The Tremendous Failures of Insurance for Mental Health Care
September 9, 2024 11:11 AM Subscribe
ProPublica is doing another set of stories on healthcare and insurance failure in the United States. This one, entitled America’s Mental Barrier: How Insurers Interfere With Mental Health Care is specifically on mental health care, the "ghost networks" - where providers are listed on sites, but have left the network for various reasons, and the providers, in this example Ambetter, never remove them - and how insurance companies treat the mental health providers who sign up with them.
Why I Left The Network - therapists talking about the effects of insurance on their practices (previously posted)
What Mental Health Care Protections Exist in Your State? - an Examination of state laws
Struggling to Find an In-Network Mental Health Provider? Here’s What You Can Do.
“I Don’t Want to Die”: Needing Mental Health Care, He Got Trapped in His Insurer’s Ghost Network
New Biden Administration Rules Aim to Hold Insurers Accountable for Mental Health Care Coverage
Why I Left The Network - therapists talking about the effects of insurance on their practices (previously posted)
What Mental Health Care Protections Exist in Your State? - an Examination of state laws
Struggling to Find an In-Network Mental Health Provider? Here’s What You Can Do.
“I Don’t Want to Die”: Needing Mental Health Care, He Got Trapped in His Insurer’s Ghost Network
New Biden Administration Rules Aim to Hold Insurers Accountable for Mental Health Care Coverage
The story about ghost networks got me. I'm from St. Louis, and Centene is this big company there that local media like to think will help the area somehow with building buildings, giving it tax revenue, donating to galas and nonprofits, etc. I sent the article to my family over the weekend, because this is how they're making all that money. It's despicable and should be a footnote to any article about Centene's charitable giving. I also had no idea what that company even did, so now I know!
Issues with ghost networks and other ways to deny insurance coverage aren't confined to mental health providers. It reminds me of when I switched insurance plans like 3 times in rapid succession last winter, right after I injured my Achilles. I scoured the list of in-network podiatrists and orthopedists and managed to find one podiatrist out of the whole list with the correct specialty area and an opening for new patients on my last day of insurance coverage. She referred me for X-rays, because she said insurance wouldn't cover an MRI until I'd had X-rays, even though this was likely a tendon issue that wouldn't show on an X-ray. I had to wait more than a week for COBRA to actually kick in to even get X-rays. The podiatrist never followed up with results or a referral until prodded—apparently they'd been sent through an EHR portal I'd never been told to set up. By that point, it was January, and a new insurance plan kicked in on COBRA, and the podiatrist and the orthopedist she referred me to were then out of network for me. So I started over and scoured the new list of in-network orthopedists, identified maybe 3 or 4 who had the correct specialty area and an opening for new patients, and contacted them. If I recall correctly, a couple never replied, one replied but didn't have openings for months, but one was able to get me in that week. I was lucky enough to get a new non-COBRA plan a couple months later, but my prescriptions started getting denied, because the plan was with the same insurer I'd had COBRA with, and they kept insisting I still had secondary insurance. It's still an issue months later, and luckily my prescriptions are cheap, because I've ended up paying out of pocket for several when I couldn't resolve the insurance block.
It really does start to get to the point where following up becomes a job in itself, one I only had time for because I was between jobs when this whole saga started, which is why it started. And I only had time for the months of physical therapy that I ended up needing because I've been freelancing. And this is with a "good" insurance company, not an exchange plan. And this is in one of the most populous cities in the world (I've been in NYC for a while), where presumably there are more doctors than in almost any other city. None of this is good for one's mental or physical health.
posted by limeonaire at 12:49 PM on September 9 [10 favorites]
Issues with ghost networks and other ways to deny insurance coverage aren't confined to mental health providers. It reminds me of when I switched insurance plans like 3 times in rapid succession last winter, right after I injured my Achilles. I scoured the list of in-network podiatrists and orthopedists and managed to find one podiatrist out of the whole list with the correct specialty area and an opening for new patients on my last day of insurance coverage. She referred me for X-rays, because she said insurance wouldn't cover an MRI until I'd had X-rays, even though this was likely a tendon issue that wouldn't show on an X-ray. I had to wait more than a week for COBRA to actually kick in to even get X-rays. The podiatrist never followed up with results or a referral until prodded—apparently they'd been sent through an EHR portal I'd never been told to set up. By that point, it was January, and a new insurance plan kicked in on COBRA, and the podiatrist and the orthopedist she referred me to were then out of network for me. So I started over and scoured the new list of in-network orthopedists, identified maybe 3 or 4 who had the correct specialty area and an opening for new patients, and contacted them. If I recall correctly, a couple never replied, one replied but didn't have openings for months, but one was able to get me in that week. I was lucky enough to get a new non-COBRA plan a couple months later, but my prescriptions started getting denied, because the plan was with the same insurer I'd had COBRA with, and they kept insisting I still had secondary insurance. It's still an issue months later, and luckily my prescriptions are cheap, because I've ended up paying out of pocket for several when I couldn't resolve the insurance block.
