Doug Ford to cap OHIP-covered psychotherapy

[Muscarinic_xo]

OHIP-coverage for psychotherapy is on the chopping block to be capped based on a OMA working group. Any thoughts?

Anyone know of how I could reach out to someone within the working group about this? This would be a decision that would impact me personally. 

https://lfpress.com/news/local-news/mental-health-advocates-critical-of-proposed-ohip-talk-therapy-cap

 

[Yellowhead]

Far too many GPs are offering ongoing psychotherapy when they are ill-adequately trained to do so. Presently, they can bill OHIP for an unlimited number of "psychotherapy" sessions per year. This contravenes the scope and purpose of evidenced-based psychotherapy which is most commonly limited to X number of sessions. Ford's proposed plan aims to hold doctor's accountable who unscrupulously bill OHIP for mental health care rendered that is not always in the best interests of the patient. The proposed changes do not seek to cease the ability of doctor's to provide psychotherapy, but rather to limit the maximum number of sessions doctor's can bill OHIP under this category, and further, to discourage the practice of "boutique psychiatrists" i.e. those psychiatrist whom only see a select few patients multiple times per year and who selectively avoid new patient intakes. The proposed changes are reasonable and justified. Increased efficiency and improved quality of care are steps in the right direction.

[Muscarinic_xo]

@Yellowhead  Thanks for the perspective. Are there any considerations or options for patients who require more frequent therapy? Wouldn’t more training be a better solution given our current mental health crisis if scope and readiness are concerns?

 

I would prefer that strategies to target misuse instead of a blanket policy that restricts everyone based on an arbitrary cap instead of medical need. 

[ellorie]

I disagree that it is reasonable to globally cap. There is a subset of patients (typically with complex trauma and personality disorders) who it is well known tend to not fully respond to 12-16 sessions of psychotherapy and need more. 

These patients are often high users of inpatient and emergency settings and present with a great deal of disability. 

It is not right or okay to prevent these people from accessing the treatments that are most useful to them (medications typically help these folks minimally if at all) simply because some patients could be better treated in short term modalities. 

Long term dynamic therapy has a role in psychiatry. I have seen it work for people who would never have responded to a brief course of CBT and in fact have had that and not made gains. 

[Muscarinic_xo]

16 minutes ago, ellorie said:

I disagree that it is reasonable to globally cap. There is a subset of patients (typically with complex trauma and personality disorders) who it is well known tend to not fully respond to 12-16 sessions of psychotherapy and need more. 

These patients are often high users of inpatient and emergency settings and present with a great deal of disability. 

It is not right or okay to prevent these people from accessing the treatments that are most useful to them (medications typically help these folks minimally if at all) simply because some patients could be better treated in short term modalities. 

Long term dynamic therapy has a role in psychiatry. I have seen it work for people who would never have responded to a brief course of CBT and in fact have had that and not made gains. 

I have seen this too. @ellorie do you know how someone could contact members of the working group to express this?

[Butterfly_]

1 hour ago, Yellowhead said:

Far too many GPs are offering ongoing psychotherapy when they are ill-adequately trained to do so. Presently, they can bill OHIP for an unlimited number of "psychotherapy" sessions per year. This contravenes the scope and purpose of evidenced-based psychotherapy which is most commonly limited to X number of sessions. Ford's proposed plan aims to hold doctor's accountable who unscrupulously bill OHIP for mental health care rendered that is not always in the best interests of the patient. The proposed changes do not seek to cease the ability of doctor's to provide psychotherapy, but rather to limit the maximum number of sessions doctor's can bill OHIP under this category, and further, to discourage the practice of "boutique psychiatrists" i.e. those psychiatrist whom only see a select few patients multiple times per year and who selectively avoid new patient intakes. The proposed changes are reasonable and justified. Increased efficiency and improved quality of care are steps in the right direction.

How many GPs actually abuse the system anyway? Why are we penalizing the patients and not the perpetrators? Also, if the problem is the lack of training, then why don’t we just provide the training? We definitely don’t have enough psychiatrists to meet the psychiatric needs of our patients. The wait time for a psychiatrist in Ontario is 6 months—too long.

[Yellowhead]

On 4/23/2019 at 6:06 PM, ellorie said:

I disagree that it is reasonable to globally cap. There is a subset of patients (typically with complex trauma and personality disorders) who it is well known tend to not fully respond to 12-16 sessions of psychotherapy and need more. 

These patients are often high users of inpatient and emergency settings and present with a great deal of disability. 

It is not right or okay to prevent these people from accessing the treatments that are most useful to them (medications typically help these folks minimally if at all) simply because some patients could be better treated in short term modalities. 

