September 6, 2021

No matter what one’s position about abortion might be, the Texas abortion law, SB 8, that became operational on September 1st must necessarily raise grave concerns. This law, prohibiting abortions as early as six weeks after conception, not only denies women in Texas their constitutional right to health care, but criminalizes the participation of anyone who “aids and abets” a woman seeking an abortion. (To read the full text of SB 8, go to https://capitol.texas.gov/tlodocs/87R/billtext/html/SB00008E.htm)

SB 8 poses an immediate threat to Texas LCSWs. Using the consulting room to help clients work through the often traumatic decision to abort may now be seen as “aiding and abetting” in Texas. Texas law is indirectly telling us that LCSWs can no longer provide a compassionate safe place for our patients to discuss difficult choices when an unwanted pregnancy occurs (no exceptions for rape or incest) without risking a $10,000 fine and attorney’s fees.

Limiting what can be talked about in the therapy session undermines our ethical standards and the confidentiality we guarantee, but there is another element of this new law that is even more chilling: enforcement of this new law is placed in the hands of private citizens, incentivizing a ‘bounty-hunter’ approach designed to intimidate. Further, a spouse or family member who perceives an LCSW as supporting an abortion could report the clinician to authorities.

Purposely drafted to make it difficult to challenge in court, SB 8 carries the stench of Jim Crow, disproportionately impacting people of color, people with low-income, and other historically marginalized communities. Nonetheless, legislatures in several other states are already drafting copycat legislation.

The disappointing refusal of the US Supreme Court in a 5-4 decision to consider the Texas law - with vigorous dissent from Chief Justice Roberts and Justices Sotomayor, Kagan, and Breyer - leaves the law in place for now. However, some of the organizations actively fighting this blatantly unconstitutional law include the Lilith Fund, Whole Woman's Health Alliance, Inc., Texas Equal Access Fund, Jane's Due Process, Clinic Access Support Network, Support Your Sistah at the Afiya Center, West Fund, Fund Texas Choice, Frontera Fund, and The Bridge Collective, and the ACLU. New challenges have already been filed.

CSWA supports all efforts to stop Texas from interfering in the work of clinical social workers, and will be working with our Texan colleagues who are clearly at risk if they treat women seeking abortions. We are gathering information about the protection that may be available through malpractice insurance and other potential resources, if indeed other states follow the Texas lead. We urge members to consider signing the petition prepared by Texas social worker Dr Monica Faulkner, PhD, LMSW, at https://www.change.org/StandWithSocialWorkers, and to pay close attention to what is happening in your local state legislatures.

August 27, 2021

As you know, each August CMS puts out changes to the rules that govern the Physician Fee Schedule (PFS). These changes affect our practices and CSWA sends comments on the rules, which go into effect the following year.

Below please find the comments which CSWA has sent on the PFS 2022, a 1747-page document. CSWA chose three areas for comment, Mental Health Disparities, Telemental Health Coverage, and Telemental Health Parity in reimbursement. CSWA encourages all members to send their individual comments on any or all of these areas. CMS is asking that members not send a standard message. Use any of the language in the CSWA comments for your own comments. Send them by September 13, 2021, to https://www.federalregister.gov/documents/2021/07/23/2021-14973/medicare-program-cy-2022-payment-policies-under-the-physician-fee-schedule-and-other-changes-to-part.

As always, let me know when you have sent your comments and send a copy. Thanks for your help.

- Laura W. Groshong, LICSW, CSWA Director of Policy and Practice

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August 27, 2021

Centers for Medicare and Medicaid Services, Department of Health and Human Services

RE: Comment on Physician Fee Schedule 2022

https://www.federalregister.gov/documents/2021/07/23/2021-14973/medicare-program-cy-2022-payment-policies-under-the-physician-fee-schedule-and-other-changes-to-part

The Clinical Social Work Association (CSWA) is pleased to have the opportunity to submit comments on the proposed Physician Fee Schedule for 2022 (PFS2022). We also want to take this opportunity to thank CMS for covering mental health treatment provided through videoconferencing and audio-only delivery during this Public Health Emergency (PHE).

