Insurance Disincentives

[smalltownpsych]

Opinion | Can't find a therapist who takes insurance? Here's why.
I thought this was a pretty thought provoking read and very much mirrors my own experience and where I am at with my career right now.

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[R. Matey]

 

[Sanman]

It's a great article. It neglects to mention a few points though. Most therapy practices are small businesses, which means that they may struggle with costs for admin folks and EHR software that larger systems can swallow easily. Rising costs of real estate and office space can mean that low insurance reimbursements present a barrier to accessibility as a provider can only see so many patients. I do think that technology and telehealth can be leveraged to help solve these issues.

 

[erg923]

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[smalltownpsych]

It's a great article. It neglects to mention a few points though. Most therapy practices are small businesses, which means that they may struggle with costs for admin folks and EHR software that larger systems can swallow easily. Rising costs of real estate and office space can mean that low insurance reimbursements present a barrier to accessibility as a provider can only see so many patients. I do think that technology and telehealth can be leveraged to help solve these issues.

Like your points, but based just on my own experience, telehealth is more beneficial for the clients who are higher functioning/less in need and those people tend to be less underserved anyway so I'm not sure how much that helps. It's better than nothing, I guess, but sometimes when we open a door like that, then that becomes the expectation or standard of care.

 

[Sanman]

Like your points, but based just on my own experience, telehealth is more beneficial for the clients who are higher functioning/less in need and those people tend to be less underserved anyway so I'm not sure how much that helps. It's better than nothing, I guess, but sometimes when we open a door like that, then that becomes the expectation or standard of care.

Well, yes and no. I agree that it does little to solve the issue for those with higher acuity needs, there is often little we can do as individual providers without structural support regarding those issues. Meanwhile, I do feel that individual providers may be more likely to see insured patients if they can pocket a greater percentage of their fee by reducing structural costs. For example, I would consider seeing insurance based folks from a home office or reducing my fee for telehealth only therapy. I may not do so if I am required to rent an office that becomes a significant percentage of structural costs. This will likely benefit lower acuity folks more, but outpatient psychotherapy has always skewed toward lower acuity and higher income.

 

[smalltownpsych]

Well, yes and no. I agree that it does little to solve the issue for those with higher acuity needs, there is often little we can do as individual providers without structural support regarding those issues. Meanwhile, I do feel that individual providers may be more likely to see insured patients if they can pocket a greater percentage of their fee by reducing structural costs. For example, I would consider seeing insurance based folks from a home office or reducing my fee for telehealth only therapy. I may not do so if I am required to rent an office that becomes a significant percentage of structural costs. This will likely benefit lower acuity folks more, but outpatient psychotherapy has always skewed toward lower acuity and higher income.

So I should cut the insurance company a deal so they don't have to pay for my office space? I don't think so. I get what you are saying, but I also think we are too reasonable and nice and trying to help our patients while the insurance companies keep grinding us and our patients down. Me and my patients deserve a very nicely appointed and reasonable office space to meet in and if people say they are going to cover my services then that is part of the deal. The truth is they don't want to pay and they will never stop the race to the bottom. They are business people only, they have no souls. Well, the last part might be a bit over the top, but...
My main point is don't give them an inch. Also, the government agencies that regulate the industry work with the big insurance companies, not us, so they are really no help either.

 

[Sanman]

So I should cut the insurance company a deal so they don't have to pay for my office space? I don't think so. I get what you are saying, but I also think we are too reasonable and nice and trying to help our patients while the insurance companies keep grinding us and our patients down. Me and my patients deserve a very nicely appointed and reasonable office space to meet in and if people say they are going to cover my services then that is part of the deal. The truth is they don't want to pay and they will never stop the race to the bottom. They are business people only, they have no souls. Well, the last part might be a bit over the top, but...
My main point is don't give them an inch. Also, the government agencies that regulate the industry work with the big insurance companies, not us, so they are really no help either.

I never said you should cut them a break. I just said the rate would be more palatable for some providers with minimal overhead. If they are paying $100 no matter what, I am more inclined to accept a contract if I net $80-90 vs if I net $65 a session. Beyond that, you are welcome to charge what you like outside their confines if you can make a living.

