Colleges across the country are failing to keep up with a troubling spike in demand for mental health care — leaving students stuck on waiting lists for weeks, unable to get help.
STAT surveyed dozens of universities about their mental health services. From major public institutions to small elite colleges, a striking pattern emerged: Students often have to wait weeks just for an initial intake exam to review their symptoms. The wait to see a psychiatrist who can prescribe or adjust medication — often a part-time employee — may be longer still.
Students on many campuses are so frustrated that they launched a petition last month demanding expanded services. They plan to send it to 20 top universities, including Harvard, Princeton, Yale, MIT, and Columbia, where seven students have died this school year from suicide and suspected drug overdose.
“Students are turned away every day from receiving the treatment they need, and multiple suicide attempts and deaths go virtually ignored each semester,” the petition reads. More than 700 people have signed; many have left comments about their personal experiences trying to get counseling at college. “I’m signing because if a kid in crisis needs help they should not have to wait,” one wrote.
STAT requested information from 98 campuses across the country and received answers from 50 of those schools. Among the findings:
At Northwestern University, it can take up to three weeks to get a counseling appointment. At Washington University in St. Louis, the wait time runs nearly 13 days, on average, in the fall semester.
At the University of Washington in Seattle, delays in getting care are so routine, the wait time is posted online; it’s consistently hovered between two and three weeks in recent months. In Florida, where educators are pressing the state legislature for millions in new funding to hire counselors, the wait times at University of Florida campuses can stretch two weeks.
Smaller schools aren’t exempt, either: At Carleton College, a liberal arts campus in Northfield, Minn., the wait list can stretch up to 10 days.
A few weeks’ wait may not seem like much. After all, it often takes that long, or longer, for adults to land a medical appointment with a specialist. But such wait times can be brutal for college students — who may be away from home for the first time, without a support network, and up against more academic and peer pressure than ever before. Every class, every meal, every party can become a hurdle for students struggling with eating disorders, depression, and other issues.
Many counseling centers say that they are often overwhelmed during the most stressful times for students, such as midterms and finals. Creighton University in Omaha, Neb., for example, reports a wait time of up to a month during busy periods.
In most instances, STAT’s examination found, students who say that they are suicidal are seen at once, and suicide hotlines are available for after-hours emergencies. But some students are uncomfortable acknowledging an impulse to harm themselves, and thus get pushed to the end of the line, along with undergrads struggling with concerns ranging from acute anxiety to gender identity issues.
Campus counselors are acutely aware that they’re leaving students stranded but say they don’t have the resources to do better.
“You’re making sure people are safe in the moment,” said Ben Locke, who runs a national college counseling network and directs counseling services at Pennsylvania State University. “But you’re not treating the depression or the panic attacks or the eating disorders.”
‘I needed to see someone’
Constance Rodenbarger, now in her third year at Indiana University, first sought help at the counseling center in her second semester, as she struggled to deal with an abusive relationship on top of long-term depression. The next appointment was at least two weeks away.
“I was just looking at that date on the calendar and thinking, ‘If I can just make it one more day,’ but then it became just one more hour, and then one more minute,” she said.
“I just couldn’t hang on.”
The day before her appointment, on Nov. 17, 2014, she tried to kill herself.
Her roommate found her, and Rodenbarger was rushed to the hospital. She called the counseling center from the hospital to say she wouldn’t be able to make it in the next day.
“When I called that day and said, ‘I need to see someone,’ I needed to see someone,” she said.
Indiana University now says it connects with all students who seek counseling within two days. But that connection can involve simply setting up an appointment — for up to three weeks away.
“We, like centers across the country, are working on expanding our staff,” said Nancy Stockton, the director of Indiana University’s counseling center. “We certainly need more clinicians.”
Indiana University and several other large schools said they employ one counselor for roughly every 1,500 undergraduates. That’s at the high end of the range recommended by national experts. The numbers reported in an annual national survey are even more stark: In 2015, large campuses reported an average of one licensed mental health provider per 3,500 students.
When students do get in to campus counseling centers, most see therapists, social workers, or perhaps psychologists.
Just 6 in 10 college counseling centers have a psychiatrist available, even part-time, to prescribe or adjust medications, according to the annual survey , conducted by the Association for University and College Counseling Center Directors. That’s a serious mismatch, given that about one-quarter of college students who seek mental health services take psychotropic medications.
There are other hurdles, too. While many schools tout free counseling, they often cap that benefit. Students at Brown University, for instance, get seven free sessions a year. At Indiana University, students get just two free sessions and then pay $30 per visit.
And it can be hard for students to develop a consistent relationship with a therapist when so many college mental health providers work limited hours. Wellesley College, for example, has a counseling staff which includes six therapists — but three of them are only on campus part-time.
While dozens of colleges provided STAT with detailed information about their mental health resources, the public relations staff at others, including Georgetown University, Dartmouth College, and Grinnell College, refused to provide information after repeated requests.
Others, such as Harvard and Yale, declined to provide specific staffing information. In some cases, such as with the US Merchant Marine Academy, media relations staff expressed discomfort about being compared to other colleges.
Columbia University told STAT it employs the equivalent of 41 full-time counselors for just over 6,000 students, which would be an enviable staffing level, far better than most other schools its size. Columbia said its wait time varies, but did not provide a specific range. All enrollment numbers come from U.S. News and World Report.
A spike in crisis cases
Demand for counseling on college campuses has been rising steadily for several years.
And the latest data, released in January, show a recent spike in cases of students in acute crisis.
One in three students who sought counseling last year said they’d seriously considered suicide at some point in their lives, according to a report out last month from the Center for Collegiate Mental Health. That’s up from fewer than 1 in 4 students in 2010.
And those are just the students who admit they’re in crisis. Untold others don’t know how to respond when an employee at the counseling center asks if it’s an emergency. They may downplay their situation, telling themselves others are in more dire condition or it must not be a true crisis if they have the presence of mind to ask for help.
That’s what happened to Adrienne Baer during the fall of 2015, in her junior year at the University of Maryland. Both her grandparents had recently died. So had a high school friend.
“It was a lot to wrap my head around,” she said. With a push from friends, she decided to call the counseling center. “I didn’t exactly have an education on what their resources were, but I got one,” Baer said.
Baer said she was asked on the phone whether she was experiencing an emergency. She didn’t know how to answer that: No one gave her a definition. So she said no and was shunted to the end of the waiting list. It would be two weeks before she could see a counselor.
