Thursday, October 27, 2016

Boy, You've Got to Carry that Weight

It isn’t easy navigating healthcare today, finding the providers you know and love in a new network. You want to continue with your therapist, but when you thumb through the lists of mental health providers, no surprise, she's not there.

It hasn't been easy for those of us on the provider side, either. When the Affordable Care Act passed, we knew that we would be denied claims from these seemingly wonderful, spanking new, mega-cheap health care plans, especially the ones offered by the big companies-- United Health Care, Blue Cross Blue Shield, Aetna, Humana. Some of us didn't want any part them. We told our patients: Before you sign up, do some research . .  if you want to keep this thing we have, going.

We had no idea (still don't) whether or not insurance would pay us for services rendered.

Then it began to happen with regularity, and it continues to this day. An established patient would give us a choice: Do you take this insurance? Or this one? 

Then she would explain: My boss says I have to choose a new one. These are the only plans they've got.

Somewhat shaken, a provider might gently answer:  Likely neither. But call the number on the back of the card and ask for customer service. Mention me by name. See what they say. 

Providers like me felt compelled to add the ugly truth; Oh, and even if they say I'm on that list, the answer might still be, No, they're wrong. They make mistakes, and if that happens, I know it sounds bad, but you have to be prepared to pay out of pocket when my EOB comes up bubkus (Yiddish for Zero paid to provider).

How does it happen, that the customer service rep at the other end of the line deliberately delivers the wrong information? The answer lies in the lists. They are likely using an old provider list. Providers drop out, but companies don't retire our numbers. We're still on the mental health provider panel, although we shouldn't be. Is it intentional? You have to wonder.

The situation puts us in an adversarial position. We're the ones having to explain, post facto: Maybe I'm on the list, but I ended my contract with that company a long, long ago. If they don't pay, or don't pay enough, you'll have to cover the bill. I'm so sorry. It stinks, I know, and but I'm pretty sure that EOB will return with a big fat zero next to Provider Paid.

We sound like the broken records we are.

Suddenly a beloved provider is the enemy, a source of patient stress. We're stressed, too, as providers, because we knows we're stressing the people who count on us, people we would much rather commit to helping through their troubles. But we also know that if we work for less, if we aren't paid what we're worth, we will resent the work and the patient, and likely that will manifest, show itself somehow, in some subtle way. Here come the negative Yelp reviews. Not good.

For those of us who had trimmed third party payers well before the act passed, shaved them down to only "some Blue Cross plans" Obama Care has been less of a challenge. We simply denied new patients with insurance we didn't recognize, might say, I only take a few of the Blue Cross plans, sorry, but there are great people out there. Find one. Because there are.

We could see the writing on the wall years ago, that the only ones making money in this system are the CEO's, executives who are not paying self-employment taxes, as are all of the mental health practitioners in private practice, taxes that slice into our earnings significantly (it is as if we pay social security twice-- once through our wages, like everyone else, but also as our employers, who happen to be ourselves; we pay that other half of the social security net-- we're essentially dinged twice).

So we dropped out of the many provider panels that had never paid us enough, considering our educations and experience. Then we determined a tolerable fee schedule, fees for service that we could live with, not resent, that a middle class client, someone likely to take his family to Disney World for vacation, might be able to afford. We would see patients less often, perhaps, but our time would be be well worth it, quality time. It would be that, or refer those with "bad" insurance" along.

Someone like me, who once would see a couple weekly, would cut that back to every other week, or even monthly when insurance went to the wind. I'd suggest that each partner use the new insurance to see someone in their plan, get individual help for the things we had been working on for some time. Then, when we could, even if it would be once a month, we would catch up. They would pay out of pocket. If you have the volume, you can be creative, do that sort of thing.

But mostly we found a few groups, or a few good insurance plans, and made sure that the patients we would see affiliated with those.

