In 2008 the Mental Health Parity and Addiction Equity Act (MHPAEA) was made a federal law in an effort to ensure that group health plans and insurance companies were providing equal access to mental health and/or substance use disorder (MH/SUD) treatment that they were for other types of medical care. Now, 15 years later, that act is being looked at once more to determine if coverage for MH/SUD are in fact being treated equally to other services such as primary care visits, surgeries, and more.
As a licensed professional clinical counselor (LPCC) in the state of Minnesota, I can only speak from my experience when I say that, mental health care still very much has a stigma associated with it and that it is in fact treated as a whole different type of care than traditional medical care. On July 25, 2023, President Biden brought to the attention of the nation the giant loop holes that insurance companies have been utilizing to continue to treat MH/SUD treatment as something totally different than other medical conditions/care. He called attention to the fact that in the United States of America, getting care for ones mental health should be the same as getting care for a broken bone--but it's not. When you read the technical release (found here) about the call for comment on the Mental Health Parity and Addiction Equity Act, you will find numerous questions about different (and very detailed) aspects of insurance company networks, care, and more. As a therapist who feels passionate about everyone having access to care if they want it (at a rate that pays therapists what they are worth without sending clients in the debt), I wanted to address some of the questions that I feel like have some pretty obvious answers based on my own experiences as a professional. I also want to acknowledge that I don't have answers for every question they ask in the release. The medical system and care in this country is broken. And without a complete overall, I'll quote Taylor Swift and say that, "band-aids don't fix bullet holes".
Location & Networks
Many of the questions the government is looking for answers on are related to how many providers should be permitted to join insurance networks and how many providers are needed for a given area. Just for a little context, right now many mental health providers (since that's what I can speak to) are being denied access to joining insurance company networks (being in network with an insurance company means that subscribers can use their insurance benefits that they pay for to see those providers) due to there being "too many providers" in a specific area. To put it bluntly, insurance companies are getting free range to decide what the need is as far as the number of providers for a certain population area (eg: 1 provider to every 100 people). My question for insurance companies and the government is this: With the technology we have, which increases access to services for people, regardless of their physical location, why are we determining things based on geographical location? With the effective delivery of therapy virtually in this day and age we can provide quality care to anyone, anywhere. It should be mentioned too that right now, therapists are only able to practice in states in which they are licensed due to licensing boards. But that is a whole separate issue we won't be going into today. Physical location no longer feels relevant if we are ACTUALLY trying to do something about increasing access to services and working towards a resolution of the mental health crisis everyone is talking about in this country. In small communities, the odds of having a provider in the town or even within a reasonable driving distance are slim. Not to mention, if a provider lives and works within a small town, it increases the likelihood that a dual relationship which will be formed (which are frowned upon in the mental health world) and decreases clients privacy.
To complicate things further (for those who are not in this field), many providers get in-network with insurance companies when they are working for a bigger organization or larger group practices. When they leave these jobs however, they remain "in network" because the employer they worked for is still in-network. As a result, insurance companies still count these providers as part of their network, even if they are no longer providing services. This of course skews the number of providers that appear in-network and able to serve those in need, making insurance companies believe there are more providers and greater access than their are in reality. Insurance companies are not looking to see which providers are actively submitting claims and serving those in their network. If we can just look at the number of subscribers to an insurance plan and base the number of MH/SUD providers off the total number of people who may one day need support, we are then proactively treating our citizens. It seems simple enough to me when we think of people, rather than profit first.
Therapist Workload
Which leads me to the next complicating factor with insurance company being able to determine the appropriate therapist to client ratio. When insurance companies are allowed to determine this ratio, they are essentially dictating how much therapists should be working. Most therapists that I know have to base how many clients they see a week off of their financial needs due to the (in my opinion) low payouts from insurance companies to therapists for their services. Amongst the therapists that I have communicated with, most say that if they weren't concerned about their finances, seeing somewhere between 15-20 clients a week (doing 1 hour long sessions) feels sustainable. Keep in mind that therapists are ONLY paid for the time they are sitting face to face with a client even though they have many other obligations such as paperwork, continuing education, coordinating care, etc. But how does this actually look when you lay out the numbers? Let's see. All therapists practice differently and each client has a different treatment plan that best fits their unique situation, but for the sake of this discussion, let's say that a therapist recommends someone to come in every two weeks. Let's use the number of 15 clients a week (because we want QUALITY mental health professionals) times two, so that we are filling a full schedule for two weeks. Thirty. In this scenario, the ratio should be 1 therapist for 30 clients/insurance subscribers. While I may not know what ratio insurance companies are using (because they certainly don't actually TELL providers anything), I would bet BIG money that their ratio is not 30:1.