She dashed off an angry email to the counseling center the minute she hung up the phone:
“I am currently struggling with the issues I wanted to discuss with a therapist or counselor, but even I don’t know how I’ll be in 24 hours, let alone 2 weeks.…
I don’t know if all that constitutes an emergency or if I need to have a mental breakdown to be seen prior to a two week wait but I am seriously disappointed in the lack of availability in mental health resources.”
That got their attention. She was given a quick appointment for an initial assessment. But for continuing care, Baer was put back on the waiting list. It would be five weeks before she could see a psychiatrist who could prescribe medication.
“I had to wait. There was nothing I could do,” said Baer, now a senior. “It was just a roller coaster that I couldn’t control.”
Sharon Kirkland-Gordon, director of the University of Maryland’s counseling center, said she knows her staff can’t keep up with demand, though she said they’re “working overtime to meet the needs of students.”
Requests for appointments shot up 16 percent last year alone, she said.
Nationally, about six in 10 undergrads seeking counseling are women, and 5 percent are international students. There are roughly an equal number of freshman, sophomores, juniors, and seniors.
Kirkland-Gordon has started to bring on part-time seasonal staff to help handle the workload. Many campuses also use therapists who are still in training work one-on-one with students, as long as they report to licensed counselors.
“If we had a magic wand, I think you’d probably hear the same thing from all of us counseling directors,” said Kirkland-Gordon. Their wish list is simple: more resources.
No one is entirely sure why student demand for mental health services is rising; factors may include increased pressure from parents or peers on social media, or a difficult job market. Another possible reason: increased awareness about the risk of mental health conditions.
In the past decade, the federal government has given out tens of millions in grants to suicide prevention programs that raised awareness of risk factors. A generation of students trained by such programs is now in college — and seeking help when they feel warning signs. But not every college got a bump in funding to meet the surge in demand.
“If you want a perfect recipe to generate reduced availability of treatment, that would be it,” said Locke, of Penn State, who also serves as director of the Center for Collegiate Mental Health, a national network.
Locke notes that college health centers would never require a student with strep throat to wait two weeks for an appointment. Yet that’s what’s happening to many students with anxiety, depression, and other serious mental health concerns. “It puts the student’s academic career, and potentially their life, at risk,” he said.
As for Baer, she said she made it through that stressful semester by leaning on friends at school and family back in Pennsylvania. She wonders what would’ve happened to an international student or to a freshman without a reliable support network.
“I do feel like I fell through the cracks,” she said, “but I feel like I fell onto a safety net that other people might not have.”
A college president sounds the alarm
In an era when colleges are ranked by the number of their professors and the quality of their food — or whether their gyms house rock-climbing walls — it can be tough for the counseling centers to make a case for more resources.
Some turn to quick fixes, touting “stress-busting” programs like bringing in puppies for students to pet during midterms or handing out free cookies in the library during finals.
Others are making a concerted effort to respond to the surging demand.
The wait times at Ohio State University were so alarming to Dr. Michael Drake — a physician who stepped into the president’s office in 2014 — that he hired more than a dozen new counselors. That pushed the school’s ratio down to one provider for roughly every 1,100 undergraduates.
“We were doing it to really smooth the pathway of success for students,” Drake said. National data suggest the additional providers will help; 7 in 10 students who seek counseling say the mental health care improved their academic performance.
The University of California system moved to update counseling services in 2014, as wait lists grew and students with acute needs sought care. It took another year to get a dedicated funding stream to hire more counselors, in the form of increased student fees.
“Things start to back up like a traffic jam,” said Gary Dunn, director of counseling and psychological services for the University of California, Santa Cruz. “A lot can happen in four or five weeks during a quarter in college. It really wasn’t OK to have that delay in place.”
Students who have lived through mental health crises welcome more staff. But they also urge better training so that everyone on campus knows to treat mental health concerns as seriously, and with as much empathy, as a physical injury.
Nick, who asked that his last name not be used, was diagnosed with depression before college and had a difficult transition to his freshman year at Ithaca College in upstate New York. “I had no idea how to cope with all of it and I floundered a bit,” he said in an interview.
He sought help early on — during orientation — because he knew he’d likely need it. But he said he was bounced between two counselors and had difficulty getting appointments that fit into his schedule. In the end, he had to pay for a private mental health specialist off campus.
Ithaca did not respond to requests for information on its mental health services, saying its counseling center staff was busy. At the time he sought care, Nick said there were just two counselors for the school’s 7,000 students.
“I was so badly handled. Not by any fault of their own, they were just woefully underprepared,” he said.
This year, by contrast, he had to take time off for a surgery. Getting help with a physical injury was a breeze, he said.
“The administration and professors have been much more understanding and willing to help when it’s something tangible and physical,” he said, “when the doctors can say, ‘Here’s what’s wrong with you and here’s how you can fix it.’”
Drawing lessons from trauma
Rodenbarger, the Indiana University student, is still feeling the echoes of her struggles to get mental health help on campus. Her suicide attempt cost her both her job and her off-campus apartment. The medication she was put on cost her a pilot’s license.
But she is recovering — with the help of a mental health provider off campus. She’s easing off the medication. She’s on track to graduate in the summer of 2018 with two degrees, a fine arts degree in printmaking and another in astronautics.
She’s also excited to have seen the school expand its walk-in services for students in need of urgent mental health care. It’s a step forward — and she wants to see more like it.
“Had I gotten help when I reached out for it,” she said, “it would never have gotten to the level that it did.”
The Shortage of Child Psychiatrists
Buying the coolest new toys, being creative and keeping the inner child alive are part of the daily routine for child psychiatrists.
But this profession has the greatest staffing shortage of any medical specialty. Parents are waiting months for appointments for their children.
"Figures for children needing care are, sadly, about the same as adults -- around 20 percent," says Dr. Pippa Moss. She is a child and adolescent psychiatrist.
"Mental health, as a whole, requires a higher proportion of the health-care dollars to have equitable funding. The proportion of mental health dollars available to pay for children's treatment, taking into account the percentage of children in the population, is also too small," says Moss.
"When one considers that the average child patient's care requires about two to three times the amount of resources and time as the average adult patient's care, the relative shortage of resources becomes even more obvious!"
Moss adds that job prospects are pretty rosy for the foreseeable future.
So why is there such a shortage?
