Policy change can be hard, slow, and seem daunting. This is especially true at the federal level, but many of the important changes happen at the more accessible state and local levels. For example, Pennsylvania leaders recently helped to change state Medicaid policy to allow licensed professional counselors (LPCs) and licensed marriage and family therapists (LMFTs) working as integrated clinicians in FQHCs to bill Medicaid. In this blog post, Cheri Rinehart, President & CEO of the Pennsylvania Association of Community Health Centers (PACHC), answers 5 questions about why and how this policy was changed.
What is the history of this issue in Pennsylvania that prompted you and your collaborators to take it on?
As the number of health centers working to integrate behavioral health (BH) increased because HRSA made this a priority, PACHC received growing feedback about the challenges the FQHCs faced in recruiting eligible providers. The need became even more evident and pressing when one of our partner organizations, the Health Federation of Philadelphia, negotiated managed care organization approval for a “warm handoff” initiative in health centers in Philadelphia. When discussion with the Department of Human Services (DHS) was initiated in the summer of 2012, our original goal was approval of licensed social workers (LSWs), LPCs and LMFTs as BH providers eligible to generate an FQHC reimbursable encounter. It became clear very quickly that if we adopted an all or nothing attitude, we would get nothing, because DHS felt strongly that LSWs should not be included because they do not exercise independent judgment. We agreed on that compromise and DHS agreed to pursue a state plan amendment to initiate the change to add LPCs and LMFTs. And then nothing happened. For a long time. And then, in response to one of our regular inquiries on status of the issue, DHS asked for validation of need. This was the pattern over many years: We would reach what looked like agreement and then a new question would be raised, requiring new data, analysis and time. Each time, after allowing ourselves to feel the disappointment, we regrouped, re-strategized and recommitted to the goal.
What was your overall strategy in framing and advancing the case?
It is important to share that our relationship with our partners at DHS was established long before we started this advocacy journey and has strengthened along the way. We both feel that our overarching goal is the same: improve access to quality, affordable health care, especially for the most vulnerable individuals and families. We recognize one another as important partners. Key officials from both organizations meet every month. Our initial discussions and exploration of DHS’ opinion on this issue were a more informal part of these regular meetings. Our first goal was to listen so that when we moved to the more formal step of submitting what we refer to as Recommendations for Consideration, the document would reflect and address issues and concerns that DHS had raised.
Who were the key collaborators and stakeholders and why was their involvement important?
The health centers across Pennsylvania were our key stakeholders and they served as collaborators on the initiative by regularly sharing with us their frustrations in trying to recruit a workforce adequate to meet the needs of the individuals and communities they serve. That meant that we could share with full honesty and integrity in our meetings that it was a rare week when we did not receive multiple calls and emails from health centers desperate to respond to the need and asking for an update on progress on the policy change to help them in doing so.
Why do you think you were successful?
Many factors contributed to our success, but the key to successful advocacy on any issue is clearly identifying and staying focused on the end goal so you don’t get distracted by the barriers you are sure to encounter on the advocacy pathway. Our end goal in this case was to expand the FQHC workforce to improve access to integrated BH services. While we identified early in the advocacy process what we thought the best solution was, if we had solely focused on that solution rather than the end goal, it would have gotten in the way of success. Success in advocacy requires development of relationships before you need them, being prepared for unexpected turns, extreme patience, a willingness to compromise, persistence, maintaining professionalism even when frustration levels rise, and seeking to understand as well as be understood. Several times over the years we thought we were close to the finish line and then were confronted with a new obstacle, but we never gave up and remained gently persistent, always including the issue on meeting agendas with DHS.
What lessons learned would you share with CFHA members seeking policy changes at a grassroots level?”
You know what you want and why, but success also requires understanding, framing and responding to the issue from the viewpoint of those responsible for making the change you are advocating. Because this issue for us was very FQHC-specific, we did not engage other advocacy partners, but that is not usually the case. Identifying and engaging the stakeholders who might support or oppose your proposal is an important early step in advocacy on any issue. Be prepared for success to take time and that you might have to change course multiple times. In a world that generally moves quickly it is hard for those awaiting the change to understand why it is taking so long, so it is important from the beginning to set an expectation of preparing for a marathon, not a sprint, and for progress at “the speed of government.” A single person in a key role can be a barrier—it does not feel fair, but it is often reality. Feedback from our members anxious for the policy change was not an annoyance—it was essential to keeping our commitment to success high. Never give up if it is truly something you believe is the right thing to do—reevaluate strategies and alternatives, but don’t relent. When we were feeling most weary from the journey it was hard to believe, but true, that success was just around the corner.