Why psychiatrists don’t take insurance

In 2007, I wrote a post called “Why Shrinks Don’t Take Insurance.”  The post is a bit dated, the CPT codes have changed since then, and the reasons to not take insurance have increased.  Many other doctors don’t take insurance now, though psychiatry remains the number one specialty where doctors don’t participate in health insurance plans.  This is an updated version of that same post.

Many psychiatrists in private practice don’t participate with insurance insurance panels. They require the to patient pay and then the patient has the option to submit a claim to his health insurance company as an “out-of-network” service,  and reimbursement is made directly to the patient.

This may mean that the patient has a higher co-pay and deductible, and the hassle of doing the paperwork.  It also means that if the insurance company does not send reimbursement, that the cost is incurred by the patient, the doctor has still gotten paid.  If a patient sees a psychiatrist in his network, he pays the deductive and co-pay and the hassle of getting the rest of the money falls on the doctor.  Now the overall expense of an out-of-network psychiatrist may or may not be lower — some plans have excellent out-of-network coverage — but any way you look at it, the hassle and financial risk are less if a patient sees doctors who participate with their insurance.

Because many psychiatrists do not participate, it means that access to psychiatric care may be limited to those who have the money to pay up front,  and the wherewithal to stick their statements into an envelope and send them to the insurance company– after they’ve called a separate managed care company, gotten pre-authorization, and had Dr. Shrink submit a treatment plan. They must assume the financial risk that the insurance company might find some reason not to reimburse.

Over on PsychPractice, our colleague has a post up about an insurance company that lost the claim, then wouldn’t pay it because it was then submitted late, and then wanted the psychiatrist to provide references as to why out-of-network service is necessary.  It’s about the number of hoops, how high one must jump, and whose going to do the jumping.

By not accepting assignment, the doctor has greater control about what he is  paid, but the patient supply becomes limited in a way that restricts access to care.   Patients who want the financial and logistical benefit of remaining in their network are often surprised to find that it’s difficult to find an in-network psychiatrist (even though the insurance company often has a large list of dead providers) or that those psychiatrists aren’t taking new patients, or that they see patients for brief med checks but not for psychotherapy, or that it’s hard to find a psychiatrist who feels warm and fuzzy enough. From the patient’s point of view, it’s not fair. There’s a reason for this: it’s not fair.

So why don’t all shrinks accept assignment, why aren’t they lining up to be members of insurance networks who would funnel lots of patients their way? Let me tell the story from the psychiatrist’s point of view.

If a psychiatrist doesn’t accept assignment, s/he sets his own fee — generally what the market will bear. This one is easy, everyone understands wanting more money, and the insurance company fees are often less that what a psychiatrist can charge if he does not participate.

For some psychiatrists, that’s the bottom line. For many, however, it’s about much more: the paperwork and the freedom to practice psychiatry as he wants.

If the psychiatrist accepts assignment, he agrees to practice according to the terms of the insurance company. He sees the patient and collects the copay. Maybe it’s a flat $30 co-pay, after a certain deductible. Maybe it’s 80% for the first 5 visits and 70% for the next 5 visits and 60% for all the visits after that oh but the patient is only covered for 25 visits a year and the psychiatrist has agreed not to balance bill as part of the deal. I don’t know what happens if the patient needs a 26th appointment, I believe the doc eats the fee or simply doesn’t offer the extra sessions. At any rate, the doctor now needs to figure out how much the patient has to pay and it’s his responsibility to collect this.

Oh, but it’s not 80%/70%/60% of his fee that the insurance company will pay, it’s 80% of what the insurance company has decided is usual and customary rate (UCR) which is set by the insurer. And while it might be a piece of cake to calculate if the the UCR was say $100/appointment and the patient paid $20 and the insurance company paid $80, but it’s a pain in the neck if the UCR is $97.84/ session and you have to keep count of the sessions and figure out the percentages. Should I mention that different insurance policies by the same company can have different payment rates so someone has to call for each patient, verify the insurance, find out the terms, co-pays, deductibles, and this involves sitting on hold and dealing with assorted prompting menus.

Did I mention that some patients have two insurance policies?  When I accepted Blue Cross in the early 1990′s, they would send me checks for $12.44 for 50 minute sessions.  I never did figure that one out, nor could my three billing secretaries explain it.