Long term dynamic therapy has a role in psychiatry. I have seen it work for people who would never have responded to a brief course of CBT and in fact have had that and not made gains. 

 

Interesting perspective.

The Ontario Ministry of Heath and Long-term care has proposed limiting OHIP coverage to 24 hours of psychotherapy sessions per year. This is well-above the 16-20 hours of psychotherapy reserved for many evidence based psychotherapy approaches such as CBT. Of course, some patients may need more comprehensive and long-term care, and we should appropriately strive to create a system that can fulfill the needs of such patients.However, villainizing a system that seeks to create checks and bounds is not entirely fair. It is also counterproductive in creating a health care system that is effective and efficient.

Perhaps, a more important question to ask is whether GPs are the most qualified professionals to provide psychological care (let alone such care to patients with complex and ongoing mental health care needs) to begin with? Access to health care and effective and appropriate health care are not synonymous. The reality is that GPs are not specifically trained to manage psychiatric disorders. Authorizing GPs to bill OHIP for an unlimited number of psychotherapy sessions per year may not only cause inadvertent harm to patients (i.e. increased dependency, worsening of symptoms) and doctors; given the unique demands associated with providing psychological care, but may also lead to increased wait times and diminished quality of care for other patients. In my opinion, a more appropriate avenue would be to implement a program that provides public funding for psychotherapists, psychologists and/or clinical counsellors i.e. those solely trained to manage and/or treat psychiatric illness, while still allowing GPs to provide psychotherapy within a system that has implemented the appropriate checks and bounds to ensure quality of care and prevent misuse. Mental health care is undoubtedly important and I think it's important that patients receive the most appropriate and effective care. This, is second to none.

[Yellowhead]

https://nationalpost.com/health/boutique-psychiatrists

[freewheeler]

I don't like provincial governments trying to create further division among and within specialties.

[LittleDaisy]

On 4/24/2019 at 6:37 PM, Yellowhead said:

 

Interesting perspective.

The Ontario Ministry of Heath and Long-term care has proposed limiting OHIP coverage to 24 hours of psychotherapy sessions per year. This is well-above the 16-20 hours of psychotherapy reserved for many evidence based psychotherapy approaches such as CBT. Of course, some patients may need more comprehensive and long-term care, and we should appropriately strive to create a system that can fulfill the needs of such patients.However, villainizing a system that seeks to create checks and bounds is not entirely fair. It is also counterproductive in creating a health care system that is effective and efficient.

Perhaps, a more important question to ask is whether GPs are the most qualified professionals to provide psychological care (let alone such care to patients with complex and ongoing mental health care needs) to begin with? Access to health care and effective and appropriate health care are not synonymous. The reality is that GPs are not specifically trained to manage psychiatric disorders. Authorizing GPs to bill OHIP for an unlimited number of psychotherapy sessions per year may not only cause inadvertent harm to patients (i.e. increased dependency, worsening of symptoms) and doctors; given the unique demands associated with providing psychological care, but may also lead to increased wait times and diminished quality of care for other patients. In my opinion, a more appropriate avenue would be to implement a program that provides public funding for psychotherapists, psychologists and/or clinical counsellors i.e. those solely trained to manage and/or treat psychiatric illness, while still allowing GPs to provide psychotherapy within a system that has implemented the appropriate checks and bounds to ensure quality of care and prevent misuse. Mental health care is undoubtedly important and I think it's important that patients receive the most appropriate and effective care. This, is second to none.

The GP psychotherapists that I know, have extensive training in psychotherapy often during residency or doing additional training. Over years of working, they become extremely knowledgeable working with mental health patients.

Patients who use GP-psychotherapists, are often complex, could not afford private psychotherapy, a good psychologist costs 100-200$ per hour. There are a lot of allied health professionals who do psychotherapy, social workers or counsellors, who are not psychologists per say, but have psychotherapy training in their education. Regardless, private SW charge 100$ per hour. 

Currently, the Ontario government is cutting funds everywhere. Hiring clinical psychologists, psychotherapists would end up being costly to the system, than having GPs who do psychotherapy as a side job.  Unfortunately, psychotherapy exists mostly in private healthcare system, only well-off people could afford private psychotherapy. The residents' Manulife psychotherapy only covers up to 500$, which is like 2-3 sessions max.  The sickest patients are very vulnerable, from low SES background, they cannot wait 6 months to see a psychiatrist as someone mentioned, and those patients end up seeing GP-psychotherapists.

