Friday, October 16, 2009

health reform from a provider's perspective

Here's what I'm seeing in my practice. I've been doing this for ten years now. Long enough to declare a trend.

And no, stodgy research types, I don't need to conduct a double blind placebo trial in order to render opinions of substance. This is my peer reviewed blog.

Copays are going up. When I first started, the $15 copay was routine. Maybe the copay of highest frequency. I even saw a few $10 copays. Copays of $20 and $25 were the next most routine. But now? The most frequent copay has inched up (and by that I mean, nearly doubled) to $30 and $35. I have a few people who pay $50 per visit. And yes, that's a copay. And I haven't seen a $10 copay in years.

Deductables are higher. And I'm seeing them more often, too. When someone comes in for psychotherapy, especially for the first time, they mistakenly believe their mental health copays and deductables will be the same as a visit to the medical doctor. But the reality is that most of the time? As in, 90% of the time? The mental health benefit requires more cha-ching. (90% was derived from my unscientific, morning cup of coffee to jostle the memory, study).

Usually the most jarring shock is delivered in the form of the mental health deductable. It is not unusual, these days, for me to see $1500 and $2500 before their copay kicks in. Of course, for most, this is a no-getter. No getter therapy. No getter better.

Score one for the insurance industry. They got their premiums. Now you don't get your therapy.

Number of sessions authorized? Going down. It isn't at all unusual, these days, to see "20 visits per year" maximum. Or, lifetime maximum, 60 visits. That's lifetime, people. Which means, if you are diagnosed bipolar you can count on 20 visits per year for three years. Or it might be a dollar amount maximum. $3000 lifetime max. That doesn't cover very much therapy over the adult lifespan, which could be 60 years, easy.

Fees paid to providers? Not going up. Much. Or at all.

A couple days ago my daughter, TwinB, who is at a new school and meeting lots of new friends, approached me, wide eyed. That day she had told a new friend that her mom (me) is a psychologist. "Wow." The girl replied. "You must be rich." TwinB tilted her head at me, as if to say, "What the heck?!?"

This is the same daughter I took to the thrift store earlier in the week to shop for "new" jeans. She looked at me that way because she sees nothing of the rich lifestyle at our house.

We therapy shrinks, the ones paid by health insurance companies, are not making money hand over fist (what does that saying even mean?). Therapy shrinks as opposed to medical shrinks, that is. You know, those real doctors.

But, last I checked the business page, the insurance companies are making it hand over fist. How do we think they have become one of the most powerful lobbies in Washington? Their good looks?

One example. For ten years a certain health insurance company, whose name rhymes with poo-knighted wealth bear, has not increased my fee. Ten years. This lack of regard for inflation means many providers drop off the network. When a poo-knighted client of mine requires psychiatric care, I wince. Good luck finding a quality psychiatry doc who can see you before the next Perseid meteor shower arrives.

Which brings me my next point:

Provider networks are shrinking. No pun intended. I recall when my family doctor posted a sign that they no longer accepted, guess which one? Poo-knighted wealth bear. I knew why. But I asked anyway. The doc, looking none too comfortable discussing his bid-ness with a patient, said he was "having trouble getting payments." I wanted to ask, "Trouble getting a raise, you mean?" But didn't. I had a sick child before him. And I understood his decision. And endorse it even, from the hope that if enough doctors drop off the networks, people will see that insurance companies are dropping the ball.

It's common knowledge that when psychiatrists get a big enough clientele, or patientele, they drop off insurance networks. Private pay only. Those are some pretty discouraging words to hear when you're suffering from major depression because your husband has left you for a younger woman and you have no job because you've been raising his kids for the past twelve years and all you've really got left of your marriage is the fact that he still claims you as his dependent on his health insurance and that will only last until the divorce goes through so you need help now.

And there's more. There's HMO forms and authorization requests and stalled payments and denied payments and being on hold for fricking forever when you call the claims department. But that's about all I have time to go into right now because it's time to head into the office, and you know, be the provider.

But here's my end of the rant summation: The health insurance system, from my view, has tilted into the direction of the wealthy get healthy but the middle class get screwed. And dropped coverage. And depressed. And in need of mental health services but can't afford it.

Ok, after all of that, I'm depressed. I need to make an appointment with a shrink. Oh, but wait. That's right. I can't. I'm self-employed. I don't have mental health coverage. Can't afford it.

So I guess we providers on the networks are shrinking in more ways than one. Or we want to. But we can't afford the coverage.


Lisa Wheeler Milton said...

