I just heard from a colleague that she is signing off of all managed care panels effective September 1. She says she can’t grow a practice with her reimbursement rates declining and is ready to go with a managed care free practice.

While I applaud her biz savvy-ness for knowing that she needs to change her business model, I want to ask her.

“Now what?”

What else is she changing? Why should I refer assessment cases to her, rather than the 3 other psychologists in town who do take insurance?

If I were completely eliminating all dependence in managed care starting tomorrow, this is what I would do.

1. Niche, niche, niche, (but you know that).

2. Offer unique, specialized services.

3. Work hard to offer remarkable, outstanding, amazing services that people rave about.

4. Be better than my colleagues who do take insurance. Better services, better office decor, better amenities.

5. Cut my rates. I know, that sounds like heresy. However, taking insurance is expensive. With all the time, paperwork, preauthorization, you need to charge higher rates to make up for all the time you don’t see clients to deal with the red tape. But, if you eliminate all that wasted time, you can charge less per service and still make a bigger profit.

6. Offer services in packages, programs and “bundled” formats at a discount.  How about 6 sessions for the price of 5 or a free parent education course that you offer when a child participates in a course of treatment.

7. Market my awesome, unique,bundled services  to all of my referral sources, telling them that to offer such amazingness I need to cut ties with managed care.

8. Be present online so people can find me and check out my practice and services on their own time, compare and contrast what I offer to what the guy who takes insurance offers and come to clearly understand that it is worth their hard earned money to invest in my services, rather than take what they can get for a co-pay.

9. Have a detailed plan for all of the above. A change in business plan and income stream should NEVER be undertaken on a whim or haphazardly.

Going forward I predict more and more health care professionals will opt out of accepting managed care.  How will that change the quality and types of services we offer?

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As our population gets more and more “plugged in” how do we treat their mental health?

With millions of people meeting romantic partners online, how do we help them sort out issues of meeting a partner, courtship, cultural differences and possible separation?

When someone who is happily married can find their high school sweetheart and re-connect via Facebook, how do we explore the concepts of virtual infidelity?

How should we address cyber bullying – the bullies and the bullied?

When a child sees her father only via Skype because he is working for our country in Afghanistan, how do we help her connect with “the daddy on the computer”?

When a teen only comes down from his bedroom to dinner when his mom sends him a text, should we worry about their relationship or view it as a normal part of modern life?

When a child loses a friend because of comments she put on her Facebook wall, how do we support her in her confusion and sadness?

When you work with divorcing couples and one sees the other in a picture on a dating site with their kids, how do you help them understand online boundaries?

When a client of yours tells you her daughter is studying abroad, doesn’t speak the language of the country she’s living in and is depressed, could you help with a referral to someone who could help?

Our world of relationships is changing. We need to be able to treat a plugged in population. Rather than check technology at the door of our offices, maybe it’s time to invite it in and work with it in ways to benefit our clients.

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Can I be honest?  Some therapists are satisfied with “good enough.”  They are “good enough” clinicians, with “good enough” training and a “good enough” salary.

I don’t want you to be one of those people.

Why? Because in today’s culture and economy “good enough” is not enough.

Not enough to fill your clinical hours.

Not enough to make a decent income.

Not enough to justify investing in marketing.

Not enough to make a difference in people’s lives.

The truth is, to escape the mediocre wage, frequent client turn over pattern in private practice, you need to be exceptional, remarkable and unique.

People value quality. People value exceptional. People value unique. This is why a Mercedes costs twice as much as a Kia, and a Starbucks coffee costs three times  more than the coffee at 7-11.

Mercedes and Starbucks are not “good enough.” They are exceptional and unique.  Whether you like their coffee or not, you hear about Starbucks, coffee, but you hear nothing about the coffee at 7-11.

We’re trained to be adequate and that’s not enough

Many therapists are trained in ways that encourage conformity, earnestness and adequate performance.  No one ever pushed me to be a better therapist, even in my training.  I followed the rules, understood ethics, kept good notes. Maybe that was enough way back when. Maybe that was all my supervisors had to do to get sessions authorized and paid for by managed care, or to get people to pay their fees out of pocket.

Not now.

Now you need to kick a** and take names.