Whatever we put into place, whatever new fee schedule, however we vetted insurance, it can backfire when we're talking about really sick people. Some patients really need that weekly checkup, and they won't be able to make our magic number when the insurance changes, or the job disappears, and it is a matter, truly, of life or death. How do you tell someone who wants to die that he needs to find a new life preserver?

As soon as you get the news from the patient, I've lost my job or I've had to change my insurance and you're not on the plans, it is a very big problem. It shouldn't be, this is hardly a terrorist attack. You might secretly even want the patient to move on, not liking the responsibility of carrying that weight, but it is your weight, and you know how to carry it, and you know, deep inside, that nobody knows it better, or will do it better, than you. Not right away.

So you say, We'll work something out.

And the patient says, I need to know. How much do you charge, anyway?

Because his insurance has covered all of it, until now, except for a co-pay of $10-$50.00.

So you say, My fee is more than you will want to pay, even if you have saved your pennies*, and I still have to see you every week to feel comfortable being your therapist. We have to work something out.
And the patient says, What does that mean, we have to work something out? How much is working something out per week?

Then you do some brief calculations in your brain, might offer: What if I see you for a half an hour a week for $60.00?

And the patient says, I can do that every other week. 

And you say, Done. But we talk for a few minutes on your lunch our on your off weeks.

And the patient says, But what if I don't ever get a new job? What if I run out of money?

You smile and you say, I have confidence in you. I'm sure you'll find a new job.** And whatever happens, we'll work it out. There's always a solution. 

The clincher is the confidence, having confidence in the patient's resilience, and it is much easier to do that with young patients, when we're talking about finding another job, even young patients with bad disease, chronic major affective depression, for example. They get hired faster, even with severe symptoms (no, they don't talk about those in interviews) than patients in their fifties and sixties with less oppressive mental illness.

In my practice, just this past year, it has happened four times (really, four times) what I'm calling sudden treatment-coverage interruptus. Each patient had sought me out, initially, with serious suicidal thoughts or plans, and we had worked for months, sometimes for over a year, grappling with recurring symptoms. When the insurance stopped, or the patient was let go from a job, a crisis loomed. But in each case, following that lag, sudden treatment-coverage interruptus, (not service-interruptus), after some months, the patient either found a new job with decent insurance, or transitioned over to another therapist. We held hands along the way. It felt good, not saying, prematurely, goodbye.

The affordable insurance climate is, in a word, formidable. But therapists have established practices, signed up with people well before the President signed the bill, made the changes, and in those very first meetings, we committed to helping people, or to helping them find help. We can't just close our eyes, run from the insurance crisis, when it presents itself, leave them hanging when the going gets tough. And when we don't do that, what we're seeing in the aftermath of it all, having held on tight, is that not only did our patient grow from the ordeal, toughing out the emotional adversity, but we providers do, too.


*We know if they have saved their pennies or have not, generally recommend that they do when they talk about things they think they want to buy, comfort retail. it is a part of the job, talking about one's relationship to money.

**When the patient is in late middle age, the you'll find something is replaced with, something will change for you. Like they may have to move in with someone, be of service, eat a good deal of pride.

Sunday, October 02, 2016


It was an afterthought. 

I was writing about dysfunctional obsessive behaviors: drinking, drugging, gambling, sex, over-eating, and watching way too many baseball games on television.
Chicago Cubs WIN Flag
he usual coping strategies. And I added, as an afterthought, I considered, just for a moment, prayer. 

But stopped right there. Because, can we really pray too much?

This is the time of year that Jews pray for the welfare of the entire world. Our attention, highly introspective, drilled into us by parents, teachers. God is thought to be closer, He, She's sweating the details, paying attention, trying to see who's been naughty or nice. Santa, sorry, is a total steal.

In the synagogue daily, for the past month, or maybe at home, if you live with a musician, the blow of the ram's horn, the shofar, is a wake up call. Wake up! Think about what you really value, think about the important things. Pray for what matters, strive for better, reach to be a better person, extend yourself. We say that God judges the world, all of it on Rosh HaShana, the Jewish New Year.