We will be commenting on three major areas of the bill which are of particular interest to Licensed Clinical Social Workers (LCSWs). These areas are 1) addressing mental health disparities; 2) telemental health continuation after the Public Health Emergency; and 3) reimbursement parity between in-person mental health treatment and telemental health treatment.

Mental Health Disparities

The disparities between mental health access, treatment, and outcomes for white populations as compared to Black, Indigenous, and People of Color (BIPOC), have been well-documented and it is past time to address the root causes. CSWA is pleased to see the request in the PFS2022 for comment on p. 434: “Solicit comments on addressing health disparities and promoting health equity.”

Health disparities are costly: approximately 30% of direct medical costs for African Americans, Hispanics and Asian Americans are excess costs due to these health inequities, and the economy loses an estimated $309 billion per year due to the direct and indirect costs of disparities. (Nov. 2012, Henry J Kaiser Family Foundation)

A major root cause driving these inequities lies in Social Determinants of Health (SDOH). According to the peer reviewed journal,

Health Affairs, disparities “may be rooted in differences in insurance coverage, inequalities in access to good providers, or discrimination by health professionals in the clinical encounter. Disparities may be the result of years of institutional racism, lack of trust due to years of broken promises, cultural traditions, and more.” (Health Affairs, 2008, https://www.healthaffairs.org/doi/full/10.1377/hlthaff.27.2.393)

When it comes to mental health treatment, whites are more likely to receive psychotherapy and medication on an out-patient basis, whereas BIPOC citizens are more likely to be referred to in-patient treatment for the same conditions

(Health Affairs, 2015, https://www.healthaffairs.org/doi/full/10.1377/hlthaff.27.2.393)

Yet, the rates of depression are lower in Blacks (24.6%) and Hispanics (19.6%) than in whites (34.7%). Correspondingly, depression in African Americans and Hispanics tends to be more persistent, likely due at least in part to difficulties accessing effective and affordable out-patient care.

Further, since untreated mental health issues tend to exacerbate physical health issues, treatment costs related to physical health tend to rise as well. Simultaneously, outcomes become less hopeful, and may come to include disability, addiction, homelessness, and incarceration - again disproportionately affecting BIPOC communities.

Indeed, the prison population has become the largest group of people with diagnosable mental health disorders, between 45-60% (When Did Prisons Become Acceptable Mental Health Facilities?, Stanford Law School, 2017.) Lack of critical mental health care during incarceration has been persistent, as are the difficulties accessing mental health care through Medicaid upon release. Here, then, is another example of the SDOH role in exacerbating disparities, especially given the excessively high numbers of brown and Black people incarcerated in the US.

CSWA would be happy to provide additional data on how SDOH factors are connected to mental health disparities and need to be addressed.

Telemental Health Coverage

When the Public Health Emergency was implemented in March, 2020, most LCSWs began providing psychotherapy through virtual telemental health (videoconferencing) and audio-only (telephone). The decision by CMS to cover these new delivery systems during the PHE has been crucial to the wellbeing of Medicare beneficiaries living in areas without local mental health services or accessible transportation to more remote care. Previously unable to obtain in-person psychotherapy, they finally have the needed treatment because of the new delivery systems. It is unrealistic to expect them to begin treatment in person when the PHE ends unless SDOH transportation and other barriers to access are addressed.

CSWA therefore recommends that all three forms of treatment delivery be approved and reimbursed at the rate being paid for in-person treatment. LCSWs who provide services through videoconferencing and audio-only are working as hard, if not harder, than when they see patients in person. Further, even the requirement that patients being treated via videoconferencing and audio-only must be seen in person every six months is highly problematic; certainly it would be a huge barrier to seeing patients who can ONLY access treatment through virtual means.

The elderly - the main group of Medicare beneficiaries - are chronically underserved when it comes to mental health treatment. Not all Medicare beneficiaries have access to Rural Health Centers and Federally Qualified Health Centers; many had the opportunity to establish virtual psychotherapy relationships with independent LCSWs as a result of the PHE. However, the biannual in-person requirement has created a barrier to virtual treatment. If it is not eliminated, these beneficiaries may well find themselves back among the “chronically underserved”.

