NYSPA TASK FORCE ON LICENSURE FOR SUBDOCTORAL SCHOOL PSYCHOLOGISTS December 28, 2007 Task Force Members: June Feder, Ph.D. (Chair,),Larry Bake, Ph.D., Richard DioGuardi, Ph.D., Rosemarie Flanagan, Ph.D., Eric Garfinkel, Ph.D, Jerry Grodin, Ph.D., Rita Perlin, Ph.D., John Stokes, Ph.D., Dianne Polowcyzlç Ph.D & Rudy Nydegger Ph.D. ex-officio,) . Executive Summary The recent CMS ruling limiting reimbursable services for Medicaid- eligible students in New York schools to providers holding credentials which would qualify them to provide the same services outside the school setting, has led to a push by NYASP for passage of its long-standing bill on licensure for subdoctoral school psychologists for independent practice. In recognition of the potential impact of this on both psychological services in schools and the practice of psychology in New York, Dr. Dianne Polowczyk instituted NYSPA’s Task Force on Licensure of Subdoctoral School Psychologists in November to explore ways to address the Medicaid problem and propose an organizational position on the issue of licensure. Based on an investigation of APA and NYSPA policy, review of Medicaid reimbursement procedures in other states and for other groups of providers in New York schools and analysis of NYASP’s proposed bill, the task force recommends opposing the legislation. While the task force recognizes the critical importance of maintaining quality psychological services, supporting the invaluable work of school psychologists for New York public school students and retaining critical funding to schools for these services, the investigation it undertook revealed other viable solutions to address the problems created by the CMS ruling while circumventing a range of negative consequences. Options addressed include in-school only licensure, direct supervision of non-doctoral school psychologists by licensed school psychologists and strategies to increase the pool of doctoral level licensed psychologists available in schools. In our view, these alternatives would serve to maintain funding to schools without, at the same time, sacrificing standards of psychology practice in the community which have long served the public interest and giving rise to other potential risks such as loss of qualified psychologists from schools and diminution of the quality of school psychological training. Statement of Position In a recent Centers for Medicare and Medicaid Services (CMS) ruling, which redefined in several areas criteria for reimbursement of in-school services to Medicaid- eligible students, it was stipulated that counseling could not be billed unless providers of those services held credentials that allowed them to “provide the same services outside of the school.” That is, providers of in-school psychological services i.e. certified school psychologists would be disqualified from providing reimbursable services to Medicaideligible students unless they were already licensed to practice independently in the community. Currently, New York State law provides eligibility for licensure in psychology to doctoral level-only practitioners. As a result of this ruling, the New York Association of School Psychologists (NYASP) has been aggressively advocating for the passage of its long-standing bill on licensure of school psychologists for independent practice (which, it should be noted, they have been actively pursuing since the late 1970’s.) In early November, 2007, the New York State Psychological Association’s (NYSPA) President, Dr. Diane Polowczyk, established a Taskforce on the Licensure of Master’s Level School Psychologists for the purposing of exploring this issue and establishing the framework for an organizational position. To date, investigation of this issue by the taskforce has involved conferral with the American Psychological Association (APA), review of APA’s credentialing standards and long-standing policies for professional psychology, review of NYSPA’s historical position on licensing, exploration of policies and practices in other states re: Medicaid reimbursement for in-school services as well as review of other potential remedies, preliminary data gathering about the actual impact of the Medicaid ruling change on services to students and analysis of NYASP’s actual bill with consideration about potential consequences of its passage. As a result of this investigation, the task force recommends opposing the legislation being proposed by NYASP for subdoctoral school psychologists to be licensed for independent practice by the New York State Board of Psychology. In the following sections, the task force outlines reasons for this positions as well as proposing other perspectives about the Medicaid ruling and ways to address problematic outcomes related to it. • Alignment with APA policy. The American Psychological Association, which is the sole nationally recognized accrediting body for professional psychology programs across the country and which develops nationwide policy and standards for the profession, has established doctoral level training as a fundamental requirement for its recommendations to states regarding licensure in the field of psychology. In a recent draft revision of its Model Act which serves as a prototype for drafting state legislation regulating the practice of psychology, it is stated that “psychologists are recognized as Health Service Providers if they are duly trained and experienced in the delivery of preventive, assessment, diagnostic, therapeutic, intervention management services