While many psychiatrists in private practice are able to manage their practices without secretarial support, a psychiatrist who practices in-network usually needs a secretary, an overhead expense his I-don’t-accept-assignment friends may or may not want or need. And he now has to have an office big enough to accommodate secretarial space. I’ll also tell you that while the secretary is paid an hourly fee, his ability to get paid is only as good as her motivation to follow through on dealing with the insurance companies, refiling denied claims, clarifying primary versus secondary insurance and getting the amount of the co-pays correct.

And if the insurance company finds a reason not to pay, the doc is stuck — he can’t bill the patient, he’s just out the time/money. For a psychiatrist who does psychotherapy and sees 8-11 patients/day at an insurance company discounted fee, doing work that does not get reimbursed is a problem. A doctor may decide he can afford to take on some patients at reduced fees, but it’s infuriating to be subsidizing an insurance company because the forms were filed with something coded wrong, or because the insurance company lost them.

Increasingly, insurers have requirements for how the doctor practices.  Medicare has it’s 1.5% fee cuts for doctors who don’t e-prescribe.  They have incentives to get doctors to figure out meaningful use.  There are fee cuts if PQRS codes are not done.  They still take paper claims, but will likely soon require electronic submissions.  Every segment of these mandates requires a large investment of time and often money.  Really?  Click on the meaningful use link I  provided and try to read the entire page.  Here it’s hard to figure out where the hoops are, much less how to jump through them.

So why does any psychiatrist accept insurance?  Some doctors don’t get enough referrals without participating, some are simply afraid they won’t so they don’t drop out of networks, others practice in areas where people simply can’t afford to take insurance.  In some areas of the country, this is just not a mind set: everyone takes insurance, and psychiatrists just do med management.

Insurance companies pay reasonably for short appointments with a psychiatrist.  A psychiatrist who sees two patients in an hour makes more than a psychiatrist who sees one patient in an hour, and often the insurance companies (perhaps eager to encourage their policy holders to seek psychotherapy with a cheaper clinician) will pay a reasonable amount for a shorter session (perhaps they make this worth doing).

A psychiatrist who can see four or five patients in an hour and who has a secretary and has a system in place can do well financially by billing insurance companies, but it does require volume.  A psychiatrist who sees patients for hour-long sessions will be disadvantaged and that’s why in-network psychiatrists don’t usually provide psychotherapy.

What you don’t hear when you read about how psychiatrists don’t take insurance is that we still like what we do.  I still have a job where I spend each hour listening to patients without interruption, I then put a note in a real paper file in a metal filing cabinet.  I just read that the average primary care doctor spends 2/3 of their time on clerical work.

I’m happy to say that I spend the vast majority of my time in e-free sessions with my patients and I’m hanging on to that for as long as I can.  But it’s not just about the money, it’s about three things: the money, avoidance of mountainous paperwork hassles, and the the freedom to practice psychiatry in a rewarding way.

Dinah Miller is a psychiatrist who blogs at Shrink Rap and co-author of Shrink Rap: Three Psychiatrists Explain Their Work.

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  • Duncan Cross

    Seems like it boils down to this: even many psychiatrists don’t think mental health is all that important. Otherwise, they’d be advocating to ensure their patients get the necessary care, rather than seeing the less well-to-do locked up in prison. If only folks with money can afford mental health, it’s by definition a luxury good, and not essential to normal human well-being — insofar as not being able to pay for mental health care is totally normal for humans in this society.

    As somebody who clearly and deeply needs mental health treatment, the whole “no-insurance” thing is a huge barrier to my care. It’d be great if mental health care was more broadly helpful across socio-economic lines, but as long as the bottom line is whether it’s rewarding for practitioners — not patients — I guess I’ll be fine living with my psychoses. What’s the worst that could happen, right?

  • guest

    Reply to Duncan Cross:

    I think what needs to be remembered is that there are essentially two types of psychiatric patients: there are the severely mentally ill, who typically are seen in a clinic setting, where public funding pays for their care, the psychiatrist is a salaried employee, and there is ample support staff available to help with the types of emergencies that occur with severely mentally ill people.