Telemental Health Parity

As noted in the Proposed Rule, “the estimated cost impact of this proposal is unclear, the proposed requirement that a modifier be appended to the claim to identify that the service was furnished via audio-only communication technology would allow us to closely monitor utilization and address any potential concerns regarding overutilization through future rulemaking” (p.1198). This comment applies to videoconferencing as well.

In fact, LCSWs and other mental health clinicians have been involved in an in vivo application of these two delivery systems throughout the pandemic. We ask that this data be collected and analyzed to see how much these services are being utilized and how their use affects cost offsets of medical conditions before CMS moves forward on plans to limit or eliminate them.

CSWA recommends that all three forms of treatment delivery be approved until CMS completes such a study, and that all three be reimbursed at the rate being paid for in-person treatment. LCSWs providing mental health treatment through videoconferencing and audio-only means are working just as hard, if not harder, providing professional clinical treatment virtually as when they provide services in person.

LCSWs have been long been called the backbone of psychotherapy services, and with more than 250,000 licensees, LCSWs are the largest mental health provider group in the country. However, as you know, LCSWs are reimbursed by Medicare at 25% less than psychologists for providing the same services, with the exact same CPT psychotherapy codes. LCSWs have equivalent clinical training, experience, client overall satisfaction, and provide long-term relief of emotional problems. The reimbursement disparity for LCSWs has not gone unnoticed and the number of LCSW Medicare providers has continually dropped. Lowering reimbursement for telemental health services would likely result in even fewer LCSW Medicare providers.

CSWA hopes that these comments are helpful developing the Proposed Rule and would be happy to discuss them with you further.

Sincerely,

- Kendra C. Roberson, PhD, LCSW, CSWA President

- Laura Groshong, LICSW, CSWA Director of Policy and Practice

August 6, 2021

By Laura Groshong, LICSW, CSWA Director of Policy and Practice

Though we are in the dog days of summer, there are many things going on that affect our clinical practices. CSWA is pleased to offer information on the following four topics that are currently affecting us: (1) ways to determine what the COVID risk is in your area are by county; (2) a template for writing letters that confirm medical necessity when insurers question the validity of our treatment; (3) an update on the Physician Fee Schedule which will affect our reimbursement in 2022; and a (4) a member survey to determine where people stand on the decision to return to in-office practice and additional topics to gauge ways to better support members.

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COVID Issues

The rise in COVID-19 cases due to the new Delta variant and others is cause for concern. But in this case, as in much of the pandemic, all concerns are not created equal. To understand the risk we face on the personal and professional level, it is necessary to get information that is specific to our location. The CDC has just created a new data base that provides the current level of infection for every county in the country. The COVID Data Tracker is updated daily and can be found at https://covid.cdc.gov/covid-data-tracker/#county-view CSWA suggests that whether you live in an area that is a hot spot for infection or one with low levels of infection, it is prudent to continue to wear masks and maintain social distance of 6 feet in public indoor areas.

The topic of whether to return to seeing patients in person is also on the minds of LCSWs. Please see the two hour webinar I recorded on July 22 to get detailed information on how to make your own decision about what is best for you. You can find it at https://www.clinicalsocialworkassociation.org/CSWA-Webinars#ToBe in the Members Only section.

To give members an overview of the way others are viewing returning to the office, CSWA is asking all members to take the short anonymous Survey to gather this information:

Please click here to complete the survey.

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Medical Necessity

More and more often, LCSWs are receiving letters questioning the “medical necessity” of our treatment. To address these often baseless conclusions, CSWA has developed the response template which you may use to explain the validity of your treatment decisions. Click here for the MEDICAL NECESSITY LETTER [Template].

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Physician Fee Schedule

As happens every August, the Center for Medicare and Medicaid Services (CMS) has issued potential changes to the rules that govern all medical practice which includes clinical social work practice. The CSWA Government Relations Committee is developing comments on this year’s PFS and will send them to members before the August 23 deadline for review.

Thanks for your support of CSWA and have a great summer!