relative to the psychological and physical health of consumers based on: 1) having completed scientific and professional training in a doctoral degree in psychology.” NYSPA has historically and consistently aligned itself with APA’s position on education requirements for licensure. • Review of provisions in other states related to Medicaid reimbursement for in- school services. NYASP has argued that the solution to New York’s Medicaid reimbursement issue for school-based psychological services requires independent licensure of nondoctoral school psychologists. However, in researching Medicaid reimbursement policies for the same services in other states, we quickly discovered that two school districts in two states - Maryland and Texas— receive reimbursement for these services by school psychologists licensed for in school only rather than independent practice in the community. It is1ikely to conclude that this also goes on in many other states and could be done in New York as well. Therefore, we feel that this and other solutions to the reimbursement problem are more viable than the push for independent practice. Should this not be possible in New York, an alternate solution is for school-based psychological services to be provided under the supervision of a doctoral level licensed psychologist, mimicking a current practice in New York regarding school-based speech services Medicaid permits billing for services provided by a licensed speech pathologist or an unlicensed speech pathologist who is under the direct supervision of a qualified speech pathologist. In light of this, the task force wonders why Medicaid could not make a similar arrangement for services of non- doctoral certified school psychologists supervised by psychologists — rather than requiring the establishment of a new professional license category. Finally, a third option could be to enlarge the pool of doctoral level licensed psychologists available within schools, (This could also operate in conjunction with either of the first two proposed solutions.) Under current regulations, those school psychologists seeking licensure must obtain supervision for their one post- doctoral year’s requirement from a licensed psychologist employed on their site. Since, in some school districts, these individuals may not be readily available, unlicensed Ph.D. level psychologists may be unable to fulfill the supervision requirement. To increase the likelihood that those seeking licensure might obtain it, it may be worthwhile for SED to consider optional arrangements for this requirement such as supervision from licensed school psychologists from other school districts or in the community. • Increased risk to the public. As mentioned above, NYASP has argued that the solution to the Medicaid reimbursement issue requires independent licensure of non-doctoral school psychologists — meaning it wants school psychologists without a doctoral degree (e.g. PhD, PsyD, or EdD) to be able to practice independently outside of schools in the same way as does a New York licensed psychologist (one with a doctoral degree). As already noted, most states restrict non-doctoral school psychologists to practice within public school settings only. The current legislative proposal would, as written, not only extend the domain of subdoctoral school psychology practice to the community but would, in addition, expand the scope of that practice to activities well beyond what is currently done within the confines of the school, such as, for example, applying DSM-TV diagnoses. By allowing school psychologists, who currently operate under the supervision and oversight of their employing school districts, to be free to operate independently without any specific oversight or supervision — especially via a broad expansion of their scope of practice, the State risks exposing the public to professionals who are improperly trained and unsupervised. As such, we are also opposed to this proposal due to the increased liability and potential harm to the public. • Failure to remedy the problem and potential loss of in-school psychological services. The proposed licensure of school psychologists does not appear likely to lead to substantial changes in Medicaid guidelines for reimbursement of school psychological services. First, the implementation of guidelines for the licensure of school psychologists at this time may be dismissed as an effort to circumvent Medicaid guidelines that are already in place. Second, the implementation of this legislation may have the unintended consequence of having school psychologists leave the schools for independent practice. Such migration to private practice is most likely to occur in areas which are already underserved- an objection voiced by many school administrators in Texas when a similar proposal was advanced in that state. Additionally, loss of school psychologists to private practice may result in seriously negative consequences for the estimated 90% of special education children who are not eligible for Medicaid reimbursement. • Exacerbation of public confusion about providers of psychological services. We are concerned that the current legislation, which proposes the title “school psychologist,” has the potential to cause confusion for the public about psychological services. Since it is confusing enough to the public when the term school psychologist is used in the schools by individuals who do not meet the requirements for the title of psychologist outside of the schools, we are concerned