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Psych Central Professional

At times, working with managed care insurance panels in private practice felt like dating a bad boyfriend. I was constantly investing more time and attention than “he” was in the “relationship” and it started to wear me down. I got up the nerve to break it off for good. I’ve never looked back.

I understand that building a practice free of managed care isn’t for every therapist. I am grateful for excellent colleagues who participate on insurance panel because and there is a great need for their services and I frequently refer clients to them. However, if you’re a private practitioner considering building a practice outside of managed care, I share my experience of resigning from managed care to give you the courage to take the leap, and the faith to know that it can work. So here’s my story…

9 Comments to
Why I ‘Broke Up’ With Managed Care

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  1. My mother is an LCSWC and feels the same way. It’s sad bemuse there are many people who need therapy, but can not afford the cost!

  2. Yeah, it’s good for you, but what about your clients? You are kind of screwing over 90% of them. Now if you do sliding scale, that’s a little better, but most people don’t have $120+ to spend weekly on therapy. Do you have provisions for that? what happens when a client loses their job and can’t pay your fee any more? Do you just say, good riddence? Plus, even if they do get reimbursement for any therapist, they typically don’t when it’s going to come either.

    I understand the reasons for doing it, but you are really really doing a disservice to the people who pay $$$ to get good health insurance and then can’t see you without forking over $$$ on top of their premiums.

    What happens if every therapist does this? Or if you the only therapist nearby who specializes in a specific problem? Then everyone who isn’t well-off who needs mental health care is in trouble.

    • “a client” — It’s a pretty bold statement to say that I was “screwing over 90% of my clients” when you have no information on how I made this transition. I informed my clients months in advance of the changes I was making in the business aspect of my practice so we could process and plan for the transition. For a couple of long-term clients I set up single case agreements with their insurance company so we could finish out treatment. Others decided to submit a monthly superbill and seek reimbursement through their out-of-network mental health benefits. Other decided to come every other week or to come for 25 minutes instead of 50 minutes. A few decided they needed to transfer to another provider on their health insurance panel and I helped them find one that would fit their needs. If a client loses their job during our treatment, I work with them to problem solve ways we can continue working together and/or explore other treatment options.

      How am I “doing a disservice” to people who pay for health insurance? People who have insurance have the choice to see providers on their panel or to pay for a non-participating therapist out of pocket. I fall into the latter category.

      Frankly, if every therapist decided to resign from managed care I believe that it could greatly benefit therapists by forcing managed care companies to provide better compensation to their providers (some offer $40 per session including client co-pay!) and less red tape in order to attract quality providers back to their panel. More importantly if all mental health providers resigned it would empower clients/subscribers to demand more flexibility and choice in their mental health benefits because they could have more choice in who they’d prefer to see for therapy.

  3. I agreed to pay my therapist a much higher co-pay than I’m supposed to because her reimbursement rate is ridiculously low. This is a hardship for me, but costs less than what I would pay if she went off the panel entirely. If my p-doc went off insurance, I would have to stop seeing him. I couldn’t afford him. I understand your frustration with insurance, but most people can’t afford to pay privately. You are confining yourself to a very limited clientele by taking only private pay patients. If mental health professionals would organize themselves the way other docs do, they could press for higher reimbursment. Instead, you have all these MDs, PsychD’s, LICSWs, EDD’s doinZg the same work and not working together. The behavioral health managed care providers then pick you all off like flies. My p-doc gets almost three times as much as my SW does for doing a hour’s therapy. The p-docs are organized. The SWs are not. And the SWs don’t make common cause with the MDs.

    It’s the patients who suffer when T’s won’t take their insurance.

  4. No. I didn’t mean the clients that you were seeing at the time of the switch. I meant that 90% of all POTENTIAL clients most likely wouldn’t be able to pay for your services. Yes, they could see another therapist, but what if your clinic is the only one in the area? Or what if you specialize in something specific? Or what if the client, really wants to see someone in your clinic but can’t afford it? I’m sure you know the relationship between the therapist and the client is of the upmost importance. Therapist’s aren’t interchangeable.