The problem is at least three-fold, says Dr. Thomas Anders. He is a professor of psychiatry and behavioral sciences at the UC Davis M.I.N.D. Institute in California.
"Firstly, there is a long period of training, and that comes with a debt burden to the students," says Anders.
After four years of medical school, students undergo five or six more years of training. During that time, they make a modest income -- but they must also begin to repay their debts.
Also, reimbursement rates from insurance companies are the same for child psychiatrists as for their adult counterparts. But treating a child often takes much longer than treating an adult, since the psychiatrist often has to talk with the family, school or other caregivers. That means child psychiatrists make less money compared to other doctors with the same amount of training.
"The second reason is that there are so few child psychiatrists in the country that very few are in teaching. So, some students in medical schools will make it through school without even meeting a child psychologist. There is an under-representation of role models," says Anders.
Plus, psychiatry has a bit of a bad reputation among medical professionals.
"Some doctors consider psychiatry to be a 'soft science,' and see us as counselors rather than doctors," says Anders. "Some students may be discouraged to enter the psychiatry field by our colleagues."
Moss agrees that the field has an image problem.
"I suspect that medical students get very negative messages about psychiatry as a whole. There is a lot of stigma and fear about mental illness and behavioral disturbance, and this rubs off on those who care for these patients," she says.
"Even the portrayal of psychiatrists in the movies and on TV tends to be far from complimentary, and not at all realistic," she adds.
"Rates of pay have not been as high as for other medical specialties, though this is being addressed. If more medical students knew about child psychiatry, as it is practiced outside the medical schools, they would be interested."
For those who are willing to face the challenges, the career can be very rewarding.
"The rewards have to do with constantly being stimulated and constantly learning. Work is always challenging and not boring," says Dr. Roslyn Seligman. She is an associate professor of child and adolescent psychiatry at the University of Cincinnati College of Medicine.
"Helping people, especially young people, is very gratifying. Seeing the sparkle in patients' eyes or seeing patients make it in life is very rewarding."
Psychologists and social workers offer therapy, but they can't write prescriptions. General psychiatrists may treat some children or adolescents, but they don't specialize in children's issues. Pediatricians can write prescriptions for kids, but they're not mental health specialists.
Child psychiatrists are experts on how psychiatric drugs work in children. That means they're better equipped to deal with complex problems.
"There are currently job opportunities across all aspects of child psychiatry, but especially in the subspecialty areas, such as eating disorders in children and in community child psychiatry -- rurally based," says Moss.
"If you are a high-energy person who loves living on the edge, you could enter forensic child psychiatry!"
Anders spends much of his time convincing students that child psychiatry is a good career. He says it allows you to live a relatively decent lifestyle compared to surgeons, who must work nights and weekends.
Child psychiatrists work intensely, but not in the same way. They have more time to spend with their families and pursue their own interests.
"No day is the same. Every child, family and challenge is different. Every adult has a little child inside, and this is a wonderful opportunity to keep that child alive," says Anders.
"As part of my daily work evaluating children, I get to get down on the floor and play with kids. I go to toy shops and buy new toys, and I keep up with all the latest toys and games. It keeps me young."
- American Academy of Child and Adolescent Psychiatry
A wealth of information, all provided as a public service
- American Psychiatric Association
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How much does therapy cost?
Seeing a therapist in an office is not affordable for most Americans. This is unfortunate for people who have looked past the stigma of therapy and committed to living happier lives but can’t afford the therapist’s rates. The average therapy session costs $75-150 an hour, and good luck if you live in a place like New York where the range jumps to $200-300.
People who rail against therapy accuse therapists of being greedy, but therapists actually have valid reasons for their high prices. Nonetheless, don’t believe you are stuck paying for therapy you can’t afford. Learning why it is so expensive is the first step toward searching for alternatives and paths to affordable therapy.
Becoming a Therapist Costs a Ton of Money
Think about how expensive it is to hire a lawyer. Clients are hiring someone with years of schooling on the subject in which they invested hundreds of thousands of dollars. It’s the same deal for a therapist — most therapists have postgraduate education and many have a Ph.D. — but misconceptions about therapy prevent people from seeing it this way. Remember, you are not paying to chat with a friend. You are hiring a mental health professional.
Therapists Don’t Get Paid for Every Hour They Work
When people work a typical 40-hour week, their company pays them for every hour they work. Therapists, on the other hand, can only bill for the time they see clients.
Most therapists cannot manage 40 clients a week, said therapist Sarah Lee . If they fill up all their time with sessions, they would not be able to organize their clients’ information, market themselves and perform administrative duties such as negotiating rates with insurance companies.
Imagine if your company only paid you for 25 of the 40 hours you worked each week. You would need to increase your hourly rate to break even.
Then there are the cancellations, the many cancellations.
When therapist Angela Essary worked as a community mental health counselor, she booked 12 sessions a day but only saw five of those people.
“It’s a big commitment for clients and there can be lots of no shows,” she said.
Who Pays the Rent for that Nice Office with the Comfy Couch?
Think about how much your rent or mortgage payments cost. OK, now double that and add some more for good measure. This is what many therapists — at least those not affiliated with an online therapy network or firm — have to do because they have no company to pay for the spiffy office they host clients in. Some buildings don’t even cover their utilities. Then there are office supplies such as the tissues they keep handy and office phones. It adds up.
The office often costs more than their home’s rent or mortgage payment. They could save money and lower prices by inviting you to their homes and hosting the session in the living room, but that wouldn’t be the most ethical thing.
Therapists Pay More Insurance Too
Getting sued and not having any protection set up in advance is terrifying. Therapists use liability insurance to avoid tread water during lawsuits in case a client sues them. It also helps them maintain their licenses. It’s yet another cost they can’t use a company to buffer.
That’s only one kind of insurance. They may have insurance for their office in the same way people buy renters or homeowners insurance.
Those Certificates on Their Walls Have a Sort of Interest to Pay
Therapists don’t stop their education once they receive those fancy degrees you see framed on their office walls. Maintaining a license or certification means investing in annual training such as continuing education fees [CEUs]. Therapists need to keep up with advances in their field the same way doctors need training on new medical technology and treatments.
