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I’ve gotten multiple calls over the last several weeks from people who do not know me. They don’t know where my office is, they don’t the kinds of issues I treat, they don’t know how I work, they don’t know if I have experience in what they are calling for, and they don’t know if anyone at all would even recommend me.
They do know some things though.
They know my name, my phone number, and most importantly: They know that I accept Cigna insurance.
The people who call often have the tone of voice that you get after sitting on hold with Comcast for two hours, getting bounced around from one customer service rep to another, retelling your story over, and over, and over, until you can feel your soul slowly withering away and you are left with a robotic shell of a voice. You become certain that your problem will not be solved by the person you are speaking with and nor the next 15 people, but you keep trying. This is how the people who call me sound. Hopeless but refusing to give up.
They sound this way because they have been going down the list of therapists who “accept” Cigna coverage. Over and over again, they tell me, that each time a call is placed to someone on the list one of two things happen. Either they leave a voice mail message that never gets returned or they are told by the therapist that they are not talking on any new patients. And I believe it, because it’s how I respond too.
Well, not with the first option. I respond to every voicemail with the thought that if someone takes a risk and reaches out to a therapist we are, at the very least, responsible to let the caller know we have received their message even if we can’t help them further. I feel my duty to be therapeutic begins the moment of the first contact, which may be long before I see someone in my office.
But the second option, saying that I am not taking on any new patients. Yes, I do say that. I say that even when my next call, two minutes later, is to someone to set up an initial session. I’ll probably even give them a few choices of available times. So, what am I hiding? What are my colleagues who respond in similar ways hiding? What is it that causes me to turn away someone in pain, someone who has made ten calls before speaking to me only to be turned away by all of them, and who is about to be turned way again? No surprise here, it comes down to money.
An elderly gentleman called me recently. He wanted help with his marriage and “there is some shit going on at work.” I could hear in his voice his pain was big. Right off the bat he explains he has Cigna and I am immediately clued in that I’m not the first person he has called. I have no space I explain with as much empathy and compassion I can convey over the phone. I never mention money, only space. I tell him “I can give you some other names to try” (I already know the answer they will give). I hear the fear in his voice, the fear when you are sinking and there is no one willing to grab your hand. His words are angry, how is it that no one has any space? Why will no one help me? He attempts to answer his own questions. “I thought you got into this job to help people” “you only care about money” “money is all anyone thinks about.” His fear and anxiety are clear and in a panic to explain his situation he has hit reality. The reality that money is a significant factor in my decisions about helping people, and my decision to not reach for his sinking hand is indeed about money.
For a therapeutic hour of my time Cigna will pay me $85 minus what the patient’s copay is. That amount is about 65% of my full fee ($130), and about 75% of typical insurance rates ($110). If I take on just two (only 2!) Cigna patients as opposed, for example, Blue Cross patients ($112 per session), and I work with those two patients in once weekly therapy over the course of a year, I am losing over $2,500 in potential income. What if I were to take on five? Ten? All of my 32-35 weekly spots? (It wouldn’t be hard) What if I look at the difference over multiple years?
The cost of accepting Cigna patients starts to go up real quick, and this doesn’t even take into account things like being reimbursed more for an initial session. It’s common to be paid more (around $200 or more) for an initial session due to the extra time it takes to set up the paperwork. And, there is extra time involved. In my office it is not only my time going through three or four additional pages of paperwork, but it is the time my receptionist takes to set up two files (one for me and one for the billing), and the time it takes for the folks in our office who verify insurance and provide details to the patient about things like how much deductible they have to meet or what their copay is. How much does Cigna pay me for that initial session? $110. After all my costs associated with that initial session I will probably be paid for my time, but it won’t be much.
So, for these reasons I choose to not accept Cigna. Yet, while many therapists choose to not accept Cigna, some therapists do. Some therapists welcome patients with Cigna insurance with open arms. Applying zero amount of actual research, my interactions with these mythical therapists have led me to see them in one of two ways. They either are early (very early) in their career and attempting to build a practice or they simply are not very skilled therapists.
This leads me to another ugly fact: the company of your insurance may dictate the quality of the mental health treatment you receive. And there is no way the holder of that insurance would ever know.