that this confusion will be multiplied when consumers outside of the school setting are asked to distinguish between a “School Psychologist” with a more limited scope of practice and a “Psychologist” whose training is “School Psychology” with a more expanded scope of practice. In addition, the discrepancy between practicing psychologists with doctoral level training and those without could add to public concerns about what constitutes adequate training for competent practice. We would suggest that the term “psychologist” be a designation reserved for doctoral level practitioners only. Even in states with master’s level licensure, most titles for these practitioners exclude use of the word psychologist. Examples of titles in other states are Psychological Associate, Psychologists Associate, Specialist in School Psychology, Licensed Educational Psychologist, Psychological Examiner, Licensed Psychoeducational Specialist or Licensed Specialist in School Psychology. • Conflicts between regulatory agencies about in-school psychological services. Under the proposed legislation, non-doctoral providers of school psychological services will be responsible to multiple authorities including building principals in the provision of regular education services, special education directors for provision of special education services, and Office of Mental Health for Medicaid-reimbursed services. Under the best of circumstances, there are often difficulties that school culture presents with respect to accommodating professional psychological services. The further fragmentation of authority for providers of mental health services could lead to serious obstacles for service delivery. Moreover, because the New York State Education Department has abolished the positions of Chief School Psychologist and Chief Social Worker, there is limited way for the school-based practitioner to address professional concerns that may arise within the school setting. • Diminution in the quality of school psychological training and school psychological services. The adoption of a master’s entry level for independent practice of school psychology is likely to have a negative impact on the numbers of professionals who seek the highest level of credential for professional practice in school psychology. With no incentive for achieving the doctoral degree, school psychology will increasingly become a non-doctoral level profession within New York State. The loss of advanced training that is brought by the doctoral level practitioner is likely to adversely impact the availability of qualified supervisory personnel and diminish the ability of schools to address the real mental health needs of children. Although providing school psychologists licensure may have a positive effect on numbers within the school, one could also envision a scenario where the most experienced school psychologists leave the schools to enter private practice — something that clearly would not remedy the current Medicaid problem. Moreover, any reduction in the doctoral level supervisory staff in schools will impact children negatively because universities that have training programs for doctoral level school psychologists will have limited options for internship placements because the internship supervisor must be a licensed professional school psychologist at the doctoral level. Not only is this is a very serious concern as there is already a national shortage of school psychologists; there may be several unintended consequences that include a reduction in the numbers of highly trained school psychologists as well as the exit from New York of those who need to find an appropriate internship. Either scenario will likely result in fewer highly -trained and talented school psychologists. On December 18, 2007, NYSPA’s Executive Committee approved the Task Force’s statement of position for use as NYSPA’s official position until a NYSPA Council review and vote in January. Minority Position DRAFT POSITION STATEMENT: NYSPA CONCERNS REGARDING INDEPENDENT LICENSURE FOR SCHOOL PSYCHOLIGISTS The DRAFT POSITION STATEMENT states that in accordance with standards promulgated by the American Psychological Association (APA), the New York State Psychological Association (NYSPA) strongly objects to the legislation being proposed by the New York Association of School Psychologists (NYASP) for school psychologists to be licensed for independent practice, asserting that the doctoral degree is required for the practice of psychology. I have given a great deal of thought to the DRAFT POSITION STATEMENT and have prepared a few comments for the Task Force to consider. My first concern is how best to meet the needs of children and to recognize our moral responsibility in making sure that children receive the services they need. We have learned that because of the Medicaid reimbursement requirements, some school districts are hiring fewer school psychologists and more dually certified/licensed staff such as school social workers who are licensed to practice as social workers in the private sector. This would also apply to school counselors, many of whom have been recently licensed under article 163 as mental health counselors to practice in the private sector. I think we all agree that while school social workers and school counselors make significant contribution to the well being of students, they lack the extensive training and knowledge that school psychologists bring to the school environment and cannot duplicate the services that school psychologists