Some therapists are able to have companies or firms cover their CEUs while others spend more than $1,000 a year on them, said Talkspace therapist Jennifer Fuller Gerhart. Here are some other training and certification maintenance expenses she and Foster mentioned:
- professional development courses (not necessarily part of the CEU and can cost around $400 per course, according to Foster)
- therapy-related books for self-study or homework for clients
- state-licensure fees of up to several hundred dollars a year, varying depending on the state
- fees for additional credentials tend to cost several hundred dollars a year
- fees for professional association memberships
- insurance billing services or payments to an assistant or billing specialist ($500 to $1,000 or more)
Therapists Need Therapists
A good therapist will stay calm during sessions and not show how much the client’s issues are impacting him or her. Still, it’s not like that stress magically evaporates. They need a therapist to deal with it and, as we’ve been discussing, that can be expensive. Also, therapists are normal people, and anyone can benefit from therapy.
But Don’t Despair — Here’s How to Receive Affordable Therapy
We want to defend great therapists from accusations of being greedy or unreasonable with their prices, but we do agree therapy is too expensive on average. The overpricing is a systemic issue, but there are ways to beat the system.
Ask the Therapist for a Discount or Look for Therapists With Sliding Scales
Most therapists are not in it for the money. If you tell them you can only afford a discounted rate, they might oblige.
“There are a few [clients] I give very low rates to because it’s part of our ethical code to extend a helping hand from time to time,” Essary said.
Then there are therapists who use sliding scales for all payments. Before sessions begin, check for this information on their website, therapy network or profile.
After a bout of breakup-induced anxiety and depression, 31-year-old New York City resident Emily Taylor decided to look for a therapist. But finding a mental health professional to accept her Anthem Blue Cross and Blue Shield insurance plan proved to be nearly impossible.
“I spent days looking for therapists near me that were covered by my insurance,” Taylor said. “For the very few I did find, I spent over five hours on the phone trying to get appointments, [only] to find that they were either not accepting new patients or the wait time was two months.”
Taylor was able to locate plenty of highly reviewed therapists available for private pay, however. But since the average cost of therapy in New York is $200 to $300 per session, according to one report , that wasn’t a practical solution.
Many people struggle to find talk-based therapy that’s covered by their insurance plans. Of all practicing medical professionals, therapists are the least likely to take insurance. Only 55 percent of psychiatrists accept insurance plans, compared to 89 percent of other health care providers, like cardiologists, dermatologists and podiatrists, according to a 2014 study published in JAMA Psychiatry.
That’s a big problem, since approximately 1 in 5 Americans will experience some sort of mental health disorder in a given year, according to the National Alliance on Mental Illness . Many will also seek counseling for divorce or grief.
Treatment is highly individualized, but experts agree that talk therapy is the gold standard for treating psychiatric problems. A 2015 study revealed that cognitive behavioral therapies were just as effective as antidepressants for treating depression.
So why is therapy so unaffordable for so many people? And why don’t more mental health professionals work with third party payers? It turns out several factors contribute to making therapy unaffordable ― many outside individual clinicians’ control.
Insurance systems don’t support therapists’ diagnoses.
Poor insurance coverage for therapy is largely a reflection of how society views mental health, says licensed psychologist Candice Ackerman.
“Insurance companies tend to see things more from a medical perspective ― where if you get sick, for example, then you take a blood test, they figure out what is wrong with you, they give you a medication and then you are all better,” Ackerman explained.
“But with mental health,” she continued, “a lot of times what we are trying to do is preventative maintenance-type work, and it makes it a lot more difficult to justify medical necessity with insurance companies.”
On the website for Ackerman’s practice in Lakeway, Texas, she explicitly states that some of the professionals there do not accept insurance because she wants to avoid surprising patients.
Even when insurance companies consider a mental health diagnosis a valid billable condition, the coverage may only be temporary. Jennifer Chen, 38, a freelance writer in Los Angeles, is waiting to hear whether her insurance company will continue to cover her therapy, since she’s no longer clinically diagnosed as “depressed.”
“After seeking talk therapy treatment for depression for four years, my mental health insurance provider is reviewing my case to determine if I still need coverage,” she said.
In other words, Chen’s insurance company may determine that she is well enough to forgo therapy, even if it’s the reason she is well.
“My therapist will be attending a review board where the insurance company will discuss my case and make a final decision if my coverage will end or not,” Chen said. “Currently, my insurance covers about 50 percent of my therapist’s fee. If my coverage ends, then I’ll have to consider discussing a sliding scale fee or reduced therapy sessions.”
Insurers are starting to feel the frustration as well. “There is a well-documented national shortage of behavioral health providers generally ― and in health plan networks specifically ― resulting in patients having to pay out-of-pocket for treatment or forgo it altogether,” said Cathryn Donaldson, a spokeswoman for America’s Health Insurance Plans , an insurance company trade organization.
Therapists honestly can’t afford to accept insurance.
The gap between a therapist’s hourly fee and the reimbursement rates they receive from insurance companies can be massive.
“I’ve seen it lower than $50 a session,” Ackerman explains. “I charge $140 a session, so that would be a major blow in terms of income for us.”
“We can’t sustain our practices when that kind of value is put on mental health,” she added.
While $140 per session sounds steep, Ackerman says it helps cover $2,500 a month in rent, the cost of business and malpractice insurance, advertising, office equipment and credit card processing fees. And like many of her colleagues, Ackerman has accrued massive student debt. “I was in school for 10 years, and at this point, my debt is six figures!” she said.
“Therapists are health care professionals that all have master’s degrees or higher. Many have doctorates, medical degrees, and [have] graduated from specialized institutes for the teaching of psychotherapy,” said Dr. Thomas Franklin, medical director at the Retreat at Sheppard Pratt, a residential psychotherapy facility in Baltimore.
“Lawyers, accountants and architects generally make $120-$400 per hour or more,” he added. “One should expect to pay the same for therapy from a competent, highly trained professional.”
Therapists are in a no-win position, says Arika Pierce at the Coalition for Patients’ Rights, an organization for non-M.D. health care providers. “Therapists are almost forced to charge the patient directly because they are not able to be reimbursed at equitable rates as their counterparts that have M.D. or D.O. behind their name,” she said.
Pierce says her organization is continuously advocating to change this to benefit non-physician licensed health care professionals and their patients.
“More equitable rates across all health care professionals would allow patients to have greater choice and access in terms of their health care decisions,” she said.
Therapists are almost forced to charge the patient directly because they are not able to be reimbursed at equitable rates. Arika Pierce, spokeswoman for the Coalition for Patients’ Rights
Filling out insurance paperwork is a full-time job.