Show that you are a short term therapy ninja with a toolbox full of CBT and watch your authorization rate soar (I’ve never had auths denied…even out of network…never).

Help people function better after 2-3 sessions and watch your name be the buzz around town, as your word of mouth referrals boom. (No one has time or money to wait 8 sessions before they see improvement)

Return every call, be on time for every appointment, keep relevant magazines in your waiting room, offer flexible scheduling and see your clients return week after week, month after month and year after year.

No one wants to work with someone who does just enough to get by

Good enough won’t cut it.  A few weeks ago someone sent me an email that said, “I just want to sit in my office and see clients. Do I have to do all this work to have a busy practice?”

Yes, you do need to do all this work.  No one wants to pay a therapist who just wants to sit there. Not even other therapists.

You need to show up, be present, curious, relevant and up to date.  Your clients, who put their total trust in you, deserve nothing less.  Do you want to work with a physician who “just wants to do physicals,” or have your child be in a class with athe teacher who “just wants to sit in a classroom and teach?” Nope.

Exceptional pays well

When you put in the time and energy into being awesome, great things will happen for you.  Clients will show up, offer to pay you more money, tell their friends and doctors about you. Insurance companies will be easier to work with (not easy, easier). Your reputation will be known in the wider community.

I can tell you from experience, this way of building a business rocks. You feel good about what you offer, the support you can provide, the lives you can change. And you get paid well, don’t need to grovel for clients or hassle with managed care.

The work pays off and it’s a great way to make a living.  But remember to never settle for “good enough.”  It’s not enough. Do you agree?

I was at a meeting of psychologists last night and we got the news that Blue Cross Blue Shield of Massachusetts will be lowering our reimbursement rates starting in September 2010. Oh, and they are eliminating payment on some consultation codes, too. Super. But, to pat my own back, I predicted this last week. What this means is my income will be less starting in September.  Since I knew that was a possibility I already started to shift my business model.

This drop in rates is bad news for most psychologists and let me tell you why. As I sat in this meeting, after we got the news a whole cacophony of protestations and declarations revolving around “Why isn’t Blue Cross cutting their own administrative salaries?! Let’s sue them!  Where do they take a financial hit?!”

No one mentioned, “Gee, I guess this means we need  a new business model.”

Because we have no control over what Blue Cross does, do we?

It’s like being dependent on foreign oil–the big company holds all the cards.  They won’t take a salary cut if they can slash your income first.  Period.  They are going to protect their profit just like you should be protecting yours.

Psychologists who get caught in the conversation of “Why don’t they change…?” are looking at this from a scarcity position and there is nothing good that can come from that.  They will run their corporation as they will. Manged care does not care how you make a living.

So all I have to say is: new models, new models, new models, new models. But you know that.

What are you doing about it? Anything? Because the insurance companies are certainly rolling out new models and aren’t going to ask you if you’re ready.

This is a question I ponder daily:

Can mental health treatment be  moved online or into a virtual space (via phone, video chat, second life) effectively and ethically?

Then the questions really start rushing in.  I ask:

What does virtual mental health treatment look like?

How does it work?

How do people benefit?

What pieces absolutely CANNOT happen in an online space?

What parts of treatment are better in a virtual space?

The Evolving Definition of “Relationship”

No one can deny our culture  is changing, as is our definitions of “relationship.”  In the world of Facebook, Twitter and LinkedIn who do your clients consider a “friend?”  Psychotherapy is a relationship-based art. But now that many people experience true relationships online, how do we adapt the approaches we use?

If we believe that the relationship is  a driver of healing and people can form real, meaningful relationships online, how does that change our work?