    If a lot more therapists ditched health insurance, then it would create a two-tiered system. The “private pay therapists” for the elite who could afford it and the ones that took health insurance for everyone else, most likely the therapists who took insurance would be of lower quality and/or have less specialization and training. At the very least, people would have to wait longer to see them in many areas. Actually many say that’s already happening in the US right now.

    If you want higher reimbursement, you should organize as a profession like many other specialities have done. Also, you could only accept insurance that paid the best reimbursements, like Medicare (many do more than Medicare). Yes you would still be limiting who you could work with, but you wouldn’t be limiting it as much as you are now.

  5. I think Julie’s is such an important perspective and inspiring for a lot of us. Having been on both sides of this equation – as a client and as a provider – I can see the complexities and the trade-offs. I am inspired by this approach because it fits me. I have been grateful as a starving student for the therapists who have either been in training (like I know Julie has in her practice) and those energized by pro-bono, agancey and sliding scale work, I have benefitted from both. I have also benefitted from therapists who are passionate and energized by a different style of work and value their time, experience, investment highly and have charged what they are comfortable with and I have made sacrifices to pay their fees. The bottom-line for me is any resentment in the relationship (with one’s work or a provider/client) does not work AND fit is crucial. Thus, as I embark on my own business, I am grateful for the mentors, like Julie, who inspire me to follow a path that fits who I am and what I value (and may be against the tide) so I find the right fit for me and hopefully inspire others, including clients, to value this for themselves (as well as their own self-care). Working this way gives me time and energy to provide volunteer, pro-bono and unpaid labor (e.g. in my own home) in a meaningful way and in ways that also energize me & provide balance and variety. Thanks Julie for opening up this very important dialogue!

  6. As a clinician, I have no plans to take insurance. It has become a source of anger and resentment and I will not bring that into my sessions. There are plenty of clinicians (who are NOT substandard) who work with insurance panels and they are good at what they do. I just know that I am no good to anyone if I am unhappy and resentful every time I go to work.

    I think it’s a little unfair for people to expect that a clinician should sacrifice their time and energy (with endless paperwork) and take less than a third of their fee. If you went to work tomorrow and found out that you were now going to be paid 1/3 of your salary, but expected to work twice as hard, would you be interested in that arrangement? But somehow, because one is a therapist, one is expected to do that or risk being told they are “in it for the money” or are “harming clients” or any number of things I’ve seen and heard hurled at therapists.

    I wish that our lobbies were as powerful as that of the AMA, but they’re not. So, we will continue to keep getting jerked around by managed care until people start saying enough is enough. I’ve said it, and I hope that more clinicians do too.

  7. There are 2 sides to our work. Business being one and every private business has the right to make policies within the law. I have NEVER accepted insurance in my private practice and yes, I do work with an exclusive population. It’s my choice. I specialize in one area. In my FT job at a human service agency, I make crap pay and get insurance. I love my work in both areas. If children were valued more by our society, I wouldn’t have to make this choice because the FT work would pay enough to survive.

    I am surprised by how judgmental the responses are.

  8. I applaud you for making the change. PPl have no diea what it is like to NOT get paid for the work you do, to answer to clerical staff who decide not to cover clients after a “care manager” review session (also unpaid). It is unhealthy to provide services w/o getting back fairly. An unhealthy system. Guess what, the insurance companies are who are “screwing” the public.

  9. I at least applaud your openness in explaining your rationale, though the decision does absolutely cut out a huge segment of the population from coming to you. Much of that population is people who put themselves on the line for us every day. Policemen, firemen, service workers, bus drivers, paramedics, etc., all of whom are in managed care situations. But that’s the way it goes.

    I guess I would feel better about it if psychotherapists who do not take insurance were to do what lawyers do, and that is to take on a non-trivial amount of pro-bono (not reduced fee, but free for those who could not afford it at all) work.

    Do any of the psych professional organizations ask therapists to do this? How much pro bono work (not 50% fee, or 35% fee, but zero fee for really poor clients) is done out there?