With healthcare costs spiraling out of control everyone is crying for reducing costs wherever possible. A worthy goal that has been twisted by misguided accountants when it comes to mental health treatment. While I can’t comment on the quality of Cigna providers in other areas of healthcare, I can say this about their mental health services: you get what you pay for. And Cigna doesn’t pay much.
I can imagine this seems like an argument to push Cigna to raise their reimbursement rates and I suppose that it is, but that isn’t why I am sharing this. I am sharing this because I believe a potential patient should not have to navigate this with a blindfold. I think that this discussion begins with understanding the power of insurance in mental health and the impact it has on determining treatment (a quick spoiler: the impact is big, almost always in a negative way).
Mental health is not the simplified and trite practice that our culture sees it as. Pills and workbooks are band aids on a hemorrhaging heart. The human mind is a complex web of thoughts and feelings so intricate that words can only begin to approach being able to communicate what lies in the deep. There are no short cuts in these woods, no quick ways out, and whether or not the thought is conscious I expect every single patient that steps into a therapists office is feeling that if they are going to make this journey they better know for damn sure that their guide is competent enough and willing enough to go with them into the woods.
In such a vulnerable place I would think that it would be common sense for such a traveler to be as well informed as they can be about the journey ahead. Yet, psychologists (myself included), have allowed others to make such a clouded mess of the work that patients do not even know the questions to ask. Who would think to ask, “will insurance X give me a better treatment than insurance Y?” I know that if I was undergoing heart surgery I would do just about whatever I could to have the best treatment I could get, and so I would expect patients looking for a different sort of heart surgery would want the same.
 
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Hold on, why have you posted 3 blogs within the span of just about 30 minutes? You should probably just combine all your entries in single blog to avoid cluttering the blogs section. Would be easier for people to respond and for you to maintain a conversation as well.
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It's this way because mental health is not seen as emergency care that the state has to provide. It can wait. Except, it can't, and honestly a lot more people would be coping in their tax-paying jobs instead of unemployed or underemployed if they had access to essential mental health services.
The service you're describing isn't something that should be worse for people with lower ability to pay / 'worse' insurance. It should be a baseline for all citizens for the public good in the same way that people who break their leg get (I'm not even talking nationalised healthcare here).
The specific problem you describe is a function of the badly designed US healthcare system, and the lack of seriousness in the perception of all mental health conditions (that is a worldwide problem).
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It sounds like you are living paycheck to paycheck (which would be sad given your rates).
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While I imagine most people can respect that you have to make a living, most people can't see things from your perspective. Most people (myself included) just see someone way above a station we hold (or probably ever will) who is concerned that he won't make as much money he could accepting a more affordable insurance when the salary you would earn accepting the more affordable insurance is probably several times what most people make annually.
While your problem is probably very real from your perspective because of where you are in the social circle; for most what you're talking about holds almost no weight. For an example, there in 2011 house congresswoman Linda Sanchez complained that she has to live paycheck to paycheck ($174,000 was the base pay of congress officials in that year). While next to the rest of the congressmen it is probably easy for her to feel that she is broke because she is compared to people in her tax bracket, but that base pay of 174k was 3.5 times what the average household made during 2011 (and 16 times the salary of a household on the upper edge of the poverty line).
Most people (myself included) see your post as a comment on the hugely corrupt healthcare system in this country and (most likely) would say you could deal with the loss to help people when you're much better off than the average American to begin with. At the same time, you're completely justified in saying that you worked hard for what you have and you should get all that you can get.
Thus, we have another comment on why financial tensions are so high in the US right now.
C'est la vie
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So my dentist charges me $50 extra bucks for a cavity filling because my insurance only covers $130 of the $180 bill. Guessing he's using some fancy white material instead of the normal cheaper stuff, but I guess this isn't possible in mental health? All or nothing?
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do other insurance companies do this as well?? And I assume this kind of practice is similar in other medical fields?
god i hate medical insurance in the states
Also what aerisky said. Really interesting blog youve got going but consolidate into one or spread them out to one a day rather than spamming all at once!