New Ideas

Here are a few ideas I have about the future of mental health treatment:

• I see intensive work happens face-to-face, but when people begin to integrate coping skills and adopt healthier habits and patterns, we can begin to work with them via phone, email, text to follow, up, support and check in.
• Issues that are less intensive, such as parent skills, stress management, behavior change can be initiated and treated in a virtual space.  We can utilize individual phone/video work along with live telegroups and online forums.
• National networks of psychotherapists and psychiatrists will need to emerge.  We will need to collaborate with one another to support those in our communities and online. For instance, if I am doing parent coaching will a mother in California, but realize she will better benefit from individual therapy, I will need to be able to network with colleagues in her geographical area to provide an appropriate referral.
• More of our work will be virtual.  We’ll need to grapple with the concepts of confidentiality, how to protect information, defining our professional boundaries.
• Turf wars will need to cease. Psychologists, social workers and masters level therapists will need to work together in an online/virtual space.  We will need to be able to practice over state lines.
• Niches and specialties will be absolute necessities as we all become available to a much larger pool of potential clients.
• The role of managed care reimbursement will change. I”m not sure how, but it will need to evolve, too.  What do you think?

I’m excited for this evolution! How about you?  What are your ideas about the future of mental health treatment?

Recently there has been a lot of talk in the psychotherapy community about the appropriateness of Googling a client when one is concerned about him/her.  Some argue it is a good way to help someone in distress when they have not divulged information to us personally, others argue it is an invasion of privacy.

You know I am a lover of all things online: marketing, services, communication.  However, I would NEVER Google a client without their explicit written permission. Here’s why:

Before the internet and Google we always had a good deal of personal information about our clients: home address, workplace, phone numbers, etc .  But just  because I know my client’s home address, do I just drop by for to say hello or hang out in their back yard to see what they do on weekends?  Or just because I have their cell phone number do I call them just to check in? No way.

I have 2 main reasons why I would not Google:

1.  The relationship I have with my clients happens in my office,not in cyberspace (at least for now).  They bring what they want to bring into that relationship in that space.  They are not planning on me checking out their life online. To Google without  their knowledge feels like a breach of trust.

2.  What if I Google a client and find out information they never divulged in a session?  I work with teens so maybe I found out an adolescent has been out all night, or is using drugs/alcohol, is being bullied online–but they never told me personally. Now what do I do? Confront them, tell the parents, report to the police?  Now I’m in a bind. I might find out information I am legally and ethically obliged to report, but I was essentially snooping (because I didn’t tell anyone I consider this part of our relationship).  And let’s say I do report, but the family feels I overstepped my boundaries. Can they sue me?  Bring up an ethics complaint?

Where does it start and end?

Now imagine I do this for every client. How much “secret” information do I see? How to I proceed? How do I know what is real, made up, an online persona, a game? I have no context to make that judgment. Or if I only do it for certain clients, how do I determine when it is ok to do it and when it is not?   This could be a real ethical nightmare.

And none of this has been legally tested yet, so no one can tell us if it is ok or not.  One day someone will do it, get sued and we’ll find out. But I don’t want to be that person.

And I realize the information is public, but again, I could park my car outside my client’s home to see what they are up to on a public street. Totally legal,  but we would all say that behavior by a therapist to be very intrusive and inappropriate.

It’s all about the relationship

It’s important to keep in mind that social media is another way to have personal relationships.  Many people have contacts online they have never met in person, and relationships in person they never associate with online.  The relationships can be compartmentalized.  Most people would never expect their therapist to Google their name, unless explicitly told that it might happen.

Let’s put it this way, how would you feel if you visited your primary care doc and she told you, “If I have concerns about your health I can Google you at any time?”  I’d never sign on for that!  If you wouldn’t engage in the behavior in “real life” then you should not engage in it online. I would not park my car outside my client’s home, randomly call them to check in, or hide in their bushes to see what they are up to outside of their appointments with me. I won’t do the equivalent online either.

Some argue it is acceptable to Google a client if you have concerns about their safety.  How did we handle those situations prior to Google?

If I have a concern about a client I will 1) tell them in session, 2) possibly call them to check in, 3) if it reaches a point of emergency I would tell their parent, ask for police intervention, or call Department of Child and Family Services (depends on the case).

Those who tell clients they may search them online in case of possible emergency are entering a slippery slope. Depending on your clients’ personality structure, you may find that people “test” your online search option, making vague comments about unsafe online activity while in session. What do you do with that if you explicitly state that you have the option to Google and search for their information online?  If you say you might search, and a client tells you their unsafe behavior can be found online, then you must search and then…what?  It’s a door I can’t open because the possibilities for miscommunication and misunderstanding are enormous.

