It’s been three years since Teresa experienced her first manic episode the summer before she went to college, but her mother, Maria, still sometimes thinks about how hard it was to get her help.
Theresa’s other mother had insurance through the Johns Hopkins University employer health program, so her stay at a Hopkins hospital was covered. But Maria called more than a dozen psychiatrists before she found one who took her daughter’s insurance and hadn’t been booked in for months.
After Theresa was diagnosed with bipolar disorder and her psychiatrist suggested she see a cognitive behavioral therapist, Maria again called every therapist she could find who worked with the insurance plan.
“Finally, I said, ‘You know what? “I don’t care if I have to work until I’m 90,” said Maria. “I will get her the help she needs and deserves. We pay completely out of pocket — still — for her therapy.” The Baltimore Sun is identifying Theresa and Maria by their middle names to protect Theresa’s privacy.
In 2023, Americans paid an average price of $8,435 for individual health care coverage and $23,968 for family coverage, according to a report by the health policy research nonprofit KFF. Health insurance is supposed to make getting medical care easier and more affordable, but that’s not always the case when it comes to mental health care.
In Maryland, people are nearly 9 times more likely to go out-of-network to get behavioral health care than to get primary care, according to a 2019 report commissioned by the Bowman Family Foundation. This disparity – the fourth worst in the country – cannot simply be explained by a lack of mental health workers. Although the state lacks nearly 100 mental health providers, according to federal data, it is short even more primary care providers.
Instead, much of the problem can be explained by a decline in the number of mental health providers accepting insurance. A decade ago, fewer than half of American psychiatrists accepted any form of insurance — a percentage that experts say has declined since then.
Therapists across the state said they just don’t like accepting payments directly from patients and potentially becoming unaffordable for some of their clients. But with stagnant reimbursement rates and time-consuming administrative tasks, some say insurance companies forced their hand.
Last year, Deborah O’Donnell, a clinical psychologist at St. Mary’s County, stopped accepting CareFirst BlueCross BlueShield after seven years of care for patients covered by the insurer. The costs of running her practice had skyrocketed in recent years, and the company — Maryland’s largest health insurer — denied her request for a rate increase.
Every week, she said, she gets calls from people who have CareFirst and can’t afford her out-of-network fee. They tell her about all the therapists they tried calling before her and how they also don’t take CareFirst or are booked.
“I have to leave these calls with the unsettled feeling of knowing there’s a person who desperately needs help,” O’Donnell said, “and the best they can do is get on a waiting list.”
‘We are tired of it’
Earlier this year, hackers broke into the nation’s largest health insurance claims clearinghouse and unleashed what some experts consider the worst cyberattack in U.S. health care history. For months, Change Healthcare — a subsidiary of United HealthGroup that processes billions of health care transactions each year — grappled with the fallout.
Several Baltimore-area therapists said CareFirst, a client of Change Healthcare, owed them thousands of dollars in unprocessed claims, forcing them to make difficult decisions to keep their practices afloat.
In an emailed statement, Brian Wheeler, CareFirst’s executive vice president of health services, said the company continued to accept claims through other partners after Change went offline and most providers switched clearing partners within days. CareFirst offered interest-free advances to providers who struggled to switch partners, he added.
But as of April, CareFirst still owed Ellicott City Village Counsel about $24,000, said Amy Philips, owner of the 30-physician practice. For months, her office staff spent hours on the phone with the insurer, trying to track down the missing payments. Some of the doctors stopped seeing CareFirst patients — who make up half the practice’s caseload — because they couldn’t afford to offer free sessions.
CareFirst has since caught up on most of the missing payments, Philips said, but she’s still frustrated with the insurer. Despite numerous attempts to negotiate a reimbursement increase, CareFirst has raised its rate only slightly since it began accepting it in 2015.
“We’re helpers,” Philips said. “We’re not asking for much, but we’re tired of it.”
Wheeler said the company’s rates are based on market and wage data in the region. For example, he said, a social worker in Maryland would be paid more than $100 an hour as a base rate.