It’s a Catch-22: To keep overhead low, many therapists don’t hire staff or assistants. But without them, the job of working with insurance companies is overwhelming.
“Many people who work in mental health don’t have the volume of patients that primary care [physicians] might have,” said Dr. Lynn Bufka, an associate executive director at the American Psychological Association . “They might see seven or eight patients max in a day, where a primary care practice might see many more and also have dedicated staff who handle billing and who are very familiar with what the requirements are with all the different payers out there.”
Submitting a bill to an insurance company can involve jumping through an array of hoops, according to Ackerman, including justifying your services to an insurance representative, providing status report updates and getting on the phone with providers to track down late payments.
This can be particularly complicated because not everyone who sees a therapist has a diagnosable mental illness.
“Common reasons for coming to therapy, like couples counseling and grief counseling, are typically not covered by insurance,” said Ackerman.
In other cases, the diagnosis may be controversial in the field. “I have a client with dissociative identity disorder, which is formally known as multiple personality disorder,” Ackerman added. “I don’t know if that would get reimbursement, just because it’s a controversial diagnosis.”
Some therapists say it’s helpful to accept insurance.
Not everyone agrees that accepting insurance is impossible.
Dr. Patti Johnson has dealt with her share of insurance issues ― excessive paperwork, late payment and the hassle of continuously submitting her clients for coverage authorization. But the Los Angeles psychologist, who is currently maxed out with her patient load, finds that accepting insurance helps keep her schedule full, and along with patient referrals, allows her to sustain a lucrative private practice.
“Individuals generally check with their insurance companies when looking for referrals to a therapist. This is a positive and easy way for clients to know about you and your services without a large marketing budget,” she said.
Johnson also notes that allowing patients to bill their insurance opens up her client base to people of all income levels. “Most people can’t easily afford to pay $600 to $800 a month for weekly therapy, and without the ability to use insurance, they wouldn’t be able to get the care they need,” she explained.
Therapists and patients have to make hard choices.
To make it more feasible for psychologists to take insurance, the American Psychological Association would like to see therapy become a standard part of integrative health. So instead of a fee-for-service model, payment would be based on treating a particular condition. (In other words, patients would pay a lump sum rather than a payment every time a service is performed.)
“If it were up to me, our health systems would allow three or four appointments with a mental health provider every year, no questions asked, no need for a specific diagnosis,” the APA’s Bufka said.
This kind of yearly care could help patients address small problems before they grow into bigger ones. For example, a person could learn how to better manage their sleep, work with an anxious child or navigate a complication at work. This would probably lead to better mental and physical well-being, Bufka said, but the current billing system doesn’t support it.
For now, the insurance conundrum for therapists remains. “You struggle with wanting to help people that come to you that seem that they need it, but also keep your lights on in your office and make a profit,” Ackerman said.
Taylor eventually gave in and signed up for sessions with a highly recommended psychologist who charges $250 an hour.
“I’m feeling so much better and am still going, because it’s helpful,” she explained. But even though she thinks her treatment is worth the price, she hopes to cut down her sessions soon.
“I’ve gone about five months and paid about $5,000 out of pocket,” she said. “I just don’t have the money. I used my whole Christmas bonus to help with the costs.”
--from THIS article
By Ed Stannard
A national shortage of psychiatrists who treat children, and difficulty in getting in to see those who do, means that many young people who need psychiatric medication are denied that service.
Only 20 percent of children with psychiatric problems receive treatment, according to one veteran child psychiatrist, and the problem is much worse in the interior of the country.
Whether this will affect the young people of Newtown who survived the horrific Dec. 14 shootings cannot be known for certain, but the need for mental health services has been demonstrated by the many professionals who have gone to the town to help in the wake of the killings of 20 children and six staff members at Sandy Hook Elementary School.
Newtown does have a Youth and Family Services agency with a board-certified child and adolescent psychiatrist on staff, according to its website. Agency staff are not speaking to the news media at this time.
The problem is highlighted by the Newtown tragedy, but it affects every town and city, according to numerous professionals consulted.
"It's really, really hard for someone to get an appointment quickly," said Suzanne Serviss, a social worker at Branford High School. One case took two months before the child got an appointment, she said.
"That is a nearly universal problem all over the country," especially away from the coasts and cities, said Gregory Fritz, director of child and adolescent psychiatry at the Brown University School of Medicine and academic director for Bradley Hospital in Providence, R.I. "It's been a problem for a long time.
"What is behind it is basically that there are too few child psychiatrists," with at least twice as many needed as the 8,000 certified in the United States. He said only a fifth of children who need such help receive it.
FEW TAKE INSURANCE
Few child psychiatrists will take health insurance, so the out-of-pocket costs can be burdensome. Parents have to pay the doctor's full fee of as much as $200 and then submit the bill to their insurer, assuming the doctor is on the insurer's roster of providers or the family's insurance plan covers out-of-network providers. Even then, there may be a high deductible.
"Essentially there's no competition," Fritz said. "In most places, they can see people and just say, 'I'm not going to fool around with insurance.'"
There are essentially three reasons for the shortage, according to Fritz:
►It takes a minimum of five years in medical school to become certified in both adult and child psychiatry and can be longer, similar to some higher-paying specialties. More years in school mean higher student loans.
"The medical students to my eye now pay a little more attention to income ... and the reason is their debt is much higher," Fritz said. He said child psychiatrists earn about the same as general practitioners. So, many students who want to work with children go into pediatrics instead.
►Insurance reimbursements are given for the service, not the time spent on evaluations or medication sessions. "The problem is it takes longer to do it for a child," because parents and teachers must be consulted. "Fundamentally, the payment per hour is less," Fritz said.
►Finally, "there is still significant stigma about mental illness and psychiatric patients, and that stigma also applies to those who treat those stigmatized patients," Fritz said.
In addition to many child psychiatrists not being willing to take insurance reimbursements, there are other symptoms of the malady:
►The wait to see a doctor can be weeks long.
►Since child psychiatrists are certified to see adults as well, those who take insurance may fill part of their schedule with older patients, bringing quicker reimbursements and limiting the slots for children.
The Register called several doctors' offices listed on Aetna's website as "Psychiatry, child and adolescent." Of those who responded, all said they treat adolescents only, despite being listed as treating children as well.
"I will see about age 15 and my partner will see a little bit younger; he'll see 14," said Dr. Douglas Berv of Hamden. "I'm not trained or certified with children and that's where you're running into a problem."
