David Newton, Director of Operations and Marketing, SunCloud Health
LET’S JUST START BREAKFAST WITH THIS….
Mental Health does not get the same treatment from payers as other medical issues, and it should…. “Let’s just start breakfast with that…”
As musician Ben Harper passionately said in a recent interview for radio station KEXP in Seattle when talking about ongoing racism and what inspired one of his most recent songs, “Call It What It is”, I too was “grabbed by the back of my neck” to write about something that isn’t right.
Like Ben, I wish I did not have to write this. However, in a very simple way my personal experience speaks to one of the main reasons we struggle so immensely in dealing with the crisis we face today with drugs, alcohol and so many other mental health issues. Payers do not want to pay for it, and for those that need the help and cannot afford to pay themselves, this can make the difference between getting treatment or not.
My story- I see a psychiatrist on average 3 x/month. I am scheduled for once/week but with holidays and missed appointments because of work or family commitments, I average a little less. My psychiatrist is a board certified MD who has been practicing in Chicago for at least 30 years. He may not be the best but he is well educated, has a solid reputation and no doubt he has been good to and for me. He bills 250/hour. Is he expensive? YES. Do I wish he were less expensive? Answer- Of course I do. Worth it? Answer- I think so, though we don’t measure outcomes and I wish we did. Does he take insurance? Answer- he used to actually bill insurance but today he touches none if it. Like so many outpatient psychiatrists, he gave up negotiating with and arguing with insurance companies over things like “medical necessity” a long time ago. So, I pay him cash and then I submit to my insurance company for reimbursement.
We have pretty good insurance. One of the top three carriers in the US actually who is supposed to have some of the best mental health benefits in the country. In fact the plan is offered through an employer that is itself one of the largest mental health companies in the world. As I do every year, last year I took the painstaking effort of submitting copies of all of my paid invoices through the mail to the PO box on the back of the card for what I hoped would be some reimbursement. I have never really understood the algorithm for reimbursement but I do know that every year the amount has gone down and yet I remain optimistic and hope to maybe see a few bucks…. Each time a few months later I would receive a claims benefit form showing that they knocked the 250/hour down to their accepted rate of ~ 90.00/hour, applied that ~90.00/hour to my special mental health benefit deductible, then to my even more special out of network mental health deductible and at the end of the year after submitting at least $10,000.00 in bills to them, I received not a dime back. I had my assistant call a few times to make sure they got all of the bills and did not make a mistake because I could not believe this. After having to go through each and every bill we determined that they had in fact received all of them yet the reason for no reimbursement is that I did not meet the extra special out of network mental health deductible of…..
At the same time last year I also submitted a few bills to this same payer for my annual post cancer screening and MD visits. I think my total charges from the hospital (actually it was from maybe 4 providers including the hospital, and I could not tell who did what or why to be honest) for this post cancer check-up totaled about 10k as well. For these charges, however, the multiple providers all billed insurance directly, I eventually got a bill for around 2500.00 as “my portion”, I paid it and insurance apparently paid the rest- though I wonder how or if they could tell what was done, by whom and why….The stark contrast between how my mental health costs and my cancer costs are handled could not tell a more clear and concise story. Thank goodness I can afford what I need today from my psy doc and I know that ~10k spent in keeping me healthy in this regard is more than offset by the quality of life I live partly as a result. A portion of this “ROI” is measurable in things like my productivity, my physical health and the taxes I am fortunate to pay as a result of the income I generate. Some, however, like my peace of mind, “medical” co-morbidities that I am likely avoiding by remaining mentally healthy and my ability to maintain healthy relationships with my wife, my kids, and my business contacts may not be so measureable. Regardless, I know I am a better and healthier person as a result of the care that I seek in this regard and that I pay forThere are far too many people who face a similar situation and in many cases much more dire. I am fortunate I can afford to pay for this treatment myself. Many cannot. Why is there such a difference? Maybe it’s my policy, but I don’t think so. Of course I wonder what I would have done if insurance did not cover me when I had cancer… That would have been a disaster. I also wonder what people do who need mental health support or therapy yet who cannot afford it and whose benefits, like mine, just don’t cover it. And how in the world do we think we are going to make a dent in the opiate crisis, for example, if patients can’t afford to get help because payers won’t help pay for it. We won’t.Payers are not the enemy and from a pure business standpoint I understand why this is happening. Yet there are sound business solutions that address what can ultimately be a pretty strong a barrier to treatment, and for the sake of all of us we need to solve this problem sooner than later.As Ben said, “Let’s just start breakfast with that…”
Like Ben, I wish I did not have to write this. However, in a very simple way my personal experience speaks to one of the main reasons we struggle so immensely in dealing with the crisis we face today with drugs, alcohol and so many other mental health issues. Payers do not want to pay for it, and for those that need the help and cannot afford to pay themselves, this can make the difference between getting treatment or not.
