By Michael Birnkrant
Recent legislative changes affecting mental health insurance coverage coming about due to The Mental Health Parity and Addiction Equity Act (2008) and the Patient Protection and Affordable Care Act (ACA, 2010) will result in more people than ever having access to mental health treatment, especially those who can’t afford out of pocket treatment.
All good things can have a cost, though, which brings me to thinking about what it means to have a metaphorical third in the room. Today, the most commonly encountered third party involved in mental health treatment is the insurance company. As more people seek mental health treatment through their health insurance plans, it is a good time to slow down and have a dialogue about how these changes will affect the work.
How ethical and accurate is it to diagnose a patient on the first visit—which is required if the therapist wants to get paid right away? What will it mean to keep patient records electronically (a requirement of ACA for all providers by 2017)? I read almost daily about breaches in security and identity theft (see the recent attack of 2/4/15 on over one million Anthem/ Blue Cross Blue Shield customers). When a third party is paying, how much can they dictate the duration and type of the treatment? Currently, that is an issue for many who feel it is impossible to disclose to a client the duration of a course of treatment before it starts—even though that is included in some insurance company agreements with providers and in some fields’ ethical codes.
While speaking to multiple clinicians about their experiences working with insurance companies, it became clear that most of them were very frustrated that the insurance companies become the authorities on patient care. If an insurance company does not approve more authorized sessions due to lack of medical necessity, and the patients are unable to pay out of pocket to continue treatment, the clinicians have to end treatment with their patients or rethink the wording of their requests to make the patient sound more pathological, resulting in a medical record that might not be accurate and may create a pre-existing condition which could impact future coverage options for the patient.
Another issue brought to my attention by some clinicians is that the initial resistances related to setting the fee can no longer be studied when the insurance companies set the fee—cutting off what is often a loaded and symbolic communication to be understood. A clinician who accepts insurance informed me that he is still able to study resistances patients have to paying copayments, and that he has observed many interesting ways that some of his patients overpay or underpay their copayments, but is that enough?
In the past seven months, I spoke with both undergraduate and graduate level classes about the potential ethical dilemmas pertaining to third-party interference. At the end of my presentations, I was consistently surprised when students would say that they wanted to re-think their choice of future careers as therapists and mental health providers. They reasoned that all of the realities of working with patients and their insurance companies did not align with their vision of what they had hoped and imagined for their future careers in mental health.
I let the students know that despite the realities of working with insurance companies, if they are passionate about becoming clinicians, then they should keep working towards that goal. There is always an option to self-pay and literally cut out the middleman. Each time I left the classrooms where I presented, it seemed that there were many questions left unanswered, and many of the students appeared to be deep in thought about the topic at hand.
A dialogue needs to be opened, in which clinicians can freely discuss their positive and negative experiences working with insurance companies. Splitting and rigid yes or no’s will not help. All the players need to come to the middle and openly discuss options and solutions. More articles on this topic should be written, and increased public dialogue needs to occur.
With so many changes to insurance coverage and policy quickly unfolding, it would be a disservice to all clinicians affected by these changes if the voices of mental health professionals went unheard, and if clinicians were unable to put their thoughts and feelings on the present topic into words!
Michael Birnkrant, M.A., is a graduate of the Master of Arts in Psychoanalytic Counseling program at BGSP, and a current student in the Doctor of Psychoanalysis program. He also works with inner-city youth as a clinical fellow in the School-Based Fellowship Program at the Boston Institute for Psychotherapy.