I'm sorta blue after reading this too, because therapy saved me - saved me - at just the right time, when I needed it.

Therapy made my fairly happy life possible.

To see it growing out of reach for so many is a health crisis, and one we will all collectively pay for, as our communities fall apart.

Fiona of Cork said...

As always, I am standing and applauding you and your amazing ability to lay it out there, perfectly and succinctly. (Now why does Blogger say you've "blocked me" as a follower?)

Jenn @ Juggling Life said...


Magpie said...

Is fucked up.

Thanks for writing this.

hokgardner said...

Thank you for offering a provider's perspective to this issue. Our pediatrician dropped BCBS, as did every other pedi in town, so I had to pay out of pocket for every appointment, to the tune of $100 per kid. It got really expensive.

The radio show This American Life, last weekend and this coming weekend, is broadcasting a two-part series on the health care issues. It should be required listening for all legislators and all people who don't think the system needs to change.

Mary Alice said...

Thank you for writing this. Mental health is serious business, all too often overlooked. I'm linking to you.

Stacie said...

I almost started crying when I read this post. I see a psychiatrist for PPD and OCD. IF.. Blue Cross Blue Shield were to pay for this, it would be a $40 dollar copay... but they don't. My regular dr copay is $40 (six per year at this rate, rest applied to deductible and then they pay 80%), ER $150, deductible $5000, deductible on scripts $500. We pay $600 a month and because we are in GA that is probably a song compared to those who live in NYC or someplace like that. We too are self employed so we get that whopper 15.7% social security tax too which IMO should help us out with medical expenses somehow...but we make too much money. In the mean time, I am paying outright for my psychiatric visits and $65 month for meds after I pay the deductible. This might be TMI for some but I don't think things will change for mental health providers or patients until we all start yelling about it. I didn't ask for this illness I have and a heart patient has a better chance of preventing heart disease than i do mental illness but we are treated like we are "making it up."

blognut said...

Excellent points - all of them.

I kinda love you right now.

Rachel Cotterill said...

Fascinating reading - especially from a British perspective, because I know very little about your system. (e.g. never heard the word copay - is that what the patient has to pay themselves?)

Interesting if your medical insurance wouldn't cover you to have therapy. Because as I understand it, all practising psychotherapists/counsellors in this country are actually obliged to have regular sessions themselves.

Jodi Anderson said...

Holy freaking moly. This really hit home with me. After almost 20 years of great health insurance, my husband's employer switched to one that was supposed to be a better deal for everyone.


Our copays did indeed double to $35. My daughter and I have type 1 diabetes and use insulin pumps. The price of all of these meds have doubled. It's ridiculous.

We felt lucky to not be affected by the poor economy, until the insurance situation.

This is a really informative post and I love your perspective.

Sinda said...

Great post. Nice to see other perspectives.

We just went through annual enrollment at work, and one of the notices was about mental health coverage - something to the effect that the gub'ment was making companies offer mental health coverage that was equal to medical health coverage - no limit to visits, same co=pays, etc. Did I read that right, have you heard anything? I didn't notice anything in the media.

OK, it occurred to me that I could Google this, so I did:

Seems like this will be a positive change for you? Maybe?

phd in yogurtry said...

Rachel -- yes, copay is a small payment due at the time of service. not all plans have copays. and yes, some training programs require therapist and psychologist students to attend therapy. there is no requirement for working professionals.

Sinda -- thanks for the excellent link. I knew a parity bill had been passed. I was looking for changes starting Jan 09 but saw none. This is the first I've heard confirmation that 'a change is a comin' so I'm glad to read this.

This was a bummer to read: "the Mental Health Parity Act does not require plans to include mental health and/or substance abuse disorder benefits" Makes me wonder if fewer companies will offer the mental health component?

But at least the parity of benefits, when offered, will be in place. That's helpful. More visits per year, for example. It's so hard to predict. Insurance companies are going to CTA (cover their tush) one way or the other. It's hard to feel genuinely optimistic.

We shall see. I also wager that mental health copays won't come down; rather medical copays will increase. What do you want to bet?

Anonymous said...

Interesting and informative!! WHY can't people see how broken our system is? I get so tired of people trying to defend it, and making themselves look rather ignorant while doing it, in my opinion.

Thanks for a great post.

Anonymous said...

Even though I've lived in the US for five years, I *still* don't understand the whole healthcare system. It doesn't really matter, though, because I can't afford health insurance, anyway.

When I did have insurance (through the university I was at), I couldn't make heads or tails of the information they sent me. I had no idea what treatment I was entitled to or not. And I'm an educated person!

