Earnings Potential for the Doctor of Behavioral Health
Introduction
The DBH program is a significant investment of time and money, and the answer to the question “What will my earnings or salary be once I have the DBH?” is critical for any prospective student considering enrollment. The DBH is unique in that it is explicitly designed to prepare our graduates to search, identify, evaluate and pursue opportunities for enhanced personal income. The curriculum is designed to prepare students with the skills necessary to demonstrate the value added they bring to the health-care system in areas such as quality, outcomes, cost-effectiveness and return on investment. A central assumption of our program is that the health-care marketplace is moving in a direction in which integrated behavioral care, accountability for clinical and cost-of-care outcomes combined with business entrepreneur skills will lead to enhanced opportunities for earnings for behavioral clinicians, especially relative to reimbursement in the traditional behavioral health-care market.
Trends in the Health-Care Market
There are a number of trends that point towards increased value for behavioral clinicians who specialize in integrated primary behavioral healthcare:
National Health-Care Reform
President Barack Obama has made health-care reform a priority of his administration. Many lobbying groups that have historically opposed significant reform are now invested in changes. Key components of reform include addressing the shortage of primary care physicians and improving delivery services in primary care by using a Medical Home model, in which ancillary providers such as behavioral clinicians work as a team to address patient care.
National health-care associations are actively lobbying the Obama administration to include increased integration of behavioral care in primary care and reform of payment mechanisms so that behavioral interventions in primary care are reimbursed both more easily and more fairly.
Payers of Health-Care Search for Solution to High Cost of Co-morbid Conditions
The major payers of health-care services—the government, health plans, managed care companies, large employer groups—are searching for approaches that will successfully address the problem of high utilization and cost of care for patients with co-morbid chronic medical and behavioral conditions. These payers are increasingly critical of popular disease management and case-management programs that have grown into a multibillion-dollar industry but have not delivered on promised cost savings. The primary care behavioral interventions that are a foundation of the DBH program have demonstrated the medical cost offset that is so sought after. We believe the key for success is to deliver these interventions co-located in primary care, where patient trust, convenience and engagement are high, compared to approaches that rely on telephone outreach from distant companies.
Existing Examples of Integrated Behavioral Care
Another common question is “Are behavioral clinicians already providing integrated care in primary care settings?” The answer is a resounding “Yes!” The Veterans Administration Medical Center (VAMC) and United States Military (e.g., Army, Air Force) have been co-locating behavioral clinicians, typically psychologists, in primary care and medical settings for years now. In addition, across the country psychologists and social workers have begun to establish integrated care practices. [add examples here]
Projected Earning$
We have undertaken several steps to quantify the earnings for DBH clinicians. Following are several examples that provide salary or fee-for-service ranges based on concrete examples. These include salary surveys from current job postings, consultation with leaders in integrated behavioral care, and fee-for-service reimbursement based on the Health and Behavior CPT Codes (see Fee for Service Reimbursement section below) that are increasingly used to reimburse behavioral clinicians in primary care and medical settings. In each section below, a summary statement of anticipated earnings is listed in bold, followed by evidence for the projection.
Annual Salaries
It is anticipated that a DBH will earn in the range of $70,000 to $100,000 plus, based on the years of experience and region of the country in which he or she practices.
A Federally Qualified Health Center in Arizona has maintained a team of master’s degree, licensed counselors providing integrated behavioral care in the medical units of the center. The director of the service reports that master’s degree, licensed counselors earn in the range of $40,000 to $50,000.
The VAMC routinely posts openings for psychologists, and occasionally social workers, in primary care behavioral clinician positions. The salary range for these positions is from $60,000 to $110,000, depending on the grade level, which generally is tied to years of related experience.
A psychologist who is involved in training, research and consultation with psychologists has filled positions in Hawaii. The annual salary for these positions is $115,000. This does reflect the higher cost of living in Hawaii. However, he also reports that due to a shortage of behavioral clinicians trained in integrated behavioral care there is a shortage of these positions, and due to demand qualified clinicians earn approximately 25% premium over an average psychologist’s salary in traditional specialty behavioral care settings.
A psychologist in the Midwest runs an integrated behavioral health program and reports salaries in the range of $60,000 to $80,000 or more based on experience and degree of management responsibilities. In this case, note that the area of the Midwest has a lower cost of living than many other parts of the country. This psychologist also noted that a clinician with solid foundation of integrated behavioral health skills who can also train and supervise others will have a premium of $5,000 to $10,000 in salary relative to a more traditional behavioral clinician.
Earnings for Behavioral Providers in Primary Care are Greater than other Settings
The average annual wage for behavioral providers working in primary care and medical settings is greater than the average wage for behavioral providers in traditional outpatient settings. The premium or value added will range from ten to twenty percent greater average salary.
According to the Department of Labor, the mean annual wage for a psychologist was $68,150 in 2006. For the 75th percentile it was $80,320 and the 90th percentile, $104,520. The industry in which the psychologist works also affects salaries. The average salaries for psychologists in physician offices or the offices of other health-care practitioners are significantly greater than the mean salaries for psychologists in traditional specialty care settings.
| Industry | Annual Mean Wage |
|---|---|
| Physician Offices | $93,330 |
| Offices of Other Health Practitioners | 481,160 |
| Outpatient Care Centers | $60,890 |
| Elementary and Secondary Schools | $66,040 |
These finding that behavioral clinicians in medical settings have higher annual wages is consistent with recent feedback from psychologists who are familiar with recruitment and hiring. The increased focus on improved integration of behavioral care in primary care settings in the current proposal for national health-care reform lends support that this trend will continue. Finally, the DBH program is designed to prepare graduates to immediately move into health-care administrator roles, a process that normally takes behavioral health professionals a long time to accomplish without the DBH degree.
