How Finding a Therapist is Like Visiting a Dating Site (Only Worse)

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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.

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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:

  1. 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.
  2. 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.
  3. 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.

Boo!

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.

An Inside Story on (Mental) Health Insurance Reform

There is much misinformation and misunderstanding about the workings of the health care system. Here are a few observations on how things work from the perspective of someone who is a practicing clinical psychologist with experience both inside and outside of hospitals:

1. The Doctor/Patient Relationship. In the days before managed care, doctors and patients really did make decisions without too much interference from insurance companies and the government. While insurance companies set some limits on what they would pay out (maximum benefits for mental health services were usually expressed in dollar amounts) and would pay no more than what they deemed “reasonable and customary” fees for each “service,” they did not typically require that practitioners obtain “pre-certification” (pre-authorization) of those same services. So, if you and your therapist thought you needed the treatment that he was offering, the insurance company let you obtain that care and supported it by paying in accord with the insurance contract that you held directly with them, or, more likely, held through your employer.

Managed care caused several changes. First, it required “pre-certification” for many forms of treatment, thus explaining the “managed” nature of the care. That meant that the practitioner (or a member of his staff) had to fill-out forms that explained the nature of your condition, provide a treatment plan, and justify the type of treatment that he hoped to provide.  Depending on the insurance company, sometimes pre-certification required a phone call with the insurance company’s “gate-keeper” to discuss the information just mentioned. And, depending on the length of treatment or changes in the patient’s condition, this process would be repeated so long as you were in the care of the therapist in question.

It is important to understand that the relationship between the doctor and the insurance company was (and is), at least to some degree, antagonistic. If the therapist is unfettered by the restraint of the managed care arm of the insurance company, he stands to get paid by them for as much treatment as he prescribes and the patient consents to receive. On the other hand, to the extent that the insurance company can limit or say “no” to the doctor’s plan, the company gets to keep more of the money paid to them in insurance premiums. Both sides will maintain that they only work in the patient’s best interests, but it should be easy to see the slippery slope that both parties are on, a slope called “financial self-interest.”

Another change was the establishment of panels of “providers.” The “docs” knew they were in trouble when they began being called providers, a business-type of term, rather than doctors (which would include anyone with a Ph.D. or an M.D. or a D.O or a D.D.S) or therapists or social workers. Some providers agreed to accept discounted fees (saving the insurance companies and patients some money) in return for having patients steered in their direction. Usually, the insurance companies would then give patients encouragement to use practitioners on their list of such “preferred providers,” and better insurance coverage when they consulted those individuals, rather than doctors who were “out-of–network.”

HMOs (Health Maintenance Organizations) worked a bit differently. The care was usually even more strictly managed. There were fewer doctors and hospitals from which to choose, and typically smaller co-payments (the amount the patient paid out-of-pocket to the healer). Even more services were managed and required a referral from the patient’s “primary care physician.” Depending on the nature of the contract between the doctor and the HMO, he or his medical practice might lose money to the extent that he authorized too many referrals and too much treatment. This was clearly another step in the conflict between getting treatment and the ability of the insurance company (and sometimes the docs) to make money.

At present, there are relatively few insurance policies (very, very expensive ones) that don’t attempt to limit your choice of doctors or hospitals, or manage your care in some fashion. So, when you hear some politicians say that they don’t want the government to interfere with the doctor/patient relationship, be aware that your insurance company almost certainly already does that.

Negotiated Fees for Services. I’m always amused when the press, insurance companies or politicians refer to the “fact” of doctors and insurance companies “negotiating” fees for the healer’s services. Understand that doctors have virtually no leverage in these situations. If they wish to participate in “preferred provider” panels in the hope of obtaining more patients, they are typically given a fee schedule as part of the contract that they are offered. Large institutions may have some leverage (hospitals or very, very large practices), but solo practitioners and small practices, which make up most of the providers you would routinely consult, are pretty much told to “take it or leave it” in terms of the contractual conditions and the fee schedule by which they will be compensated. Again, if politicians tell you that they are defending the rights of doctors to negotiate such fees, I’m not exactly sure who they have in mind. Most of the psychologists, psychiatrists, and social workers I know must choose either to take what the insurance company or PPO (Preferred Provider Organization) offers, or to be “out-of-network.” As an out-of-network professional, you can set your own fees, but don’t benefit from the PPO or insurance company’s efforts to send you patients.