    On the other hand, there are the “worried well,” who are generally high-functioning enough to have private insurance, and whose psychiatric needs run more along the lines of mild to moderate depression or anxiety. These are the patients who are seen in the type of private practice being described above. And yes, unfortunately, most of them have private insurance that creates huge barriers to their getting decent care, so psychiatrists choose not to accept it. However, refusing to volunteer your services to care for someone who is working and functioning but has an insurance plan that would like to treat you abusively, is not the same as “not thinking mental health is that important.”

    The fact is that most people with private insurance basically don’t have insurance for mental health care. Your insurance company might like to tell you that you do, but the benefit that you are actually provided is, quite frankly, a joke. And here’s what is puzzling: it’s your insurance, not the doctor’s insurance (the doctor has his or her own lousy insurance to deal with). Why are the patients not out there advocating for better insurance coverage for themselves? Why are they insisting that the doctors, who have nothing do to with insurance companies, should be somehow able to force the insurance companies to do better? The patient is the one who is the customer of the insurance company, not the doctor.

    Personally, I think the answer is that corporate medicine has done a masterful job of convincing the public that all of our healthcare delivery woes are the fault of the doctors, not the fault of an increasingly corporatized healthcare system which exists not to care for patients, but to make money for corporate executives and wealthy shareholders.

    • Duncan Cross

      This is a more generous response than most people would offer, so I appreciate your taking the time to reply. I wouldn’t let corporate healthcare — nor my insurers off the hook — for anything. I know they give terrible reimbursement for mental health, because I’m the one who has to file for it. But that’s the health care as it is, and it’s the system almost every sick person has to live in.

      We can blame insurance for all the sins of the world, but unless you have a generous sliding scale, you’re slamming the door on plenty of sick people. There is a significant gulf between the severely mentally ill and the ‘worried well’, filled with people whose mental health problems are real and difficult but not amenable to the billing practices in the OP. And these unwell folks are expected to change the healthcare system… how?

      My sense is that psychiatrists, by distancing themselves from that
      system rather than working to change it, contribute to the stigma that
      mental health isn’t ‘real’ medicine — i.e., if it was ‘real’ medicine,
      you’d take insurance, like ‘real’ doctors do. That in turn reinforces
      the idea that mental health issues — anything short of
      institutionalization — aren’t ‘real’ health problems. Patients — not psychiatrists — bear the brunt of that stigma. Psychiatry as a profession could do a lot more good in this country, but won’t as long as psychiatrists are content to sit on the sidelines of health care.

    • Kristy Sokoloski

      In answer to your question about why don’t the patients advocate for better health coverage for themselves, and why it is that they insist that doctors be the one to force the hands of the insurance company to do better it’s because the insurance companies don’t listen to a word the patient says if they try to do it themselves. I had a doctor one time try to tell me that if I wanted to have a certain medication covered by the insurance that I be the one to push for it. The reason he gave? “Because they will be more likely to listen to you than they would to me”. That’s a bunch of hogwash and it’s wrong.

      • southerndoc1

        It’s my insurer refusing to pay for my medicine. How dare you suggest that I take responsibility for the situation?

        Classic!

        • DoubtfulGuest

          So…is it possible that some patients are genuinely confused about insurance? It’s not necessarily so straightforward if you factor in that doctors prescribe the medications, and either do or do not contract with the insurance companies. Particularly for those who are inexperienced with needing medical care.

          Doesn’t mean you should put up with rudeness from anyone. I’d just consider a possible information gap before I made assumptions about personal responsibility?

          • guest

            Of course insurance is confusing, because it’s to the insurer’s benefit to make processes as opaque as possible. It greatly increases the chances that patients and physicians will give up seeking the benefits to which they are entitled.

            But, the processes are as confusing to physicians as they are to patients. And the fact remains that a physician being “contracted” with an insurance company means exactly one thing: that he or she has been approved by the insurance company to receive payment for caring for the insurance company’s customers

            Being on the insurance company’s provider panel does not give the physician any leverage at all, in fact it’s quite the reverse because the physician is essentially an employee of the insurance company. What that means, as with any employee, is that if you make enough trouble for the insurer, they have the option of refusing to renew your contract to be on their panel. And that’s a problem for a number of reasons including that one of the questions that is always asked when you apply for a medical license or privileges at a hospital is “Has any insurance company ever declined to renew your contract to be on their provider panel?”