I have referred patients to GP-psychotherapists, because they can't afford private psychotherapy; nor can resident physicians with 500$ cap with our Manulife plan. The waitlist for GP-psychotherapist has gotten longer, the demand is there. What Ford is doing is cutting down mental health psychotherapy, and even attacking public funded GP/ psychiatrist funded psychotherapy, which is unfortunate.

What is ironic, is that the sickest patients afflicted with mental health, they do not have the means to access private psychotherapy. Psychologists and counsellors often work in private, and only who are financially well-off with a good private insurance plan could afford private intense psychotherapy. 

[heydere]

What are some training programs or electives to consider doing for GP psychotherapy? 

[Bluecolorisnice]

Ford spent 30 million$ on legal fees to argue carbon tax lol and he wants to save money by cutting mental health care, education for low income students, removing teachers and slashing public health. Its a joke that he won and it goes on to show how horrible things can get when you vote for some asinine leader that only cares about promoting cheap alcohol. Would be nice to see efficiencies instead of cuts and i strongly hope ford doest win next term. 

[Edict]

On 4/23/2019 at 5:17 PM, Yellowhead said:

Far too many GPs are offering ongoing psychotherapy when they are ill-adequately trained to do so. Presently, they can bill OHIP for an unlimited number of "psychotherapy" sessions per year. This contravenes the scope and purpose of evidenced-based psychotherapy which is most commonly limited to X number of sessions. Ford's proposed plan aims to hold doctor's accountable who unscrupulously bill OHIP for mental health care rendered that is not always in the best interests of the patient. The proposed changes do not seek to cease the ability of doctor's to provide psychotherapy, but rather to limit the maximum number of sessions doctor's can bill OHIP under this category, and further, to discourage the practice of "boutique psychiatrists" i.e. those psychiatrist whom only see a select few patients multiple times per year and who selectively avoid new patient intakes. The proposed changes are reasonable and justified. Increased efficiency and improved quality of care are steps in the right direction.

This is a good point. You'll be surprised at how much waste is present in our system. 

[Muscarinic_xo]

 

On 4/23/2019 at 5:17 PM, Yellowhead said:

Far too many GPs are offering ongoing psychotherapy when they are ill-adequately trained to do so. Presently, they can bill OHIP for an unlimited number of "psychotherapy" sessions per year. This contravenes the scope and purpose of evidenced-based psychotherapy which is most commonly limited to X number of sessions. Ford's proposed plan aims to hold doctor's accountable who unscrupulously bill OHIP for mental health care rendered that is not always in the best interests of the patient. The proposed changes do not seek to cease the ability of doctor's to provide psychotherapy, but rather to limit the maximum number of sessions doctor's can bill OHIP under this category, and further, to discourage the practice of "boutique psychiatrists" i.e. those psychiatrist whom only see a select few patients multiple times per year and who selectively avoid new patient intakes. The proposed changes are reasonable and justified. Increased efficiency and improved quality of care are steps in the right direction.

@Yellowhead - If we are worried about lack of adequate training, isn't improving training a better solution? When wait lists are already so high, I feel like we should be encouraging more GPs and psychiatrists to offer psychotherapy. In many instances, access to psychotherapy saves Ontario from more expensive treatment options because ailments have escalated.

Regarding limiting the number of sessions, I still fundamentally believe this should be based on patient-need rather than an arbitrary number. There are definitely reasons why patients may need more or less than 24. I don't see why limiting things to "24 sessions" is improving quality of care. Like care of physical ailments, I believe it is the doctor that should be deciding the length of care required for each patient, based on their specific condition and unique circumstances. If boutique psychiatrists are the concern, surely policies can be created to target that rather than an arbitrary limit. 

[OntarioPatients]

This is a very thoughtful thread. Australia introduced gated access to more than 50 psychotherapy sessions called Medicare Item 319. It has created much controversy and excluded people from accessing needed care. They are in the process of loosening the restrictions on it and addressing privacy violations concerning the separate billing code that everyday administrators can see.

There is now a collective of patient groups opposed to the 24 hour psychotherapy cap. Please follow @OntarioPatients and @sick_of_cuts. We have organized a petition to submit to the Ontario Legislature before it rises Dec. 12. The House will not reconvene until after the AWG makes their decision in January so we only have until Dec. 12 to make an official protest there.  To get a copy of our petition (which must be submitted in original hard copy) please email ohipsychotherapy@gmail.com. We would be grateful for any signatures we can get.