He said of the rosters of providers issued by insurance companies, "Their lists are never correct."
Another on Aetna's "child and adolescent" list, Dr. Robert Ostroff, head of adult psychiatry at the Yale Psychiatric Hospital, said he does not treat children and has heard of the problems in finding doctors who do.
"It's been very hard to get my insured patients' children seen by child psychiatrists," he said. "I have people who can't afford to pay out of pocket. ... It's a real problem."
When asked about the combined "child and adolescent" category, Susan Millerick, a spokeswoman for Aetna, after reviewing the issue, said Aetna would look into whether the categories could be divided on the company's DocFind service.
"Given the difficulties that exist in finding a child psychiatrist or behavioral health practitioner for small children, we want to make it easier for people to find those practitioners," she said. "We should make it as easy as we can."
HELPING IN NEWTOWN
This isn't to say child psychiatrists are not caring about those who need help. "So far there have been 50" adult and child psychiatrists "who have gone down to Newtown and the total hours have been over 300," said Jacquelyn Coleman, executive director of the Connecticut Psychiatric Society in Bloomfield.
Dr. Shaukrat Khan, chairman of CPS's Disaster Psychiatry Committee, said many more have volunteered to help. Coincidentally, a disaster training course had just been held Nov. 10, he said. "We are not prescribing any medications there," Khan said. "We are just bringing post-trauma counseling, grief therapy."
There are limited alternatives to private practice psychiatrists. For a town that has a children and family services agency, child psychiatrists may be easier to see.
The Branford Counseling Center has six part-time child psychiatrists available, three of them through an arrangement with the Yale Child Study Center, according to Patricia Andriole, head of the town department.
"Each year, we have three fellows who have finished their general psychiatric training and they are in their second year of a fellowship for child psychiatry," Andriole said.
That has a downside for psychotherapists who refer their clients to the Branford Counseling Center, because the center requires that patients seeing its psychiatrists must also see its therapists.
"We think that you need to have your treatment all in one place," said Andriole. "The psychiatrist is not the primary therapist."
"I'm a private practice clinician and I see children and families," said Linda Young, a licensed clinical social worker from Madison. "In order for some people who need a child psychiatrist to access their municipal services, they're required to see someone" in the youth and family bureau in their town. So Young loses the client.
The situation comes up because "usually there are no child psychiatrists on insurance panels," so the family can't use their work-related health benefits, Young said. "They're all private and I heard recently of someone charging $300 an hour." To use an out-of-network psychiatrist, Young said, a family would have to use up its deductible, which could be as high as $15,000.
Katrina Clark, executive director of the Fair Haven Community Health Center said the lack of child psychiatrists "is definitely an issue for our pediatric patients. We are working with Clifford Beers Clinic to provide several hours a week of a social worker on site for our pediatric patients, which will be a small improvement." She mentioned a situation in which a pediatrician was "told to wait months if not years for an appointment to diagnose a child with a condition such as autism."
NURSE AS ALTERNATIVE
There is an alternative route some therapists have taken: referring their patients to advanced practice registered nurses who have additional training in psychiatric medicine.
"APRNs are easier and that's who I refer to by and large," said Serviss. "I find them accessible and good and they communicate with me."
Ellen Prasinos, who has her own practice in Guilford as an adult and family psychiatric nurse practitioner, said APRNs "are a good alternative if they have good training on kids." (She said the state classifies nurse practitioners as APRNs. Those trained in psychiatry must collaborate with a psychiatrist.)
But, Prasinos said, "there are very few of us" who are certified to prescribe medications to children.
She said she doesn't take insurance because of the time she spends with her clients, both in the office (she sees each client for a minimum half-hour, even if it's to review medication) and off-hours.
"I text 24/7 with the kids that I take care of and their parents. When you see a kid you're really dealing with a whole family," she said.
Another possible ray of hope is the 25-year-old pilot programs run by nine medical programs that turn out doctors trained in both adult and child psychiatry in five years, said Brown's Fritz.
"It hasn't really grown much because it requires a lot of collaboration between the departments," he said.
Meanwhile, Bradley Hospital has to subsidize the child psychiatrists on its staff.
"If we paid only what their clinical work brought in, we couldn't attract child psychiatrists to do outpatient work," he said.
Kaiser Permanente’s newly opened medical center in Oakland. (Lisa Aliferis/KQED)
This is the second of two parts about mental health services at Northern California Kaiser.
In January 2013 a woman named “Nina” had a terrible falling out with her father. Soon after, she found out he had incurable cancer and was going to die. In the ensuing weeks, she tried to patch things up, but with the pressures inherent in the last months of a dying man, was unable to attain any form of closure. Some six months after their fight, he was gone.
“Nina,” who did not want us to use her real name for reasons of privacy, had been prone to depression. Zoloft had helped, but the now irreparable family rift left her severely depressed, with occasional thoughts of suicide. “I was in a state of constant emotional pain and confusion,” she says. “It was affecting all aspects of my life.”
She went for an intake appointment at the psychiatric department at Kaiser Permanente’s Oakland Medical Center, with the expectation she’d be able to see a therapist for individual appointments during this severe emotional crisis. She requested those sessions, but the intake therapist told her Kaiser only offered group therapy.
“I said I’m not comfortable talking about my situation with a bunch of strangers,” Nina says. “She very kindly tried to make me aware of the value of group therapy. But I knew in my heart it wasn’t where I wanted to be.”
Nina left even more dispirited. Over the next year, she white-knuckled her depression on her own, before having the epiphany that maybe her medication needed adjustment. She went to see a Kaiser psychiatrist and mentioned she’d been told there was no individual therapy.
The psychiatrist seemed startled. She told Nina individual therapy was offered. “They probably just didn’t have the space,” the psychiatrist said.
Nina was shocked. “I could not believe that a professional therapist would lie to an obviously depressed patient who was sincerely seeking help.”
She finally did get to see a Kaiser therapist, whom she describes as “fantastic,” but who told her she could only book Nina maybe once every four weeks. At that point, Nina’s expectations had been lowered to the point she was grateful to get any therapy at all. She also availed herself of a free Kaiser yoga class, which she considers to have been useful in her recovery.
Her therapist, she says, is really helping her with the depression.