            Unfortunately, the fact remains that medicine becoming corporatized by third party payers means that physicians really have no power at all any more. The only vestige of power left lies in the hands of the customers, that is to say the patients, or more accurately, the patients’ employers.

          • DoubtfulGuest

            This is all really helpful to know and it seems fair that patients should take on the responsibility. I just feel bad when I see D and P snap at one another. It’s tremendously valuable (unpaid) work you are doing, to explain all this stuff. Much appreciated.

      • guest

        “That’s a bunch of hogwash and that’s wrong.”

        Well, it’s apparent that you are angry about the situation, but making unsupported assertions doesn’t help anyone. If doctors are telling patients that the insurance companies are not receptive to input from the doctors, I think that’s something that patients should be paying a lot of attention to, because it’s a reality that carries some pretty scary implications for the future of our healthcare.

        Of course, it’s much easier to dismiss the information the doctor is giving you and blame them for your inadequate care. Also, it’s exactly what the insurance company wants you to do.

      • Suzi Q 38

        Kristy,
        I actually have been able to get MRI’s covered when first denied by the insurance. I admit that I haven’t tried to get medication covered when first denied, though.
        I simply called the insurance company and gave then valid reasons for why I wanted the MRI’s. It wasn’t bad, and I figured that since they already denied it, what did I have to lose?

      • querywoman

        Kristy, I recently got the “tier” lowered on a Medicare D plan for my Victoza. I know how the doc needs to work it now. That doctor was too lazy to help you. Of course, they have to hear it from him.

  • Suzi Q 38

    I think that asking your patient to pay up front is difficult, but doable.
    If you provide the form and the doctor provides the diagnosis and other numbers for the visit and signs the form, all the patient has to do is mail it in. Let the patient keep track of the request for payment and all paperwork. Let the patient wait for the money to reimburse them for what they have paid the doctor.
    One of my dentists used to ask us to do that.
    We were fine with it.
    On the other hand, I am not psychotic, severely depressed, or suicidal.
    Asking patients with severe mental problems to fill out forms and mail them in may be asking too much.

    • Duncan Cross

      The difference is that your dentist doesn’t advertise as helping people with impaired cognitive processes. A person really struggling with depression may not have the energy for that paperwork, which is why the practice is a bit hypocritical in this case.

      • guest

        If the patient is genuinely so depressed that they are unable to complete basic activities of daily living, such as filling out insurance forms (which people with devastating medical illnesses such as advanced cancer also have to do), then they should probably be receiving inpatient treatment.

      • Suzi Q 38

        Your point is well taken, but i still say that some people can do this. A high functioning obsessive compulsive may do a better job than you are I. I suspect there are other patients who may be capable of doing so as well.
        If not the patient, then a responsible family member or friend.

      • DoubtfulGuest

        Duncan, I think we should take on the insurance/billing reimbursement ourselves, if only because it could make our doctors easier to get along with. Until recently, I had no idea what a time vampire it is for them to deal with. I AM very sympathetic about cognitive difficulties and trouble with activities of daily living. Been there myself and taken a lot of heat for it. I had doctors snap at me for “not listening”, with a yet-to-be diagnosed hearing loss. Others called me stupid and irresponsible when I was really just tired and confused. The reality for many of us is that some things get done some of the time. When things slide, there are negative consequences and it’s so hard because we didn’t ask to be sick. I think we should try, and then ask for help if we run into difficulties.

    • querywoman

      And the person would have to be able to afford the full payment in advance!

      • Suzi Q 38

        So true.
        If the patient has no money there will have to be other arrangements made.

    • johnfembup

      It’s at least mildly ironic that what you describe is exactly what we all used to call “insurance” back in the day.

      • guest

        Exactly. I am still scratching my head about how the medical profession could have sat by while insurance companies made them assume the burden of filing insurance claims for the patient. It makes absolutely no sense at all, and it has evolved into a system where the doctor frequently needs to have paid employees in order to obtain payment for his or her services, because the reimbursement process has gotten so abusive.