Googling a client will just leave me with too much random information that I can’t clinically process.  Again, how much of that information is “real”?  I have no way of knowing because I have no context.  I can only address and take responsibility for what my client’s share with me personally. If I  suggest that the whole cyberworld can become part of our relationship, I’m open to a whole lot of liability.  Unless a  court or my ethics code tells me I *must* search my clients in times of possible emergency I won’t.  Just because information is easy to access, doesn’t mean we should avail ourselves of the option.

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I just got off the phone with a client who tells me some of  her colleagues are vehemently against her becoming innovative in how she structures her private practice business.  Their reasoning, “It’s not the way we do things.”

Hm….if Freud stuck with the established way of doing things, he would have continued working in  neurology, dissecting eels (no kidding) and not founded psychoanalysis which changed the practice of psychology forever.

It’s All Different Now

The emerging business of health care is different than what was done before.   But I would argue our whole economy and culture is evolving. Do you agree?

When things change, it is those who adapt who are successful and those who stay put, refuse to bend and stick with what “should” work who are soon out of business.  Need proof? Just look at the music industry that tried to hold the line fighting online downloads and losing all their market share to iTunes and Amazon.com.  Adapting to a new way of distributing music would have been much better than just closing the doors and shutting off the lights on their dying industry.  The thing is, people still buy music, just not the way to big record labels wanted them to.

If you want your private practice to succeed, you must adapt to a new economy and new technology.  The “old ways” are just that “old.”  The next generation of clients communicate via text message, Facebook and AIM.  They don’t pick up a phone, and are accustomed to getting access to exactly what they want and need at the touch of a button.

You can’t change the cultural shift. You can’t change the new economy or health care reform.  You CAN change how you structure your business so you are successful.

Adapting to the new is a choice.  Some of you will chose change and often your colleagues will not support you.  That’s ok.  Just keep moving forward and speak to your clients’ needs. You aren’t wrong. You’re just ahead of the curve.  And for some perspective, back in the day Bill Gates and Steve Jobs were considered crazy mavericks and look where they are now…….

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If you are a physician, therapist or any other helping professional whose business model relies on third party manged care reimbursement you are engaged in the World’s WORST business model (and that’s not hyperbole…keep reading to see what I mean.)

Let me start with a story to set the stage:

Imagine you are a bright, idealistic college student. You’re good at academics, want to make a difference in the world and have hundreds of career options in front of you.

After lots of thought and planning you invest $100,000 in a graduate education. After all is said and done, you are in school anywhere between 2-12 years past your college graduation.  You train to change people’s lives, heal what pains them. You make a difference and you sacrifice your life goals to prioritize your career. You may delay getting married, having children, taking vacations.

You do good work, finish school and training proving yourself and set out to make a living practicing in your area of expertise.

The first order of business is to figure out how you will get paid for all of your good work.  The standard business model is accepting payment from a third party and this is where the business model gets funky, so pay close attention…..

This third party decides how much your work is worth.

The third party sets limits on how  much work you can do with each customer.

The third party can reject your invoices at any time for any reason.

The third party prohibits you from discussing your fees with other providers of the same service.

There are many of these third party payers and they all pay different, seemingly arbitrary rates.

The third party can change what they pay you at any time.

If you don’t follow all of the rules of the third party they don’t have to pay you at all.

The business model requires you to rely on an outside source to determine what you work is worth, set your rates and reimburse you on their terms. They can change the rules at any time. Outside forces constantly and consistently determine your bottom line. You have no choice, no chance to test price points. If you want to add a new service that isn’t recognized by the third party, they don’t pay you. The third party tells your customers that YOU are responsible for accessing their funding on their behalf, so no one knows what they really pay you or what your services are worth.

If you have any entrepreneurial spirit at all, please re-read the above paragraphs and tell me if you would sign up for this business model.  Honestly, it’s ridiculous, don’t you think?  Who in their right mind would invest $100,000 and years of their life in education, training and business and then turn over all hope of a profit to an outside entity?

Why don’t health care providers do anything about the model?

