‘For Students and Educators’ and ‘For the Public.’ An article entitled Moving into Primary Care was hidden behind a link named ‘Five ways to collaborate with physicians’ in the ‘For the Psychologist’ section. On the other hand, an article named ‘What is Integrated Care?’ was listed under ‘For the Public.’ The information would be quite appropriate for professionals who are wanting to have an understanding of just what this integration of mental health care and general health care is really all about.

When I went to the website of the APA Practice Organization, I was more disappointed. I found no headers about integrated care or pay for performance. When I used the search box for those terms, I did find some articles. Unfortunately, only one was recent (2013). The next most recent article was written in 2009.

The website of the National Council, on the other hand, has easily-found, current information about their Center for Integrated Health Solutions, a joint project with SAMHSA. Clearly, the public behavioral health community is rapidly moving in this direction.

I am afraid that psychologists and other private practice mental health professionals might be having a difficult time figuring our where they might fit into a different kind of marketplace, or even that a different kind of marketplace is on its way, because their professional associations are doing a terrible job of helping them conceptualize and create the alternative practice structures that will be needed to survive in this turbulent arena.

What is your organization doing to redefine, re-position and reinvent your practice to assure that you will thrive well into the future? Please share your comments below.

Encryption of Backups: Must I?

A few weeks ago, Seth Krieger, President of SOS and our own HIPAA Privacy Officer, was asked a question about encryption and backups. Since we are regularly faced with behavioral health organization customers who have no backups and many others who have questions about HIPAA, I thought you might be interested in this brief Q & A.

Question: “Does HIPAA require local backups to also be encrypted?”


There are no HIPAA rules that explicitly require encryption anywhere, but there certainly are severe penalties for failure to secure data, and a provision for a safe harbor if the data is encrypted. That is, if media containing protected health information (PHI) should be stolen, you are in a world of hurt. There can be fines; required publication of the breach in the local newspaper (if the breach includes over 500 patients); mitigation of potential identity theft by purchasing identity theft protection policies for all patients; impact on your reputation in the community; potential civil suits and criminal prosecution; etc.

On the other hand, if the data you lose is encrypted, HHS does not regard it as a breach. The rule explicitly states that the loss of encrypted data does not constitute a breach, so you are not required to report it, or to notify your patients in any form.

That, friends, is a giant carrot, dipped in chocolate!

Let’s review: If I don’t encrypt all my media containing PHI (including the hard drives in my computers, flash drives, and backups), I could face major, major losses, starting with some pretty severe fines but potentially so damaging that the practice might not survive. Alternatively, I could follow some easy encryption steps and be the proud owner of a cloak of invulnerability (where data breaches are concerned). Tough choice, huh?

Because backup media are, or should be rotated to an off-site location, they could be lost or stolen much more easily than media inside of servers and REALLY should be very high on the encryption list. The easiest way to go is just to use backup software that provides an encryption option. Most every commercial backup software has such an option. All you have to do is to check the box and type in a password. In most every case, that choice becomes part of the configuration and will be automatic for every future backup you do with that software and backup configuration. Easy!

That is not to say that a stationary drive need not be encrypted — it absolutely does. The low hanging fruit here, however, is any media that travels. Every phone, laptop, tablet and flash drive should be encrypted if there is any chance at all that it could contain PHI. Think in terms of patient telephone lists, letters, reports, acknowledgements to referral sources, practice management software, etc. Electronic Medical Records are not the only place you might have PHI that you are required to keep secure and private.

For more thoughts and advice regarding encryption, please see this earlier post:

Get Out of HIPAA Jail Free

Here are some others on related subjects:

The Devil and Database Encryption

Mobile Data Security a Big Concern

Please share how you have used encryption to secure your cloak of invulnerability!

Congress Throws a monkey wrench into ICD-10 Implementation

I don’t know about you, but I am tired. I am tired of being told U.S. healthcare costs too much for too little, but the powers-that-be not having the character to do what is necessary to change it. I am tired of the Affordable Care Act being blamed for all the faults in our health system. I am tired of steps being organized and taken by an entire industry to move toward modernization only to have a group of power-mongers throw the work out. I am tired of politics being played with our healthcare system.

Nothing I have read has any real explanation for why Congress has delayed implementation of the ICD-10. One article suggested that some groups of physicians were rewarded for something that is not at all clear. Since many other physician and industry groups are strongly opposed to such a delay, it is difficult to see what the gain is. Most have no real idea why a delay in ICD-10 implementation was added last week to yet another temporary fix to the Medicare Sustainable Growth Rate (SGR) fix, referred to by the media as the ‘doc fix’.