        Back when I had indemnity insurance for myself, my insurance company would never have dared to deny claims on ridiculous technicalities the way they do now, because I would have called my husband’s HR people and kicked up a huge fuss. Since doctors are not the insurer’s customer, however, and since they are socialized to be docile in the face of authority, they don’t react the same way and there is no check on the types of fraudulent behavior you see insurers engaging in now.

        • johnfembup

          “. . . I would have called my husband’s HR people and kicked up a huge fuss . . .”

          At one time I was head of benefits for an organization with more than 20,000 employees – you would instantly recognize our name. People complained to my office all the time, just as you did.

          It was astonishing to me how many people just had their facts wrong when they complained, and how many times I found that the physician’s office had not submitted enough info to settle the claim. On the other hand, many times I was able to secure payment if the insurance company had made an error, or if additional Information could be supplied. (I once persuaded Aetna to pay for a Viagra prescription for one of our female employees – but that’s off topic).

          In my experience most mistakes and misunderstandings occur because medical care is very complex and accordingly medical insurance is, too. As the debacle of Obamacare suggests failure to respect complexity by paying attention to details has serious consequences. Perhaps the greater lesson is that reform of insurance is not so helpful as reforms in medical offices and methods of delivery would – or could – be.

          BTW, my office also worked with Medicare, on behalf of our retired employees. Compared with Medicare, private insurance was a picnic.

          • guest

            “Astonishing to see how many people had the facts wrong.”

            I would venture to guess, that when you, an HR executive, called the insurance company to inquire about a snafu, that you probably got to talk to a more senior and more knowledgeable person than I did when I, a mere employee’s wife called. I cannot count the number of times I would call the insurance company and get a confusing/incorrect answer about what was going on with a claim. But of course I was talking to someone who had probably worked at the insurer for a relatively short period of time, and was probably poorly paid and poorly trained to address a system of such complexity.

          • johnfembup

            First of all, I was a financial exec. It’s just how we were organized, those were the chairs I rose thru.

            And whether it’s you on the phone, or me, shouldn’t change the facts of the claim.

            But to your point, I agree with you that insurance people tend to speak in their own arcane language which is most unhelpful when speaking with people who only want to understand their situation.

            It’s no wonder that insured people mistrust insurance companies. The insurance companies train them to be mistrustful, when they are attentive to their own scripts, and not to the real person on the other end of the phone.

            That doesn’t mean they should have paid out more. My experience is that most claims are paid correctly when full and complete claim information is presented. National data from independent sources agree – here’s a good one for example:

            http://www.athenahealth.com/our-services/PayerView/medical-claims-billing.php?intcmp=OUR-SERVICES/PAYERVIEW.PHP

      • Suzi Q 38

        I remember “back in the day.”
        I did have a few doctors ask me to pay for my visit, then file my own form to the insurance company for reimbursement.

  • Duncan Cross

    Thanks — I’ve not seen anyone explain the difference between community and academic physicians before, and how that difference affects the latter’s advocacy. It’s an interesting problem.

  • DoubtfulGuest

    Wow, what an insightful conversation, both of you. Thank you for writing this, guest. Your explanation pulls a lot together for me as well, in terms of impressions I’ve gotten from my own care and statements I’ve heard from different people. Based on my day to day life, I have to agree with DC that mental illness seems to fall into more than two categories of severity…at least “small, medium, and large”? I know lots of people who are functioning at a low level due to psychiatric problems. They’re not having emergency/inpatient care, although some have in the past. But no one who talks to them would describe them as “worried well”. I’m acquainted with some “worried well” folks, too. That’s my limited perspective, though. In-depth, but with fewer people (25 or so that I’ve known in my life).

    • guest

      Basically, in the eyes of the mental health care system, if you’re able to work, you are not severely mentally ill. I agree with you that there are degrees of psychiatric illness that can lead to a significant impact on someone’s level of functioning, and that a lot of those people have had limited access to mental health treatment, because they don’t meet criteria for having a severe mental illness.

      However, I would like to point out that the psychiatric community has put a lot of effort into ensuring that the Mental Health Parity Act was passed and enforced, and a lot of us are hopeful that this legislation will lead to improved insurance coverage for the types of patients you are talking about.

      http://www.cnn.com/2013/11/08/health/hhs-mental-health/

      • Duncan Cross

        See… this is a huge step, and your community should be applauded. But even with this change, the billing practices outlined in the original post still pose a significant disincentive to patients who should be seeking mental health care.