Also we have two online petitions to show MOHLTC and the AWG that there is popular opposition to this funding cap: 

https://www.change.org/p/ontario-provincial-government-remove-the-cap-on-psychotherapy and 

https://you.leadnow.ca/petitions/stop-doug-ford-cuts-to-psychotherapy-1

Please support us any way you can on social media, with the petitions, letters or tweets to Minister Elliott @celliottability and Minister Tibollo @MichaelTibollo or even AWG co-chair and Ministry rep Joshua Tepper @DrJoshuaTepper. AWG is a closed negotiation so public opposition has to express itself in other ways.

For further background see https://eopa.ca/about-us/opa-psychotherapy-initiative especially op-ed by Norman Doidge

If you have any questions please contact ohipsychotherapy@gmail.com

[Muscarinic_xo]

On 11/15/2019 at 5:59 PM, OntarioPatients said:

This is a very thoughtful thread. Australia introduced gated access to more than 50 psychotherapy sessions called Medicare Item 319. It has created much controversy and excluded people from accessing needed care. They are in the process of loosening the restrictions on it and addressing privacy violations concerning the separate billing code that everyday administrators can see.

There is now a collective of patient groups opposed to the 24 hour psychotherapy cap. Please follow @OntarioPatients and @sick_of_cuts. We have organized a petition to submit to the Ontario Legislature before it rises Dec. 12. The House will not reconvene until after the AWG makes their decision in January so we only have until Dec. 12 to make an official protest there.  To get a copy of our petition (which must be submitted in original hard copy) please email ohipsychotherapy@gmail.com. We would be grateful for any signatures we can get.

Also we have two online petitions to show MOHLTC and the AWG that there is popular opposition to this funding cap: 

https://www.change.org/p/ontario-provincial-government-remove-the-cap-on-psychotherapy and 

https://you.leadnow.ca/petitions/stop-doug-ford-cuts-to-psychotherapy-1

Please support us any way you can on social media, with the petitions, letters or tweets to Minister Elliott @celliottability and Minister Tibollo @MichaelTibollo or even AWG co-chair and Ministry rep Joshua Tepper @DrJoshuaTepper. AWG is a closed negotiation so public opposition has to express itself in other ways.

For further background see https://eopa.ca/about-us/opa-psychotherapy-initiative especially op-ed by Norman Doidge

If you have any questions please contact ohipsychotherapy@gmail.com

Thank you for sharing!!! Appreciate the work behind all of this. I hope we can pull together as much support as possible. Crossing fingers.

[Iamokayyyyyy]

On 4/24/2019 at 6:37 PM, Yellowhead said:

 

Interesting perspective.

The Ontario Ministry of Heath and Long-term care has proposed limiting OHIP coverage to 24 hours of psychotherapy sessions per year. This is well-above the 16-20 hours of psychotherapy reserved for many evidence based psychotherapy approaches such as CBT. Of course, some patients may need more comprehensive and long-term care, and we should appropriately strive to create a system that can fulfill the needs of such patients.However, villainizing a system that seeks to create checks and bounds is not entirely fair. It is also counterproductive in creating a health care system that is effective and efficient.

Perhaps, a more important question to ask is whether GPs are the most qualified professionals to provide psychological care (let alone such care to patients with complex and ongoing mental health care needs) to begin with? Access to health care and effective and appropriate health care are not synonymous. The reality is that GPs are not specifically trained to manage psychiatric disorders. Authorizing GPs to bill OHIP for an unlimited number of psychotherapy sessions per year may not only cause inadvertent harm to patients (i.e. increased dependency, worsening of symptoms) and doctors; given the unique demands associated with providing psychological care, but may also lead to increased wait times and diminished quality of care for other patients. In my opinion, a more appropriate avenue would be to implement a program that provides public funding for psychotherapists, psychologists and/or clinical counsellors i.e. those solely trained to manage and/or treat psychiatric illness, while still allowing GPs to provide psychotherapy within a system that has implemented the appropriate checks and bounds to ensure quality of care and prevent misuse. Mental health care is undoubtedly important and I think it's important that patients receive the most appropriate and effective care. This, is second to none.

Is it 24 sessions per patient? or 24 sessions total per year the GP can bill OHIP?

[ellorie]

20 minutes ago, Iamokayyyyyy said:

Is it 24 sessions per patient? or 24 sessions total per year the GP can bill OHIP?

The proposed cap was intended to be per patient per year.   There is a lot of opposition and it has not happened as of yet - hopefully we can continue to hold it off.

[BigM]

21 minutes ago, Iamokayyyyyy said:

Is it 24 sessions per patient? or 24 sessions total per year the GP can bill OHIP?

it certainly won't be total/year (all patients pooled), that would be absurd.

