FIXING YOUR SPICY BRAIN IS BAD FOR BUSINESS

insurance companies are keeping their circle small to turn you off

I’m reporting live from the Venice Boardwalk today. This letter unpacks why it’s easier to make a reservation at a Top NYC Restaurant than to find an in-network psychiatrist or therapist.

I won the lottery in 2019—no, not that one. I found a Ph.D psychotherapist in my insurance network. While my friends relied on out-of-network and out-of-pocket therapists, my employer’s insurer cast a wide behavioral health net. It was nice while it lasted. My therapist would inform me that she had to leave the network in 2022 and her rate was $450/hour. She cited administrative hurdles, delayed payments, and a desire for autonomy when choosing the best treatment for her patients. FAIR. But for a moment, I was lucky. In 2021, only 1/3rd of Americans with a mental health diagnosis were treated by a mental health provider.

What does it mean when a doctor is “in-network”? Insurers negotiate deals with hospitals and doctors to charge less for services, AKA the reimbursement rate. In turn, the payer (insurance company) sends them patients (you). Seeking in-network care is cheaper for insured patients because they’re in-network. It’s like the SSENSE Private Sale for healthcare.

Why is it easier to book a table at The Polo Bar than find a good in-network therapist? We’ve moved past the mental health stigma to the point where caring for your mind is as important as caring for your body. Therapy as a gym for your brain, if you will. Yet people seeking mental health care can’t always get it. Why? It’s a combination of three things: it’s expensive, insurance offers poor coverage, and available appointments exceed weeks or months. The only thing worse than being ghosted is finding a therapist in a phantom network. That’s when an in-network doctor is not taking new patients. To add salt to injury, a look into Medicaid claims data found that programs pay psychiatrists less than primary care doctors. It makes sense that psychiatrists are opting for private-pay patients instead. These are health system gaps, but the burden of navigating these challenges often falls on those who are already struggling.

Sure, we don’t have enough mental health professionals to treat everyone. But that’s not the only issue. When I worked for a clinical neuropsychologist, her status as an in-network provider meant I’d often chase insurers for months before we got paid. Whether or not insurers paid on time, we still had to pay employees, pay malpractice insurance, and make rent on time. She eventually dropped most insurance companies, favoring companies with better coverage and a sliding scale private pay clientele. Fast forward 10 years, mental health professionals still face this issue, with the additional financial burden of stagnant or shrinking reimbursement rates.

A ProPublica investigation published late last month found many other mental health practitioners in her position. They spoke with over 500 psychologists, psychiatrists, and therapists and found that many were forced to leave insurance networks, unveiling disruptive insurance company interference patterns. A psychologist in Eugene, Oregon, Melissa Todd, tells the story of a woman in crisis after her dad’s passing. Todd followed existing treatment guidelines to address her bipolar symptoms, meaning using a combination of talk therapy and medication. Their first hurdle was finding a psychiatrist who was both in-network and taking new patients. The patient, who was suicidal, had to rely on an out-of-network psychiatrist and pay $$$. After 6 months of therapy, the insurer thought she had had enough. They thought she wasn’t sick enough. Todd made her case but ultimately chose to leave the network so she could treat her patient without the red tape. A New York-based therapist had to call his patient’s insurer ~45 times before getting paid. Some therapists saw their patients for free while they spent hours appealing insurance denials. Some got second jobs to compensate for treating insured people. ProPublica highlights many similar anecdotes, where insurers don’t pay on time, pay too little, or make them jump through hoops for their money.

Is this legal? Nationwide, insurers must provide mental health, behavioral health, and substance abuse coverage comparable to physical health care, thanks to the 2008 Mental Health Parity and Addiction Equity Act. The caveat? It doesn’t require insurers to offer mental health coverage, but it ensures that coverage is on par with other health conditions if they do. This distinction, seemingly small, has profound consequences. Insurers still wield the power to exclude certain diagnoses, deem treatment "medically unnecessary," and deny care that could be life-saving. State laws also require timely payment to providers, but enforcement varies.

The market has found system workarounds, like treating private-pay/out-of-pocket patients on a sliding scale or low-cost therapy by graduate students. But these workarounds financially incentivize insurance companies to drive out mental health patients and their doctors.

For insurance to cover your care, mental health professionals must tell payers that something is wrong with you (diagnosis) and what they did about it (procedure). But this isn’t always seamless—mental health symptoms don’t always fit neatly into medical diagnosis boxes, and insurers often have restrictive “medical necessity” criteria. This forces therapists to be tape-and-glue guys for severe and acute symptoms instead of addressing longer-term complex traumas or focusing on prevention. Diagnosing a broken left arm is straightforward. The patient complains of pain in the left arm, doctors observe swelling and bruising and then get an x-ray. Congrats, it’s an ICD-10-CM Diagnosis Code S42.302A (unspecified fracture of shaft of humerus, left arm, initial encounter for closed fracture)! In psychiatry, diagnoses can be elusive.

Psychiatry, as a medical field, is less than 200 years old. She’s baby. The Diagnostic and Statistical Manual of Mental Disorders (DSM) is its bible. Mental health providers reference the DSM to diagnose patients based on a patient’s symptoms, how long they last, and how they interfere with their daily life. But symptoms overlap. Sometimes, what looks like borderline personality disorder is a net of coping mechanisms from being raised by someone with personality disorders. There’s also the unsettled debate on biological vs nonbiological causes of mental illnessFor example, when scientists found that some people developed dementia and grandiose delusions from untreated syphilis infections. Or when homosexuality was pathologized in the DSM until 1973. Remember lobotomies? We’re also learning more about the gut-brain connection. Insurers may exploit this ambiguity, but I see it as the scientific method at work.

What’s the policy prognosis? It depends on where you live. Forbes published a list of the best and worst states for mental health care. The worst states were Texas, Georgia, Florida, Mississippi, Arizona, Indiana, South Carolina, Kansas, and Colorado. Vermont beat out the rest of the country as the best state for mental health care. The Biden administration launched a push to promote insurer compliance with the Mental Health Parity Act, which is a good start.

Mental health care access reflects how we care for one another in times of need. We have proven treatments that help people with mental health conditions, such as cognitive-behavioral therapy, dialectical behavior therapy, EMDR, lifestyle changes, and drugs. Thus, expanding access to mental health care is our societal responsibility to ensure that people can access mental health professionals if they need them. This includes incentivizing prevention and addressing the provider shortage issue through loan forgiveness, community training programs, and telehealth therapy. Policymakers may lower patient cost-sharing by either setting limits on out-of-pocket spending for low-income patients seeking mental health care or setting a separate deductible threshold for behavioral health. However, in our push to broaden access, we must also uphold quality of care and ensure that mental health professionals are fairly compensated for their work.

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