I want to stop and address for a moment all of the people who look at 15-20 client hours a week and have a negative reaction to that. "Therapists have it easy. They just sit and talk to people." "I work 60 hours at my job!" On and on, I feel like I've heard it all. In this situation we are only looking at client contact hours because that is the only thing that insurance companies pay for. In addition to those 15-20 client hours therapists are writing notes (required by insurance companies), doing treatment plans, connecting with other providers to coordinate care, finding resources for clients, furthering their education, etc. Not only that, those 15-20 hours a week that a therapist is being paid are times where the therapist is required to be 100% focused and dialed in. Engaging in active listening. Remembering the details of a clients life. Integrating their knowledge of humans and psychology with the nuances of each individual client's situation. This is not 15-20 hours of mindlessly sitting at a desk or walking a job site. This is intentional, skilled, and focused work. To keep it in perspective, imagine going into a meeting at work and being unable to zone out because you have to provide a summary after so that someone else can determine if you listened and understood well enough to actually get paid for your time. Now do that 14-19 more times over the course of your week. It's no walk in the park and not as easy as people want to believe it is. Sitting with people through some of the worst moments of their life without turning off your own humanity is not for the faint of heart. If you are still someone that thinks they could do that for 20 hours a week, I challenge you to notice how many times you check your phone during your work day. Or get up and go to the bathroom whenever you please. Or simply get lost in your own thoughts or problems. We therapists don't have those luxuries when we are working.
What's Mental Health Care Worth?
The next set of questions the government is looking for answers to are the appropriate cost of MH/SUD treatment compared with other types of medical treatment. In my opinion, MH/SUD treatment should be treated/paid similarly to physical therapists, occupational therapists, and chiropractors. Typically, people don't seek out these type of providers until there is a problem. Then, when the problem is resolved or better managed, there is maintenance care that is helpful for preventing relapse. While all of the providers listed use different CPT codes and bill for services differently, if we looked at the average dollar amount billed for any given hour these professionals work, we would better be able to determine what more equal pay would be for those in the MH/SUD field. I'm sure that someone would like to make the argument that physical therapists, chiropractors, etc. are technically "doctors" and therefore should be paid more than masters level therapists. So I will say this, my husband, who is a chiropractor, has about one trimester more of education than I do as a mental health counselor. For some perspective, for me to obtain a doctorate degree (which would then allow me to be called a doctor) I would need to go to school for somewhere between 4-7 MORE years depending on the program. We need to be looking at the amount of education a professional has, not their title, which can be very deceiving. If we are going to treat mental health as the same priority as physical health, we need to determine an average that each professional, based on their education, can earn in an hour and make some decisions from there.
Hidden Challenges
While not asked about this in their call for comment, another power that insurance companies wield over MH/SUD providers that the government (and society as a whole) should acknowledge is the insurance companies ability to clawback previous payments to providers. What this means is that anytime within three years after a service is provided, insurance companies can decide that they overpaid or that there was some other issue and take back their original payments to providers. That means, at any time the insurance company may decide, providers can be saddled with a large bill without any warning. Providers are then responsible for repaying the insurance company, retracting what could be a very substantial part of their income with no way to compensate for it. While some providers may try to pass off this repayment off to clients, often times clients don't remain in therapy for three years so tracking them down for payment years after the fact is often fruitless.
Lastly, while I know it is typically required of all types of service providers, the need for approved diagnoses to get treatment paid for is maddening. To be frank, life is really hard sometimes. That doesn't mean that someone is mentally ill or is a good match for a mental health diagnosis. For example, divorce or other major life change is an excellent reason to seek out therapy. And while the individual may have some symptoms present associated with the change, providers are then required to pathologize the individual seeking help, even though their reaction might be how we would anticipate any human to react. We are required to give someone a label, just so that the insurance that clients already pay for monthly, will cover mental health services. Insurance companies want only people who meet criteria for things like major depressive disorder, generalized anxiety, or PTSD to be able to get help. They aren't interested in helping someone deal with their grief after a significant loss or the parent looking for ways to manage their own stress while raising children. They do this to try and limit the people who can get mental health care while also continuing to perpetuate mental health stigma that so many people say they want to break.
And now what?
I could get into the weeds explaining the ins and outs of mental health treatment and all of the things I would like to see change, but this post has already become more lengthy than my others. I think its necessary to address some of these very real (and fixable) barriers for people seeking mental health care and help mental health professionals in the field trying to do this hard work. I truly hope that changes to the MHPAEA can do that. I'm incredibly passionate about treating people like the important beings that they are. Everyone deserves to be taken care of and have access to services and resources that help them lead quality, fulfilling lives. Clients deserve to not have to worry about paying for care in the midst of their struggles. Providers that get into the trenches with people deserve to not have to decide between paying their bills and their own mental health. We cannot continue to be reactive to the mental health of those in the United States. We need to get proactive in teaching people how to care for themselves before they get into states of crisis.
What other questions do you have about the field of mental health that you want to see answers for?
If you want to send in your comments on the MHPAEA you can email your comments to mhpaea.rfc.ebsa@dol.gov I'm crossing my fingers and hoping we see some really good change for the people seeking help and the people doing this incredibly hard work.