July 20, 2021

There is much information coming out about the level of risk we face at this time to the COVID-19 virus. There are several new variants, particularly the Delta variant, which are spreading quickly. The unvaccinated population varies widely and is a major factor in the likelihood of infection, even for those that have been vaccinated.

This surge, which just resulted this weekend in Los Angeles returning to mask-wearing in public places, comes at the same time that many LCSWs are starting to consider returning to seeing patients in person. CSWA is offering a 2-hour webinar on this complex topic on July 22, 2021, at 1 pm EDT (see www.clinicalsocialworkassociation.org to register).

While it is very difficult to fully assess the level of risk that LCSWs face in going back to our offices or other small spaces like restaurants, we can educate ourselves about our own city/region. Here are some articles to help with that process:

Currently, 48.9% of the US population has been fully vaccinated and another 7.6% have been partially vaccinated. The US COVID-19 new case and fatality rate 7-day averages have doubled in the last two weeks (see "Coronavirus in the U.S.: Latest Map and Case Count" at (https://www.nytimes.com/interactive/2021/us/covid-cases.html).

Despite growing evidence that vaccination curbs mutation (see "COVID-19 Vaccines May Be Curbing New Virus Mutations", (https://www.medscape.com/viewarticle/954621), the political (and largely regional) rift between the vaccinated and unvaccinated is growing (see "Coronavirus latest: Chicago adds Delta-variant hotspots Missouri and Arkansas to advisory list" (https://www.ft.com/content/95716f06-c92d-4f9a-b2f7-30e30ce7cb22).

WHO Director-General Tedros Adhanom Ghebreyesus said " The Delta variant is ripping around the world at a scorching pace, driving a new spike in COVID-19 cases and death," noting that the highly contagious variant, first detected in India, had now been found in more than 104 countries, deaths are again rising and many countries have yet to receive enough vaccine doses to protect their health workers (see " WHO Says Countries Should Not Order COVID-19 Boosters While Others Still Need Vaccines" (https://www.medscape.com/viewarticle/954643).

Where COVID restrictions are loosening, anxiety is increasing according to this Medscape article: https://www.medscape.com/viewarticle/954793. New psychotherapy patient calls (already at a record high since the pandemic began) have risen dramatically during the past week.

July 15, 2021

Please visit the CSWA Position Papers page to view the Position Paper on Voting Rights. 

May 14, 2021

Several members have pointed out the part of the CDC guidance that is aimed at health care providers:

“The guidance reiterates the need for health care providers to continue using personal protective equipment (PPE) in health care settings. Continuing to use telehealth strategies while maintaining high-quality patient care remains the prudent option in many circumstances.”

This guidance is likely to apply to hospitals and high-volume medical offices. In the typical LCSW office, LCSWs are vaccinated, patients are seen one at a time, waiting rooms and restrooms are often still not being used, HEPA filters are still being used in the office, and patients who are not vaccinated are not being seen in person. Under these circumstances, the risk of passing on COVID-19 by seeing patients in person who are vaccinated is low.

As noted in the previous post, LCSWs with weakened immune systems should continue to use masks and have patients do so as well, if patients are seen in person.

May 13, 2021

Today the Centers for Disease Control (CDC) announced new guidance on the use of masks indoors. This guidance has a direct impact on the way LCSWs practice psychotherapy.

The CDC now recommends that people who are fully vaccinated can meet indoors without wearing a mask or physical distancing. This is a relatively sudden shift from two weeks ago and is reflective of the increased level of vaccination that has occurred, About 117 million US citizens are now vaccinated and 154 million have received one vaccine dose. The recent expansion of vaccination for 12-15 year old children will further increase the number of citizens who are vaccinated. COVID-19 variants should be stopped by the vaccines available.

There is no mention of whether building air filtration systems or in office HEPA filters are useful. It may be a good idea to maintain the use of HEPA filters until herd immunity has been reached.

One factor that may lead to continued use of masks and physical distancing are for people who have immunosuppressed or weakened immune systems from organ transplants, cancer treatment or for other reasons. This of course applies to us as LCSWs as well as patients.

Let me know if you have any questions about the recent CDC guidance on protections against COVID-19.

