Mental Health Therapy and Insurance
Our fee-for-service system is broken.
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.
As someone who has a grand kid and to step kids who run the spectrum from manageable to chronic, the metal health system is broken. It’s all but impossible to get a diagnoses and emergency mental health intervention can be crippling financially. I three different occasions mt wife’s kids have had to have our grand get access and all three times it was a nightmare of 30 + hour waits in a large crowded waiting room filled with people who ran the spectrum from comatose to violent. If you leave for any reason you go to the back of the line waiting for a bed. Once you get a bed it could be close to where you live or halfway across the state. Once you get a bed the patient has to be evaluated then there is the problem of a shortage of mental health professionals that deal with kids.
It is a literal nightmare and all of this depends on having a parent who can put off work at the drop of a hat and sit with your kid in the scary uninviting waiting room. Also, as a step grand parent I am unable to be the guardian (until both my wife and I where made legal guardians). And still to this day there is a stigma about mental health that is positively voodoo as far as I can tell. The people in emergency rooms have no earthly clue what to do with these people who are waiting in an emergency room for a bed in a mental heath care facility and the quality of those facilities varies dramatically from the pretty well run to nightmare nurse Ratchet scenarios.
Mental heath is, at best an after thought in this country and since the propensity in society for mental heath issues is relatively low compared to accidents and emergency medical issues, the larger population just doesn’t care about it. And the frustrating thing is a lot of it can be addressed through proper diagnoses and treatment but there isn’t enough trained professionals to deal with the population and few have the insurance that will covet the needs of chronic sufferers.
The whole issues is on the bubble of awareness and you really have to go though it to understand how profoundly broken the system is.
Our entire medical system is a problem and no one wants to address it be those with good insurance don’t want to mess with it and the rest have little voice to drive change. There is too much money to be made and since deep pockets always seem to win the policy debate we are stuck with it.
My daughter, and previously my wife, saw a therapist for anxiety. And our copay was higher than this.
Part of the problem is a tendency in our culture not to think of mental-health disorders as “real” medical conditions. There’s a tremendous amount of stigma around mental illness, with people worrying about being negatively judged in a way that would be much less likely with a physical disability, and with a strong bias toward ascribing any dysfunctional behavior to a failure of character. The mental health professionals know better, of course, but the lack of understanding in the broader culture makes it that much harder to pursue a legislative solution.
The proponents of ACA saw the cost of health insurance, rather than the cost of healthcare/treatment as the problem to solve. Because the solution was to eventually increase the number of people purchasing insurance premiums, the insurance industry got onboard The article above is evidence that the health insurance industry is all about profit, not about health care.
We don’t think of mental health as ‘real’ because the implication would be that everyone at one point in their life should check in for some time with a therapist for a second opinion.
Most people understand that physical health is precarious. That’s why we have yearly checkups. But with my mental health, you can dismiss everything unless a crisis occurs.
Just want to say that as one who has navigated mental health care (both as a patient* and as a parent of a patient) in rural areas, it sucks. Our psychiatrist shows up once a week and the waiting room will contain as many as 50 patients (or more, the waiting room is always in overflow).
Mental health is the bstrd step child of American healthcare.
* I tried as a patient. Didn’t take me long to figure out that no matter how much the psychiatrist might care (he must have, it was a 2 hour drive for him and I really doubt most folks had the insurance to cover it) I was going to be lost in the shuffle.
But with my mental health, you can dismiss everything unless a crisis occurs.
Now there’s a Freudian typo.
In the early 80’s I was a business manager for a group of psychologists in private practice. In truth, at that time, the generic therapist did not qualify for insurance reimbursement. I was in MN at the time, a state that had relatively liberal reimbursement laws, but even then the threshold for reimbursement was being a Licensed Consulting Psychologist, the requirements for which, IIRC, included a Ph.D in either clinical or counseling psych and X number of years experience. Social workers, masters level psychologist and other types of counselors and therapists could get some reimbursement, if they worked under supervision, with the the supervising LCP usually taking 50% of the reimbursement. Add to that were restrictions on the number of sessions, typically 10.
Given that most people seeking mental health assistance do not require the knowledge and skill that the LCP infers, not comping other counseling professionals means mental health care is reserved for only those that can afford it or individuals who didn’t seek early care due to cost and now are in crisis.
As bad as the health care system in the US is mental health care is much, much worse.
Regarding insurance, for good or bad, it will be part of the US healthcare delivery system forever.
So here’s the thing I don’t quite understand. Whether it’s an insurance company or the government (e.g. Medicare/Medicaid) negotiating reimbursement, why are they allowed to dictate the part that’s not covered?
I live in an expensive area, so guess what? The therapists are more expensive. They’ve got costs of living, too. (I’m now seeing $250-300 for 45 minutes). If they could still be in-network to defray the patient’s cost while still having sizeable co-pays to fund the therapists’ overburdened schedule, that sure would help everybody! But as others have noted, many or most of them don’t accept insurance due to this limitation, so therapy is reserved for the rich.
Our mix of private and public medicine is really the worst of both worlds.
The entire healthcare system is being enshittified. Between insurance companies consolidating horizontally and vertically, hospital systems doing the same, and VC buying both the incentive for profit is swamping any intentions to provide excellent, patient centered medical care. There are other problems too, especially the failure to grow the physician pipeline commensurate with population growth and demographic changes, but medicine as a for profit enterprise instead of a public good is fundamentally flawed
FWIW, my therapist (and some of the people I’ve seen in the past) has completely moved off of the insurance model. So I pay out of pocket. It’s a necessary cost that I can afford. I also am lucky enough to be able to do that without making hard decisions.
I agree that our overall approach to mental health in the US is not great. I think it’s slowly getting better, but I don’t think it’s fast enough to deal with the longterm impacts of things like Covid-19 and it’s aftermath.
@Franklin:
When a provider signs a contract with an insurance company, or joins a Medicare/Medicaid panel, they agree to a total amount for each service for the subscribed patients who will be using that network. For in-network providers, the only amount “not covered” are the patient balances due to copays, deductibles or co-insurance.
For out-of-network providers, there is no contract but, depending on the state, you may have sunshine act or balance billing provisions limiting any unexpected charge to the patient and/or limiting reimbursement to a usual and customary rate.
Bottom-line that if the provider wants to be able to charge what they want, they (a) need to be out of network and (b) be explicit with the patient that they are out of network and how much it will cost them.
@Franklin:
Except for the people at the bottom of the food chain that don’t have $100 (?) for the copay–week in, week out*. The way the market deals with shortages is by pricing some buyers out. Always has been, always will be. (It’s why some places go with national health service models.)
*Of course, it’s possible that the people at the bottom have done nothing to empower themselves to deserve mental health care. Lot of that in Murka, too.
I could write pages on this but I wont. I think I would just point out that this makes clear how much the insurance companies have control over our care. They are willing to pay, just as an example, surgeons and hospitals well for joint replacements so that surgeons make close to a million a year and hospitals make big profits. As a result wait times for those surgeries is minimal. In general the insurance companies dont pay well for pediatric mental health or other pediatric specialties (with some exceptions). The result is very long wait times and care that is unavailable for many people.
Steve
@steve: I, for one, would like some in-depth perspective on how to navigate this morass of shit from someone who’s been in the trenches, if you care to expand further.