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March 10, 2016

Penn study finds drawbacks to cost-saving measures in public mental health clinics

Use of independent contractors has increased, but administrators less willing to invest in training

In an effort to stay afloat while state funding for mental health care shrinks, many public agencies are switching from salaried therapists to cheaper independent contractors. A new study from the University of Pennsylvania, however, has found that these contractors tend to have less knowledge about, and are less willing to adopt, the latest evidence-based therapies.

"There's a workforce shift occurring in mental health. ... Just identifying that this was an issue was very surprising for me," said lead author Dr. Rinad Beidas, an assistant professor and licensed psychologist.

Having an "evidence-based practice" means keeping up to date on the latest research into effective therapeutic techniques, which today often means cognitive behavioral therapy (CBT). The study suggests that agencies may be less willing to invest in training contractors on new treatments.

"I'm not saying that independent contractors do poor work — what I'm saying is that my ability to develop and enhance and train individuals is also very limited," the study quoted one anonymous executive at a mental health agency.

Another executive said that their agency is "not willing to invest money to send a contractor to an expensive training."

Beidas' team gave questionnaires to 130 therapists in 23 public mental health clinics in Philadelphia that specialized in serving youth, then interviewed executives at nine agencies in person to learn more. Contractors made up the majority of outpatient therapists at four of those agencies, including two that used them exclusively.

Therapists who were independent contractors scored five points lower on a 160-point test of knowledge of the evidence-based practice for youth. The contractors also scored 0.28 points lower on a four-point scale that measured their willingness to adopt the new treatments.

'Your financial goals were literally impossible'

Beidas emphasized that the study does not say that independent contractors are bad at their jobs or that agencies shouldn't rely on them. In fact, some agencies may be unable to survive without them.

"I ran the outpatient department when it was salaried and I cannot tell you the financial stress of running that because your financial goals were literally impossible," said one administrator at an agency that switched from salaried to independent contractors in outpatient therapy.

Contractors are cheaper because they don't get job benefits and don't get paid if a patient does not show up for an appointment, but for that same reason, they have a higher job turnover rate than salaried employees. As one executive said:

"Contractor therapists are paid a piece rate, which means that they see somebody for an hour, and their rate is about $25.50 an hour. And, if the person doesn't show up, they get nothing...they are making a lot of money, but in the back of their mind they are thinking about the other stuff they are doing that they are not getting paid for, such as note writing and team meetings."

What makes the study particularly surprising is that Philadelphia's Department of Behavioral Health has pushed hard to encourage evidence-based practices. It established an Evidence-Based Practice and Innovation Center (EPIC) in 2013 specifically to support such initiatives.

"Our city has been a true innovator in implementing evidence-based practices," said Beidas.

The irony of the situation is that financial pressures may be turning agencies away from the very treatments they've been encouraged to follow.

Read more about the study, which will be published in the March issue of Psychiatric Services, here.

Correction: A previous version of this article incorrectly stated the name of the journal  as Psychiatric News instead of Psychiatric Services. 

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