It really does start to get to the point where following up becomes a job in itself, one I only had time for because I was between jobs when this whole saga started, which is why it started. And I only had time for the months of physical therapy that I ended up needing because I've been freelancing. And this is with a "good" insurance company, not an exchange plan. And this is in one of the most populous cities in the world (I've been in NYC for a while), where presumably there are more doctors than in almost any other city. None of this is good for one's mental or physical health.
posted by limeonaire at 12:49 PM on September 9 [10 favorites]
I tried finding a therapist for my kid, and about 80% of the clinics and doctors listed on the health insurance website as in-network didn't take our insurance. Many of them never had taken it.
posted by goatdog at 1:09 PM on September 9 [2 favorites]
posted by goatdog at 1:09 PM on September 9 [2 favorites]
In United States law, depraved-heart murder, also known as depraved-indifference murder, is a type of murder where an individual acts with a "depraved indifference" to human life and where such acts result in a death, despite that individual not explicitly intending to kill. In a depraved-heart murder, defendants commit an act even though they know their act runs an unusually high risk of causing death or serious bodily harm to a person. If the risk of death or bodily harm is great enough, ignoring it demonstrates a "depraved indifference" to human life and the resulting death is considered to have been committed with malice aforethought.posted by Pope Guilty at 1:23 PM on September 9 [10 favorites]
I think the true culprit is the government's poor handling of expanding access to health insurance and medical care. The intentions were good. The federal government tried to force medical insurance companies to cover more people who normally could not afford insurance and legislated that insurance had to do so and be compensated by the government at below the cost it would really take to cover high need people. Since insurance companies are private companies and not non-profits, they are tasked with turning a profit and they will do so with any loophole they can find. So they squeezed the doctors and the patients to make up the profit lost by the government forcing them to take on people that loses them profit. It is difficult for governments to legislate their way out of this because insurance companies will always find loopholes - they have the means and the will. Government is like - there, we passed a law, and now it is fixed. Very silly.
Thus, we ended up with large networks of Urgent Care started by private equity because our regular doctors were overwhelmed and insurance did not pay them enough. Private equity always smells out opportunity to profit in spaces where people are being silly. I am currently waiting for private equity to pull the plug on Urgent Care. Meaning Urgent Care will becomes less and less usable and eventually become terrible employers but charge the same amount of money. They will be able to do this because they will become the only option available for first line care because Urgent Care drove out the most of the doctors or forced them to work for Urgent Care. This is not just about insurance but about the government making decisions without carefully considering what players will do.
Mark my words - this will happen with mental care.
Legislating expanded access without increasing the number of providers will overwhelm the providers and will drive them out of this space, force them to go private and bring private equity full into this space.
The best path would be to gradually increase providers while gradually increasing access which would be a careful multi-year plan requiring a long span of intelligent leaders. Unfortunately, we don't seem to have coherent leadership since we change governments every 4 years.
Sadly, at the end of the day, I think many wealthy folks and companies will just opt out of public health insurance entirely and either fund their own insurance or pay out of pocket.
posted by ichimunki at 1:30 PM on September 9 [5 favorites]
Thus, we ended up with large networks of Urgent Care started by private equity because our regular doctors were overwhelmed and insurance did not pay them enough. Private equity always smells out opportunity to profit in spaces where people are being silly. I am currently waiting for private equity to pull the plug on Urgent Care. Meaning Urgent Care will becomes less and less usable and eventually become terrible employers but charge the same amount of money. They will be able to do this because they will become the only option available for first line care because Urgent Care drove out the most of the doctors or forced them to work for Urgent Care. This is not just about insurance but about the government making decisions without carefully considering what players will do.
Mark my words - this will happen with mental care.
Legislating expanded access without increasing the number of providers will overwhelm the providers and will drive them out of this space, force them to go private and bring private equity full into this space.
The best path would be to gradually increase providers while gradually increasing access which would be a careful multi-year plan requiring a long span of intelligent leaders. Unfortunately, we don't seem to have coherent leadership since we change governments every 4 years.
