This morning, #KQED news, in its series Boomtown, reported about the rising costs of psychotherapy in San Francisco. I am a psychiatrist practicing at the Bay Area Children's Association (BACA) in Oakland and I myself have a psychologist who I see weekly in San Francisco. So my thoughts on this issue come from being on both sides: therapist and patient. There are several important points that the reporter missed and I wanted more consumers to have this information.
1. Working with insurance companies is easier said than done.
The organization I work for is staffed by excellent therapists - social workers, marriage and family therapists, psychologists, and psychiatrists - and we do accept insurance in addition to offering financial aid for those whose insurance coverage just doesn't cover it. Many of us chose to work at this organization because we believe in the concept of serving everyone regardless of ability to pay. Working for a larger organization gives a mental health provider the benefit of having administrative staff that can negotiate contracts with insurance companies and spend forty hours a week dealing with all of the paperwork and phone calls that come along with accepting insurance. It is a full-time job that clinicians in private practice simply don’t have the time to do. On top of that, although many of us were in school and training for over six years, none of this was included in our training and none of it is simple.
2. So why doesn’t everyone choose to work for a large organization that manages all of the insurance?
Well, BACA is unique. At BACA, I am free and encouraged to practice in way that I believe is ethically appropriate. BACA creates an environment that is ideal for both patients and practitioners - patients are not paying exorbitant amounts for services and practitioners do not feel that they are compromising care. However, many people go into private practice because they want the flexibility to do what they feel is right, and they often find larger organizations to be too restricting. When I first applied for jobs after finishing training, and was looking to serve low-income patients, I was told by multiple organizations that I, because I am a psychiatrist, would not be allowed to do psychotherapy. That is not how I trained and that is not how I feel comfortable practicing.
3. Most private practitioners offer financial assistance of some kind.
Many clinicians in private practice use a sliding scale so that they are able to see people in various socioeconomic situations. One of my colleagues is currently seeing someone who is unemployed. If and when this patient gets a job, the rates will change. When I was in training as a resident at UCSF and seeing my current therapist, she saw me for a reduced fee. The bump in salary that I received after finishing my training has allowed me to now pay her full fee. I can’t say that I’m “happy” to pay it, but it does feel more than fair and I find the service she provides extremely valuable. As for charging more for people who have the ability to pay, this is essentially what allows clinicians to provide more services to those who can't afford them. Additionally, clinicians can and often do provide patients with documentation of services that they can then submit for reimbursement by their insurance company.
4. Mental health stigma continues to rear its ugly head.
My friend recently received a bill from his cardiologist for a 30 minute outpatient appointment, coded for insurance purposes as a 99203 visit, involving medical decision making of low complexity. The cost of this visit was $485. A 99213 visit, which is a similar 30 minute visit with a psychiatrist also involving low medical decision making complexity, costs $150-250. I am not attempting to disparage cardiologists. I just don’t believe that a person’s heart is any more important than his head. Yet the difference in cost of services is glaringly apparent. I can imagine a patient not wanting to spend $485 to see his cardiologist, but he would probably do it, because it’s his heart. However, if a patient is feeling depressed or anxious, and he doesn’t feel he can afford therapy, he might just try to get by on his own, and the problem will only get worse. This is something that too many providers and patients are unwilling to talk about because of the stigmatization of mental health, but we as a society have to start talking about it if there is any hope of it changing.