ProPublica has an interesting investigative report titled “Why It’s So Hard to Find a Therapist Who Takes Insurance.” It highlights the perverse incentives of our system. The formatting is of the bizarre type increasingly popular for reasons I can’t fathom, requiring scrolling through pop-ups of blurbs before getting to the actual substance.
Although federal law requires insurers to provide the same access to mental and physical health care, these companies have been caught, time and again, shortchanging customers with mental illness — restricting coverage and delaying or denying treatment.
These patients — whose disorders can be chronic and costly — are bad for business, industry insiders told ProPublica.
“The way to look at mental health care from an insurance perspective is: I don’t want to attract those people. I am never going to make money on them,” said Ron Howrigon, a consultant who used to manage contracts with providers for major insurers. “One way to get rid of those people or not get them is to not have a great network.”
There are nowhere near enough available therapists in insurance networks to serve all of the people seeking care. And although almost all Americans are insured, about half of people with mental illness are unable to access treatment.
The consequences can be devastating.
To understand the forces that drive even the most well-intentioned therapists from insurance networks, ProPublica plunged into a problem most often explored in statistics and one-off perspectives. Reporters spoke to hundreds of providers in nearly all 50 states, from rural communities to big cities.
The interviews underscore how the nation’s insurers — quietly, and with minimal pushback from lawmakers and regulators — have assumed an outsize role in mental health care.
It is often the insurers, not the therapists, that determine who can get treatment, what kind they can get and for how long. More than a dozen therapists said insurers urged them to reduce care when their patients were on the brink of harm, including suicide.
All the while, providers struggled to stay in business as insurers withheld reimbursements that sometimes came months late. Some spent hours a week chasing down the meager payments, listening to hold music and sending faxes into the abyss.
The primary reason I opposed the Affordable Care Act (ObamaCare) despite supporting its aims was because it doubled down on the unworkable insurance-based model in ways that seemed obviously counterproductive. While I understood why they did this, given the failure of the reform effort under the Clinton Administration partly because the insurance industry put so many resources not crushing it, requiring expanded coverage, including for pre-existing conditions and mental health treatment, was at odds with making care more, well, affordable.
While I support making mental health (and vision and dental!) coverage universally available, it just makes no sense to try to do that relying primarily on a system wherein a third-party middleman is trying to skim profits. So, it’s not at all shocking that insurance companies make it hard to seek non-emergency treatment over a sustained period.
Conversely, since patients themselves aren’t paying most of the cost, there is every incentive for providers to seek to maximize profits by billing as much as the system will allow. Which tends to least to suboptimal treatment or over-treatment.
Naturally, the providers blame the insurers for this. The anecdotal nature of the report makes excerpting difficult. But there are multiple stories of providers getting pushback from their insurance networks for extended treatment regimes, being pressured to limit sessions to 45 minutes, and to limit treatment to some finite time period rather than as an indefinite relationship.
And, oddly, governmental policies contribute to the problem:
Reimbursements rates are largely stagnant and notoriously low. Therapists on average earn about $98 for a 45-minute session from commercial insurers, whereas their out-of-network colleagues can earn more than double that amount. Dozens of providers told ProPublica their reimbursement rates have barely shifted in years.
The overhead of running a private practice can also be substantial: malpractice and health insurance, billing and administrative services, office rent and utilities. Insurers pay only for time in session, not the documenting of notes or chasing down of payments.
The reimbursement rates for mental health clinicians are also lower than what insurers pay medical providers for similar services. Take two in-network clinicians: If you spend an office visit talking about depression with your psychiatrist and then have the same conversation with a physician assistant, an insurer could pay the physician assistant nearly 20% more than the psychiatrist, despite their medical school training. This is according to rates set by Medicare, which insurers look to when setting their own rates. Despite federal rules requiring equitable access to care, there are no requirements to even out provider reimbursements.
Providers could join forces to fight for better pay, but antitrust laws and insurer contracts forbid them from collectively setting fees, which limits them talking to one another about how much they make.
One imagines running a psychiatrist’s office is cheaper than most medical practices, in that there’s not much in the way of expensive equipment. But, certainly, if the Medicare-standard reimbursement rate is so low that it’s driving people out of accepting insurance, it’s self-defeating.