- Laura W. Groshong, LICSW, CSWA Director of Policy and Practice

April 29, 2021

Many members have been asking questions about the Medicare coverage of telemental health. This is an important topic because most commercial insurers follow Medicare policies regarding coverage of telemental health, as well as other coverage issues.

Medicare has covered telemental health videoconferencing for our usual and customary psychotherapy codes since March, 2020, a major expansion of telehealth coverage. Medicare also agreed to cover audio only psychotherapy in April of 2020. Both were tied to the Public Health Emergency (PHE) being in effect. The PHE was extended in three month increments until April of 2021 when CMS announced that telemental health videoconferencing would be extended until the end of 2021. Audio only treatment would be covered as long as the PHE was in effect. See https://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/Telehealth-Codes for more information.

In other words, separation of telemental health videoconferencing and audio only coverage have been part of the expansion of psychotherapy coverage since the pandemic began. The current intention from the current administration is that the PHE continue through 2021, which would make the difference between the two delivery systems moot.

At this point, I believe that LCSWs can reasonably expect coverage of telemental health and audio only treatment to last through 2021. There are several bills in Congress which would make this policy permanent. Our Government Relations Committee is working hard to see one of these bills pass. Stay tuned.

- Laura W. Groshong, LICSW, CSWA Director of Policy and Practice

April 21, 2021

We at CSWA collectively breathed a sigh of relief yesterday as the guilty verdicts for ex-officer Derek Chauvin were read by the judge. We acknowledge the monumental task of the prosecution team, the on-going protests by people around the world, each sign posted on a lawn or in a window, each hashtag crying for justice for George Floyd. This decision, after years of police murders of Black and Brown people with no accountability, is one to celebrate. The guilty verdicts serve many purposes; they break the long-standing policy of acquittal for police who have murdered Black and Brown people. They affirm what was a matter of fact – that George Floyd’s life was taken without cause. They provide a way forward that is necessary in dismantling unjust, rogue policing that has created a justifiable mistrust in institutions we all should feel protected by.

CSWA stands in support of these verdicts. We consider it the duty of all citizens, and clinical social workers in particular, to repudiate institutionalized racism and support policies that further encourage police accountability. One such potential law is the George Floyd Justice in Policing Act of 2020 introduced in June, 2020, passed by the House last month. A summary of H.R. 7120 is listed below.

This bill addresses a wide range of policies and issues regarding policing practices and law enforcement accountability. It includes measures to increase accountability for law enforcement misconduct, to enhance transparency and data collection, and to eliminate discriminatory policing practices.

The bill facilitates federal enforcement of constitutional violations (e.g., excessive use of force) by state and local law enforcement. Among other things, it does the following:

H.R. 7120 would also create a national registry—the National Police Misconduct Registry—to compile data on complaints and records of police misconduct. It establishes a framework to prohibit racial profiling at the federal, state, and local levels.

Finally, H.R. 7120 establishes new requirements for law enforcement officers and agencies, including to report data on use-of-force incidents, to obtain training on implicit bias and racial profiling, and to wear body cameras. CSWA will be advocating for passage of this bill.

Today the Department of Justice has announced a full investigation of a “possible pattern of misconduct” of the Minneapolis Police department. CSWA welcomes this investigation and hopes it will be one step forward, with many more needed, in the fight for a socially and racially just America.

- Kendra Robeson, LICSW, CSWA President

April 20, 2021

The project sponsored by Department of Defense and Council of State Governments to create an interstate compact for clinical social workers is moving along. CSWA is one of the three main stakeholders. The formal kickoff will be on May 20 at 2 pm EDT. All CSWA members are invited to attend. This meeting is informational but will be helpful in giving an overview of how the project will move forward.

The event is free but you must register which you can do at https://csg-org.zoom.us/meeting/register/tZUqdOqqpz8jE9JjZpkwTn2_gHKIuCbtRmpN.

To see the original announcement of the event go to https://www.defense.gov/Newsroom/Releases/Release/Article/2537098/dod-receives-approval-for-grants-to-develop-interstate-compacts-for-licensure-p/

I hope to “see” you at this Zoom event. Let me know if you have any questions.

- Laura W. Groshong, LICSW, CSWA Director of Policy and Practice