Doctors, therapists and other health care providers are not business people. We are not trained to pay any attention to how we get paid or who pays us.  Many of us work in organizations that take care of all the adminstrative silliness so are have no idea how broken the system is.  We are trained to do work that “insurance will pay for,” or to “find something that the insurance will reimburse.” Nice, huh? Your doctors are trying to find things wrong with you so they can get paid.  It’s not their fault..it’s the business model and no one questions it.

Those who understand that business model, CEOs of insurance companies think it is a GREAT business model. They call the shots, they are in charge, they have the power and they make lots of money managing your business and our health care.  Those in power never want to give it up. Just read Shakespeare if you don’t believe me.

As providers we are also brainwashed that if we don’t accept this crazy business model our patients will be harmed. “How will they afford care? Who will take care of them?”   But, in the USA, we don’t want to provide a public health plan to help out those who are less able to afford care, so providers are put in a bind: take the lousy capitalist model that puts you in a subservient position to third party payers, or be a guilt ridden, selfish person for not buying into the model and getting the respect and pay you deserve.

What can we do about it?

Create different business models.  Take ownership of our careers.  Declare, “We’re not going to take it anymore!”

Imagine what would happen if doctors, therapists, dentists, and all other helping professionals declared this at once?  What if we only worked with third party payers who treated us with respect? What if we only accepted insurance that had a real person answer our calls and handle our questions?  What if we dropped insurers who pay us insulting rates and make us fill out 5 pages of busy work to access that cash?

And what if we informed patients that it is their insurance company that restricts their care, pays low rates, makes us wait on hold for hours? Or how about we put the onus on the patient to submit all insurance claims, understand how complex and time consuming it all is? It’s their care after all. [And don't tell me the public 'can't figure it out.'  They figure out auto insurance, life insurance, home insurance. They can figure it out. Now we just enable ignorance].

Do you think the public would speak up? Complain to their insurance company, employers, government officials, congresspeople and senators? Well, yeah, they would.  Would health care policy  need to change if the providers of care stood up and demanded respect, a fair system and lower overhead costs?

Let’s not agree to business models imposed upon us. Let’s educate ourselves about business and empower both the medical profession and consumers to be proactive in how health care is accessed and paid for. If we are told that health care is a business, and entrepreneurs run the system, let’s even the playing field so that the competition is fair.  We have a choice.

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Hey, have you seen the most recent Newsweek article by Sharon Begley?  It seems antidepressants don’t work. Apparently, 82% of the improvement people feel is placebo effect.  If you are a mental health professional, you know this, whether or not we want to admit it.

Let’s face facts, folks. When it comes to curing mental illness, we are in the dark ages.  We have NO IDEA what we are doing. It’s not our fault. The brain is just so stinking complex!  But we have this need to say we know stuff that we don’t.  I know we get pressure from our clients/patients, other professionals for an easy answer, a quick fix, the little sad blue pill that turns yellow and happy after taking Prozac (remember those commercials?).  It seems good marketing trumped good science but we all wanted to believe it was that simple.  And yet, in the face of the evidence,people treat the researchers like criminals and they are labeled as anti-science.

Again I ask: How does this help people? How does it improve lives?  If we KNOW something is not working, why hold on to the fallacy that we are “doing good” by perpetuating a non-effective intervention?  I’m sure money is a motivator, so is laziness and fear. But I don’t want to talk about that, because looking for a scapegoat or a cause of the issue doesn’t solve the problem we have in front of us.

How do we help people with depression?

Let’s start thinking about  collaborating vs. going solo. If psychiatrists, therapists, and researchers all got together and worked together on how to address the complexities of depression we could come to a better answer.  But now, we have therapists saying therapy is the answer (and they seem to be right, but can’t agree on what approach is most effective-CBT or psychodyanamic), psychiatrists saying medication is the answer (and this is a weaker argument by the day), and researchers saying they don’t have an answer, but know what doesn’t work (but will tell the public it does because  a placebo effect, is better than just doing nothing.)

What a mess.

And the truth is, we are failing people who need our support. The more the evidence surfaces that we are at a loss on how the brain works and how to improve people’s mental health, the more the public sees us like the man behind the curtain in the Wizard of Oz. Because we claim to have answers we don’t have.

We are failing alone, publicly.