Still, Nina’s contact with Kaiser’s psychiatric department left her unnerved. “I started thinking maybe it’s my problem,” she says about her rejection of group therapy. “It just added to my anxiety. But to share with other people what I was going through was just too much for me at that time. How depressed did this therapist need me to be in order to make room in the schedule for individual therapy?”
Kaiser Under Fire
Last year, Kaiser was fined $4 million by the California Department of Managed Health Care for not accurately tracking patient waiting times for initial mental health appointments. And now the health plan is in the middle of another controversy over its mental health care: Some of its therapists and patients say there is a dangerous lack of access to individual therapy appointments and an over-reliance on group therapy.
Kaiser maintains that hiring in its psychiatric departments is up, and that patients do not have problems getting appropriate care. It points to its high rating in behavioral and mental health on the 2014 California Office of the Patient Advocate report card . In addition, it has asserted that much of the controversy has been fueled by the union representing mental health clinicians, the National Union of Healthcare Workers (NUHW), which has been embroiled in contract negotiations with Kaiser since 2010.
In reporting this story I talked to some two dozen current and former Kaiser clinicians and mental health patients as well as outside therapists. The vast majority express similar complaints: While health plans are required to provide medically necessary appointments within 10 business days, Kaiser patients have to wait long periods, sometimes months, between individual therapy appointments. These critics say Kaiser is referring patients to group therapy even in cases where ongoing individual sessions are clinically necessary. The reason, the union and clinicians say, is a serious staff shortage.
Therapists, Patients Speak Out
As we’ve reported , the issue came to a head this year when a behind-the-scenes blog by Andy Weisskoff, a now-former therapist at the health plan’s Santa Rosa Medical Center, detailed long waiting times for therapy appointments and the deleterious effects on both patients and therapists.
“When I see someone today with suicidal thoughts … I am often uncertain how well they’ll fare in the intervening weeks,” he wrote . “Did I miss something in our hour long interview?… Maybe I should have sent them to our intensive outpatient group instead of a skills group designed for people who are higher functioning. And then I wait, at least a month, to see if my intuition, one way or another, was correct.”
One Kaiser therapist from a Northern California facility described similar concerns. She wants to remain anonymous out of fear for her job. She is unnerved by the common practice of steering patients into groups instead of individual therapy sessions.
“I feel unethical when I go home at night, and feel really guilty,” she said. “People are suffering, and I fear some of my patients will commit suicide for lack of ongoing treatment, but I’m powerless to treat them because I don’t have return visits available.”
Another therapist who worked at a South Bay Kaiser says she quit her position earlier this year because she considered the treatment of patients there “unethical.”
“Patients that need individual therapy are not getting it,” she said. “We had to tell patients we offer group therapy. … The patients that are the most severely mentally ill are the ones that can’t speak up for themselves, and the ones who get lost in the system. With the Affordable Care Act, we’re seeing more and more of those patients.”
A number of Kaiser patients also reported similar dissatisfaction with the unavailability of individual sessions. Loran Watkins’ story was typical of the complaints many patients described to me.
Watkins, 53, said that in 2010 her husband was battling cancer and “desperately needed therapy to get through this. They said he could go to a group. There was no way in God’s green earth he would have gone to a group. He was already a social introvert, was on six different kinds of pain medications so his ability to focus was very limited.”
After “pushing and pushing and pushing,” Watkins says, her husband was finally given the okay to see a therapist, but only once a month.
“Here you have a man actively battling cancer, was relapsing,” she said. “After the seventh or eighth appointment, the therapist said he was retiring, and that there were no more appointments available.”
Watkins added that when her own longtime therapist at Kaiser’s Walnut Creek medical center retired, she told Watkins there was no replacement available.
“I asked her for a referral. She said there’s no one to refer you to. The only thing I can do is they will place me in a group type setting; there’s no individual therapy appointments anymore.”
Kaiser responded to an email outlining these accounts and disputed the allegations that individual therapy is not available:
We apologize if there are members who may have received incorrect information about the availability of services. All of our medical centers provide individual therapy as part of the wide range of mental health treatments available to Kaiser Permanente patients.
We encourage our members and staff to share their concerns, and we investigate thoroughly and work to resolve any issues. We take the examples in your email very seriously. Out of respect for patient privacy, we cannot respond in the media about individual cases. Each patient’s concern is important to us and we will investigate with the information we have. We believe these descriptions are not reflective of the millions of mental health visits we provide each year in Northern California, but we recognize that we have opportunities to make our program even better and are committed to doing so.
Group Therapy vs. Individual Therapy
Dr. Mason Turner is Kaiser’s director of patient operations for regional mental health services in Northern California. He takes umbrage at the notion that individual therapy is the “gold standard,” as he puts it, and that group therapy is somehow inferior. “This is a disservice to the hundreds of thousands of Kaiser Permanente members — and millions throughout the country — who have benefited from this type of proven, effective treatment and to the mental health professionals, including our Kaiser Permanente therapists, who provide it.
“There is no evidence that individual psychotherapy is superior to group therapy.”
I asked Dr. John Norcross, a psychology professor at the University of Scranton, if that was true. Norcross’ research is on treatment adaptations — “how to tailor therapy for individual patients,” he says.
Norcross is a “big supporter” of group therapy, but only when indicated. And group treatment is contraindicated, he said, if the patient has a strong preference for individual therapy. That can make a difference in both retention of the patient and effectiveness of the treatment.
“There are dozens of studies that show we should always begin with patients’ preferences if ethically or clinically possible,” he said.
I recounted to him the experience of Nina, the woman who had expressed a preference for individual therapy at Kaiser Oakland and was erroneously told it wasn’t offered. Norcross said in her case a group would not be effective.
“If this woman wants 50 minutes to express and resolve longstanding conflicts, you’re not going to get that kind of opportunity in a therapy group of 6-12 people,” he said.
Andy Weisskoff, the former Kaiser therapist who blogged about his experience at Kaiser Santa Rosa, wrote that only a quarter of those who were referred to groups attended one.
“The assertion that groups are better than individual therapy is a little bit beside the point if they don’t go to the groups in the first place,” he says.
Some patients who I spoke with amplified his concern. For example, a 60-year-old woman who uses Kaiser’s Roseville facility and suffers from panic disorder said the last time she had an appointment, the therapist told her she could be seen maybe once every three months.
Instead she was sent to a group, where she says the discussions triggered her anxiety attacks. She estimated the number of patients in another group at about two dozen — “like cattle in there, how can anyone’s needs be met?” she said. So she quit.