Sadly, at the end of the day, I think many wealthy folks and companies will just opt out of public health insurance entirely and either fund their own insurance or pay out of pocket.
posted by ichimunki at 1:30 PM on September 9 [5 favorites]
The best path would be to gradually increase providers while gradually increasing access which would be a careful multi-year plan requiring a long span of intelligent leaders. Unfortunately, we don't seem to have coherent leadership since we change governments every 4 years.
Does the federal government actually have any say (or realistic influence) over how many providers the various schools spit out every year?
posted by Thorzdad at 2:30 PM on September 9 [1 favorite]
Does the federal government actually have any say (or realistic influence) over how many providers the various schools spit out every year?
posted by Thorzdad at 2:30 PM on September 9 [1 favorite]
Does the federal government actually have any say (or realistic influence) over how many providers the various schools spit out every year?
Sure, via incentives for work in certain specialties or locations. But that takes time, which calls back to changing government periodically. No time to stay consistent. Or if there is continuity, can you trust it will remain in four years when that could be the length of a program?
posted by m@f at 2:35 PM on September 9
Sure, via incentives for work in certain specialties or locations. But that takes time, which calls back to changing government periodically. No time to stay consistent. Or if there is continuity, can you trust it will remain in four years when that could be the length of a program?
posted by m@f at 2:35 PM on September 9
I'd really love it if we could center the conversation here around MENTAL health care. It's easy to point at the entire US healthcare system and identify it as the dumpster fire that it is, but the truth is the mental health care is even worse (so, so much worse), and it feels invalidating/diminishing to say "it's everything, actually."
I'm experiencing this on the provider side as a therapist setting up a private practice. I won't go into why I don't want to take insurance - the articles do a great job of explaining it. The simple fact is that reimbursement rates for mental health services are criminally low and have not kept parity with medical services.
But to address the clinicians shortage piece: in the state where I live, they're trying everything to fix it except the one thing that will work: paying therapists a fair wage.
posted by carlypennylane at 2:40 PM on September 9 [12 favorites]
I'm experiencing this on the provider side as a therapist setting up a private practice. I won't go into why I don't want to take insurance - the articles do a great job of explaining it. The simple fact is that reimbursement rates for mental health services are criminally low and have not kept parity with medical services.
But to address the clinicians shortage piece: in the state where I live, they're trying everything to fix it except the one thing that will work: paying therapists a fair wage.
posted by carlypennylane at 2:40 PM on September 9 [12 favorites]
I believe the insurance companies are cutting back on paying all therapists and providers in their networks for the reasons that I listed. The mental health payment piece is only a small part of the fair wage for therapists, doctors and other providers under health insurance. This is part of the collateral damage from health policy reform.
I see a therapist regularly and she was originally covered by my health insurance about 10 years ago but she is no longer covered. My son's therapists (PT, OT, Speech) all do not take health insurance either. They used to take insurance a long time ago but decided the payments were not worth it and the bureaucracy was incredibly awful. So now I opted for a high deductible plan and dedicate about 3 hours a week to work out health insurance and claims. When I first started filing, it took me a couple of days of calls and workarounds to figure out the correct codes that would get me reimbursed.
The insurance companies are going to squeeze to get a profit no matter what. So if you advocate to have them pass a law to pay you and your particular line of therapy a fair wage, the insurance companies will probably figure out a way to make their profit elsewhere. To make a long story short, I really think we were at a stable place a decade ago with health insurance. We can't turn back time to fix what happened.
I think moving forward the new normal will be high deductible plans, people paying out of pocket with employer support and a severely limited network with long wait times for everyone else. Insurers are already cutting back on/no longer offering out of network high deductible plans because it costs them too much money as more people are piling on. It was a great deal while it lasted though! I can see companies putting money directly into accounts for employees to use as they wish equal to the cost of health insurance they had paid and cutting out insurance altogether. If I were an insurer, there may be money to be made in only offering catastrophic health insurance or severely limited high deductible plans at cheaper cost to employers - the balance might make them money because employers would probably spring for it and offset their employee medical costs with a dedicated savings account.
On a related note, I see now why my family always wanted to make sure we had a doctor (we have a giant extended family) in the family. It was not about how much money they made but about access to medical care and advice. This worked in developing countries and sadly, this is true now in the United States.
posted by ichimunki at 3:39 PM on September 9 [4 favorites]
I see a therapist regularly and she was originally covered by my health insurance about 10 years ago but she is no longer covered. My son's therapists (PT, OT, Speech) all do not take health insurance either. They used to take insurance a long time ago but decided the payments were not worth it and the bureaucracy was incredibly awful. So now I opted for a high deductible plan and dedicate about 3 hours a week to work out health insurance and claims. When I first started filing, it took me a couple of days of calls and workarounds to figure out the correct codes that would get me reimbursed.