    • Cynthia, Thanks for your comment. I realize that it cuts out a huge part of the population from coming to me at this point in my career. I did, however, spend several years working with managed care, and 2 years of internship with clients through government subsidized agencies. Currently, I do a lot of pro bono work, most of which is educational in nature, like speaking to community groups. My clinic is offering free therapy for a week as part of the opening of an additional location and I am offering several pro bono hours that week.

  10. Julie! Congrats to you! I’ve been in private practice and managed-care FREE for about 15 years now and it was the best thing I’ve done . . . for me and for my clients!

    What a_client doesn’t seem to understand is how restrictive working under managed care can be and how that, in turn, impacts the work we actually do with our clients. I am not anti-managed care but I am pro-choice meaning I want my clients and potential clients (as well as my colleagues)to be informed – fully informed – when they choose to work with or use their managed care benefits. The consequences are not as obvious or as innocent as many would like to believe.

    I’m rambling here (and have written more about this on my blog) but just wanted to say “thank you” for stating what many of us know to be true. There is much broken about our mental health care in the USA and mental health professionals can take at least some of the steps to begin to heal the system. As far as I am concerned, you’ve taken a big step in that direction.

  11. I just found your site and am very happy to read your insights. I am not “making it” in private practice and signed on with a company who pays me 45% of what comes in. For this, I get an office, health insurance, their insurance panels, they do the billing and some of the marketing. I am working 10+ hours per day M-F as well as see one private client on Satuday, and work 6 hours on Sunday in a detox unit. I thought it would be a good idea to leave my job and do this I am fnally so burned out, I don’t know what to do. I welcome any thoughts.

  12. I find that psychotherapists do more pro-bono work than most professions. I built my practice by committing to take on clients for whom I felt I could do the most good. Whether they can pay or not. I have pared down to participation in 2 insurance panels that treat me and my clients with respect and care. The others will have to adjust their models before I will return. In the meantime, I continue to see and take on new clients on a case by case basis. This works well for me and my clients. I find that if I try to do the right thing by my clients and also myself, there is more mutual respect and what comes around goes around. I received excellent mentoring from Julie in the beginning and I have exactly the caseload that I desire. I work Tues, Wed and Thurs, 7-8 clients each day. I have time to do my own billing, and I get paid. At the end of the day, that is what will keep me in business.

  13. Great article. If one can build a full caseload of cash pay clients, working with insurance makes no sense! Even if you charge less, one will still make out better because of the time or expense with billing. However, I’ll say this. A decade ago when I stated in the field, clients used to call me and sheepishly ask “will you take my insurance?” Today, they demand it, and if I don’t take their particular plan, they hang up before I have a chance to talk with them about about of network payment. How quickly things change!

  14. I am relatively early in my career and have been considering transitioning to private practice. I have absolutely no interest in dealing with insurers and wouldn’t do private practice at all if that were my only option.

    Something that isn’t mentioned here in the discussion above of pro bono services & reduced fees is the huge number of completely uncompensated hours psychology grad students must provide while learning the profession. This is part of the educational system and (if it were not for the fact that we pay huge tuition bills for the privilege of providing those free services) makes sense. However, now that we have developed these skills and (for many of us) must pay back the loans that allowed us to do so, we have the right to charge fees that allows us a reasonable standard of living. Even with insurance, I sometimes have difficulty affording the services of other providers, like my dentist. Should he lower his fees?

    To my knowledge, every county in this country has a community mental health agency that provides services free or at reduced cost for those who cannot afford to pay. There are always treatment options. Currently, the county that I’m considering setting up my practice in has no full-time therapists (masters or doctoral level). So right now, individuals must drive at least 45 minutes to a private practice or utilize the services of the CMHC that places therapists here a few days a week. If I join the market and add additional services that weren’t available before and offer those at reasonable prices for the area (that also allows me to have a livable income and time with my family), should I feel badly about excluding some individuals who cannot pay for my services?

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