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On March 11 2013 16:22 iTzSnypah wrote:
It sounds like you are living paycheck to paycheck (which would be sad given your rates).
Hi iTzSnypah - Reading back, I can understand how you'd come to that conclusion. I'd like to clarify that the tone of "I can't afford" it is referring to affording to maintain my style of living which includes things like having 6 months of savings, contributing 15% to a 401k, and being able to make substantial contributions to charities, etc. I make plenty of money and I want to make sure that I am not sending the message that I feel like I am broke.
Thanks for reading.
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On March 11 2013 14:42 Aerisky wrote:
Hold on, why have you posted 3 blogs within the span of just about 30 minutes? You should probably just combine all your entries in single blog to avoid cluttering the blogs section. Would be easier for people to respond and for you to maintain a conversation as well.
do other insurance companies do this as well?? And I assume this kind of practice is similar in other medical fields?
god i hate medical insurance in the states
Also what aerisky said. Really interesting blog youve got going but consolidate into one or spread them out to one a day rather than spamming all at once!
I apologize for the spam. I had written this out for a different blog and decided to share it here. Perhaps combining them together would have made it more cohesive. I guess I had written each entry in different times and so each one felt distinct to me and I hadn't considered putting them together. I'm still learning the art of forum posting 
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On March 11 2013 19:34 Burrfoot wrote:
So my dentist charges me $50 extra bucks for a cavity filling because my insurance only covers $130 of the $180 bill. Guessing he's using some fancy white material instead of the normal cheaper stuff, but I guess this isn't possible in mental health? All or nothing?
Hi Burrfoot - Your guess is accurate. Unlike some other medical professions I cannot adjust my rates. They are set by the insurance panel (Cigna, BlueCross, etc.) I am on. If I exclude myself from the panel I can then bill myself as an "out of network" provider, which allows me to set my own rates, but that also means that my patients end up paying a significantly higher copay too. I could (and probably will) write a whole entry on the craziness of the system when it comes to in-network vs out-of-network.
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no problem homie! it happens.
your blog is quite interesting though, and learning more about the health care system through the lens of the doctor would be cool.
so what made you go into this field anyway, and what is your educational background??
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On March 11 2013 16:28 Arisen wrote:
While I imagine most people can respect that you have to make a living, most people can't see things from your perspective. Most people (myself included) just see someone way above a station we hold (or probably ever will) who is concerned that he won't make as much money he could accepting a more affordable insurance when the salary you would earn accepting the more affordable insurance is probably several times what most people make annually.
While your problem is probably very real from your perspective because of where you are in the social circle; for most what you're talking about holds almost no weight. For an example, there in 2011 house congresswoman Linda Sanchez complained that she has to live paycheck to paycheck ($174,000 was the base pay of congress officials in that year). While next to the rest of the congressmen it is probably easy for her to feel that she is broke because she is compared to people in her tax bracket, but that base pay of 174k was 3.5 times what the average household made during 2011 (and 16 times the salary of a household on the upper edge of the poverty line).
Most people (myself included) see your post as a comment on the hugely corrupt healthcare system in this country and (most likely) would say you could deal with the loss to help people when you're much better off than the average American to begin with. At the same time, you're completely justified in saying that you worked hard for what you have and you should get all that you can get.
Thus, we have another comment on why financial tensions are so high in the US right now.
C'est la vie
Hi Arisen - Thanks for your thoughts, you brought up a perspective I had not considered. It makes sense to me that you (and others) might assume that Cigna is a "more affordable" insurance and come to the conclusion that I am excluding individuals who cannot afford to purchase higher quality insurance. I do not believe this to be true. I don't have any actual numbers to compare in reference to how much each insurance policy costs, but everything I do know suggests that Cigna is actually a higher cost insurance. Almost always they have the lowest copay for the patient and are used by some very high profile businesses (Intel for example).
I do not mind reducing my rates to allow individuals access to the services that I provide who would not normally be able to pay. I keep regular spots in my schedule to see patients who can pay only 20% to 30% of my usual fee. I have no issue with accepting a lower fee in order to help someone. I have a large issue accepting a lower fee in order to help an insurance company.