        • guest

          Well, I agree that psychiatrists who don’t accept insurance should have a sliding scale so that they can provide care to a range of patients. Some of the ones that I know do do that.

          But others feel, and I can sort of understand their point, that if they assume the burden of caring for underinsured patients, then no one will push the system to do what’s right, and make sure that psychiatric patients are not underinsured in the first place.

  • DoubtfulGuest

    Actually, now that I think about it, perhaps many of the “moderately” ill people I’m referring to might fall into your “severe” category. You did say “clinic” setting, not necessarily “emergency”.

    Also, I had a thought about why people don’t advocate for themselves with their insurance…my take on this is that many folks struggle with a feeling of overwhelm, they don’t know how to take charge of their lives, and by default they don’t know how to take responsibility. I experienced this to some extent when I was younger, assuming that others were in charge and nothing I did would have much of an effect on the world, either positive or negative. Fortunately, most people can work on this and get better at it. For some, it’s more challenging than for others. I can see how it would be hard for a severely depressed person to take initiative to fill out forms and send them in. Not impossible, but a major challenge.

  • Jason Simpson

    The pendulum has swung too far the other way. There’s a lot of mentally deranged people that need to be warehoused for life, just like in the old asylum system.

    The problem with the old asylum system is that it put EVERYONE in there who ranged from a little “weird” to severe deranged violent psychopaths.

    This isnt rocket science. Most people who are mentally ill are not violent. But the ones who ARE violent will be violent for their entire lives, “community” based outpatient treatment doesnt work for them, and therefore we should warehouse those people in asylums.

    We can warehouse the violent mentally ill in asylums without having to go back to the “bad old days” where every quirky person gets locked away for no reason at all.

    • guest

      Actually, fewer of them than you think really need to be “warehoused for life,” although every couple of months I do in fact admit a patient who would probably be happier spending the rest of his or her life in the State Hospital, which is almost impossible to get into these days.

      For a huge percentage of the rest of the severely mentally ill, they could do quite nicely out in the community if they had stable and supervised housing and case managers who visited them daily, made sure they were taking their meds, and got them involved in appropriate work or volunteer or therapeutic activities. This was the model of “Assertive Community Treatment” that was offered as an alternative to long-term hospitalization when so many of the chronically mentally ill were deinstitutionalized in the 1960′s.

      The problem is that it’s easy to cut funding for Assertive Community Treatment. No one but the patients, their families and maybe an alert psychiatrist here and there will notice if you cut funding for 24 hour supervised residential programs and they become “24 hour staff available” supervised programs, where there is actually not staff physically there 24 hours a day, there’s just someone who can be called to come if there’s a problem. And so, over time, that is what’s happened, until the community supports that were promised to patients coming out of the state hospitals have been watered down to a point where they no longer provide meaningful support, and you have chronically psychotic patients not taking their medications, and out unsupervised in the community, with predictable results.

  • guest

    That was my point exactly. A patient who is functioning so poorly that he or she cannot negotiate with his insurance company may need inpatient treatment, as he or she is likely performing poorly in other important areas of his or her life. And yet, insurance companies are allowed to deny such treatment and the response of the public is not that the insurance companies should be sued, or that legislation be enacted to prevent such predatory practices, but that psychiatrists should see those patients for free, and if they don’t, they don’t really care about mental health.

    Again, this is exactly the outcome that third party payers are hoping for. They are taking handsome profits for themselves, while adroitly making sure that physicians continue to hold all of the responsibility for patient care in a system that is rigged against both patients and providers.

    • Duncan Cross

      Nobody is demanding psychiatrists see patients for free. It’s not that the patients can’t negotiate with their insurance companies: it’s that these billing practices put that burden on vulnerable patients. It seems disingenuous to blame patients, insurers, and government for that decision.

      • guest

        So, if the psychiatrist agrees to take on the burden of negotiating with the patient’s insurance company, and spends an hour or his or her time, unpaid, on the phone, trying to unravel an issue with a denied claim for payment, in what way is that psychiatrist not providing a free service to the patient?