In fact, this decision throws the work of the many players into question. CMS has said they will step back. study the rules, then decide what to do. But what about those in private industry. The insurance carriers and clearinghouses, the hospitals and physician practices, software vendors and software users, those training billing coders and those doing the billing…all who have been working hard to be ready to start using ICD-10 diagnosis and procedure codes on October 1, 2014. It might be costly to make this switch, but dragging it out for another year has just increased the cost. and those of us who are paying that cost are not getting any help from our elected representatives.

I, for one, would vote in a heartbeat for a single-issue candidate whose purpose was a single-payer healthcare system…one payer, one set of rules, one set of expectations to meet!

And, oh yes, you must use the new CMS 1500 claim form, version 02.12, to file your claims. Just be sure to keep using the ICD-9 codes on the claims.


Simply Put: Simplify

A bit over a year ago, a couple of weeks after the death of my mother, I received an email from a blog entitled ‘Becoming Minimalist.’ I don’t know why I received it; I do not remember expressing interest in the topic of removing possessions as the driving force in my life. I like to think that someone who knows me sent it to me because they knew I need it.

I read the post and created a folder called ‘Simplify’ to save the ones I liked. I have not even developed the habit of reading the posts when they arrive in my mailbox each week, but I know that I have that as a goal and have them there whenever I am ready to dig in. Just seeing the email arrive reminds me that I also have as a goal to simplify my life.

When I received today’s post, I was reminded again of something I learned a long time ago but seem to need regular lessons in. The lifestyle I live often gets in the way of the lifestyle I think I want to live. As I once learned in a Twelve Step program, I behave as if I am a human doing rather than a human being. Part of the reason for that is that I have placed so much importance on success in my job and the ownership of nice things. I think I must be constantly doing in order to maintain what I have and get more of the same. That is not really all I want in life, but it is how I behave.

When I was a child, I learned that developing different patterns of behavior took a constant focus on that new pattern and practice of it. As a psychologist, I taught clients how to do that. In my daily life, I forget that over and over again. It is as if I never learned how to change one habit and create a new one. Had I read the post I received last Friday, I would have been reminded again that there is a science to change and we can all accomplish it.

Part of the reason for my ongoing re-learning of these lessons is that I usually focus outside myself rather than inside. While I have always experienced an internal locus of control (for all you psychology-types), I have for some reason spent my energy on behaving to a certain effect in the world rather than on regularly re-confirming a commitment to a certain way of being and developing the patterns of behavior which accomplish that.

I did better when I was a therapist; helping others learn to decide what they want to be and to behave in that direction helped me do the same for myself.  What do you do; what circumstances do you create that allow you to become more of the person you want to be each day? Your comments and suggestions are welcome.


Performance-Based Compensation: What is your plan?

If you are a solo provider of mental health services in private practice, you entire income is based on your performance as a psychotherapist or diagnostician or prescriber. There is really nothing between you and your patients. You see them; they are satisfied and continue coming to see you, or they are not and do not return. That is ‘performance based compensation’ of the most basic sort. I have often wondered precisely what others mean by that term.

Earlier this week, I read an article by Sarah Threnhauser of Open Minds that very much enlightened me. Making Performance-Based Comp Plans Work is an excellent look at the compensation plan of Manatee Glens, a specialty hospital and outpatient program in Bradenton, Florida. The article discusses the criteria they use for measuring performance as well as the steps they follow to measure each clinician’s functioning relative to the criteria. One of their measures is number of client no-shows; another is clinician completion of concurrent documentation with the client. Surpassing the criteria results in additional pay to the clinician.

Does your organization use any sort of performance-based compensation? How have you made it fit the personality and structure of your practice or agency? What kinds of functions do you measure? What criteria do you use?

Please share your comments and responses in the comment section below. We would love to have our discussion here on this blog site!


Government Entities are not sheltered from HIPAA requirements

For the first time, the Office of Civil Rights (OCR) has levied a fine against a government entity for a possible HIPAA breach.

Skagit County, WA, a small county (118,000) in the northwest part of the state, was fined $215,000 for its failure to protect patient information controlled by the county Health Department. Even after a data breach in 2011 that the county reported to OCR, the county failed to implement adequate policies and procedures to prevent future breaches.

In its report about this incident, FierceHealthIT also cited the compromise of information for 169,000 clients served by the Los Angeles County Department of Health Services. A third party billing vendor, Sutherland Healthcare Solutions, was the victim of theft of unencrypted computers containing the not-so-protected PHI of these clients.

