Carter J. Carter became a therapist to help young people struggling with their mental health. Rosanne Marmor wanted to support survivors of trauma. Kendra F. Dunlap aspired to serve people of color. They studied, honed their skills and opened practices, joining health insurance networks that put them within reach of people who couldn’t afford to pay for sessions out of pocket. So did more than 500 other psychologists, psychiatrists and therapists who shared their experiences with ProPublica.
But one after another, they confronted a system set up to squeeze them out. Although federal law requires insurers to provide the same access to mental and physical health care, these companies have been caught, time and again, shortchanging customers with mental illness — restricting coverage and delaying or denying treatment. These patients — whose disorders can be chronic and costly — are bad for business, industry insiders told ProPublica.
There are nowhere near enough available therapists in insurance networks to serve all of the people seeking care. And although almost all Americans are insured, about half of people with mental illness are unable to access treatment. The consequences can be devastating. To understand the forces that drive even the most well-intentioned therapists from insurance networks, ProPublica plunged into a problem most often explored in statistics and one-off perspectives. Reporters spoke to hundreds of providers in nearly all 50 states, from rural communities to big cities.
A psychologist from Eugene, Oregon, Todd was treating a young woman with a history of trauma whose father had died unexpectedly. When the patient came to Todd, she was often unable to sleep more than an hour or two for days on end. “She described it to me as maddening,” said Todd, who recognized an array of symptoms that fit a diagnosis of bipolar disorder.
Longstanding practice guidelines recommend that providers consider a combination of therapy and medication when treating patients with bipolar disorder, so Todd sought a psychiatrist who could manage the young woman’s prescription. Although the patient was covered by UnitedHealthcare, America’s largest insurer, Todd was unable to find anyone who had openings. Her patient had to pay hundreds of dollars for out-of-network psychiatry sessions. Then, six months into treatment, UnitedHealthcare began to question whether therapy was even necessary.
Todd walked an insurance reviewer through the details of her patient’s fragile state. Even when the woman had periods of calm, Todd said, she knew the disorder was unpredictable. She worried her patient could attempt suicide if care was cut off at the wrong time. The reviewers responded that the patient needed to be actively experiencing severe symptoms to continue with treatment and suggested that the therapy wasn’t working.
In the end, the reviewers demanded a date when therapy would no longer be needed. Todd left the network so she could treat her patient without interference. The patient could afford to pay out-of-pocket because of a small settlement after her father’s sudden death. People are more than twice as likely to pay their full bill out of pocket for visits to mental health providers than primary care physicians, according to a ProPublica analysis of federal survey data.
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