Like it or not, equity in healthcare is unlikely to come with the nicest office. I have treated the poorest of the poor and the richest of the rich. I have also seen patients in a storage room and rooms with multi-million dollar art on the walls. When working in the nicest digs, it was generally seeing folks who had money. Taking care of the poor will never pay well unless you are cutting corners/commiting fraud.

 

[WisNeuro]

I never said you should cut them a break. I just said the rate would be more palatable for some providers with minimal overhead. If they are paying $100 no matter what, I am more inclined to accept a contract if I net $80-90 vs if I net $65 a session. Beyond that, you are welcome to charge what you like outside their confines if you can make a living.

Like it or not, equity in healthcare is unlikely to come with the nicest office. I have treated the poorest of the poor and the richest of the rich. I have also seen patients in a storage room and rooms with multi-million dollar art on the walls. When working in the nicest digs, it was generally seeing folks who had money. Taking care of the poor will never pay well unless you are cutting corners/commiting fraud.

By far, my highest net payoff per hour has been my travel work. So, technically, I make the most money doing work out of a hotel conference room bu quite a wide margin. Though, technically not clinical work as it's been IME stuff. Still, I make more outside of my physical office.

 

[Sanman]

By far, my highest net payoff per hour has been my travel work. So, technically, I make the most money doing work out of a hotel conference room bu quite a wide margin. Though, technically not clinical work as it's been IME stuff. Still, I make more outside of my physical office.

True, even then, I assume the deeper the pockets, the nicer the hotel. Ironically, my richest clients were not my highest paying either. You would be surprised who opts to use their Medicare.

 

[WisNeuro]

True, even then, I assume the deeper the pockets, the nicer the hotel.

Sometimes, but sometimes you work with what you have depending on the location. I'll often offer to book travel arrangements myself. Then I have my choice of quality and location, and I'd rather get the bonus points on my business card if it's just going to get reimbursed the following week anyway. At least for the domestic work.

 

[smalltownpsych]

Rich vs poor is a bit of a false dichotomy. I also said a reasonable office and was referring more to our continually being squeezed middle/working class type people. I think that when we are talking about insurance and access, we are often talking more about these folks and workplace provided insurance as opposed to medicaid or Medicare.

 

[Sanman]

Rich vs poor is a bit of a false dichotomy. I also said a reasonable office and was referring more to our continually being squeezed middle/working class type people. I think that when we are talking about insurance and access, we are often talking more about these folks and workplace provided insurance as opposed to medicaid or Medicare.

It may be a bit of a false dichotomy, but it not really. Psychotherapy really depends on having the time for therapy and money for copays in addition to insurance. This, in my experience, skews the population to white collar and upper middle class as well as some blue collar union types. It really depends on your geographic area though. My experience lies mostly on the east coast. I am also including medicaid and medicare in the conversation as this is my experience. For adult outpatient services, medicaid is often not viable, but medicare is usually in line with private insurers.

 

[WisNeuro]

It may be a bit of a false dichotomy, but it not really. Psychotherapy really depends on having the time for therapy and money for copays in addition to insurance. This, in my experience, skews the population to white collar and upper middle class as well as some blue collar union types. It really depends on you geographic area though. My experience lies mostly on the east coast. I am also including medicaid and medicare in the conversation as this is my experience. For adult outpatient services, medicaid is often not viable, but medicare is usually in line with private insurers.

Exactly, also, insurers will usually move in lockstep with Medicare. Example, Insurer Y generally pays 120% of Medicare rates. If Medicare cuts reimbursement for a certain set of codes, you will almost always see the insurers adjust accordingly.

 

[smalltownpsych]

Exactly, also, insurers will usually move in lockstep with Medicare. Example, Insurer Y generally pays 120% of Medicare rates. If Medicare cuts reimbursement for a certain set of codes, you will almost always see the insurers adjust accordingly.

The insurer I just turned down paid 75% of Medicare rates.

 

[WisNeuro]

The insurer I just turned down paid 75% of Medicare rates.

Those definitely exist, there are 2 in my area that I do not panel with due to rates and hassle factor.

 

[Sanman]

Those definitely exist, there are 2 in my area that I do not panel with due to rates and hassle factor.