I can't help but think that the insurance companies do that on purpose so people sign up for crappy plans they don't understand, thinking they'll be taken care of, and then they get sick, and find out they won't be.

My experience of psychiatrists here has not been good. Psychologists and therapists work much, much harder, I think, from a more holistic point of view, whereas shrinks just throw a prescription for anti-depressants at you.

Reluctant Blogger said...

Obviously I am not familiar with the US healthcare system (thankfully). But there was an article in the UK press last week, which highlighted the fact that

"Mental illness in its "classic" sense, including depression and schizophrenia, affects one in four people in the UK each year but receives just 5% of total health research spending."

You can read the article here if you wish.

Fantastic Forrest said...

Great post. I'll be using this in my health care policy reform class.

When I was growing up, members of your profession seemed to be strictly for the rich or celebrities. But as an adult, I appreciate them tremendously, and think everyone should have access to this type of care.

Susan said...

Glad you posted from the care provider's side. We now have Kaiser (HMO) and pay $1350. per month for the family, with a $30. copay.

I was having trouble getting a referral to mental health so I was paying $130. per visit to see a psychologist until I lost my job early this year. Even when you pay, you don't get coverage - that's what tick me off!

Stacie said...

Susan- $1350 a month! My heart goes out to you...

Sorry I got to angry before it's just that this subject makes me so frustrated. Individuals and self employed are the worst off. When will we have to choose between health insurance or our mortgages?

Also, I wanted to ask, are there any professional memberships mental health providers can join to get better rates? Of course, illustrators don't have one, but I thought something as big as your industry would have a sort of group organization just for this sort of thing.

Anyway, thanks for letting me rant.

phd in yogurtry said...

Stacie -- There used to be a group plan through the APA (American Psychological Association) but I don't think that is available anymore. Our local city Psych Assoc tried to get a group plan in place, but the plan was about the same cost as my individual (at that time) plus the insurance company proffered wasn't as desirable (refer to my post). All this to say, I am not aware of a group plan for psychologists.

~annie said...

Thank you for this excellent post! I'm lucky to have health insurance. I think... Because of the cost, my employer changes plans every year, shopping for the cheapest one. I can't keep it straight anymore - what my benefits are, what the co-pays amount to, whether there are some of those pesky "lifetime" benefits, etc. etc. It's enough to make me crazy. Except I'd better not, because at this point I'm not sure if it's covered...

Mental P Mama said...

It makes me so sick. Sick.

Becca said...

whose name rhymes with poo-knighted wealth bear,

thank you for the laugh. I used to have them and can attest to the fact that they SUCK!

Kathleen Scott said...

I'm glad you're putting this out. The only people who know how bad the situation is are the ones who are hit--providers and patients. But everyone needs help sometime. Which means that in the long run, society will suffer.

I heard from Paula at that she'd like to reference your piece on her blog to help spread the word.

You're doing good work.

Casey said...

Yep, yep and yep. My therapist (one of those medical types) has not participated in any insurance networks in years, and I don't begrudge her that decision at all. A single mother has to pay the bills, and the insurance hassles and piddly reimbursements weren't cutting it.

My insurance company reimburses for crap on mental health visits, too. It's so discriminatory, and it's been that way with every major provider we've ever had. Currently I can have 30 physical therapy sessions a year at 100% coverage (minus that whopping $25 copay each visit) but mental-health therapy to keep that PT-healed body going? Are you crazy?

Margo said...

thanks for explaining this. I love hearing your perspective on this. One of my good friend's husbands is a family practice doc and he has gone totally private not accepting insurance. It sounds like a great thing to some - but if this is where it's headed that leaves most of us out of the loop.

patti said...

I am so lucky.
My son was hospitalized last spring for almost 6 weeks.
My insurance covered hospitalization 100%. Which is good, because the bill was more than I make in a year.
Monthly meds monitoring with a psychiatrist: covered 100%
Meds: $4 per month.
phd level Psychologist: $12/weekly visit.
If I had to deal with a financial crisis as well as well as a mental health crisis, my son and I would both be lost right now.
All this plus my employer gave me a 6 month paid leave so I could just focus on his recovery.
We are slowly getting back to real life and doing really well.

Therapeutic Ramblings said...

patti: I think we all need your insurance!! I formerly had amazing insurance, but that went away with the economy and life changes

As for insurance companies....they were the main reason I decided that when I open a private practice, it will be cash only. For a part-time person, it isn't viable to take insurance. I know I'll limit myself, but hearing some of the reimbursement numbers out there make me cringe.