Fee-for-Service Reimbursement
In areas where a clinician is eligible for reimbursement using Health and Behavior Codes for claims, the average hourly fee-for-service reimbursement will be approximately $100 per hour.
Several years ago CMS adopted new Current Procedural Terminology (CPT) reimbursement codes call “Health Behavior Assessment and Intervention” or “H&B” codes for short. These codes are designed for reimbursement of behavioral health interventions delivered by behavioral clinicians for patients with a primary medical diagnosis. The codes are for behavioral interventions used to identify the psychological, behavioral, emotional, cognitive and social factors important to the prevention, treatment or management of medical conditions. The codes are reimbursed in fifteen-minute units of service. Here are the codes:
96150–Initial assessment
96151–Re-assessment
96152–Behavioral intervention provided to an individual
96153–Behavioral intervention provided to a group
96154–Behavioral intervention provided to a family with the patient present
96155–Behavioral intervention provided to a family without the patient present
While the H&B codes are available in many areas of the country, there is great variation from state to state in terms of which payers reimburse these claims and which providers are eligible for reimbursement. There are specific rules for reimbursement for these codes beyond the scope of this paper. However, see this SAMHSA document for more information: [add SAMHSA “Reimbursement of Mental Health Services in Primary Care Settings” ]
In Arizona the H&B codes are reimbursable by major health plans for licensed master’s-level clinicians (counselors, social workers, marital and family therapists). On average, the rate of reimbursement is in the range of $25 per 15-minute unit of service, with the exception of the 96153 group, that is closer to $5 per 15-minute unit. In other states the model of reimbursement may be significantly different or not available. We encourage prospective students to research reimbursement for H&B codes in the state in which they plan to practice. Where available, these codes provide a rate of reimbursement that is often greater than traditional CPT codes for psychotherapy.
Contracting with Payers for Population-Based Interventions (Disease Management, Health Coaching)
DBH clinicians proficient in contracting directly with payers (e.g., health plans, large employer groups) may be able to earn significant income on a per-member, per-month (pmpm) payment model. For example, a contract to follow 100 high-cost patients for one year and $2 pmpm will result in an annual reimbursement of $2,400. Please note that with payers representing large populations the number of high-cost cases is typically in the thousands.
Across the country an army of clinicians, typically nurses and social workers, are working for health plans, managed-care organizations and other national companies providing what is referred to as disease management, condition case management or health coaching. In general these approaches are based on identifying a population that is at risk for higher than average utilization and cost of medical care due to a combination of behavioral and medical conditions. Once the population is identified, usually based on claims data, health-risk assessments by the health plan or employer, the patients are contacted by mail and phone and invited to “enroll” in the health program. The health programs typically involve providing educational materials, self-help resources and completing exercise in workbooks or, more commonly on the Web, on how to manage their chronic condition. Data are collected on patient enrollment, participation and completion, as well as clinical and ideally utilization and cost-of-care pre- and post-intervention. While there is consensus that patients who actively participate in these programs do show clinical improvement, to date the anticipated cost savings have not been demonstrated. This is leading payers to re-evaluate the cost-benefit of these large contracts and search for other solutions to the problem of high utilization and cost for these patients.
The DBH program is designed to prepare clinicians to conduct population-based health interventions that combine the disease management or coaching approaches common to these national companies with the advantage of improved patient engagement by initiating the program from the office of the PCP. Behavioral interventions initiated in the PCP office where the patient has greater trust and more convenience result in a higher rate of patient engagement with the behavioral clinician in the office compared to a referral to a distant company or office. The DBH courses in population-based health management, technology in behavioral health, evidence-based behavioral interventions using stepped-care, and of course business entrepreneurship—how to develop, present and implement a business case with a payer—are designed to meet this emerging need in the health-care system. We anticipate that DBH clinicians who practice locally will be able to approach local and regional payers to contract for these services. The reimbursement for these services are typically computed based on how many patients the clinician will engage and follow over time based on a set amount paid “per member per month,” meaning for each patient carried in the clinician caseload a monthly fee will be paid. These fees typically range from as little as $1 to as high as $15, depending on the level of intensity of follow-up, complexity of the patient population, etc. We anticipate that in addition to seeing patients routinely for integrated care in the primary care office, the DBH clinician with an interest in this type of work can maintain a caseload of patients who he or she communicates with initially in person, but more routinely by phone or e-mail over time.
Salaried Positions for Disease Managers or Health Coaches
DBH clinicians will be well-suited to work as telephonic disease managers, case managers or health coaches for health plans, managed-care organizations and other companies. The salary ranges for these positions are generally similar to traditional behavioral health positions, but offer the benefits such as flexible hours and working from home.
While the primary mission of the DBH program is to prepare graduates for work co-located in primary care or other settings, there are also many openings across the country for behavioral clinicians to work as telephonic disease managers or health coaches (see Contracting with Payers for Population-Based Interventions section above). Traditionally these positions have been filled by nurses, and more recently by social workers. These national companies are increasingly interested in hiring clinicians with specialized skills in behavioral interventions for patients with co-morbid medical and behavioral conditions.