Licensed Mental Health Counselors and the Military Health System

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1 Licensed Mental Health Counselors and the Military Health System LT Rick Schobitz, Ph.D., USPHS Deputy Director, Behavioral Medicine Division Office of the Chief Medical Officer TRICARE Management Activity

2 Overview The Committee s Charge National Defense Authorization Act for Fiscal Year 2008 Issues for Review The Military Health System (MHS) Introduction Characteristics of the population we serve TRICARE Benefit Additional support available from the DoD 2

3 National Defense Authorization Act for Fiscal Year 2008 (Public Law ) Requires the Secretary of Defense to conduct an independent study of the credentials, preparation, and training of individuals practicing as licensed mental health counselors (LMHCs) make recommendations with respect to the independent practice of LMHCs under the TRICARE program 3

4 The Population We Serve While most of our population is relatively healthy, a number of complex conditions are faced by military mental health providers Active duty combat veterans Increased risk for PTSD, depression or anxiety PTSD prevalence as high as 19% (more than five firefights) Hoge et al, NEJM, 2004 Deployment can result in stress for the entire family A significant proportion of TRICARE mental health users are spouses of active duty members or retirees with adult children serving in active duty status Meredith et al, RAND,

5 The Population We Serve Other conditions that providers may see in our population include: Alcohol and Drug Abuse Physical Injuries Traumatic Brain Injury (TBI) These conditions are often co-morbid Complex assessment is often needed to determine symptom etiology Ex. Soldier complains of problems with concentration. Mental health provider may have to differentiate between psychological causes such as PTSD and major depression, physical injuries such as TBI, or both 5

6 The Population We serve Complex treatment planning is necessitated by the interaction of psychological and physical illnesses Multidisciplinary treatment teams Referrals for blast specific assessments such as need to refer for assessment for tympanic membrane injury with suspected cases of TBI Providers in the MHS must have a strong biopsychosocial foundation and ability to work with multidisciplinary medical teams to treat the military population 6

7 Critical Issues for IOM Review Do state standards ensure that an LMHC can independently diagnose, treat, and appropriately refer patients with the complex psychological and physical conditions that military service members face? Is there consistency among state standards regarding the education, training, and clinical experience required for licensure as an LMHC? Are the education, training, and experience requirements for licensure as an LMHC in some states consistent with independent practice in the TRICARE program while the requirements of other states not? If so, which states require the education, training, and experience that the committee believes prepares an LMHC for independent practice in the TRICARE system? 7

8 The Military Health System and the TRICARE Benefit

9 The Military Health System: Who We Are TRICARE: A health care plan using military health care as the main delivery system Augmented by a civilian network of providers and facilities Serving members of the uniformed services, their families, retired military, and their families worldwide 9.2 million beneficiaries 1.4 million active duty uniformed service members Military Health System Mission: To provide optimal health services in support of our nation s military mission anytime, anywhere Separate system from the VA, but coordination of care continues to develop 9

10 A Week in the MHS 19,600 Inpatient admissions 14,600 purchased care 5,000 direct care system 642,400 Outpatient visits Direct care system 2,220,000 Prescriptions filled All points of service 2,100 Births 1,100 purchased care 1,000 direct care system 102,900 Dental seatings Direct care system 3,500,000 Claims processed 65 Medical centers / hospitals 412 Medical clinics 414 Dental clinics 132,700 MHS personnel 86,400 military 46,300 civilian $754,000,000 Weekly bill 10

11 Three managed care support contractors in the US North: Health Net South: Humana West: Tri-West Regional contractors work with TRICARE regional offices (TROs) under TMA guidance Regional contractor responsibilities include: Establishment of provider networks Operation of TRICARE service centers Administrative support TRICARE The Military Health System 11

12 TRICARE Benefit Under the Basic Program TRICARE covers medically necessary and appropriate treatment/procedures/devices/drugs, some preventive services, and some well child care. As a general rule, medically necessary care that is proven safe and effective and considered standard of care in the United States will be a TRICARE benefit unless it is expressly prohibited by law or regulation. 12

13 TRICARE Mental Health Benefit Constraints TRICARE coverage is constrained by both statute and regulation Title 10, U.S. Code: Inpatient mental health services may not exceed: 30 days in any year (patient 19 years of age or older) 45 days in any year (patient under 19 years of age) 150 days in any year (residential treatment center) Provision for waiver of these limits Requirement for preauthorization of inpatient mental health services 13

14 TRICARE Mental Health Benefit Constraints TRICARE coverage is constrained by both statute and regulation The Code of Federal Regulations: Authorized providers Certification requirements for PHPs, SUDRFs, RTCs Mandatory preauthorization / approval of continuation of inpatient services for mental health admissions Mandatory preadmission authorization for all PHP admissions 14

15 TRICARE Mental Health Benefit Outpatient Mental Health Outpatient mental health services are covered when the following conditions are met: Services are medically or psychologically necessary for the treatment of mental disorders Services are rendered by an authorized provider Mental disorder is listed in DSM-IV-TR and is of a severity not only to cause the patient distress but also to interfere with the patient s ability to carry out usual activities Coverage includes: Individual psychotherapy, group therapy, crisis intervention, collateral visits, family therapy and psychoanalysis, psychological testing, medication management, etc. 15

16 TRICARE Mental Health Benefit Authorized Individual Providers Without physician referral and oversight: Psychiatrists, clinical psychologists, clinical social workers, psychiatric nurse specialists, and marriage and family therapists may render behavioral health care services without physician referral and oversight. With physician referral and oversight: Licensed mental health counselors, licensed professional counselors, and pastoral counselors may render behavioral health care services, but a letter of referral and oversight is required prior to the initial evaluation. This letter of referral must be submitted by a physician (MD or DO). This is a current requirement of the Code of Federal Regulations, 32CFR199.6(b)(3)(iv)(B) and 32CFR199.6(b)(3)(iv)(C) 16

17 Additional Support offered by the DoD Outside of the Military Health System Military One Source Offers counseling free of charge to active duty, reserve, and National Guard service members and their families. These services are provided by a nationwide network of mental health providers who are not part of the military healthcare system and who do not report to military commanders. Military Family Life Consultants Licensed, experienced mental health professionals who provide confidential counseling outside of the health care system with no documentation in the medical record. The goal is to remove potential barriers to treatment. DCoE Outreach Center 24/7 behavioral health support on the range of psychological health (PH) and traumatic brain injury (TBI) issues. 17

18 Questions?

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