        • Duncan Cross

          If you say your fee is $200 an hour, but that hour requires another hour of work, then you’re getting paid $100 an hour. I sometimes work on fixed-priced contracts, and if I get the work done within my estimate, I get $30 an hour; but if not, I recognize that I’m earning less per hour than I expected — not working for free.

          • guest

            Right, and the point that the column is making is that the amount per hour the psychiatrist ends up making (significantly less than $100/hour I might add) does not cover the cost of rent, malpractice, health insurance for the doctor’s family, taxes, and repayment of medical school loans. It’s not a sustainable business model. The doctor needs to be able to pay all those expenses and still be able to afford to send his kids to college.

          • Duncan Cross

            I understand the economics fine. In the individual case, it’s rational: overall, the message is, sending their kids to college is more important to psychiatrists than mental health. Also — and I’m sorry, but this is where I totally lose patience with you — I can imagine the all-paperwork-no-pay-job because that’s been my life. I don’t have the luxury of worrying about whether I enjoy it or not, because it’s my life. My career — that I trained for through 15 years of rigorous higher ed — has been wholly derailed by my illness, especially the extraordinary burden of managing my condition in our health care system. Complaining about your job will earn you no sympathy from me. For someone whose time is so valuable, you’re spending a lot of it arguing against the people you expect to pay for your help.

          • DoubtfulGuest

            Many doctors feel just as cruddy as we do, at work. They just don’t tell us they have depression, lupus, cancer, and so on. Doctors have even less access to mental health treatment than we do, since they can face disciplinary action for seeking care.

            You have a point, and I would like it if in exceptional cases, doctors and staff would help deal with the insurance company. Like the patient says “I sent the forms and called three times and they’re just running me right over because I’m so exhausted. Can you please lend a hand?” However, I think the default should be that patients take this responsibility. Why not agree to even try?

  • querywoman

    Psychiatrists do not have 1/4 the other procedures to bill for that other doctors do. They are not usually dealing with infectious disease or multitasking.
    This explanations given for them not taking insurance is inadequate.
    The real truth about why most of them just do short medication management sessions instead of longer therapy sessions is they have more patients than they can handle.

    Psychiatrist make an adequate income, but they are one of the more underpaid specialties because they don’t bill for extra procedures.
    A lot of them who need to do something like lithium testing have a family doctor do it.
    I’ve known of shrinks who accept $35 from an insurance company for a 20 medication management session, but charge direct pay patients $90. It’s more profitable.

    The discounted rate should belong to the patient, not the insurance company.
    You need to come up with a better explanation.

    • querywoman

      Three thumbs down! That’s greed!

  • querywoman

    Regrettably, too many hospital beds were closed with the idea of treating ‘em in the community.
    Many people do need to do be locked up!
    Texas child killer Andrea Yates got bull dinky treatment in private insurance mental hospitals that include stuff like seminars on alcoholism and chemical dependency, which she didn’t need.
    She should have been put in a state mental hospital, where the insurance companies aren’t calling the shots.

    • johnfembup

      “She should have been put in a state mental hospital, where the insurance companies aren’t calling the shots.”

      Sounds reasonable. Get the patients to state institutions where the state calls the shots and they are in the patients’ interests.

      “Regrettably, too many hospital beds were closed. . . ”

      Closed by whom? Surely not by the states?

  • kidmodel

    A bit off topic (3rd party payors) so I apologize up front, but when a politician’s family member is squarely in the ‘mental health’ news (Sen. Creigh Deeds’ son who recently stabbed his politician dad and subsequently killed himself), a temporary spotlight is shone on the specialty. Problems within psychiatric circles are myriad, legion, steeped in history and even in antiquity due to a simple reality: we fear of mental illness because it’s mysterious and scary. Worse, we are not now, and haven’t historically done well treating it. While some progress has been made since the days of lobotomies and ‘insane asylums’ proportionally there is still a paucity of improvement when one considers the leaps noted in most other specialties.
    Deeds laments that the ‘system’ failed his son. Doubtless this is true as it is for thousands of other families who must deal with the chronicity and omnipresence of the symptoms which afflict their mentally ill loved one. However the number of psychiatric beds or PESS services won’t matter much in the face of revolving door exacerbations unless science and the molecular biologists come up with some better treatments for mental illness that actually work without profound sedation. Is such treatment in the future? Research and money will determine the answer. Until then, society (you and I and our loved ones) will continue to pay the price of a flawed and grossly inadequate approach to ‘mental illness.’
    Can we ever ‘fix’ a ‘sick’ brain?

