You didn’t want to. In fact, you tried everything to avoid it. Nothing worked. Now you will do the thing you never thought you’d do: go to therapy.
Here is what you weren’t told about the people who guard the gate to the counselor’s couch.
You didn’t know the entrance was guarded? Few therapy-virgins do. Most people have a better idea of how to buy a car than how to obtain a counselor. What’s more, car research is interesting and test-driving is fun. When you are in the market for an auto, your head is relatively clear. You know your budget. You understand safety ratings. You owned a car before and drove it thousands of miles.
The search for a head-shrinker is different. You are depressed, anxious, confused, grief-stricken, or all the above. Perhaps a crisis is occurring. Perchance you lost your job, your dog, your lover, or your parent. Losing your mind is next. Now you must get a grip and research a therapist.
The best of us are not at our best under the pressure of pain. Patient study is compromised. You want help now. You ask a friend or your primary care physician for a referral. Or you call the insurance company because your informational booklet so advises.
Ringing them up is a bit like phoning your mum and asking her to fix you up on a date. Her list of priorities in making a match is different from yours. To the good, we hope she cares. But her agenda is not your own and her judgment is suspect. Indeed, she resembles the gate-keeper to whom you will speak when you call the number on your insurance card.
Let’s say you or your employer purchased medical coverage through Fly Right Insurance Group of Historic Transylvania, aka FRIGHT. Remember when your brother told you he was afraid of FRIGHT? He was right.
FRIGHT’s rules are typical of most, but not all of those created by the insurance industry.
The voice on the other end of the toll-free number asks you a few questions and appears most concerned about where you live and work, how far you are able to travel, and getting to the next person in the phone queue. Unless you are suicidal, that is, in which case you are told to go to the ER.
The process of personal disclosure you’ve begun will most likely continue, with the counselor’s assistance, once you are in treatment: the world of Big Brother welcomes you. Your initial conversation can be recorded, coded, and kept in your medical file. Indeed, the U.S. government can take a look at some of your therapy records if it believes national security is at stake.
I am not making this up.
The insurance employee offers you a few names or directs you to the “providers” listed on their website. Beware the word “provider.”
The noun suggests FRIGHT views therapists as no different from any other member of the service industry — for example, a man who is going to “provide” you with a paint job, a shoe shine, or dry cleaning. FRIGHT seems preoccupied with the commercial transaction involved in obtaining treatment — the cents and dollars at stake.
The word also seeks to knock the doc off his pedestal. “Doctor” is almost a mystical noun, complete with associations to being a good parent, an all-knowing chief of the tribe (“medicine man”), and a wonderful soul who can be trusted with your life. A provider, by contrast, is just another guy trying to sell you his work. No knock on those who shine shoes, but I imagine you’d want your insurer to be more concerned with the quality of the therapy service than the brilliance of your shoe shine. Their choice of terminology makes you wonder whether they do.
In general, the panel of practitioners is limited. The insurance firm’s protocol is the same when you sustain a car accident and need to take your vehicle to a repair shop. In both instances you are given a reduced group from which to choose. In the former case, you receive the names of those therapists with whom FRIGHT has a contractual agreement. The same is true of auto repair establishments. A similar written commitment applies to them.
It is important to understand why FRIGHT created its own panel (network or list) of shrinks. Equally, you will be curious why those same counselors (or auto body shops) agree to the insurer’s conditions. For each party, financial concerns drive the process. While insurance companies usually indicate that the contract’s conditions have been “negotiated,” FRIGHT and most other insurers operate on a “take it or leave it” basis.
The shrink promises to discount his fee in return for being on the list. There are three factors at play with respect to fee reduction: one benefits the insurance company, the second helps the patient financially (but reduces his choice of therapists), and the third is in the interest of those providers who agree to the insurer’s terms, but not without a cost to them:
- The insurance company’s payable portion of the fee is reduced. In other words, if the full value of a therapy session is $150 and the insurer pays 80%, FRIGHT would have to lay out $120 per session. But, if the charge is discounted to $100, the company’s outlay is only $80 ($100 x .80). The insurer saves $40.
