Access denied

It shouldn’t be harder to find a therapist than a dentist or an optometrist, but somehow it is. Most Americans value the importance of mental health care but, according to a 2015 survey conducted by the Anxiety and Depression Association of America, the American Foundation for Suicide Prevention and the National Action Alliance for Suicide Prevention, only about 38 percent of Americans have seen a mental health professional, and about one-third consider mental health care inaccessible, mostly because it’s expensive and not supported by insurance.

Caitlyn Wallace is a licensed clinical social worker at the Renown Behavioral Health. She specializes in maternal mental health care.

“There are access issues within mental health because insurance carved out mental health,” she said. “For a lot of people, it’s not included in their standard insurance.”

This problem is especially acute in Nevada, a state that attracted national headlines in 2013 when the Sacramento Bee broke the story that the state’s largest mental hospital, Rawson-Neal Psychiatric Hospital in Las Vegas, approached the problem of mental health care by putting more than 1,500 patients on Greyhound buses and sending them to other states. And things haven’t gotten much better since then.

“Nevada is hard because other states have a lot more public funding for those sorts of things, whereas Nevada doesn’t have public funding,” Wallace said.

The federal government has laws, like the 2008 Mental Health Parity and Addiction Equity Act, that require parity among insurance companies for covering mental health alongside physical health. And the 2010 Affordable Care Act required small-group and individual health plans sold on insurance marketplaces to cover mental health services at levels comparable with medical services. But these laws have been difficult to manage at state, county and municipal levels.

For patients with Medicare or Medicaid, it can be difficult to find a provider because many clinics—especially privately owned ones—won’t accept their insurance.

“A lot of private practice therapists don’t take either because the reimbursement rates are not sustainable,” Wallace said.

But it can be just as difficult to find a therapist with private insurance. In March, a federal judge in Northern California ruled that the insurance company UnitedHealth Group “had created internal policies aimed at effectively discriminating against patients with mental health and substance abuse disorders to save money,” according to the New York Times.

According to the Times, D. Brian Hufford, an attorney representing the plaintiffs said, “When the federal parity law prevented insurers from placing sharp limits on behavioral health coverage, the companies ’came up with an even more insidious approach,’ … by developing internal rules that focused on providing expensive outpatient and residential care only when patients were acutely ill. … Once the acute condition was treated, the companies would reduce or deny services, he said. The care ’wasn’t addressing the underlying issue or the chronic condition.’”

The insurance company is expected to appeal the decision.

Apart from insurance woes, many therapists aren’t taking new clients because their schedules are full. This is especially true in places like Reno, where the population is growing faster than the infrastructure can handle.

Some therapists will petition insurance companies directly for coverage for a single-case agreement on an individual basis, but that creates a lot of extra work for the clinician.

“In maternal mental health, for example, there’s no one who regularly takes Medicaid right now—they’re both out on maternity leave,” Wallace said. “And no one who takes UHC. And in terms of Cigna and Aetna, I’m the only one who takes them. But it’s a two-and-a-half-month wait list for me, and for a postpartum mom, that doesn’t work. They need help immediately because they’re at high risk. So there’s a therapist in town who doesn’t normally take those but because they’re at-risk, high-need postpartum moms, she will write up the case agreement and submit it.”

Family counseling has other challenges. Insurance companies only want to pay for what they deem “medically necessary” treatment, which doesn’t usually include couples’ therapy. So therapists either won’t take insurance at all or are “forced to do something slightly unethical,” according to Wallace.

The therapist needs to identify a diagnosis in order to bill insurance. One of the clients, usually whomever is the primary insurance holder, gets diagnosed with an issue that then becomes the focus point of treatment. In other words, the billing needs of the insurance companies dictate the focus point of treatment—not the needs of the patients or the assessment of the therapist. And insurance companies don’t place any value on the mental health care equivalent of preventative care.

Wallace thinks the long-term solution could be an insurance plan that allows for eight-to-12 mental health sessions annually without requiring a diagnosis. “Get rid of the syndrome-based reimbursement system that insurance companies work under for mental health,” she said.

This would benefit people who suffer from some of the symptoms of a disorder—like PTSD—but don’t quite fit the full requirements for a diagnosis. And a patient wouldn’t have to attempt to self-diagnosis before seeing a therapist that “specializes” in whatever problem they think they might be suffering from.

When looking for a therapist, Wallace recommends using the websites Good Therapy and Psychology Today to find professionals in your area, and then cross-checking those results with your insurance company’s website. And still, if, after that two-step process, you’re not satisfied with your therapist, don’t be willing to settle. A personal connection can be important.

“The number-one thing—and it’s hard to tell if you don’t know them—is how comfortable you feel with them,” Wallace said. “The biggest thing that makes people successful in therapy is how safe and comfortable they feel with their therapist.”