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So glad I don't currently have to deal with the American medical system! I still remember when my health insurance agency sent me a letter saying my rates were going from $58 to $85 / month (pretty much the cheapest I could find - about 8 years ago). Fortunately I was able to get something else through my employer.
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On March 11 2013 22:53 QuanticHawk wrote:
no problem homie! it happens.
your blog is quite interesting though, and learning more about the health care system through the lens of the doctor would be cool.
so what made you go into this field anyway, and what is your educational background??
Hi Hawk - Thanks for your grace. Those are some interesting questions, I'll probably write more on them down the road. For now, here is the short version. I think I got into the field out of a motivation to help people that was driven by my sense that I was alone to deal with my own issues and my own pain. That is an ever evolving thought though, and I expect it will continue to take shape.
My education went from a BA in psychology, to a masters in Clinical Psychology, to a Doctor of Psychology (Psy.D. - which is a clinical doctoral degree as opposed to a PhD which tends to be more research focused). It was quite a journey - five different training institutes, three states and two countries.
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On March 11 2013 15:34 Solarsail wrote:
It's this way because mental health is not seen as emergency care that the state has to provide. It can wait. Except, it can't, and honestly a lot more people would be coping in their tax-paying jobs instead of unemployed or underemployed if they had access to essential mental health services.
The service you're describing isn't something that should be worse for people with lower ability to pay / 'worse' insurance. It should be a baseline for all citizens for the public good in the same way that people who break their leg get (I'm not even talking nationalised healthcare here).
The specific problem you describe is a function of the badly designed US healthcare system, and the lack of seriousness in the perception of all mental health conditions (that is a worldwide problem).
Hi Solarsail - Thanks for your thoughts. I certainly agree that mental health care is given a low priority and we end up paying the price for it. I remember some time ago there were a few studies done that looked at the physical health care savings that mental health services provided. For example, someone being treated for anxiety in therapy which potentially led to the individually avoiding needing high blood pressure treatment for the rest of his life (this wasn't in the study, just trying to illustrate how mental health and physical can be connected).
The numbers were astounding. Looking at the savings on physical health care alone (so not factoring in things like potential lost wages, increased productivity, etc.), it was something like (and I am having to do a rough estimate here, I can't find the study again) two to three times the cost of providing the mental health services themselves.
In other words, if more people used / had access to mental health services it would significantly reduce the overall healthcare costs. But instead it seems our system directs us to only treat the symptoms when they arise rather than the actual problem.
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Interesting read. I think this sort of exemplifies how screwed up health care (in general) is in the US, when even insured patients have to "shop around" like they are buying a car.
One thing I find odd is that you knowingly refuse someone that is obviously in need of your "medical attention," citing dollars and cents, while at the same time try to argue how important and necessary mental health care is. While our health care system is screwed up, most hospitals or doctors wouldn't turn away a physically injured patient over dollars and cents (mostly because it is illegal in most cases). Although it does happen, unfortunately.
If you want your profession to be taken more seriously (and I, like most Americans, don't take it that seriously, excepting some extreme cases) then maybe you should treat it more like a real medical profession than a business practice (that advice could go for a lot of "real" medicine as well, though).
Be a part of the solution, not the problem?
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On March 12 2013 06:52 HardlyNever wrote:
Interesting read. I think this sort of exemplifies how screwed up health care (in general) is in the US, when even insured patients have to "shop around" like they are buying a car.
One thing I find odd is that you knowingly refuse someone that is obviously in need of your "medical attention," citing dollars and cents, while at the same time try to argue how important and necessary mental health care is. While our health care system is screwed up, most hospitals or doctors wouldn't turn away a physically injured patient over dollars and cents (mostly because it is illegal in most cases). Although it does happen, unfortunately.
If you want your profession to be taken more seriously (and I, like most Americans, don't take it that seriously, excepting some extreme cases) then maybe you should treat it more like a real medical profession than a business practice (that advice could go for a lot of "real" medicine as well, though).
Be a part of the solution, not the problem?
Hi HardlyNever - Thanks for your feedback and thoughts. I'd be interested in hearing you expand on them a bit. I'm always interested in how psychology/therapy is viewed by people in other professions. In particular I wonder why it is that you feel it is difficult to take psychology (or just psychotherapy) seriously?