provide to students. Any reduction in the number of school psychologists in the school system poses a real threat to the ability of children to receive needed psychological services. This is not the first time in recent history that the ability of school psychologists to maintain their distinct role as school psychologists has been threatened. A proposal was made around 2002 (which has not been discarded and so remains a continuing concern for school psychologists) that there be a new title under New York State Education Department (SED) teacher certification called Providers of Learner Support Services with special preparation areas for school counselors, school social workers, school psychologists, school attendance teachers and school nurse teachers. These core competencies essentially usurp the role of the school psychologist by not differentiating the role of the school psychologist from the roles of other practitioners (school counselors, school social workers, school attendance teachers and school nurse teachers) who provide support services to students. A significant portion of what school psychologists do such consultation with classroom teachers and instructional intervention is assigned equally to all of these practitioners. The core competencies for all of the Providers of Learner Support Services can be found in the January 9, 2002 memo from Charles Mackey, Jr. of the office of teacher certification. Examples of the core competencies for all Providers of Learner Support Services are listed in an appendix to this document. The blurring of roles among the various providers of pupil services in the schools presented a clear threat to school psychologists. The strong lobbying efforts by NYASP, NYSPA’s School Division and APA’s Division 16 helped defeat this proposed change in certification. However, this experience can serve as a reminder that psychologists are vulnerable to those who wish to take on their role. In the interest of children, we need to recognize that as a group, school psychologists are the best trained to provide psychological services in the schools, and in the best interests of children, we need to support them in any way we can. We also need to remember that school psychologists are the first face of psychology to the public. It is often due to the positive experience a student or parent or even a member of the school staff has had in working with a school psychologist that will cause someone to seek out a psychologist as the practitioner of choice when seeking mental health services. We would do ourselves an injustice to interfere with this referral source. Despite the position of APA on doctoral requirements for psychologists, some of you may know that psychology was not always a doctoral level profession. It was not until 1956 with the passage of article 1 53 that New York State required the doctorate for licensure, although hundreds of psychologists were grandfathered without the doctorate under article 1 53. The DRAFT POSITION STATEMENT goes on to note that NYSPA has some very specific concerns about components in the current proposed legislation. These include title, scope, educational requirements, internship requirements, and supervision requirements. NYASP is requesting NYSPA’s support n achieving licensure for school psychologists and has made it clear that they are seeking licensure with a limited scope of practice. It is my understanding that NYASP has the support of legislators and many school/educational groups. There is a good possibility that they will achieve licensure without the support of NYSPA. At this point, NYASP has expressed a willingness to review title, scope, educational requirements, internship requirements, and supervision requirements with NYSPA in order to gain NYSPA’s support for the licensure of school psychologists. This provides NYSPA with an opportunity for significant input to a proposed licensing bill for school psychologists. It is my hope that any reservations concerning the licensing of school psychologists is not a guild issue, but a genuine desire to maintain high standards of training for psychologists. NYSPA’s input would help achieve that goal. NYSPA should take the time to fully deliberate this important licensure issue. Following a thorough review by the Task Force, the Executive Committee might wish to make a recommendation to Council. Council needs to review this with their Divisions and Regions before voting on this. Since the membership of many of the Regions include a large number of school psychologists, it would be most appropriate to ask for membership input before Council votes on this issue. I cannot help but agree with Dr. Larry Baker in concluding that licensing of school psychologists “would not be a bad thing for psychology.” I do not see how a licensing bill with clear and limited parameters that allowed school psychologists to provide the same services outside the school setting that they provide within the school setting can pose any genuine threat to psychologists. There is a need for professionals who are both skilled evaluators and knowledgeable about school issues to work with students and parents on school related concerns. Helping school psychologists achieve a limited license for independent practice would not only help assure that students receive the services they need from well qualified professionals. It would also reflect well on the profession of psychology as a cohesive, unified profession with various levels for the delivery of service.