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position on these professions. States that have not done so should consider vendorship laws to bring reimbursement policies into congruency with licensure laws by affirming the right of these professions to practice independently and be reimbursed by third party payers.2 An interim policy that might address rural access needs would be to authorize direct reimbursement to these professions only in designated shortage areas. A precedent for such a policy can be found in the Federal Employees Health Benefits Program policy that “requires non-HMO FEHB plans to reimburse beneficiaries, subject to their contract terms, for covered services obtained from any licensed provider in [underserved areas] (our italics; Federal Register, 2001)

  • 3.

    Several strategies could be employed to reduce professional competition over the right to practice and be reimbursed. New Hampshire has addressed this issue by allowing candidates for licensure to be supervised by almost any mental health profession, and by requiring providers to provide “…proof that they do not work in professional isolation…” by submitting evidence of participation in a minimum of 25 hours of specified collaborative activities with members of other professions. Several other states have begun to address this issue through combined boards or mental health professional practice acts. The professional associations that represent these professions must provide leadership by taking the lead at the state level in working toward mental health professional practice acts and consolidated regulatory functions.

  • 4.

    New graduates of programs that train mental health professionals can begin to address rural needs soon after graduation, if arrangements can be made for them to receive the supervision required in all states. Supervision may be easier to arrange in states where it is permissible to be supervised by a member of another profession. Another way of facilitating supervision is to explicitly allow telephone and tele-health technologies to be employed in supervision. A few states, such as Colorado, Kansas and Wyoming, explicitly allow electronic supervision, acknowledging its necessity for rural practice sites. In rural states where electronic supervision is not permitted, professional associations, state rural health associations, offices of rural health, and Medicaid programs should work together to effect changes in licensure laws to allow it.

5. The effect of changes in reimbursement, supervision, and regulation of these professions on the geographic distribution of practitioners must be evaluated. Unfortunately, effects cannot be accurately assessed with current workforce data. Few states have accurate data on the practice locations of all mental health professionals in a format that would enable such analysis, and there is no systematic data gathering at the federal level. The dearth of good data has resulted in most states continuing to use psychiatrists as the only profession considered in the process of designating mental health professional shortage areas (Bird, Dempsey, & Hartley, 2001). Improvement in the availability of mental health workforce data should be made a priority. The most likely federal agency to lead this effort is the Bureau of Health Professions.

2 Studies have found no significant increase in costs to insurance carriers resulting from extending reimbursement to new mental health professions through such laws (Frank, 1989, Lieberman, Shatkin, & McGuire, 1988). One of these studies found that the number of social workers practicing in rural settings almost doubled following passage of a vendorship law (Lieberman et al., 1988). Had these studies been conducted more recently, the effects of


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