No Stupid Questions

one of the most frustrating aspects of being a therapist in america in the past 10 years is the hand waving of the ethics involved in the financial renumeration of our relationship with those we serve

I would say a significant stressor for the overwhelming majority of the clients I have is financial woes. And because the system is backwards, those with high paying jobs well into their career tend to have the fancy PPO plans with no deductible where seeing me (or anyone) is only $10 despite the fact that they could much more easily afford a 5-10k deductible. Meanwhile the people who are making 20-50k a year on the other end of the spectrum almost always have those high deductible plans with sometimes massive deductibles and rarely have employer funded hsa.

I’m not an idiot, I run my own practice and I do the books for it. I can do the math to figure out how much take home pay someone has with those salaries. I can also conceptualize the cost of housing, food, phone, transportation, etc because I am also paying these things. So when I meet someone here and their appointments are $140 per meeting I am in a tough spot. I am asking them to take on a burden of $560 per month (assuming weekly sessions). That’s immense. And if the deductible is 5k, 7.5k, 10k, it will take ages to meet especially if they’re younger and not really making contact with many other medical providers.

I am contractually obligated to charge what your insurance pays me in these instances. If your insurance pays me $140 for the hour I have to charge you that until you hit the deductible. I could be dropped from the network if I modify this for you and get caught.

I can ask you to skip using your insurance and charge a lower out of pocket rate but this is complex. For one, many therapists can’t adjust their rate much lower. I have flexibility here because my practice is entirely telehealth so my overheads are much lower. But if you see them in an office? They are paying about 40-50% of that just in rent most places.

Additionally even with telehealth I have to be careful with adjusting rates. Insurance only pays me for specific timed and coded sessions. If you and I have a phone call for 25 minutes? Not covered. If you ask me to collaborate with your psychiatrist and I talk to them for 40 minutes? Not covered. The time I spend dealing with billing and this system, which works out to an average of 20-30 minutes per session? Not covered. So the 25% of my week doing billing shit and the overtime hours doing phone check ins, case collabs, etc. has to be covered by that.

This is why many therapists give fee schedules and charge you for all of these things. If you want paperwork from them it’s $1 a page, phone calls are $75/hr, etc. I can make it work without this because I’m not paying for office space but if I was I would need to do this to keep myself afloat.

This is also part of why many, many therapists simply don’t take insurance anymore. Just pay me the $140 directly. I can collect it via square or whatever and your billing is done. I no longer spend 5-10 hours a week on billing nonsense like fighting retracted payments, finding out why claims were denied, etc. You can submit receipts for out of network reimbursement and you deal with them.

I understand why my peers do what they do. But ethically it’s a mess. I signed up to help people and what I have become is a gigantic cash sink that puts a tremendous amount of pressure on the people I serve and is counterproductive to our work.

At the same time I deserve a fair salary for my work and this is the only way to get it. And if I protest the system by leaving it because it’s so broken then the end result is that there’s 1 less mental health provider who takes insurance. If I stop taking insurance altogether I alienate a ton of people with high need who can’t afford to pay out of pocket forever and/or don’t know how to navigate out of network reimbursement.

I cannot tell you how many times I do a screening call with someone and they say “this sounds like what I need”, they tentatively schedule, and then once I run their insurance and give them the actual numbers of what treatment will cost they simply ghost. It is a system that actively deters people from seeking assistance because it is so cost prohibitive

And the insurance lobby has its fingers so deep into the framework of america that this will simply never be fixed. It will only be changed. Look at Kamala Harris’ proposed Medicare for all: it still allows private plans. That will be a movement in the right direction because it will end the idea of someone being “uninsured”, which is great, but it will also create a two lane system in which many practitioners will do whatever they can to avoid taking basic Medicare patients in favor of the commercial plans. Commercial plans, at least in my area, simply pay more. Significantly more. Like $80/hr vs $140/hr. And in the end I will have the same problems because the unnecessarily complex private insurance system will still exist and be very powerful. I will just have one more insurer to add to the web of complexity. But no politician will ever remove the private health insurance industry. To do so would alleviate so much spending waste, so many wasted administrative dollars and man hours, but it would also result in layoffs of hundreds of thousands, if not millions, of americans whose jobs rely on processing the complex bullshit of this system