There are a lot of people suffering from a mental health condition who need therapy. And there are a lot of therapists who want to help them. But both sides believe the insurance companies that are supposed to bring them together are actually keeping them apart.
Insurance companies, for their part, say there鈥檚 a shortage of therapists.
But it鈥檚 not that simple. Especially in urban areas, there are lots of therapists. They just don鈥檛 want to work with the insurance companies.
Take Michael Klein, a psychologist practicing in San Francisco for more than 20 years. He considers it his spiritual calling to help people calm their social anxiety and to help couples stop fighting and build trust.
鈥淲ith the right kind of support, they blossom,鈥 he said.
Klein doesn鈥檛 accept insurance. In fact, nearly half of therapists in California don鈥檛 take insurance, according to a from the California Association of Marriage and Family Therapists. The same is true of . There are two reasons why, Klein says.
鈥淥ne, because the reimbursement rates don鈥檛 provide a living wage,鈥 Klein said. 鈥淵ou can鈥檛 own a home and drive a car and survive on what in-network providers pay you.鈥
Most insurance companies pay therapists in their networks between $60 and $80 per session. In the San Francisco area and Los Angeles, therapists say the market rate for therapy is more like $150 to $200 a session.
鈥淭he second thing is the paperwork. For an hour of psychotherapy you spend a half-hour on paperwork,鈥 Klein said. 鈥淚 got into this field because I don鈥檛 like paperwork,鈥 he said, laughing.
On that first point 鈥 money 鈥 insurance companies acknowledge that they may have to raise their rates to attract more therapists, particularly in rural areas. But they also say it鈥檚 on therapists to compromise.
鈥淚 think it鈥檚 unrealistic to expect either the state of California taxpayers or for health plans to just pay providers whatever they ask to be paid,鈥 said聽Charles Bacchi, CEO of the California Association of Health Plans, a trade group for the insurance industry.
鈥淭hat鈥檚 not sustainable,鈥 he continued. 鈥淪o you鈥檙e either in the system, and you want to be part of our health care system. Or you want to do concierge service outside of it and just pretend our health care system doesn鈥檛 exist. That鈥檚 your choice as a provider. Our job is to find providers that are willing to be part of the solution and willing to provide coverage to those of low and moderate income.鈥
That鈥檚 exactly how San Francisco psychologist Jonathan Horowitz feels. He wants to take insurance, but he has hit roadblock after roadblock. He sent out 10 applications to insurance companies and got nowhere.
鈥淚 might knock on Cigna鈥檚 door and say, 鈥楬ey, are you guys accepting any new therapists in 94105?鈥 鈥 he said, referring to his ZIP code. 鈥淎nd they might say, 鈥楴o, we鈥檙e not doing that. We鈥檙e totally full.鈥 鈥
Six different companies told Horowitz their networks were full.
So even though a patient might call seven therapists in her insurance network and not be able to get an appointment, insurance companies are telling new and willing therapists that there鈥檚 no demand for them.
鈥淚 definitely think it鈥檚 to control costs,鈥 Horowitz said. 鈥淭hat鈥檚 very clear.鈥
He says he tried for a year, and one company finally said yes. Sort of. Horowitz never got a formal notice saying his clinic was admitted to the network.
鈥淚t was just like, 鈥極h wait, it looks like we鈥檙e suddenly getting a couple referrals from them. I wonder if we鈥檙e in their directory,鈥 鈥 he explained.
They were. Sort of. The clinic was listed in the directory. But the therapists who work at the clinic weren鈥檛 approved yet, meaning there was no one who was allowed to see the clients calling the clinic.
So Horowitz tried to call the insurance company to clear things up. He tried many, many times. I sat with him during a recent attempt to navigate the automated phone system:
Insurance company automated attendant: First I鈥檒l need your provider identification number. If you need a moment, say, hold on.
Horowitz: Hold on.
Sound familiar? Turns out therapists get the automated run around as much as patients do. Horowitz persevered.
Insurance company: OK, please say or enter your PIN.
Horowitz: My PIN? Is this my PIN?
He enters a few numbers.
Insurance company: I鈥檓 sorry I couldn鈥檛 find an account using the info you gave me. Do you already belong to the network?
Horowitz: I think so?
Insurance company: Sorry, yes or no.
Horowitz: Um, I don鈥檛 know 鈥 yes?
Insurance company: All right. And have you already requested a credentialing application?
Horowitz: Yes.
Insurance company: Sorry, could you repeat that?
These experiences didn鈥檛 bode well. 鈥淗onestly, I got a really bad feeling about it,鈥 he said.
Horowitz figured, if this is what it鈥檚 like just finding out if he鈥檚 in the network, how鈥檚 it going to be when he has a problem with a claim?
鈥淚 could just see that getting out of hand really quickly,鈥 he said. 鈥淪o at that point we just said, do we really even want to do this?鈥
Furthermore, he says, the reimbursement rate was even lower than he expected, and the billing was so complicated that he was going to have to hire someone to do it. He says he couldn鈥檛 afford that.
鈥淲e made the decision that we鈥檙e just going to cancel the contract and continue to go with cash,鈥 he said.
Easier said than done. Horowitz hasn鈥檛 been able to get through to anyone on the phone to cancel the contract. In the meantime, prospective patients are finding his name on the directory and are calling for appointments. Horowitz says he just has to say no.
This story is part of a partnership that includes , and Kaiser Health News.