[Iamokayyyyyy]

Oh ok - and does anyone know what the situation is like in Quebec? I wasn't able to find any information about it. Can GPs offer counselling/Psychotherapy there? Does anyone know?

[ana_safavi]

I think there should be an exception to the cap for physicians who have training in psychodynamic therapy. Very few physicians have this type of training anyway (and probably next to no GPs). But the ones that do should be able to offer unlimited OHIP-covered psychodynamic therapy to their patients. This is really a tiny subset of patients anyway. But in general I think the  patient population would be better served if OHIP dollars were shifted to covering other trained psychodynamic therapy providers (particularly clinical psychologists) rather than funding unlimited, non-specific "supportive therapy" sessions by MDs.

And the OMA should push the expansion of early CBT through online group sessions. Patients love therapy groups and it's a much more cost-effective way of delivering CBT. Moving it to videoconference makes it cheaper and also solves accessibility issues (travel is a big barrier for many patients).

I even think that some basic CBT and DBT techniques should be taught to all high school students to give them the tools to cope with (at least routine levels of) anxiety. That way they'll already have some rudimentary coping skills in place when they start university so they won't end up in the ER during mid-terms from exam stress.

[ellorie]

1 hour ago, ana_safavi said:

I think there should be an exception to the cap for physicians who have training in psychodynamic therapy. Very few physicians have this type of training anyway (and probably next to no GPs). But the ones that do should be able to offer unlimited OHIP-covered psychodynamic therapy to their patients. This is really a tiny subset of patients anyway. But in general I think the  patient population would be better served if OHIP dollars were shifted to covering other trained psychodynamic therapy providers (particularly clinical psychologists) rather than funding unlimited, non-specific "supportive therapy" sessions by MDs.

And the OMA should push the expansion of early CBT through online group sessions. Patients love therapy groups and it's a much more cost-effective way of delivering CBT. Moving it to videoconference makes it cheaper and also solves accessibility issues (travel is a big barrier for many patients).

I even think that some basic CBT and DBT techniques should be taught to all high school students to give them the tools to cope with (at least routine levels of) anxiety. That way they'll already have some rudimentary coping skills in place when they start university so they won't end up in the ER during mid-terms from exam stress.

Almost all psychiatrists train in psychodynamic psychotherapy to some degree during residency, and I imagine we are providing the vast majority of MD psychotherapy.  Clinical psychologists don't all train in psychodynamic either.  I also doubt that many clinical psychologists would want to drop down to OHIP rates given what they can make in private practice - they won't be any more affordable than we are.

I think there is far too much of a push away from individual psychotherapy towards group and far too much emphasis on CBT as a panacea for mental illness.  I really don't want to see any more involvement from the MOH in determining who needs what type of therapy, because I think the current trend in psychiatry is moving away from what our most complex, impaired patients actually need.

If we are doing supportive therapy, most of us are doing it with complex, traumatized, marginalized, polydiagnostic individuals who need that level of care.

Also, most of the patients I see are sick of groups and want individual.

[ana_safavi]

1 hour ago, ellorie said:

I also doubt that many clinical psychologists would want to drop down to OHIP rates given what they can make in private practice - they won't be any more affordable than we are.

Problem is that it can be hard for patients to find a psychiatrist who is willing to do extensive psychodynamic therapy -- especially in a smaller town. The wait list can be extensive. If OHIP covered other providers, patients could have better access and greater choice. Although perhaps all this COVID stuff will normalize therapy over videoconference as an option for people in smaller towns.

I totally agree with you about CBT being overrated. It was kind of a fad that took hold (complete with self-help books) and then they tried to shove it indiscriminately down everybody's throat because...worksheets feel like you're making some kind of concrete progress even if you're not? I don't get it. Like good luck mustering the motivation to fill out a bunch of paperwork about your maladaptive thoughts in the midst of the cognitive fog of depression. That's why I think it's more useful as a universally taught skill than a therapy per se.

Do we have stats on what % of patients actually get >24 hours of therapy in a year? That would translate into an hour every other week, consistently, for a whole year. I don't think that's the majority of patients.

Edit: ohh wait I just realized this is an old thread from 2019. My bad. Never mind.

[LostLamb]

Psychodynamic psychotherapists need good supervision. Unlikely there has ever been the threshold of therapists in one place that isn’t an urban centre to make this possible  

yes, now that there are more venues for virtual interactions the therapists can convene that way; however to be able to do supervision/case consultation rounds you need to be in person to be able to get paid—so at least in Alberta you won’t find a Psychiatrist psychodynamic psychotherapist in a small or rural place.