(Updated, 2019) Paying for mental health care is difficult for many. Even for those who are insured, restrictions on mental health coverage require many Americans to pay quite a lot out of pocket, in spite of mental health parity laws.
According to a 2016 survey by the National Alliance on Mental Illness (NAMI), in spite of mental health parity laws, many people with mental illness continue to experience barriers to finding affordable, accessible mental health care. For the one in five U.S. adults with a mental illness, about half of them go without treatment, deterred by out-of-pocket costs and other obstacles – such as finding an in-network provider. NAMI reported that 34% of privately insured Americans reported difficulties finding a therapist who would accept their insurance.
Millions of Americans experience anxiety, depression, bipolar disorder or other mental and behavioral health ills; yet for the millions of Americans who have to pay out of pocket for mental health treatment, cost is a barrier to getting the services they need.
The math: According to 2017 National Institute of Mental Health (NIMH) statistics, among the 46.6 million adults in the United States with a mental illness, only 19.8 million – or 42.6% — had received mental health services in the past year. Similarly, about half of all children diagnosed with depression, anxiety or attention deficit hyperactivity disorder do not receive treatment.
Finding an In-Network Provider
For consumers with health insurance, finding an in-network mental health provider is one of the biggest barriers to accessing care. In its 2016 survey, the NIMH found that 28% of patients who received psychotherapy used an out-of-network provider; for medical specialists, that number dropped to only 7%.
A recent Twitter thread underscores the difficulty many Americans face in finding in-network psychotherapy. Caroline Chen, ProPublica’s healthcare reporter, posed a question: “Is there anyone who’s ever managed to find a therapist who is (1) in network (2) has availability (3) is a good match because I have so many friends who have tried & tried & ended up going out of network, or didn’t have $$ for that so gave up.”
Chen’s appeal unleashed a volley of laments regarding the struggle to find affordable mental healthcare. A few offered some practical advice – such as looking for services within community mental health centers or local universities. But many gave up trying.
The main barrier is the shortage of psychotherapists who take insurance. And those who do accept insurance are often not accepting new patients. Why? Because the reimbursement rates they receive from insurance companies are so low that many mental health professionals opt out. About a third of psychologists in the U.S. refuse to take insurance, according to the American Psychological Association. As for psychiatrists, a little more than half accept insurance.
How low are their reimbursement rates? According to Enrico Gnaulati, a clinical psychologist and author of Saving Talk Therapy: How Health Insurers, Big Pharma, and Slanted Science are Ruining Good Mental Health Care, the average reimbursement by private insurers is about half the national average ($163 per 45 minutes) charged by psychologists. And a 2017 report by Milliman found that reimbursement rates for mental health providers was, on average, 20% less than primary care services.
How Much Does Psychotherapy Cost?
The fees therapists charge vary according to geographic location and levels of training. Here is a sampling of links to practitioners’ web sites and other resources with rates: Katherine Oram, Ph.D; a home-page link to the Psychology Today website, with a practitioner search tool; Dr. Neil Goldman on the Psychology Today site; Lisa Haberman’s rates page; and the rates page for Linda Beeler, a licensed clinical social worker. In New York City, psychotherapist rates run higher (between $200 and $300). Multiply these rates by one session per week, and the costs can add up faster than patients are able to pay.
Which Professionals Provide Mental Health Treatment?
A variety of mental health professionals have the training and qualifications to provide psychotherapy, including psychologists, clinical social workers, psychiatric nurses, and mental health counselors.
- Psychologist. A psychologist has a doctoral degree in psychology, which is the study of the mind and behaviors. After completing graduate school, a psychologist completes an internship that lasts two to three years and provides further training in treatment methods, psychological theory, and behavioral therapy. Licensed psychologists are qualified to do counseling and psychotherapy and provide treatment for mental disorders.
- Licensed clinical social worker (MSW). A clinical social worker has at least a master’s degree in social work and training to be able to evaluate and treat mental illnesses.
- Licensed mental health counselor. A psychological counselor is a mental health professional who has a master’s degree (MA) in psychology, counseling, or a related field. In order to be licensed, the professional counselor also needs two additional years’ experience working with a qualified mental health professional after graduate school.
- Psychiatric or mental health nurse. Some nurses have special training to provide mental health services. They can evaluate patients for mental illness and provide psychotherapy.
The Role of Psychiatrists
Among mental health professionals, only psychiatrists are able to prescribe medication. Although psychotherapy was originally the purview of psychiatry, many psychiatrists today focus largely on medication management – a reality that is enforced by the financial disincentives created by insurance companies. Psychiatrists can earn much more for three 15-minute sessions of medication management than they can for one 45-minute session of talk therapy.
“I think talk therapy is alive and well, but psychiatrists are not doing it anymore,” says Dr. Nancy Goldin, a psychiatrist practicing near Princeton, NJ. Goldin allows for longer appointment times – 30 minute sessions – so she can combine medication management with psychotherapy, but she admits she is among a dying breed. “Everything is driven by managed care and costs. Insurance companies don’t want to pay for a psychiatrist to talk to a person for 50 minutes. So they don’t reimburse for that. They reimburse for short periods of time.”
It is also often true that a general practitioner prescribes medication. This is not ideal, experts add, because experts agree that general practitioners are not trained or qualified to do an in-depth psychiatric evaluation and make long-term recommendations for returning to health. The gold standard is medication plus therapy, and yet for many this is hard if not impossible.
What You Can Do
The good news is, there are many approaches people can take to find affordable therapy. Here are a few ways to negotiate a better rate:
1) Sliding scales. Almost all therapists offer sliding scales for patients who are paying out of pocket, and/or for people with limited resources. If you are already seeing a therapist or interviewing possible candidates, be sure to ask about discounted rates, which can be as much as 30% below the self-pay rate.
2) Request flexible scheduling. While many patients book weekly sessions with their therapists, those paying out of pocket may prefer to reduce costs by scheduling sessions on alternating weeks. In between sessions, many people engage in online support-type groups such as 7 Cups, through which users can connect with compassionate listeners for free. PsychCentral.com is also a go-to website that hosts many forums catering to a variety of audiences.
3) Be direct about stating what you can pay. Therapists often have pro bono slots in their practices, enabling them to see a percentage of their clients at no cost.
4) Look into Employee Assistance Programs (EAPs): A growing number of employers offer EAPs, broad brush programs that provide access to a variety of employee needs, including short-term counseling. A 2016 report indicated that three-quarters of all employers offer some type of EAP.
5) Inquire about a payment plan. Patients whose financial circumstances have changed drastically may consider asking about a payment plan rather than abandoning therapy altogether. Therapists may accept a plan to receive a portion of their fees at time of treatment, with the balance to follow.
6) Ask for a referral. Community mental health agencies offer therapy services at far more affordable rates. Local university clinics, where students in training provide low cost therapy, are another low-cost option.
7) Go online. Increasingly, online therapy options are coming to the fore. See Part 5 of our series (list below).
This is the second piece in our mental health series. The series, in its entirety, is outlined here.