The insurance companies are going to squeeze to get a profit no matter what. So if you advocate to have them pass a law to pay you and your particular line of therapy a fair wage, the insurance companies will probably figure out a way to make their profit elsewhere. To make a long story short, I really think we were at a stable place a decade ago with health insurance. We can't turn back time to fix what happened.
I think moving forward the new normal will be high deductible plans, people paying out of pocket with employer support and a severely limited network with long wait times for everyone else. Insurers are already cutting back on/no longer offering out of network high deductible plans because it costs them too much money as more people are piling on. It was a great deal while it lasted though! I can see companies putting money directly into accounts for employees to use as they wish equal to the cost of health insurance they had paid and cutting out insurance altogether. If I were an insurer, there may be money to be made in only offering catastrophic health insurance or severely limited high deductible plans at cheaper cost to employers - the balance might make them money because employers would probably spring for it and offset their employee medical costs with a dedicated savings account.
On a related note, I see now why my family always wanted to make sure we had a doctor (we have a giant extended family) in the family. It was not about how much money they made but about access to medical care and advice. This worked in developing countries and sadly, this is true now in the United States.
posted by ichimunki at 3:39 PM on September 9 [4 favorites]
I'd really love it if we could center the conversation here around MENTAL health care. It's easy to point at the entire US healthcare system and identify it as the dumpster fire that it is, but the truth is the mental health care is even worse (so, so much worse), and it feels invalidating/diminishing to say "it's everything, actually."
Yeah, that's fair. The story in the ghost networks article just felt so similar to what I just went through with other health conditions.
posted by limeonaire at 4:11 PM on September 9 [1 favorite]
Yeah, that's fair. The story in the ghost networks article just felt so similar to what I just went through with other health conditions.
posted by limeonaire at 4:11 PM on September 9 [1 favorite]
Good luck getting insured mental healthcare in a reasonable amount of time. My late-adolescent daughter was in crisis and her therapist stopped taking patients due to an emergent medical condition. There was no one "in-network" who could see her sooner than 6-8months. Luckily I have a friend who is a psychologist and got us in contact with a psychiatrist who could see her right away and get her meds adjusted. The MD did not take insurance and we had to pay up front and then try to get reimbursed. We don't even bother. It's <$200 every 2-4months, which is luckily within our means to pay. My wife is a patient care coordinator for a dental office. For her not to want to deal with getting an insurance reimbursement says a lot about the state of things; It's easier just to pay. Imagine not being at all knowledgable trying to navigate that hellscape.
posted by AJScease at 5:24 PM on September 9 [5 favorites]
posted by AJScease at 5:24 PM on September 9 [5 favorites]
A system is what it does. Our mental healthcare system tortures and kills people for money. Pope Guilty nails it. Murder by depraved indifference.
Many factors make mental healthcare harder to research, validate and deliver, but it has become a sacrifice zone, where the very act of identifying (or mis-iding) a problem as mental health is to condemn the sufferer to a kafkaesque social punishment for their condition.
If i had an answer i'd give it. But clearly for profit health insurance is a conflict of interest and a failed paradigm.
posted by No Climate - No Food, No Food - No Future. at 1:15 AM on September 10 [3 favorites]
Many factors make mental healthcare harder to research, validate and deliver, but it has become a sacrifice zone, where the very act of identifying (or mis-iding) a problem as mental health is to condemn the sufferer to a kafkaesque social punishment for their condition.
If i had an answer i'd give it. But clearly for profit health insurance is a conflict of interest and a failed paradigm.
posted by No Climate - No Food, No Food - No Future. at 1:15 AM on September 10 [3 favorites]
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Australia for instance only lets you get 10 mental health sessions in a calendar year and it's all gatekept by GPs. So you need to pay your GP the difference between their fee and the Medicare rebate for a referral, then you need to pay the mental health professional the difference between their fee and the Medicare rebate, then after 6 session you need to go see your GP again, pay the difference between their feee and the Medicare rebate for access to the other 4 sessions.
So it ends up being a giant fucking waste of primary care resources for a minimal amount of mental health treatment. Only some upper management who "doesn't believe in all this mental health shit" could possibly come up with a such a fucking useless system for mental health.
Hell, I have Cadillac level insurance in the US and I still need to pay $80/mo for therapy once a week. The way we treat mental health in the Western world is such a fucking rort. Puritan work ethic has destroyed this sham of a society.
posted by Your Childhood Pet Rock at 11:55 AM on September 9 [7 favorites]