EXECUTIVE SUMMARY BACKGROUND
It is well-established that rural communities suffer disproportionately from a shortage of mental health professionals (Knesper, Wheeler, & Pagnucco, 1984; Lambert & Agger, 1995; Stuve, Beeson, & Hartig,1989). For example, the supply of psychiatrists is 14.6 per 100,000 in urban areas as compared with 3.9 per 100,000 in rural areas (Hartley, Bird and Dempsey, 1999). Non-physician mental health professionals include psychologists, social workers (SWs), marriage and family therapists (MFTs), and licensed professional counselors (LPCs).1 This study investigates whether and the extent to which licensure laws that determine the permissible scope of practice for each of these professions may affect the availability of mental health services.
Scopes of practice for these professions are thought to have an effect on access to mental health services due to the fact that third party payers often base their decisions about whom they will reimburse for mental health services on these laws. If a specific type of provider is not being reimbursed by Medicare, or by another major insurer providers of that type cannot practice independently. While such providers may be able to provide services in an institutional setting under the supervision of a provider who is reimbursable, such as a psychiatrist or psychologist, many rural areas do not have such settings. In fact, many rural areas have neither psychiatrists nor psychologists.
Currently, Medicare reimburses Psychologists and Social Workers directly for mental health services, but does not reimburse Marriage and Family Therapists or Licensed Professional Counselors. There is some evidence that professions that have attained reimbursement status will seek to protect this “market” by claiming that other professions do not provide acceptable levels of quality to justify independent practice. This study also investigates whether such “guild war” behavior is manifested in the language of licensure laws and rules.
This study examines licensure statutes and administrative rules for social workers, psychologists, professional counselors and marriage and family therapists in all states with at least ten percent of the population living in rural areas (total of 40 states). To determine the scope of practice for each of these mental health professions, we examined their legal authority
1 Advanced Practice Registered Nurses specializing in mental health also provide these services. They are not addressed in this paper, because the laws and rules governing their licensure are significantly different from those of the other professions. Their role in providing mental health services in rural areas will be addressed in a future study.