By 

Caroline Lewis

Published Jan 10, 2020

Alexandra Miller, a 30-year-old Brooklynite, would be hard-pressed to talk about her mental health struggles over the past few years without talking about the stresses of living in New York. That distinct sense of dread she’s felt around commuting, for instance? That started to set in after she got into a bike accident in Park Slope in 2014.

“The feeling of having something so sudden happen on the road made me feel like that type of accident could happen at any time,” Miller said. “I just noticed I was becoming more and more irrationally anxious.”

Keeping up with the high cost of living in New York while pursuing her passions has also been a source of anxiety. At one point, Miller was working two part-time jobs—one as an editorial assistant at a food blog and another as a graphic designer and marketing manager at a nonprofit—and would often become overwhelmed by the feeling of perpetually treading water to stay afloat. She would sometimes rush out of the subway well before her stop because she felt like she needed to come up for air. 

“I started to fear something going terribly wrong on my way to work,” Miller said. “I would get panic attacks on the subway, and I definitely was not able to keep taking cabs.”

These days, Miller is in therapy, and says her weekly sessions have been invaluable in helping her overcome her anxiety. But paying for those sessions has become yet another source of stress. Miller started freelancing full-time as a graphic designer in 2019 and brought in around $35,000 while building up her clientele.

“It is a strain,” Miller says of the $60 she pays her therapist each week, “especially since my income can be unpredictable.”

Miller is not alone in her struggle to budget for mental health care. Others who have reached out to Gothamist and WNYC in recent weeks as part of our health cost transparency project #PriceCheckNYC are paying hefty sums out of pocket for regular therapy sessions and visits to their psychiatrists to renew prescriptions, even if they’re insured.

Across the country, patients are far more likely to go outside of their insurance networks for mental health care and addiction treatment (collectively referred to as behavioral health care) than for other types of health care, despite laws requiring insurers to offer equitable coverage for behavioral health. And the disparity is more pronounced in New York than in many other states. Nationwide, office visits for behavioral health care were about five times more likely to be out-of-network than primary care visits in 2017, according to an analysis of insurance claims by the consulting company Milliman. In New York, they were 11 times more likely to be out-of-network.

Part of the problem is that many mental health practitioners don’t take insurance at all, and some who do still seek to limit the number of patients they see who are paying with insurance. To make matters worse, insurers have been known to do a poor job of keeping information on who’s in their behavioral health networks up-to-date. The search for a therapist, as opposed to, say, a gastroenterologist, is further complicated by the fact that the effectiveness of therapy can depend on the patient and therapist being able to develop a good rapport.

When Miller’s friends and family finally convinced her to seek out a therapist in late 2016, it took her a full year to find someone who both accepted her Oscar Health insurance and made her feel like she was making real progress towards recovery. 

The first step of Miller’s search was easy enough. She started a text chat with one of Oscar’s Care Guides, who in turn contacted Optum–the network of behavioral health providers Oscar contracts with–and delivered her a list of in-network therapists in her area. But once Miller started reaching out to the therapists on the list, her momentum began to flag. The offices she contacted either said they had no availability for new patients, were reluctant to accept Oscar, or didn’t return her messages.

“This has been a horribly difficult process for me and I need help ASAP,” Miller wrote in a chat with a Care Guide several weeks into her search.

Despite her challenges, Miller may still have had an advantage over some New Yorkers. A recent study conducted in New York City found that people who sound stereotypically white and/or middle class on the phone are more likely to score therapy appointments than people who sound stereotypically black and/or working class, even if they all have the same insurance. This highlights the broad discretion behavioral health practitioners in private practice have when accepting new patients.

“We are sorry that this process was frustrating for Ms. Miller, and glad that she was ultimately able to get care,” Dr. Neil Parikh, senior medical director of care delivery at Oscar, said in a statement. “Ensuring strong behavioral health access has become an industry-wide issue, at times complicated by many providers not accepting insurance. In recent years, Oscar and Optum have invested significant resources in building out a virtual behavioral health team to help with cases like these.”

Like many seeking ways to expand access to behavioral health care, Oscar is embracing the rise of telehealth–the use of video chat and other digital communication to link patients and clinicians–rather than relying solely on face-to-face meetings. Oscar says it is working with the company Doctor on Demand to expand its digital behavioral health services. The insurer also said it’s planning to contract with some behavioral health providers directly, in addition to using Optum’s network.

But Oscar did not mention one seemingly obvious way to boost network participation: paying more for behavioral health care. 

The average in-network rates insurers pay for behavioral health lag behind what they pay for primary care and other medical specialties, both in New York and nationwide. Clinicians in private practice have the added incentive of avoiding insurance in order to save on administrative costs, which can be particularly enticing in New York City, where rent and other overhead expenses are already high.

Leah Slivko, Miller’s therapist, is candid about her attitude towards insurance. 

“If I am on an insurance panel, the reimbursement is much less than my fee and I work at a loss, given how low insurance companies reimburse,” said Slivko, a licensed clinical social worker with a private practice in Manhattan. “If the insurance pays [for] out-of-network [care], the reimbursement often is better, so the insurance companies do not give incentive for seasoned clinicians to be on their panels.”

Slivko added that she prefers to address her patients’ economic needs by allowing them to pay on a sliding scale because it cuts back on red tape.

“Not only does insurance try to cut their own costs, they interfere with treatment with periodic reviews as to whether therapy continues to be a medical necessity,” Slivko said. “It undermines the treatment and stigmatizes the patients’ needs.”