    • DoubtfulGuest

      I don’t know how to fix it, but some pretty interesting research here:
      http://www.nature.com/nrn/journal/v13/n5/full/nrn3229.html

    • guest

      I am not sure what your recent experience with psychiatric medications has been but I would say 99% of my patients, almost all of whom are being treated with antipsychotic medications, are not objectively or subjectively sedated, that is they do not appear sleepy or slowed down (any more slowed down than they would be by their illness that is) to me or others and they deny feeling sedated when I ask them…..

      When you say “profound sedation” what exactly is it that you are talking about?

  • querywoman

    Every society has its crazies. Had Andrea got some real lockin’ up that didn’t include bully dinky substance abuse seminars that fail to stop most substance abuse, maybe her 5 children would be alive and she wouldn’t be in the mental slammer for the rest of her life.
    Rusty said he had just taken her to her doc, who took her off her meds due to side effects and told her, “Think positive thoughts, Andrea.”
    I said to my father, “Shouldn’t a man know better than to leave his wife with her children like that. $80,000 a year salary. Why didn’t he get her a maid?”
    Daddy blamed Rusty for keeping her knocked up.
    In the old Soviet Union, treatment in the hospitals was humane enough that people actually wanted in them. It’s not a good facade to post about one side, the locked up political dissidents.
    Nigeria doesn’t even have enough mental institutions. So a murdering mother or likewise is just killed by the paternal relatives and the police won’t do anything. That’s what a Nigerian immigrant told me.
    We do have SOME places to warehouse ‘em!
    Look at Adam Lansky. His poor mama had tried! And the Batman shooter, etc.
    It’s tricky to identify who’s this bad beforehand, and it doesn’t always work.
    A lot of suicides and lesser tragedies could be averted by shutting people away from society a while.

  • querywoman

    Public mental health services are well-known to be the best services. More support personnel, etc.
    The answer is putting an end to insurance companies penny-pinching on mental health. That’s the real problem.

  • Dinah

    Thank you for your comments; what an insightful discussion!
    The issue of not accepting insurance is a difficult one: it feels like the socially responsible thing to do and a means of making care more accessible to the middle class or those who can’t afford to risk that the insurance won’t reimburse them –because sometimes it doesn’t when people think it will. Somehow we’ve bought into the total non-culpability of the insurance industry, where they can refuse payment because an i wasn’t dotted, and where ‘approval of services is not a guarantee of payment.’

    The insurance company is responsible for providing a panel of qualified practitioners to it’s customers. If there are no in-network providers, the customers will be unhappy, they may complain to their HR departments and/or sign up for a different plan; it’s a competitive arena. If the services offered are poor enough, the insurance companies are forced to alter their policies, if no one will agree to provide services at the fees they offer and under the conditions they offer, it forces them to raise the fees and to alter what they will cover, and this is happening, insurers are paying more for psychiatric services. When the fees rise, the payment is assured (not contingent on making the deadlines for treatment plans which the insurance companies magically lose), the paperwork is easy, and intrusion into care is minimized or negligible, then psychiatrists will participate.

    Just another thought: If a psychiatrist sees a patient who can’t afford their fees, they reserve the right outside of insurance agreements to slide their fees, and to choose who makes sense to do this for. Insurance, with its negotiated fees, decreases the fees for their customers. This means that a wealthy patient with ample finances, gets the discounted insurance rates, and the doctor may then feel unable to slide his fees for those who have no coverage.

    Unfortunately, some plans have no out-of-network coverage (for example, Medicare and many HMOs), and the patient may have very specific desires in terms of treatment (I want a psychiatrist who can also be my therapist, I want a psychiatrist who has a reputation for being the best in the field), or there is simply no one available in the network to see the patient and they don’t have the energy to negotiate this, so they go out of network. In this case, the insurance company makes out well, instead of paying a portion of the treatment, they pay nothing.

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