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On March 12 2013 05:46 ProjectiveID wrote:
I remember some time ago there were a few studies done that looked at the physical health care savings that mental health services provided. For example, someone being treated for anxiety in therapy which potentially led to the individually avoiding needing high blood pressure treatment for the rest of his life (this wasn't in the study, just trying to illustrate how mental health and physical can be connected).
The numbers were astounding. Looking at the savings on physical health care alone (so not factoring in things like potential lost wages, increased productivity, etc.), it was something like (and I am having to do a rough estimate here, I can't find the study again) two to three times the cost of providing the mental health services themselves.
In other words, if more people used / had access to mental health services it would significantly reduce the overall healthcare costs. But instead it seems our system directs us to only treat the symptoms when they arise rather than the actual problem.
I believe the same is true for preventative physical healthcare. Because emergency care is only provided to the uninsured when it absolutely has to, that final treatment costs many times what a six-monthly checkup with appropriate screening can prevent, but the latter will never be given because it's not 'necessary'.
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On March 13 2013 00:22 ProjectiveID wrote:Show nested quote +On March 12 2013 06:52 HardlyNever wrote:
Interesting read. I think this sort of exemplifies how screwed up health care (in general) is in the US, when even insured patients have to "shop around" like they are buying a car.
One thing I find odd is that you knowingly refuse someone that is obviously in need of your "medical attention," citing dollars and cents, while at the same time try to argue how important and necessary mental health care is. While our health care system is screwed up, most hospitals or doctors wouldn't turn away a physically injured patient over dollars and cents (mostly because it is illegal in most cases). Although it does happen, unfortunately.
If you want your profession to be taken more seriously (and I, like most Americans, don't take it that seriously, excepting some extreme cases) then maybe you should treat it more like a real medical profession than a business practice (that advice could go for a lot of "real" medicine as well, though).
Be a part of the solution, not the problem? Hi HardlyNever - Thanks for your feedback and thoughts. I'd be interested in hearing you expand on them a bit. I'm always interested in how psychology/therapy is viewed by people in other professions. In particular I wonder why it is that you feel it is difficult to take psychology (or just psychotherapy) seriously?
While I do think the effort to better understand the human mind is a good thing, I don't put a lot of stock in the current practice as it is done, particularly in the US. It seems like we should be a long way from Freud and Jung at this point, but it doesn't look that way to me (from the outside looking in). Perhaps you think it is different with inside knowledge, or perhaps the profession just wants to convince you that you've come a long way, when we really haven't. I guess it just feels like it is a long way from a "hard science." But I suppose you have to start somewhere. It seems like we are getting off track, though.
Also, I think the psychology profession suffers just as much or probably even more from "symptom bloat" or "imaginary disease syndrome." I'm not sure what the technical name for it is, but I think you know what I'm talking about. Just like every month I see a drug for some new (physical) disease like "restless leg syndrome," I hear of some new psychological disorder that I should now "respect" as a "medical condition" and not "that person is just an asshole/unstable/ could use a good dose of something other than drugs." It seems like half the kids these days are on some sort of drug or have some sort of "condition" that they need special drugs or treatment for (ADD, ADHD, blah blah blah). They even tried to tell my parents I have "ADD" when I was like 2. 2 years old, and you're going to diagnose that (I don't btw, I'm a pretty laid back dude that can focus with no problems). I'm pretty sure it was just an excuse to sell more drugs.
I think the "heart" is in the right place, but it has become a business, not a medical practice (as this blog illustrates). It isn't about helping people or understanding the human mind better anymore, it is about creating symptoms and creating drugs and/or treatment (for profit) that can treat these symptoms. Then wrapping it all in the shroud of "medical necessity."
Do you even take your practice seriously? You just said you turned away someone who you knew needed help, because you could make more money elsewhere. This is one (of many) reasons I switched from pre-med back as an undergrad; I felt like the medical profession (at least in this country) was about profit, not well-being. Psychology, in my opinion, is probably the worst offender in this regard. That is why I don't respect it that much.
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So, why are you listed as accepting that insurance then?
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EPT