Although Slivko officially participates in two insurance networks, she admits that she only “occasionally will accept someone who is referred by the insurance companies if I have an hour that is not prime time.”

Slivko is in-network for Miller and the two initially started working together at the start of 2018, when Miller was on Oscar’s Simple Silver Plan, which partially covered the cost of her weekly sessions. But Miller thought she might have to cut her progress short at the start of 2019, when she downgraded to a Simple Bronze Plan that required her to spend $7,900 on medical expenses before any mental health coverage kicked in. Slivko offered to let Miller sidestep insurance and pay her $60 a week directly instead–a steep discount off her typical rate of $225 per session.

Still, to afford therapy on top of her rent and other expenses, Miller has had to get creative. She has started taking gigs walking dogs, babysitting, and cat-sitting to supplement her income. The alternative medicine practitioners who Miller says also contribute to her peace of mind–a bodyworker and an herbalist–have agreed to accept help with marketing and logo design in exchange for their services. But with her therapist, bartering is not an option.

“It’s sometimes difficult to go four times a month,” Miller admits. “I’m stressed about disappointing my therapist [by not going every week] and worried about having to cut back because of costs.”

While in-network insurance rates for behavioral health care might be a low, the cash prices some behavioral health providers charge can be sky-high. And not everyone gets a discount.

Ian, who declined to use his last name, shared that he recently became uninsured after losing his long-time job at a tech company. Shortly thereafter, his primary care doctor at Weill Cornell Medicine referred him to a Weill Cornell psychiatrist to treat his anxiety. The psychiatrist’s cash rate? A whopping $525.13 per monthly session, in addition to the cost of his Lexapro prescription. Ian said he inquired about his psychiatrist’s sliding scale but was told he made too much to qualify because of the income he was still bringing in from working for his old company on a contract basis.

“My household budget is now running at a deficit of $1,500 per month, so this is clearly not sustainable,” Ian said. “I’m actively seeking new full-time employment that would come with health insurance and hope this will come through soon.”

Weill Cornell did not respond to a request for additional information on its sliding scale policy but noted in a statement that “we also offer free services through our Weill Cornell Community Clinic, which is served by both our medical students and faculty on a pro-bono basis.”

Even if a plan covers out-of-network care, going out of network can add an extra layer of bureaucracy and financial stress. Alexandra Dziura, 27, says she has good coverage through her employer. But because she sees a therapist and psychiatrist who are out-of-network, she has to pay them up front and then submit the bills to her insurer by snail mail to receive partial reimbursement–a process that can take over a month from start to finish. She has to front $180 for each weekly therapy session and $350 for each monthly visit to the psychiatrist who manages her medication. 

“I have an AmEx dedicated to my therapy expenses” in order to cover the costs, Dziura says. “I also have a credit card I just use for my life, so I am always trying to decide whether I should pay off this card or that card. It’s a juggling act for sure.”

New York regulators can’t force insurers to lure therapists into their networks by paying them a certain amount, but they can turn up the pressure on health plans to expand their behavioral health networks, says Christine Khaikin, a health policy attorney at the Legal Action Center.

Maryland, for instance, has developed quantitative standards for network adequacy that dictate the maximum distance a patient should have to travel for in-network care, the maximum amount of time they should have to wait for an appointment and the appropriate ratio of in-network health care providers to patients in different medical categories, including behavioral health.

“These standards for behavioral health just don’t exist in New York,” Khaikin says. “I think they put some fire under insurers to look at their networks.”

Many of the standards in place for behavioral health coverage in New York come from the federal Mental Health Parity and Addiction Equity Act of 2008, which aims to prevent health plans from imposing greater restrictions or cost-sharing requirements on behavioral health services than other types of medical care. New York has also implemented its own rules in recent years limiting the ability of insurers to deny coverage for certain behavioral health services.

But the disparity between how frequently people go out of network for behavioral health care versus other types of care has only gotten worse. In 2018, the New York attorney general’s office sanctioned several health plans for parity violations and the legislature passed a law requiring insurers to submit reports to the state with data related to parity compliance.

It’s unclear, however, whether any of these enforcement efforts will significantly alter the calculations that have led therapists and other behavioral health providers to determine that they can make more money by avoiding insurance networks than by joining them.

Ensuring parity between behavioral and physical health care also doesn’t do much if a plan provides minimal coverage all around—meaning those like Miller who earn too much to qualify for government-run insurance through Medicaid but too little to afford quality health insurance on the commercial market are still in a tough spot.

Despite the financial strain, however, Miller says she’ll try to continue to prioritize mental health care in her budget because it’s been worth the investment thus far.

“I bike and I’m on the subway all the time now,” Miller says, marveling at the progress she’s made since starting her sessions with Slivko. “It was just really helpful to work with someone who could help me reframe my fear of commuting and help me pay more attention to managing my stress than worrying about some sort of subway disaster.”

Have you or a loved one had trouble paying for or accessing mental health care or addiction treatment? Let us know! This story has focused on people with private insurance, but we’re looking for stories from Medicaid members as well. Submit your medical bills below or email us at healthcosts@gothamist.com.

You can get assistance with behavioral health-related insurance issues in New York state by calling the CHAMP helpline at (888)-614-5400.

Search our database of prices and share yours at #PriceCheckNYC, our new community health cost sharing project with WNYC and research company ClearHealthCosts—more details here.

Visit Link