If you think that being small or a government entity or a not-for-profit might protect you from being penalized for the exposure of the data of your clients, best that you think again. We are all responsible for assuring that PHI is protected, whether the people involved are our own clients, or in the case of SOS, the clients of our customers who are Covered Entities. This is not an area in which you should skimp on effort made to protect information.

Please share with us and your colleagues some of the steps you have taken to assure the protection of the PHI of your clients. Do you feel that your written policies and implemented procedures are known and understood by your employees? Do they take these procedures seriously? What do you do when you learn that they are not practicing what they have been taught? When was the last time you had training on HIPAA issues? You do have training, right?

Please comment below.

Sharing Mental Health Information: HIPAA Privacy Rule Guidance

Those of us trained as providers of mental health services have been indoctrinated about the need to maintain the privacy of our patients. Unfortunately, changes in law and in rules mean that the way in which we were trained may no longer fit the realities on the ground. It is essential that you stay up-to-date on the requirements of your state (especially if those requirements are more stringent than HIPAA) and on the requirements of HIPAA for protecting the privacy of your patients.

The Office of Civil Rights (OCR) and Health and Human Services (HHS) has issued Guidance regarding the HIPAA Privacy Rule and Mental Health information. This is information you will want to read. The Department specifically addressed issues that are directly pertinent to behavioral health providers of every ilk.

In this guidance, we address some of the more frequently asked questions about when it is appropriate under the Privacy Rule for a health care provider to share the protected health information of a patient who is being treated for a mental health condition. We clarify when HIPAA permits health care providers to:

  • Communicate with a patient’s family members, friends, or others involved in the patient’s care;
  • Communicate with family members when the patient is an adult;
  • Communicate with the parent of a patient who is a minor;
  • Consider the patient’s capacity to agree or object to the sharing of their information;
  • Involve a patient’s family members, friends, or others in dealing with patient failures to adhere to medication or other therapy;
  • Listen to family members about their loved ones receiving mental health treatment;
  • Communicate with family member, law enforcement, or others when the patient presents a serious and imminent threat of harm to self or others; and
  • Communicate to law enforcement about the release of a patient brought in for an emergency psychiatric hold.

The Question & Answer format is a helpful way to quickly review the relevant information. You might take particular note of the section on the protection of psychotherapy notes. Some providers have chosen to believe that any note they write about the psychotherapy provided is protected and that they do not have to release such information when it is requested. This Guidance spells out what this does NOT mean. In other words, it specifies all the information that is not a ‘psychotherapy note’ for the purposes of the rule. You might be surprised to find, for instance, that symptoms, prognosis and progress to date cannot be considered part of the psychotherapy note.

Psychotherapy notes do not include any information about medication prescription and monitoring, counseling session start and stop times, the modalities and frequencies of treatment furnished, or results of clinical tests; nor do they include summaries of diagnosis, functional status, treatment plan, symptoms, prognosis, and progress to date. Psychotherapy notes also do not include any information that is maintained in a patient’s medical record.

Reading this new Guidance is the easiest way for you to quickly review just what your responsibilities are under HIPAA and HITECH for maintaining patient privacy. Do take a look when you get a chance, and feel free to share your comments below. 

Smartphone Apps for Behavioral Health: Are you connected?

I read a newsletter yesterday that got me thinking. Mercom Market Intelligence Report on Healthcare IT for January 27, 2014 talked about the boom in patient at-home monitoring. I wondered what kind of apps might be around for behavioral health and whether they might be useful as supports in therapy.

When I worked as a psychologist, I practiced Cognitive Behavioral Therapy (CBT), as taught by Aaron Beck and his colleagues. The biggest struggle my patients had was to remember to do their homework, self-monitoring that almost always involved daily recording of activities, thoughts and reactions. I always provided them with a pocket-sized notebook to record things (this was 20 years ago, after all). Now, I would be more likely to find a higher tech way to assist them.

And so I began my quick review. I started with a Google search for ‘behavioral health self monitoring apps.’ I was somewhat surprised at the pages of links and articles that appeared. This has clearly become a hot area. Some of the apps are aimed at young people and children; many are aimed at adults.

I have not reviewed any of these apps. I am going to give you lots of articles and links so you can explore for yourself.

There are some more formal articles and research reports on the subject.

The American Psychological Association is offering some continuing education on the subject.

And multiple organizations list smart phone apps among a variety of self-help resources.

I was surprised at the broad array of resources available. Certainly each clinician will need to review these and determine if there any that fit well with their practice and modalities and might be beneficial to their clients. Perhaps some of you have already done that.

Please share any smartphone apps you use in your practice or organization to facilitate therapy progress. We would love to know what you have found useful.