Until about 20 years ago, mental health professionals set fees based on training and experience and were reimbursed by health insurance companies a fair percentage of the bill. Mental health benefits are now part of managed care networks, meaning that patients are narrowly restricted to “in-network” providers. Providers who wish to be in-network must agree to accept significantly reduced fees – with per-session fees declining more than 40% since the late ‘80s.
Clinicians in private practice are prohibited from negotiating more reasonable fees, due to current anti-trust laws. Whereas at one time mental health professionals could enjoy financial security, now they face crisis – a money crisis.
The concept of managed care was initiated to bring equity to health care and treat the underserved. Because they seek to reduce or eliminate waste, there is continual pressure to reduce reimbursement rates. The populations we treat are especially vulnerable, as emotional crisis is subjective and patients are not always assertive enough to demand treatment.
This is extremely frustrating and presents ethical challenges to clinicians who are committed to care of their patient. Often, the highest quality of care is limited to those who can pay out of pocket. This short fall is further escalated by poverty and race.
There is an overarching lack of proper care for People of Color (POC). Here are some statistics from a recent Surgeon General’s report:
Disparities in Mental Health Care of POC Compared to Whites
- Less access to mental health services
- Less likely to receive needed mental health services
- Those in treatment often receive a poorer quality of care
- Are underrepresented in mental health research
- Disparities stem from historical and present struggles with racism and discrimination
Surgeon General’s Findings
- POC disproportionately suffer a high disability burden due to unmet mental health needs
- There are disparities in diagnosis
- For POC, stigma is #1
- It is expected that over the next 50 years, the population of the US will become increasingly racially diverse
- White population decreasing
- More than half of the Population will be POC
- In NY this diversity is already reflected in the city and the patients we serve.
- Bilingual staff is hard to find and harder to keep
- Managed care companies often do not have clinicians who can provide culturally competent services
- POC need pre-treatment work, and there is often managed care issues related to time restrictions
Communication Barriers
- POC seek/advocate for health information differently than Whites
- POC have more personable expectations of their therapist than Whites
- Research shows that therapists are often less patient-centered with POC than with Whites
- Therapists often don’t have time to address any of these issues, which leads to poor treatment and outcomes
Managed care is keeping psychotherapy costs artificially low, yet research estimates that more than a third of mental health disorders go untreated due to restricted access to care. Often patients simply cannot locate clinicians who will accept managed care fees. Publicly funded reimbursements, such as Medicare, have also been reduced. Reimbursements to clinicians have been cut near every year for almost a decade – and Medicaid payments are significantly lower than managed care rates. Clinicians in every sector are feeling the financial squeeze of managed care, from new graduates, to those in private practice, to those nearing retirement. Many who practice psychotherapy are finding other career niches.
There needs to be much more public education about mental health to educate consumers and eradicate stigma. Often parents of young children are encouraged to ignore emotional symptoms, with the notion they will “grow out of it.” This coupled with lack of access to skilled providers causes misdiagnosis, delays or untreated mental health issues.
Every family in America has felt the impact of psychological problems, either directly or indirectly. The question becomes, how do we maintain a highly skilled and dedicated network of clinicians to meet the growing needs of our patients?
