The Effect of the Affordable Care Act on Music Therapy: A Call for Advocacy

A call for Advocacy

Advocacy --> Recognition --> Access

Since 2005, the American Music Therapy Association and the Certification Board for Music Therapists have collaborated on a State Recognition Operational Plan. The primary purpose of this plan is to get music therapy and our MT-BC credential recognized by individual states so that citizens can more easily access our services. The AMTA Government Relations staff and CBMT Regulatory Affairs staff provide guidance and technical support to state task forces throughout the country as they work towards state recognition. To date, their work has resulted in over 35 active state task forces, 2 licensure bills passed in 2011, 1 licensure bill passed in 2012, and an estimated 7 bills being filed in 2013 that seek to create either title protection or a licensure for music therapy. This month, our focus is on YOU and on getting you excited about advocacy.

For the last three months, I have been focused on the Affordable Care Act and how it might affect music therapy. In order to humanize our discussion I want to relate an experience about music therapy advocacy in our area.  

There is an agency in our town in Virginia which has a weekly program that invites families with children on the autism spectrum to come together for networking, sharing and learning.  This program employs a respite care model where the children who have ASD are involved in recreational therapy, physical therapy and music therapy while the parents gather to learn and network with one another.  In the fall, two music therapy students doing their practicum assignments were part of the music therapy services offered to the children.

The music therapy was so effective and popular that the music therapy students were asked to be the highlight of a presentation for a media event sponsored by a future US Senator and his wife.  This event put a spotlight on the music therapy groups offered by the program and was widely hailed as a superb success!  In fact, the two music therapy students who demonstrated music therapy services at the event were so well received that they were offered future jobs at the agency after they graduated! Currently, these same students volunteer their time at the same program so that this agency can continue to offer some level of music therapy type activities.  

This was a great success story, but how can we make it easier for agencies to employ music therapists?  Everyone at this agency was pleased with music therapy and wants to continue offering the service, but how can we make funding programs like this easier and more accessible.  Will the Affordable Care Act impact opportunities for music therapy?  How can music therapy receive more reimbursement through health care dollars?     

Let's dig in...

Please catch up on the background stories if you have missed Part I and Part Ia of this series.

Part II is a look at what the effects of Obamacare (Full text version of law is here.) might be on access to music therapy services.  I hope that you will contribute to this post and the discussion as we explore this together.  Before I go any further, I should warn you that many of the opinions linked to in this post, as well as my own conclusions, are educated guesses about what might occur.  As we discussed in Part I, many parts of Obamacare have yet to be implemented, and to further muddy the waters, the Department of Health and Human Services has only recently begun releasing detailed regulations regarding the plan.  I also remind you that the ACA as conceived by President Obama and the congress at the time is not the same plan being implemented as result of the Supreme Court ruling in 2012.  (I will discuss the ramifications of all this in Part III.)  

Music therapy is not specifically mentioned in the ACA, but access to music therapy through insurance and medical facilities may be affected as a result to changes in funding and coverage.  While there have been some isolated success stories in obtaining third party coverage through private insurance companies for music therapy services, music therapy is generally paid for through private pay or as an included service during in-patient care, rehabilitation or hospice services.  Reimbursement through private insurance companies varies by state, company, and even by case manager.  Some people don't see an improvement in this situation and the ACA may even make things worse.  Perhaps you have a different perspective? 

At least in the beginning, Obamacare will establish state or federal run insurance exchanges or companies that will provide insurance for those who cannot obtain insurance through their employment.  (Note:  As of today, only 18 states have said they will set up insurance exchanges.  The other states have left it up to the federal government or have asked only to be a partner in the process.  These exchanges are supposed to be up and running by October 2013.)  More people will gain coverage, but for the person trying to file for third party reimbursement, it means learning about one more of 50 new state sponsored programs and new kinds of bureaucracy!  So the lack of standardization may be a real hindrance to improving reimbursement rates for music therapy.  

Sometimes music therapy has been included in billing to Medicare as part of an array of services offered in skilled nursing and rehabilitation facilities.  This money is usually a fringe benefit for facilities that include music therapy and is not used to pay outright for the music therapy personnel.  There will not be a boost to this funding, and in fact, Medicare payments to facilities and physicians may face cuts since the ACA cuts $716 billion from Medicare.  There is an Independant Advisory Payment Board (IPAB) tasked with finding ways to make these cuts.  We will just have to wait and see what happens with this.        

Obamacare also attempts to significantly increase funding for low-income  individuals and families through Medicaid.  (Again, the Supreme court ruling has left this provision in flux because it allows states to opt out of the Medicaid expansion.)  Since Medicaid coverage is a "bare-bones" type program, it has not traditionally paid for services like music therapy except through state agencies that receive block grants of Medicaid money to use as they see fit.  So the increase in people getting healthcare through Medicaid will probably not directly increase access to music therapy services except possibly via mental health treatment that involves a music therapist in a facility.

Obamacare: The Effect of the Affordable Care Act on Music Therapy, Part Ia

If you haven't read Part I, you can find it here.  

(...my apologies in advance-- while I am trying to clear away the mud so that we can figure out the essence of what exactly is the ACA, there are so many facets to the proposal that it looks like it will take me more than a three part series to simplify what is going on.  I realize this may be disheartening(!), but I hope you will stick with me through this process as it is an extremely important topic.  I promise to keep things as simple as possible, yet provide links for more in depth study.  I am also trying to steer away from the politics or linking to multiple opinions about projected outcomes.) 
  