What if someone put a grant together to pull researchers, physicians and psychotherapists to tackle these issues? What if part of the grant was to bring in a good PR person (who understands social media) and opened the doors to the progress being made? And what if participants in the studies were recruited via social media, doctors’ and therapsits’ offices?  Do you think we’d be able to find enough volunteers to help solve this really big problem?  Do you think we could get an article in Newsweek talking about the collaboration and the progress? Do you think working together we’d learn more and generate knowledge faster than we are working alone and in isolation?

What do you think?

I started my career working with gang bangers, sexual offenders and grand theft auto convicts.  All of them were under the age of 18.  It was one of the best jobs I have ever had.

In no particular order,here is what those kids taught me about life, work and business.

1.  People want to be good.

2.We need to be open to other points of view to really help others.

3. Ask questions if you want to understand. For example:

Sue: “So, Rob, you’re a smart kid. If you put your smarts to use in a legit way, you could get out of the gang and stay out of jail. Why sell drugs?”

Rob: “Sue, you know it ain’t that easy and who’s going to help me get there?”

Sue: “OK, but why do you sell drugs? You know it hurts people.”

Rob: “It’s a business. If stupid white people want to come into my neighborhood and buy my shit, that’s their problem. I’m supplying a need.”

Sue: Well, I never thought of it that way……

(Rob was 16 years old. Never did drugs. Never knew his real parents. Smartest kid I knew. Had NO support in the community. He did the best he could.  One year later was killed for dealing on someone else’s corner.)

4. You can help people with who you are, your time,your ideas and the power of your presence. You know that scene in “Good Will Hunting,” when Matt Damon (the student/client)  and Robin Williams (the therapist) just sit there for 5o minutes in silence?  Yeah, I”ve done that. It means something.

5. Actions speak louder than words. Want to help a kid who is traumatized and won’t speak to you other than to scream and throw chairs? Make him a peanut, butter and jelly sandwich (known as “PB&J therapy”),sit on the floor, then put the chairs away.  No words.

6. Nobody has the right way to heal. The best therapists in our whole program were the front desk receptionist and the cook. Two older ladies who knew everyone’s name, greeted everyone with a smile and had food.  Never underestimate the healing power of an old lady with donuts.

7.  Degrees don’t  mean anything when you really want to make a change in someone’s life. See #8.

8.  When the toughest problems are yours to solve, you get creative. Our kids couldn’t live with us in our program forever. Eventually they had to go home. But they often ended up in the same situation because their environment was the same, even if the kid was different.  Big problem we needed to solve.  So we developed what I called a “multiple family group” and told parents they had to participate to get their kid home someday.  We could change the kids AND the parents.  People came from all over the state. Took trains, buses, hitched rides with friends. We’d put 20 – 30 people in a room to talk about life on the streets, drug addiction (the parents and the kids), and cognitive behavioral therapy. We had no “evidence” it would work, there was no research to support it, no one had done it before.  We had  a problem to solve, and OMG the conversations in that room took our breath away.  The group became a family for our kids with no parents. The parents began to parent all the kids (in appropriate ways).  We shared meals together. The  boys and their parents gave me a wedding shower.   Convicted felon BOYS!! And it was a surprise.   Did that group change everyone’s life? No. Did it change one person’s life? I’d like to hope so.  Well, it changed mine.

9.  The best skills we can teach anyone are how to have empathy for others and how to take care of oneself.

How did all this help me build a business?

Those boys taught me this:

• that ideas can change lives
• new ways of thinking and doing are necessary to make a difference
• there are others who can do certain things better than I and I refer to them
• turf wars are pointless and can hurt people. Collaboration is where the power lies.
• if you build a business that meets a need,the right people will find you
• telling someone about yourself is the only way to help them
• sometimes 16 year olds and homeless people  know more than me, so I should ask lots of questions, listen and learn
• doing good work above and beyond the billable hour or reimbursed service pays dividends to the client and the professional
• what we do matters
• we can do better and more and we must not let any managed care company or politician limit our creativity, passion and drive to make the world a better place
• that any obstacle I may face as I build a business will NEVER be as difficult as one day in these children’s lives. I have no right to complain and I need to work hard to get what I want out of life because I have been given much and to fret it away is a waste.

Those kids and families drive my work to this day.  I will never forget them.