My story- I see a psychiatrist on average 3 x/month. I am scheduled for once/week but with holidays and missed appointments because of work or family commitments, I average a little less. My psychiatrist is a board certified MD who has been practicing in Chicago for at least 30 years. He may not be the best but he is well educated, has a solid reputation and no doubt he has been good to and for me. He bills 250/hour. Is he expensive? YES. Do I wish he were less expensive? Answer- Of course I do. Worth it? Answer- I think so, though we don’t measure outcomes and I wish we did. Does he take insurance? Answer- he used to actually bill insurance but today he touches none if it. Like so many outpatient psychiatrists, he gave up negotiating with and arguing with insurance companies over things like “medical necessity” a long time ago. So, I pay him cash and then I submit to my insurance company for reimbursement.
We have pretty good insurance. One of the top three carriers in the US actually who is supposed to have some of the best mental health benefits in the country. In fact the plan is offered through an employer that is itself one of the largest mental health companies in the world. As I do every year, last year I took the painstaking effort of submitting copies of all of my paid invoices through the mail to the PO box on the back of the card for what I hoped would be some reimbursement. I have never really understood the algorithm for reimbursement but I do know that every year the amount has gone down and yet I remain optimistic and hope to maybe see a few bucks…. Each time a few months later I would receive a claims benefit form showing that they knocked the 250/hour down to their accepted rate of ~ 90.00/hour, applied that ~90.00/hour to my special mental health benefit deductible, then to my even more special out of network mental health deductible and at the end of the year after submitting at least $10,000.00 in bills to them, I received not a dime back. I had my assistant call a few times to make sure they got all of the bills and did not make a mistake because I could not believe this. After having to go through each and every bill we determined that they had in fact received all of them yet the reason for no reimbursement is that I did not meet the extra special out of network mental health deductible of…..
At the same time last year I also submitted a few bills to this same payer for my annual post cancer screening and MD visits. I think my total charges from the hospital (actually it was from maybe 4 providers including the hospital, and I could not tell who did what or why to be honest) for this post cancer check-up totaled about 10k as well. For these charges, however, the multiple providers all billed insurance directly, I eventually got a bill for around 2500.00 as “my portion”, I paid it and insurance apparently paid the rest- though I wonder how or if they could tell what was done, by whom and why….The stark contrast between how my mental health costs and my cancer costs are handled could not tell a more clear and concise story. Thank goodness I can afford what I need today from my psy doc and I know that ~10k spent in keeping me healthy in this regard is more than offset by the quality of life I live partly as a result. A portion of this “ROI” is measurable in things like my productivity, my physical health and the taxes I am fortunate to pay as a result of the income I generate. Some, however, like my peace of mind, “medical” co-morbidities that I am likely avoiding by remaining mentally healthy and my ability to maintain healthy relationships with my wife, my kids, and my business contacts may not be so measureable. Regardless, I know I am a better and healthier person as a result of the care that I seek in this regard and that I pay forThere are far too many people who face a similar situation and in many cases much more dire. I am fortunate I can afford to pay for this treatment myself. Many cannot. Why is there such a difference? Maybe it’s my policy, but I don’t think so. Of course I wonder what I would have done if insurance did not cover me when I had cancer… That would have been a disaster. I also wonder what people do who need mental health support or therapy yet who cannot afford it and whose benefits, like mine, just don’t cover it. And how in the world do we think we are going to make a dent in the opiate crisis, for example, if patients can’t afford to get help because payers won’t help pay for it. We won’t.Payers are not the enemy and from a pure business standpoint I understand why this is happening. Yet there are sound business solutions that address what can ultimately be a pretty strong a barrier to treatment, and for the sake of all of us we need to solve this problem sooner than later.As Ben said, “Let’s just start breakfast with that…”
And let’s just have dinner with this (my quote- not as good as Ben’s but it makes the point)…. Despite the fact that I see my psychiatrist for minor anxiety and family related issues and not more serious complications such as psychosis, schizophrenia, eating disorders or substance use disorder, I still thought twice about publishing to the world that I even see a psychiatrist a few times/month! Yes, there has been massive de-stigmatization around some of these illnesses, but not enough. Clearly.