Parenthetically, it should be noted that few if any of the healing professionals I know got into this work for the purpose of making tons of money. Indeed, most of us didn’t think much about the business-side of our work when we chose to pursue our vocation. As you doubtless have already concluded, the business-end can’t be ignored easily.

Covered Services and Pre-Existing Conditions. Insurance companies aren’t all alike. Some have larger provider panels, some cover more services, etc. Depending on your policy, psychological testing, neuropsychological testing, individual psychotherapy, family psychotherapy, alcohol/drug treatment, and marital therapy, might or might not be covered. Indeed, some insurance policies do not cover mental health services at all.

Pre-existing conditions are those from which you suffered prior to the start-date of your insurance contract. If your insurance company excludes pre-existing conditions, it usually does so in one of two ways. It can have a waiting period (perhaps one year) before it will cover you for treatment of that condition. On the other hand, some contracts require that you have not been treated for the condition for a specified period (again, perhaps one year) before they will pay for treatment; this is based on the assumption that if you have not had treatment in that time, any future therapy will probably not be for precisely the same condition.

You should be aware that when you submit an insurance claim, or ask your doctor to do so, you have now been marked down in a sort of “permanent record” kept by the insurance industry. Whenever you apply for insurance on an individual basis, you are routinely asked to sign a waiver that allows the insurance company in question to consult your life history of insurance claims and your past medical records. If they find something that is not to their liking (meaning that it causes them to believe that you are a bad risk), they may deny you coverage either for the particular condition in question or simply refuse to issue you an insurance policy. This can apply not only to health insurance (the topic I’ve been talking about until now), but also disability and life insurance. As a consequence, some people (if they are able) prefer to pay for certain types of health care out of their own pocket, rather than creating a record of illness that might be used against them by insurance companies at a later time.

Needless to say, one of the most consumer-friendly features in the health care legislation just passed by the House of Representatives is the prohibition of pre-existing condition exclusions. The Republican alternative does not have such a provision.

The Efficiency of the Private Sector. My office manager could give you an ear-full about the difficulties that she has in getting insurance companies to do what they are contracted to do; that is, pay bills promptly and correctly. The number of “lost” claims that require resubmission, delayed payments, and incorrectly paid claims give the lie to the notion, at least among the mental health professionals who I know, that the private sector is to  be preferred in this arena to the performance of Medicare. Of course, some companies actually are quite efficient, while others are frank disasters.

Mandatory Insurance and the Idea of a National Health Insurance or “The Public Option.” In order to get a sense of how a mandatory health insurance program might work, it is useful to look at how a similar approach has fared for automobile insurance. Virtually every state in the union requires that drivers have auto insurance. There are reportedly a number of problems that have occurred with this. First, stipulating that there is a requirement doesn’t necessarily get people to buy car insurance–you need an enforcement mechanism to make certain that they follow the law. I’ve heard stories of people who didn’t have insurance and were brought to court after an accident without being required to pay the expected penalty, but instead were ordered to buy a policy and return to court with it. Doubtless, having done this, those folks might then cancel the policy, especially if they couldn’t really afford it. The expense of creating a data base and monitoring all drivers to determine whether they have current auto insurance is costly and perhaps inefficient, since most people who can afford it will probably buy it on their own without threatened penalties. Some states have chosen to attempt to single out “high risk” drivers for particular scrutiny and oversight, presumably at reduced costs.

Almost certainly, some of the same complications would be present in any national health insurance program. Without going into all the arguments for and against, it should at least be noted that we already have a form of national health insurance. Its called Medicare, and the people who have it apparently like it quite well; but it does cost a fortune and creates an enormous weight on the generations who will have to continue to pay for it.

Thus, the moral and practical dilemma: providing coverage for people who need it (before Medicare, for example, it wasn’t unusual for the elderly to live in poverty, having been wiped out by medical bills) vs. the cost of such a program in dependency and dollars.

I hope that I’ve offered at least a little bit of useful information.  Here is hoping that you will, if needed, learn more and weigh-in with your Congressman or Senator; decisions with far-reaching consequences are being made right now.