Yeah, I never understood that myself. Less money than medicare and more hassle means I am not dealing with you. Then again, that may be their plan anyway.

 

[WisNeuro]

Yeah, I never understood that myself. Less money than medicare and more hassle means I am not dealing with you. Then again, that may be their plan anyway.

Most likely. Honestly, for clinical work, when it comes to reimbursement from insurers for neuropsych evals, I prefer Medicare with supplements. Usually decent reimbursement, and the billing is super quick and easy.

 

[smalltownpsych]

Yeah, I never understood that myself. Less money than medicare and more hassle means I am not dealing with you. Then again, that may be their plan anyway.

Exactly their plan. Numbers don't lie, delaying treatment decreases costs, especially if they can keep hospital stays due to the suicidality short-lived. The one good thing about the direction that they arew going is that more people are seeing the value in just paying for it themselves. We are strating to shift to every other week sessions now so that it is more affordable for patients. I'm reluctant to do this, because I am so used to the weekly session norm, but we shall see how it goes.

 

[PsyDr]

Psychotherapy really depends on having the time for therapy....

I think this is one of the most important issues in our field. Work places extreme barriers to treatment. A patient is faced with taking 1hr/week off of work PLUS commute time. If work only gives you two weeks of PTO, your therapy appointments have just taken away half of your annual vacation and holiday time. These market forces create a demand for us to work after hours. Or have people limit treatment to medication.

 

[smalltownpsych]

I think this is one of the most important issues in our field. Work places extreme barriers to treatment. A patient is faced with taking 1hr/week off of work PLUS commute time. If work only gives you two weeks of PTO, your therapy appointments have just taken away half of your annual vacation and holiday time. These market forces create a demand for us to work after hours. Or have people limit treatment to medication.

I have found that my patients' employers tend to be fairly understanding and we can usually make things work for both of us. It also helps that I am in a fairly small community with minimal commute times. It does place a premium on the 8:00am or 4:00pm appointment slots though.
Also, what is up with liking my post that I was offered 75% of medicare, now I know how you see my value.

 

[PsyDr]

I have found that my patients' employers tend to be fairly understanding and we can usually make things work for both of us. It also helps that I am in a fairly small community with minimal commute times. It does place a premium on the 8:00am or 4:00pm appointment slots though.
Also, what is up with liking my post that I was offered 75% of medicare, now I know how you see my value.

I like that you didn't take it, and screw up the mean. Insurance is a numbers game. If the average goes down, I get less. If the average goes up, I get more. It's not a zero sum game.

 

[Sanman]

I think this is one of the most important issues in our field. Work places extreme barriers to treatment. A patient is faced with taking 1hr/week off of work PLUS commute time. If work only gives you two weeks of PTO, your therapy appointments have just taken away half of your annual vacation and holiday time. These market forces create a demand for us to work after hours. Or have people limit treatment to medication.

I am definitely seeing more flexibility in this area in white collar jobs, particularly those where folks can work from home or alter their schedule easily. It still becomes a huge barrier for many blue collar hourly folks that are not salaried.

 

[PsyDr]

@smalltownpsych @Sanman

As I rarely do clinical work, I'll trust your judgements. Maybe I'm mistaken.

 

[Sanman]

@smalltownpsych @Sanman

As I rarely do clinical work, I'll trust your judgements. Maybe I'm mistaken.

I will say that it is really location dependent as well. I sit on the jobs/PP talks at my VA. I used see more demand in the evening practicing in the suburbs. Those with offices in downtown areas seemed to have an easier time filling the daylight hours that I recall. With the pandemic, I have seen much more flexibility. However, I am not sure how long that will last.

 

[WisNeuro]

I will say that it is really location dependent as well. I sit on the jobs/PP talks at my VA. I used see more demand in the evening practicing in the suburbs. Those with offices in downtown areas seemed to have an easier time filling the daylight hours that I recall. With the pandemic, I have seen much more flexibility. However, I am not sure how long that will last.

Part of the beauty of evals with mostly retirees, they have pretty wide open availability And, when it comes to IMEs, they'll come when you have an opening. I don't start appointment later than 1PM.