On disability because of her anxiety, unable to tolerate medication, and with the cost of an outside therapist out of reach, she sees no available options. “There’s nowhere for me to go,” she said.
Corlene Van Sluizer described the same lack of options for her sister, 71. Her sister was ordered into an inpatient facility this year after telling her Kaiser Santa Rosa psychiatrist of plans to commit suicide, Van Sluizer says. Even with a diagnosis of major depression, after being released she was told she’d have to pay for any individual therapy on her own. Instead, she was sent to a group.
“It lasted 6 sessions. She got no benefit from it,” Van Sluizer says.
Many non-Kaiser therapists sent me emails asserting some of their patients have been forced to pay out-of-pocket because they cannot get individual therapy at Kaiser.
A typical response came from Karen Taylor, a therapist in Campbell: “(I) see a number of Kaiser clients. (Kaiser) tells them to go to a group or will only see them every six weeks for private therapy. Neither of these options have been appropriate or effective for my clients.”
A therapist who wanted to remain anonymous said that a patient was referred to her by Kaiser staff following his suicide attempt and hospitalization. “I considered him high risk for a second suicide. He attempted again soon after our intake. None of these incidents convinced Kaiser to provide individual therapy to him. … Kaiser continued to refer him to groups.”
In a statement, Kaiser said therapists have a responsibility to inform more senior staff of need for specific services:
The well-being of our patients is our primary concern. We would expect any therapist with concerns about a patient’s urgent needs to immediately respond and escalate appropriately, and we support them in doing so.
Kaiser Disputes Shortage of Staff
Kaiser’s Dr. Turner says any notion that a staff shortage is driving the choice of treatment options is untrue.
“We have nearly 14 percent more therapists in Northern California than three years ago, and we are continuing to recruit and hire,” he told me.
Some Kaiser mental health staff say any new hiring hasn’t kept up with the influx of patients due to Obamacare. But Turner disputes that. “Staffing increases (have) increased significantly ahead of membership growth,” he said. “Seventy percent of our therapy is individual psychotherapy.” While that figure includes the intake sessions for new patients, Turner said the “bulk” of the 70 percent figure is for return visits.
“To say that 4-6 weeks is the time between visits is not accurate,” Turner said. “We encourage therapists to look at all the different contact modalities: telephone appointments, email visits, and individual visits, to understand how best to reach out.”
He called Kaiser’s system of care “multi-modal, highly integrated,” and listed medication management, crisis intervention, “evidence-based group programs,” and intensive outpatient and inpatient services among its services for mental health.
Turner says patients can get individual therapy at more frequent intervals if they, in consultation with their therapist, consider that is the best course of treatment. He also put the responsibility for arranging appropriate care on therapists.
“We would expect our therapists, if they thought (a patient) needed to be seen sooner, would elect to discuss it with their manager and look for alternative times. Or have a discussion with their colleagues how they’ve managed patients like that before. It’s really up to the patient and therapist to make sure that occurs. …
“(But) we have ways of accommodating this when it comes up.“
Bringing Concerns to Management
Kaiser Oakland psychologist Melinda Ginne says she tried that, to no avail. She and other Kaiser clinicians eventually went to California’s Department of Managed Health Care with their complaints.
“For the past two-and-a-half years I have (been) writing my management about … the dangerously long wait times for a return appointment,” she told me. “The response was literally nothing.”
Ginne works with seniors and patients who have serious physical ailments like cancer. She sent me the email she wrote to Kaiser managers last September.
“My patients have been waiting 3 months for a routine follow-up appointment,” she wrote. “This has been a dire situation with often adverse consequences for the patients. But now they must wait 5 months.”
“Believe me,” she continued. “I can’t tell a patient with 3-6 months to live that I’ll see them in 5 months.”
One former Kaiser therapist said she brought her concerns about patients not getting enough individual therapy to management “multiple times throughout the five years I was there, and they just don’t want to hear it.”
She said it was possible for a therapist to get approval to see a client individually, but only by “really insist(ing). And even if they feel the patient needs it, they don’t have room on their schedule because of the way Kaiser books them back to back.”
Kaiser’s Regulator Weighs In
Marta Green, the California Department of Managed Health Care’s (DMHC) deputy director of communications and planning, said whether Kaiser is in violation of regulations would depend on whether it displayed a pattern of steering patients to groups instead of medically necessary individual sessions.
“If the medically necessary care to treat an enrollee’s condition is an individual therapy session, then the plan must make that session available within a clinically appropriate timeframe and comply with the regulatory timeframes” of 10 business days,” she wrote in an email.
However, if a physician or triage professional, using professionally recognized standards of practice, determines that a longer waiting time will not have a detrimental impact on a patient, that period between appointments may legally be extended.
Green said if Kaiser can’t provide individual therapy to a patient that needs it, then Kaiser would be obligated to partially pay for outside therapy. Any Kaiser enrollees who think this situation may apply to them should file a claim with Kaiser at the same time they ask the DHMC for a free independent medical review .
Against this backdrop of reports of patient and therapist dissatisfaction, Kaiser maintains that staffing complaints are driven by its four-year-plus contract negotiation with the National Union of Healthcare Workers, which represents many of the therapists. In its statement to KQED, Kaiser said the union “has not been cooperative in finding solutions that will enable us to meet our members’ needs.”
In particular, Kaiser has “entered into an agreement with Value Options,” a network of mental health providers, to “make sure that our members have timely access to therapists when we need flexibility in staffing.” But NUHW “has so far not agreed to this solution — despite the union making it clear that its members would not be able to take on the extra demand.”
Fred Seavey of the NUHW responds that clinicians have requested to bargain with Kaiser “about the impact of these changes — for example, how these changes in the acuity levels of their patients will affect clinicians’ schedules, caseloads, etc and whether Kaiser should alter the productivity quotas under which clinicians currently operate.”
Seavey says Kaiser’s clinicians have tried to get Kaiser to address staffing shortages for years. “Kaiser has simply turned a blind eye to them,” he says.
A follow-up DMHC report to the one that resulted in last year’s $4 million fine is due in the fall. The DMHC’s Marta Green said it will take into account any complaints about long waits for follow-up appointments to individual therapy.
-- from http://blogs.kqed.org/stateofhealth/2014/07/17/therapists-patients-criticize-kaiser-over-long-delays-for-therapy/