Provisionally licensed therapists are individuals who have completed their formal education and training, hold master’s or doctoral degrees from accredited graduate programs, and lack only supervised hours of practical experience in order to qualify for their licensure exam. For years, they have been able to come to North Carolina and provide much-needed therapy services to Medicaid recipients while receiving adequate supervision from licensed professionals in their respective fields.

They have helped offset ongoing, serious workforce shortages in this state, and their services are critical to providers statewide who are trying to meet the mental health needs of their communities. Their outpatient therapy services continue to be vitally important to the survival of North Carolina’s fragile mental health delivery system, which is still reeling after years of mismanagement by the very government agencies entrusted with its care and development.

In a continuance of puzzling decisions, North Carolina’s Division of Medical Assistance has announced that beginning July 1, provisionally licensed therapists will no longer be able to provide outpatient therapy for Medicaid recipients unless they work for a physician, accept only mental health referrals from said physician, and deliver all services on-site where the physician practices medicine. The physician is responsible for supervising the therapy, but provisionally licensed therapists must still seek supervision from approved licensed professionals in their field in order to accrue hours towards licensure.

If a provisionally licensed therapist does not work directly under a physician, they will only be allowed to provide Medicaid’s “enhanced” services, which consist of the services such as Community Support that the state has mismanaged into a confusing, excruciating exercise of redundant paperwork, complex authorization procedures, hours of unbillable time, and frequent denials.

As it stands, on July 1 the vast majority of provisionally licensed therapists will be forced by DMA to interrupt their outpatient therapy work. This decision was made over the clear objections of the mental health professional organization (Professional Alliance Council) that the Division asks for guidance on these issues.

Since there is still a severe workforce shortage in North Carolina, particularly in the rural areas, removing these very capable and much-needed therapists will plunge the system into further crisis. Fewer therapists providing these basic outpatient services will mean more clients deteriorating to the point of requiring more intensive enhanced services. The fact that there are not enough licensed therapists to refer these clients to will create a situation very shortly where there will be hundreds of mental health clients in rural Western North Carolina losing their outpatient therapists. This scenario will also be played out in rural areas statewide. How is this going to improve the delivery of services?

Also, relegating provisionally licensed therapists to only providing enhanced services will keep many recent graduates and many very qualified therapists from wanting to come to North Carolina. Our state already ranks near the bottom in mental health, and this will only solidify our reputation as a state that is bumbling its way toward obliteration of the mental health system with management decisions that are not progressive or even helpful.

Most importantly, perhaps, I have yet to get an answer from DMA or DHHS as to why only physicians are being anointed in the new policy, and why a licensed psychologist is not being considered qualified to do the same. Psychologists are expected to render the same decisions about medical necessity for mental health services as a physician, yet we are considered unqualified to participate in the new policy.

The fact that after July 1 psychologists and other approved licensed professionals will still be required to provide supervision according to our various licensing boards requirements essentially makes us share legal and clinical responsibility for the provisionally licensed therapists’ work. Regardless, we are barred from employing them in our agencies where we can refer to them and provide closer supervision and training.

I would also like to know where all of these participating physicians are going to come from in the rural areas. Most are up to their necks in patients and expending all of their time serving their patients’ medical needs and prefer to refer out to the mental health professionals in the community when a mental health issue is suspected. The vast majority of physicians are not adequately trained in mental health diagnosis and treatment, yet they are the ones that DMA has decided are now the most appropriate to directly supervise the outpatient therapy work of provisionally licensed therapists?

In addition, why would a practicing physician want to further risk malpractice litigation by allowing a provisionally licensed mental health therapist to bill for services through his Medicaid provider number? The only entities that this policy change will benefit are the gigantic mental health corporations that have deep enough pockets to afford their own psychiatrists. The smaller, truly community-based agencies will be replaced by more impersonal, profit-driven mental health Wal-Marts. The irony is that this is the type of situation that reform attempted to correct in the first place.

At this point, any mental health agency in North Carolina still faithfully trying to provide needed mental health services for its communities deserves a medal. Many providers have left the state or the field altogether, having grown weary of the ceaseless changes and incompetent leadership. Instead of policy changes that are going to further destabilize and demoralize us, include us in your decisions and let’s work together to create an inclusive system that works for us all.

(Raymond Turpin, PsyD, is the president and clinical director for Haywood/Jackson County Psychological Services. He can be reached at rturpin@jcpsmail.org.)