 

[Sanman]

Part of the beauty of evals with mostly retirees, they have pretty wide open availability And, when it comes to IMEs, they'll come when you have an opening. I don't start appointment later than 1PM.

Yeah, it is the one thing I like about my current work. Working with retired folks means scheduling is usually easy other than not too early as HHAs often come in between 8-10a. This works for me as I have no interest in talking to folks before 10am when my coffee kicks in.

 

[cara susanna]

Work is a HUGE barrier. Even in the VA. Actually especially in the VA, where many of us don't have evening availability.

 

[Sanman]

Work is a HUGE barrier. Even in the VA. Actually especially in the VA, where many of us don't have evening availability.

Unless the patient also works for the VA. There are a few HR folks I can never catch for this reason.

 

[cara susanna]

Unless the patient also works for the VA. There are a few HR folks I can never catch for this reason.

I don't love how the VA makes us see VA employees (at our own facility) for mental health treatment.

 

[clausewitz2]

I am definitely seeing more flexibility in this area in white collar jobs, particularly those where folks can work from home or alter their schedule easily. It still becomes a huge barrier for many blue collar hourly folks that are not salaried.

The skilled trades folks I see are almost these days inevitably sitting in the cab of a pickup immediately before starting their shift, immediately after, or their union negotiated a >60 minute lunch break and we are joined by a sandwich.

 

[Sanman]

The skilled trades folks I see are almost these days inevitably sitting in the cab of a pickup immediately before starting their shift, immediately after, or their union negotiated a >60 minute lunch break and we are joined by a sandwich.

As mentioned earlier, the union folks are often the exception. I have often seen them in during the day as leave was mandated in their union contract. My old practice used to see a lot of worker's comp insurance folks and they received liberal leave for therapy even if on modified duty.

 

[Therapist4Chnge]

The skilled trades folks I see are almost these days inevitably sitting in the cab of a pickup immediately before starting their shift, immediately after, or their union negotiated a >60 minute lunch break and we are joined by a sandwich.

This has been my experience also. It's a much easier sell to the site supervisor to do a video session from the truck than to go off-site bc 1hr appt turns into 2+ hrs w driving. Being able to do video has also been good for places that are spread out. I live in a major city, but patients often drive 1-3+ hrs to get to in-person appts, so it has allowed greater access for them.

I agree 100% w. Sanman, as I see WC patients and modified duty (often/usually) provides the option to travel in-person. It sometimes goes the other way where they want to be seen in-person bc it's more of a break from the common "modified duty" of sitting in a chair and doing 1hr of paperwork for a 4-8hr shift.

 

[ClinicalABA]

Part of the beauty of evals with mostly retirees, they have pretty wide open availability And, when it comes to IMEs, they'll come when you have an opening. I don't start appointment later than 1PM.

Same with toddlers-pretty open schedules during the the day (though afternoon nap times can conflict). I also rarely start anything after 1pm- test I morning, writevin afternoon (or evening/weekends if I have something else to do). I'm almost a purely medicaid practice, and am one of two clinics doing this at all in the larger geographic region. There's one or two private pay/select commercial plan pediatric psychs doing ASD evals in the area, but, not not as main practice and not enough to make a dent.

 

[PsychPhDone]

Work is a HUGE barrier. Even in the VA. Actually especially in the VA, where many of us don't have evening availability.

I know I've vented about this before, but I was offering early morning and evening slots for a while and they never filled. 🤷‍♀️

 

[smalltownpsych]

I know I've vented about this before, but I was offering early morning and evening slots for a while and they never filled. 🤷‍♀️

Sometimes work as a barrier is a sign of lack of motivation to change. When I was at the VA there was a significant portion of the clients that seemed mired in the first or second stage of change. I think the system reinforces some of that. In outpatient, I will flex for a patient if they have demonstrated some willingness and commitment themselves. Same goes with money. One reason that CBT is effective is that with homework, you find out pretty quickly if a patient will not follow through on minimal requirements and can directly target that without wasting a lot of time hearing about their childhood and how they can’t do anything because of… or until…
I find that as soon as I hear some of these victim, blamy, avoidant type statements and I call them out, the patient either responds and begins to become empowered to change and grow and improve or they go find someone else who will validate their pathology.