To Stay or Not to Stay in Managed Care

Why I can't afford to remain a therapist in a system I believe in

Posted Apr 03, 2018

Threephin/Flickr
Source: Threephin/Flickr

Several years ago, my therapist announced she was dropping my insurance. She apologetically explained that my managed care network had cut the reimbursement rate for psychotherapists to a pittance. The new rate made it impossible to afford her escalating East Village office rent, nor could she accept in good conscience an industry-sanctioned devaluation of her professional talents.

A part of me understood, yet another part felt betrayed. Finding a therapist who resonated both emotionally and philosophically, and accepted my insurance hadn’t been easy. I had already invested at least two years’ worth of confessions, tears, and stories --  including tales of my own financial woes.  Navigating the financial pressures of my tiny studio apartment, my barely livable salary, and my school loans, I could just swing the $30 weekly copay. We had developed a bond…or so I thought.

It felt like bait and switch.

Ultimately, I accepted the sliding scale she offered as consolation. But every year, as my fee increased, so did my resentment. We discussed these feelings, of course, as such attitudes are considered therapeutic fodder for self-exploration. She pressed me to consider the value of our work and the price of my happiness.

By the time I ended our 8-year therapeutic relationship, the price of my happiness had quadrupled since our first appointment. But implicit in my therapist’s inquiry about the price of my inner peace was also a message about what it means to value oneself monetarily in a profession whose currency is measured in states of emotional wellbeing

Today that lesson is not lost on me, nor is the irony. You see, I am also a psychotherapist. And back then, in the midst of my own financial issues and amid the initial shock of my therapist’s decision, I was slowly building my private practice by joining insurance panels.

Today, a decade later, the irony thickens as I contemplate weaning myself off insurance panels for the very same reasons my therapist dropped mine years ago.

The Great Therapist Exodus

Apparently, I’m in good company in my contemplation.

Since the early 90s, when health insurance companies began tightening their proverbial belts, there has been a mass exodus of seasoned psychotherapists, including psychiatrists, psychologists, clinical social workers, and mental health counselors, leaving the in-network insurance panels. The reasons include insultingly low reimbursement rates, customer service headaches, invasive care management practices, time-consuming chart reviews, arbitrary denials, and uncompensated administrative time.

Many therapists also resent being beholden to an industry that values science over artistry, and corporate wealth over mental health. Because what we do is hard to quantify, therapists often feel like the overlooked stepchildren of the healthcare system. From an insurer’s standpoint, it’s easier to justify paying for the removal of infected tonsils (all in a day’s work) than the subtler, long-term psychic surgery involved in removing a toxic behavioral pattern that prevents patients from forming healthy relationships or financial stability.

A recently released report by published by Milliman Inc., a national risk management and health care consulting company, showed that in 2015, behavioral care was four to six times more likely to be provided out-of-network than medical or surgical care. It also revealed a discrepancy between mental health parity laws and practices. While varying from state to state, the report showed that insurers pay primary care providers 20 percent more for the same types of care as they pay addiction and mental health care specialists, including psychiatrists (in New York, the disparity is 14 percent).

The report noted that “when both parties are unable to come to favorable terms, providers are less likely to opt in to a health plan’s network, and as a result patients may have fewer options for in-network care.” It went on to state that “some patients may want to avoid the higher costs and delay seeking needed services from behavioral healthcare providers, which can lead to less effective care.”

A Rite of Passage

Perhaps because our profession favors introspection, we therapists tend to internalize our marginalized status, secretly questioning our own worthiness. An anecdotal example: A brilliant, highly-skilled therapist friend told me that his supervisor made him write “I am worth $150 an hour” repetitively when he began charging full fees.

Upon making the leap away from marginalizing panels, therapists can charge market rates, leaving the most seasoned therapists accessible to clients with means, yet out of reach for those who are indigent, struggling financially, unemployed (a common cause of depression and anxiety) or who, like many New Yorkers, simply cannot afford an extra $600 - $800 a month for weekly therapy.

While many therapists, like me, are grateful for the dependable stream of clients panels provide when beginning a private practice, graduating from the panels has become a rite of passage once more training and experience has been attained.

In one sign of the times, the “graduation” phenomenon has spawned a micro industry of business coaches who target insurance-weary shrinks. Case in point: for $1,650, I can take Annie Schuessler’s Superpower Method for Therapists ® program.

Simply bringing up the subject of leaving the panels gives therapists at least some form of financial leverage.  I know this from personal experience.  With one insurance company, I was able to renegotiate a higher rate with the promise to remain on the panel, a commitment I plan to keep.

But other insurance firms refuse to renegotiate their rates, putting me in a tough position of having to choose between my financial health and that of my clients.  Thus: A binary choice that strikes me as fundamentally antithetical to the kind of therapeutic safety that allows healing to occur. 

It’s no surprise that some of my emancipated colleagues continue to be the loudest cheerleaders of my liberation from all managed care. They encourage me to value my skills, my 15 years of clinical experience, and professional accomplishments, which include publishing a self-help book and teaching related workshops at venues across the city.

Their encouragement buoys my courage to navigate untested financial territory – after all, in-network insurance payments comprise about 85 percent of my practice - but does little to assuage my ambivalence.

My Ethical Dilemma

As much as I value my abilities, I also value people’s right to use their insurance policies to pay for seasoned therapists the same way they pay for experienced doctors.

Unfortunately, people who need good mental health care are often the ones who don’t have access to it.  I have witnessed this personally with friends battling mental illness, and professionally, as a participant in a program that helped New Yorkers who lost their jobs in the 2008 recession.

That said, it’s easier to accept a $30 copay from a teacher who earns $60,000 a year than an investment banker who earns six figures, especially when one of my panels reimburses a mere $60 an hour, including the copay.

I recognize that many, if not most, therapists offer income-based sliding scales, operating under the presumption that higher fee clients will offset relatively lower-fee ones.

Clearly, the higher-fee, sliding scale combination is a well-traversed path for my pocketbook to follow, but what about my principles?

I believe in universal health coverage for all Americans, and I want to serve a wide range of clients from various socioeconomic levels. I further resent being put in a position where I have to put pressure on some of my clients, especially my cash-strapped millennials.

Naturally, I didn’t pursue this career for the money. Sometimes, I forget to collect fees at the end of sessions because what I do feels deeply rewarding.

Still, I live in one of the most expensive cities in the country, and I need to consider fastening my own oxygen mask before tending to others.

I suppose I can live with the ethical conflict if it means breathing easier with every bill, and not having to answer to third-party insurance overseers sitting in an office somewhere in middle America reviewing my work.

But I worry about the broader implications. As long as insurance companies continue to underpay and over-complicate the professional lives of psychotherapists, those seeking to pay for behavioral health with insurance may find themselves choosing from a narrowing pool of less experienced clinicians … while seasoned therapists remain accessible to individuals with deep pockets.

Having been on the other side of the couch from a panel-dropping therapist, I wonder if clients will feel as I once did if and when I make the leap, understanding the decision while secretly resenting me. Perhaps those that leave will take their chances with a fledgling therapist on an insurance panel who is willing to overlook the paltry reimbursement rate so they can build their budding practice, thus perpetuating cycle. Either way, it’s a risk I may need to take, albeit a conflicted one.