Part I update:

Here is my answer to a reader's question (Please explain #15 further, since this applies to myself and many Music Therapists like me) about item #15 ($716 billion in cuts to Medicare):

Here is a very good explanation from the Washington Post, although I don't think it will necessarily answer your question about how specific therapies might be impacted:

• The Washington Post

The big chunks are basically taken out of Medicare by lowering the annual increase of payments to hospitals and facilities and eliminating overpayments to the Medicare Advantage program (a private insurance program some seniors can choose to join instead of being served by the Medicare program itself.) 

A little more detail is here:

• The Incidental Economist

You will notice that Mr. Frakt is also worried about the large cut to annual increases in Medicare to hospitals and other facilities. I would suspect that this might be the most important one for us to consider since music therapy services are sometimes lumped into the billing of services "per day" for a patient in order to receive a slightly higher reimbursement "per day" for a patient. So, even though music therapy is not often directly billed to Medicare, it can increase the reimbursement amount by a little bit per day if it is included correctly in the billing. Since most facilities don't rely on this reimbursement to fund music therapy, it is unlikely that music therapy would be cut as a result of the decrease in money from the ACA. However, it has been nice to be able to show that music therapy does sometimes contribute to a higher pay out in reimbursement.

And just in case it is not confusing enough, some people say that the cuts are not really "cuts" and that they will save Medicare rather than hurt it:

• The Tuscon Citizen

Let's keep investigating! The scary thing is that nobody seems to know what is really in the law or what is going to happen! Maybe next time they can get this all figured out before passing it into law.

Understanding the "doc fix."  (Don't you just love all the little nicknames for things!  e.g., Obamacare, fiscal cliff, ...doc fix, etc.!  What will they come up with next??!)
The "doc fix" is really a yearly "fix" of the problem created by Medicaid only paying about 34% less than Medicare to doctors and hospitals.  As you can imagine, this would lead to many physicians not wanting to treat patients on Medicaid.  So every year, congress passes a temporary law to increase Medicaid payments to match the levels in Medicare.  (Note: Medicare payments to doctors and hospitals are still generally lower than private insurance payments).  The ACA has put in place a temporary "doc fix" for 2013 and 2014.  After that, individual states would be responsible for the additional cost to keep Medicaid from scaling back its payments.  (For details about the "doc fix" issue you can go here.)  

Incidentally, since I mentioned the so-called "fiscal cliff", we will have to keep an eye on the negotiations between the President and the House of Representatives.  It has been reported that the ACA has been put on the table as a bargaining chip in the process.   

In timely fashion (only 32 months after passing Obamacare!) the department of Health and Human Services (HHS) has released the guidelines for states to set up the new health care exchanges.   

Basically, these guidelines lay out what insurers will be allowed to charge for people who smoke or who are older.  The guidelines also explain minimum coverage rules and explanations about the new push for preventative healthcare and wellness programs. Specific lists are in links below:

• Essential Benefits (Including rehabilitative services and devices, wellness services and pediatric oral and vision care.)
• Tiered Benefit Plans (Platinum, Gold, Silver, Bronze: Platinum pays 90%, Gold 80%, Silver 70%, Bronze 60%)
• Wellness Programs 

Okay, this should be enough of a groundwork for us to tackle next time what the impact of ACA might be on music therapy.  I'll be back later this week with that analysis! As always, please let me know if I have missed something important, and keep the personal stories and questions coming here and on Facebook.  Thanks for reading and I hope you had a Happy Thanksgiving! 

 


 


 

Obamacare: The Effect of the Affordable Care Act on Music Therapy, Part I

This is a huge and scary beast to tackle!  Now that the election is over, however, the ACA (Affordable Care Act) looks like it will begin its inexorable creep into the healthcare system.  I present it like this only because the law is scheduled to be implemented in stages.  The first of these new policies began in 2010. The rest of the new regulations will begin over the next few years.  

I will not necessarily be presenting my point of view, although my bias leans against the government being able to do much of anything with efficiency and receive an A grade (I can think of the U. S. Post Office and Amtrak as good examples of government inefficiency which are in constant need of bailout money!).  My goal is to try and give you a sense of the key points of the law and then break it down into some possible influences on how the changes will affect patients with disabilities as well as their access to services like music therapy.  

I also see the bigger picture as something important to examine.  It seems like most people discuss or highlight the benefits or negatives of the new law, but fail to note that actual implementation will not look like the ideal presented on paper.  This is something we can no longer ignore, or put on the mental backburner for another day.  Unfortunately, the ACA is incredibly complicated and many members of congress who voted it into place haven't even read the full document or claim to not understand it!  

At the 2010 Legislative Conference for the National Association for Counties, then House Speaker, Nancy Pelosi said, "But we have to pass the bill so that you can find out what is in it...".   

I have nominated myself to bring you as much detail as a primer for your own investigation!  I will attempt to cite a variety of sources from both sides of the ideological aisle.  I hope that you will join me in the discussion and provide a sounding board as we try to figure this out together.

The music therapy profession is really in its infancy in terms of reimbursement and payment from third-party sources.  Some local and regional success stories exist regarding payment for music therapy services through private insurance companies.  There has also been some progress in getting music therapy included in group billing to Medicare for music therapy occurring as part of daily services in certain types of rehabilitation and care for older adults.  
How will this recent success in third-party billing be affected by the ACA?  Good question!  I am not sure anyone knows exactly, but shouldn't we get at the front end of this?