- Similarly, the patient’s part of the bill is also reduced. He is responsible for only $20 (20% of $100) instead of $30 (20% of $150). In other words, the client saves money IF he goes to a provider on the approved list. If not, he discovers the policy will pay a lower percentage of the fee for out-of-network professionals. This has the effect of saving the insurer money on fee payments to those individuals and discouraging the patient from selecting anyone who has not been impaneled, costing him more to visit.
- Why would a therapist agree to a fee-cut on the order of 33%? (The size of this reduction is not unusual, by the way. It can be more or less). The answer is simple. He wants the referrals: a flow of new patients he anticipates from having his name among those recommended by the insurance company. By receiving more referrals he hopes to offset the reduced income due to his discounted fee.
All of this demonstrates that therapy is a business as well as a healing art, treatment is expensive, and the proliferation of shrinks (especially in big cities) causes competition among them. Economic times have diminished the ability to pay out-of-pocket for treatment. Both the insurer and the patient have an interest in reducing costs. The patient is constrained from being treated by anyone he might choose, but is compensated by a lower per session therapy cost and a lower insurance premium. The counselor would benefit if he could keep his fees high, but is willing to lower them if he can fill his schedule with more patients provided by the insurer.
None of this focuses on quality of care. FRIGHT does not make a strenuous effort to evaluate the skill of their “providers” (admittedly a difficult task). They don’t know whether the people they refer you to are the best in their field, average, or below average. Beyond the confirmation of the practitioner’s license to practice psychotherapy and an absence (probably) of discipline by legal authorities or ethics boards, you are on your own in determining his excellence.
For the most part, insurers take a therapist’s word for his expertise. He states his range of skills: diagnostic evaluation, cognitive-behavioral therapy competence, psychodynamic treatment experience, etc. The qualities are simply checked-off by the therapist from a list required by the insurer.
What you are dealing with, then, is something like the self-descriptions on a dating site. We know how trustworthy they are.
The dominating dictate of the dollar determines which therapists you are encouraged to consult by your insurer. Money is also a significant consideration for the therapist, who not only takes a smaller fee if he wants to receive potential referrals, but agrees to other conditions FRIGHT will impose on him once you walk through his door. He creates a description of himself according to FRIGHT’s guidelines. You are expected to take him at his word, just as you are expected to take your insurance company’s word that the list they have created is comprehensive and the professionals on their website are adequately vetted and good at what they do.
Incentives exist for both parties (the impaneled therapist and the insurer) which have nothing to do with your treatment. Those motivations go beyond your well-being and are sometimes in competition with your well-being. If you don’t pay attention to them, no one will do this for you other than your suspicious brother who warned you about FRIGHT.
I should point out that without such cost-saving mechanisms, the price of psychotherapy would be higher than it now is. Decades ago insurance firms discovered how they could artificially restrain costs and guarantee profitability by so doing. In the process, they dampened the increase in health care costs for their customers, but also limited their choice of doctors, ancillary health care professionals, and hospitals.
Many practitioners are driven to discount fees as a simple matter of economic survival. Most would prefer not to deal with insurance matters at all. A small number refuse to submit claims and have flourishing practices nonetheless. Such, however, is not the typical reality of delivering the services for which treaters trained. Your therapist’s calling to help humanity probably did not include a vision of the red tape involved.
The intervention of insurance giants in the counseling marketplace and their influence on treatment is not limited to what I’ve described. Additional concerns come into play once you reach the inner-sanctum of the therapist’s office. The long, tentacle-like arms of insurance companies reach everywhere.
I’ll talk about this more in another post.
The top image, Frightened Girl, is the work of Daigo Oliva. The Halloween photo is the work of Policia Nacional de los columbianos. Both are sourced from Wikimedia Commons.