Ask anyone about a recent experience trying to find a therapist and you will be regaled with stories of unreturned calls, long waitlists and hopelessness. If they need a therapist who takes insurance, the stories quickly become nightmares.
The unrealistic expectation set by insurance companies that a quick fix is possible means therapists almost always need to fight lengthy battles to extend coverage.
As a therapist myself, I have heard firsthand the anguish of people searching for treatment. I, too, have struggled to identify providers with appropriate expertise and availability as the demand for mental health services has exploded during the Covid-19 pandemic. Although it’s estimated that nearly 1 in 5 adults in this country live with a mental health issue, nearly half don’t receive any help. The situation for children is even worse because there are fewer providers who work with them.
There is no quick fix for the shortage of therapists, who must make a substantial investment in education, training and licensing before they can treat patients. However, a major improvement could be made with a few strokes of the pen by fixing the way insurance reimburses clinicians for their work.
As it stands now, the disincentives for therapists to accept insurance ultimately pit providers against prospective patients, with insurance companies gaining from unused benefits as both are pushed out of the system. Delivering adequate care for patients and fair reimbursement for providers would allow many more therapists to treat patients via insurance, not to mention encourage more people to enter the profession in the first place.
Typically, patients covered by insurance pay a copay of perhaps $20 in return for the undivided attention of a practitioner in a lengthy face-to-face meeting. Patients might assume that their insurer then provides reasonable compensation for the therapists’ time, as they do for many other health providers. But in fact, insurers often reimburse therapists at absurdly low rates, as well as burden clinicians with extensive demands for record keeping and authorizations beyond what many doctors encounter and for which they receive no compensation. At the same time, they limit the number of covered sessions so severely as to make treatment ineffective in many cases. For therapists who need to consult with other providers on a patient’s team, their time and resources are stretched even thinner.
As a nation we want quick solutions to complex problems. Health insurance reimbursement rates reflect this bias. The time spent to freeze an actinic keratosis (a skin lesion caused by sun damage) by dermatologists is less than a minute, but they can be paid as much as $400 for the procedure. Taking down a psychological history during an initial therapy visit takes me exponentially longer, yet some insurance companies pay me as little as $50 for the session — even though the average fee for therapy is more than triple that. Similarly, mental health counselors are paid less than physical therapists by insurance because the latter can bill for procedures as well as their time even though their education level is similar.
Additionally, insurance companies restrict services to particular diagnostic codes. Someone who might want to address an issue early, hoping to avoid deeper problems, may not qualify for a diagnosis that allows for reimbursement because they’re not considered sick enough. Validating patients’ issues as real and significant while telling them they don't qualify for insurance reimbursement is a frustrating experience for a provider, who then might have to turn those patients away since they can’t get paid for sessions. Early treatment is cost-effective in terms of quality of life and better health outcomes, as well as economic outlay for services, so it's perverse to be discouraged from seeking help when you feel blue in favor of waiting for full-blown depression.
Then there’s the work each visit generates for clinicians for which there’s no hope of compensation at all. Taking notes after a session and then providing documentation for claims, as is mandatory for each one, can easily add hours onto a day. So I, like many practitioners, pay a billing company to submit my claims for me — which saves me time but further reduces my income.
Although the steps required to receive reimbursement from insurers mirror those of other health care providers, the complexity of mental health problems is far less predictable than many physical ailments, which can mean more conversations with insurance representatives to make the case that further treatment is needed. And after months of establishing trust with a patient, it’s not uncommon for me to learn about an early childhood trauma or other complicated issue that necessitates two sessions a week — which insurers routinely deny.
The unrealistic expectation set by insurance companies that a quick fix is possible means therapists almost always need to fight these lengthy battles to extend coverage for the full course of treatment. For the patient, trying to get well under the restrictions of insurance, such as a short stay for a hospitalization to detox from alcohol, can add to a sense of hopelessness and self-blame. These limitations can undermine the relationship between provider and patient and lead to questioning the skill of the therapist rather than promoting valuable continuity of care.
As can the cycle of practitioners leaving community mental health centers once they have the necessary credentials to open their own practice. A newly licensed clinician is reimbursed at the same rate per session as me, a therapist with more than 30 years of experience. Therefore, new clinicians are more likely to accept insurance as they build a practice while seasoned clinicians opt out, especially from poor-paying, state-funded insurance plans. The patients left behind not only have fewer options, but can feel betrayed and abandoned, diminishing their trust in the therapeutic process permanently.
Tragically, therefore, many of the most complex patients are treated by the least-seasoned clinicians, who work for low pay in institutions where there is high turnover, because therapists in private practice can screen out people who are suicidal or have dual diagnoses that may require lots of extra care — not to mention liability, the need for on-call backup and other burdens.
Untreated mental illness impacts our society in innumerable ways, from the personal heartache of families who lose a loved one to addiction to those who suffer injuries in a shooting spree. And everyone pays more for health insurance when hospitals and treatment centers become revolving doors rather than an opportunity for high-quality care. Done well, therapy works and is cost-effective. A successful therapy experience helps reduce visits to the emergency room, lost time at work and the likelihood of spousal abuse, just for starters. Unfortunately, the current system provides little incentive for clinicians to accept insurance to treat those in need, and that costs everyone.