It begins tonight, and the Days of Awe last 10 days. Last month, the prequel. This isn’t a party holiday, it is serious. Those of us who observe it don’t drink much in celebration, don’t want to be caught napping. There are loftier things to do, learning in particular, praying, and that's how we want to be seen, as if God, considering us for the coming year, will merely think of us this way.  

There have been extra prayers penitential prayers, beginning before the holiday, continuing until Yom Kippur, the Day of Atonement. People pray early in the morning, late at night, fall into bed exhausted. Why bother with this? Isn't praying three times a day enough?  Either you believe or you don't, is the answer, and if you believe, then you know there is much to pray for, much that neither Donald Trump or Hillary Clinton can or will even try to do a thing about. 

Our lives, the lives of the animals, the fish, the trees, gardens, insects, the atmosphere, the earth's resources, the weather, every income, our stocks, our jobs, you name it, everything is determined, the fates, sealed for a year. It is a one-year contract, designed to keep us on our toes.

Because otherwise, we take everything for granted. This is why therapists try to get you to buy into the idea (with several exceptions) that a little stress is good, a little depression, your problems good too, because these annoyances force our hands, inspire growth, creativity, change. Even learning how to manage emotion, the physiological-psychological baggage that goes with stress, all that painful emotion, is a good thing; managing it, a rite of passage.

When it's not too much.

When it is, when things get really bad, that's when some of us, if we pray at all, start to pray with a vengeance. When things are very bad, people who pray, pray harder. They ask for others to pray with them, for them, for their families. And some of us who never prayed before, begin. Coping in this fashion tends to help us find solace, a little bit of comfort, even if we don't get what we pray for. We will say, You can’t pray too much, you can only pray more. Free will? Sure, but in the end it isn't such a bad idea to ask for help

No atheists in the foxholes.

Once I had an acquaintance who, you could tell, prayed daily, maybe three times a day (since she's Jewish), with intention, meaning attention to the words. People in her synagogue thought this because at weekly Saturday services she spent a long time during the silent recitations of prayers, and she cried, sometimes a lot, sometimes just a bit. So most of us assumed that she had problems, and we guessed at what they were, but we all assumed that she truly believed in the whole idea, the idea of prayer.

Just an aside, in Judaism prayer is important, but actions are more important. During these High Holy Days we're judged on tefilah, tzedukah, tshuvah-- prayer, charity, and a return to doing what we’re supposed to do. (We're assumed to have messed up somewhere). Charity and return are behavioral, not contemplative, and an effort at all three at once holds the keys to life in the coming year.

But back to our story. So one day I noticed this friend wasn’t so intent on her prayers, that she seemed much more relaxed, chatting it up with the other women who sat near her. After services, the women were talking, just idle chatter about books and television, and she joined in. She mentioned that she liked some show that actually bothered me, it had so much gratuitous sex and violence, and I teased her, And here I thought you were so religious. 

She laughed and said, Aren’t you?

Sometimes we are, sometimes we're not. It is the way of all people who appear to be religious. 

Chances are, things picked up for her, something lightened her load. Or, she just burnt out, all that devotion, too much to keep up. She would say, my guess, is that as a coping strategy, prayer can be a masterful, powerful form of meditation, focus. Many of us concur. Still others say, It is more than that. It is life or death.

We can't help but hope that when we do pray, when we talk, when we put an invisible concept in the room, as if our words are under consideration, it will make a difference. There's nothing dysfunctional about that, obsessive or not. Perhaps insisting that others do the same, be the same, is.

Have a happy, healthy new year my friends. May God judge us leniently, give us a good one, rich and meaningful, with snapshot memories that move us to good tears, a year that only gently shakes us out of our comfort zones, motivates us to do whatever it is (for I believe it is different for everyone) that our Higher Power wants us to do.

And it wouldn't hurt, honestly, since She is paying attention, if she waved the blue and white WIN flag, and the Cubs win the World Series.