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Therapists Have No Guarantees in Tomorrow’s Healthcare Economy
Many people covet a career as a psychotherapist. Testimony to therapy’s need and value can be found almost daily in the media. Yet our large and dynamic healthcare economy is making modification of some aspects of a therapy career likely in the near future.
Managed care serves as one harbinger of change. Management companies (or MBHOs) emerged as independent behavioral payers in the 1990s, but they have now merged into health plans. Such consolidation is occurring on a broader scale, bringing both risks and opportunities for the profession.
Access to the career has already changed. Educational costs have skyrocketed. Clinicians once emerged from graduate school with a few thousand dollars in debt, and many now have obligations near $200,000. A similar fate for physicians has gained public awareness, but solutions for medical school debt are not likely to extend to graduate school debt. Can the career support such high debt levels?
Many therapists get degrees hoping to enjoy the financial rewards and autonomy of private practice. This possibility is eroding. While MBHOs once impacted the compensation and independence of practitioners, a more profound transition is now underway. A shift to salaried work is spawning the end of the private practice era. Physicians have experienced this for years. Healthcare is consolidating.
Therapists in early-stage careers are torn. They face the competing attractions of private practice beside those of salaried employment. They struggle to make sense of compensation for others in the field. Psychiatrists in 2021 had average earnings of $250,000 while psychologists earned $100,000. Yet wages are not the only tangible career rewards. Employed colleagues enjoy non-monetary benefits that are enticing.
Beyond good income, many therapists want full benefits, personal time off, administrative support, a reasonably balanced caseload, and the emotional lift from being part of a team. These desires may be brewing among many clinicians today, but only salaried employees can attain them. A private practice is supposed to bring top earnings and support some of these aspirations, but this is increasingly unlikely.
A salary looks quite attractive when private practice does not generate high income or perks. However, the quality of life for employed clinicians needs examination. It too may have shortcomings. Our field should be taking steps to ensure therapists benefit, even thrive, as healthcare consolidation progresses.
Autonomous Professionals or Tightly Managed Employees
We should not be sanguine about therapy careers. Wages will depend on whether therapy jobs are viewed as roles for autonomous professionals or work for task-oriented employees. This is an open question. Therapists will not necessarily be treated or compensated as autonomous professionals.
While therapists are licensed to practice independently, this dictates no specific level of autonomy or judgment. Wages could be modest. The therapeutic work could be tightly prescribed. The clinical norm could be treating problems with guideline-driven care, possibly as part of a stepped-care model in which digital therapeutics are offered first, followed by therapy for more severe problems.
Financial concerns could one day drive such a 2-tiered delivery system in which therapists are tightly managed. One can imagine a limited menu of therapy services provided in a highly directed work environment. Open-ended therapy might cease. After all, this was tried in the earliest days of managed care. A lower tier of digital and coaching services could go to those not meeting criteria for therapy.
Digital therapeutics are evolving toward this vision. Some digital products have open access, while others are available only by prescription. Health plans are starting to cover the latter. Coaching is also growing, with non-professionals providing services similar to those offered by therapists. While not currently covered by insurance, many primary care practices use unlicensed staff in a variety of ways.
A care delivery system structured as described here is feasible. The services exist, but a system like this has not yet been organized, funded, and promoted. One feature is likely in any case—salaried therapists will deliver services as part of a larger healthcare entity. Our field should seek to ensure that therapists are as autonomous as possible and compensated in line with similarly educated medical professionals.
A pivotal issue around which autonomy and equitable pay turns is the question of where therapists will practice. If therapists work in separate behavioral clinics, the odds increase that strict limits could be placed on their independence and earning potential. An alternative path would likely facilitate autonomy and equitable pay—partnering with PCPs in the primary care setting.
Why might therapy as frontline primary care be more highly valued? Therapists would rely heavily on judgment for their brief interventions. Far more patients would be helped than in specialty behavioral clinics. Most critically, consensus grows that primary care’s success depends on our behavior change expertise. A delivery system like this is feasible, as is one undervaluing and tightly managing therapists.
Our field should not passively await the outcome. Ensuring the most rewarding path for therapists requires strong leadership now. Let us make therapy a fine career for generations to come.
Ed Jones, PhD is currently with ERJ Consulting, LLC and previously served as president at ValueOptions and chief clinical officer at PacifiCare Behavioral Health. Carrie Singer, PsyD is executive director of Quince Orchard Psychotherapy and founder of TheraHub.
The views expressed in Perspectives are solely those of the author and do not necessarily reflect the views of Behavioral Healthcare Executive, the Psychiatry & Behavioral Health Learning Network, or other Network authors. Perspectives entries are not medical advice.
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