Physician and nurse advocates have also complained about low reimbursement rates, but they typically have more bargaining power than mental health workers, said Matthew Eisenberg, an associate professor of health policy and management at the Johns Hopkins Bloomberg School of Public Health. .
In 2022, Johns Hopkins Medicine successfully negotiated a rate increase with CareFirst after an impasse in which it threatened to drop the insurer. Most therapists and psychiatrists, however, work independently or in practices that are much smaller than the Hopkins system, Eisenberg said. It would take an increase in providers deciding to no longer accept certain insurance to prompt a company to raise its fees for mental health doctors.
Melissa Mullineaux, a Sykesville-based therapist specializing in the treatment of eating and anxiety disorders, stopped accepting Aetna and CareFirst late last year. Eventually, she said, she plans to drop all health plans. This will allow her to work with fewer clients, avoid burnout, and invest in continuing education, such as a nutrition degree, to better help her patients.
Other therapists, however, said the guilt they feel about self-paying keeps them in network with insurance companies — even when it doesn’t make financial sense. Samantha Ross, a sole practitioner in Frederick who runs Grow Through Talk, knows she could get fewer clients if she stopped providing insurance. But she is aware of how much the need for mental health help has grown in recent years.
“I don’t make enough money as a provider to pay my therapist out of pocket,” she said. “I don’t want people going into debt to do therapy.”
The paradox of equality
In 2008 — two years before Congress passed the Affordable Care Act — lawmakers tried to push insurance companies to improve coverage of mental health and substance use disorder treatment.
Under the Mental Health Equity and Addiction Equity Act, health plans are not required to pay behavioral health providers the same amount as physical health providers. However, they are required to eliminate restrictions that made access to mental health care more difficult than access to comparable physical health care.
Part of that means paying providers enough to incentivize them to stay in the network, Dr. Henry Harbin, senior advisor to the Bowman Family Foundation and a board member for the Maryland Mental Health Association.
National and local data show that it’s still much harder to get mental health help online. In Maryland, people are nearly 21 times more likely to go out-of-network for inpatient mental health treatment compared to inpatient medical or surgical treatment, according to the Bowman Family Foundation’s 2019 report. And the state’s in-network behavioral health clinicians are reimbursed 23% less than other doctors who perform similar services.
“There just hasn’t been enough enforcement [of mental health parity laws], whether at the state or federal level — even for states that have done a lot, like Maryland,” Harbin said. “They’re going to have to do more.”
In 2020, Maryland lawmakers passed a law requiring insurance companies to complete reports that would allow the state’s insurance commissioner to check their compliance with federal equality law. However, in a report released late last year, the Maryland Insurance Administration said it could not determine whether insurance companies were following the law because the documents they submitted for review were “consistently and demonstrably inadequate.” .
The agency fined CareFirst, United Healthcare and Kaiser for failing to submit completed reports — $250,000, $500,000 and $150,000, respectively — according to the report. In emailed statements, the three companies said they had since submitted completed reports.
It was the first year companies were required to submit equity reports, and there was “significant confusion,” CareFirst’s Wheeler said.
The Insurance Administration eventually reduced United Healthcare’s fine to $350,000 and CareFirst’s to $175,000, the companies said. Kaiser also paid its fine, the company said.
In the last legislative session, state lawmakers took another stab at improving mental health equity. They passed a law that gave the Insurance Administration more enforcement authority and removed a sunset for reporting requirements set out in the 2020 law. Insurance companies will be required to file reports by July 1 and every year thereafter. two years moving forward.
Meanwhile, more than a quarter of Marylanders who need mental health help aren’t getting it, according to an analysis of census data by KFF.
Theresa, who was diagnosed with bipolar disorder three years ago, just finished her sophomore year at the University of Maryland, College Park. She is doing well in school and is working with the National Alliance on Mental Illness – an organization Maria volunteers with – to start a club for students who are struggling.
But Maria remains shocked by how difficult it was to get her daughter help. She had good insurance and, since Maria works in nursing, she had many connections eager to help her navigate the health care system. And it still felt almost impossible.
“That’s always my question,” Maria said. “What in the world does everyone do?”
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