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.

therapydoc

*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.

History and Strategy

You might find this question and answer interesting.

A reader writes in response to the shame post, The Bistro and the Date (below). First he answers those all important questions* then asks

How can I keep my boundaries tight when my family tries to sabotage what I think should be a moratorium (a.k.a. cut-off ) for the sake of my mental health?

The reader worked for years to distance himself from his verbally abusive father, a man who denies his emotionally violent parenting to this day.

If I were the reader's therapist, I would explain that it is shame that is buried under those layers of denial, that his father and he may not be all that different. The difference is subtle but important. His father's shame is so tragic, so toxic, that it is no longer conscious, he has successfully defended with that most primitive of defenses, denial, unconscious denial, the worst kind. He has to believe himself a good dad. Anything else would destroy him. He hasn't psychic permission, he hasn't given himself permission, to be imperfect.

An identified patient like our reader will sometimes try to cut off communication with people in the family who were "dysfunctional" "toxic" "violent." He may try to hang onto one limb, to save a relationships with a sibling, the seemingly healthiest member of the family.

But this last branch, his only connection, will eventually become angry and resentful, may even threaten to cut him off unless he reconnects when parents become elderly and physically unwell. Siblings needs one another when that happens, when there's family work to share.

We're addressing cut-offs here, obviously. The reason people cut-off their families is not that they don't need them or feel responsible and connected to them, but their families became sources of pain. Families do abuse and shame, betray members. Mis-steps such as these (including addicted siblings who visit and steal the silverware) make us wary. We put up boundaries.

It's the permeability of the boundary that concerns me. Boundaries need to breathe.

Parents who emotionally abuse with words, who shame their children, who fertilize a child's self-doubt, sense of inadequacy, and unworthiness have to be sealed off for a little while. The fence needs some sturdy nails. Not electricity. No, I won't block the metaphor, let's keep it going.

See, you need a fence, because children who grow up with verbal abuse believe it and when it's a steady stream of negativity will join the dissension, believe the words, find someone else who will abuse them, or do the dirty work themselves, continue the lashing, cut, try suicide. Maybe succeed.

This is why therapists will advise conflicted patients to stay away from the source, to protect themselves from further emotionally violent communications with family. Heal.

But we're all human. We will want to cling to the healthiest member of the family, perhaps the one who saw the abuse, who may have also been a victim. And ultimately cut-offs fail. The family guilt and invasiveness is stronger than the average soul can stand. Therapists often get cases like these when they're sinking, shored up by a quick but ineffective hospital stay.

Sometimes during that stay the family has been involved. A family therapist like me will keep that going if I can, at discharge, will contact family members (with the patient's permission and release of information). I work to convince the family to let me take over for awhile, to give the patient less of themselves, not more. But don't worry. We'll be in touch.

And I stay in touch.

It takes time, but if a family therapist can work with the healthiest branches, things can change, really change for the best. Branches only need be a little green to grow. People change late in life, given the chance, given the relabel, the opportunity to be a hero.

But what do we do when it's too late for that, when the cut-off is fragile and not working, and Dad is sick in the hospital and our Identified Patient hasn't the strength to deal?

Not at all uncommon. The sibling, the one care-taking Dad, wielding the chain-saw (help me or you're no longer my brother/sister), is clearly of the tougher child variety. But even the tougher children wear down when they have to care-take sick parents. They look tough. But it's just for show.

Family therapists push for direct communication. First the identified patient has to be straight with his or her sibling(s), the care-taker(s), either by writing (under a therapist's direction and editorial skill) or calling (in the therapist's presence) to communicate something along these lines:

I'm going to call Dad or write to him and tell him what's going on with me. I'm sorry you're stuck with this, but for the time being I probably won't be visiting. I'm not quite healthy enough yet, but I'm working on it. Here's what I'm going to tell our father:

And here is what the identified patient would tell his or her father, either by telephone or in a letter, not face to face, something along these lines

I'm sorry that I'm too sick to reconnect with you right now, that I'm no good to you. Some children, the ones with big issues, get a little funky when parents get sick, and that's what I am right now, laid a little low, too depressed and withdrawn to get out of my shell to help out with you, visit with you.

I know you don't believe in mental illness, but you and I are different like that. You probably see this as a weakness and an excuse. So be it. It's real enough to me to make visiting impossible right now. I just can't do it. I hope that you don't hate me for it. I imagine you do.

One day I'm sure I'll regret this decision, not seeing you, not helping you. It doesn't seem fair to do this to you, especially now. But I don't see life as fair. A parent raises his kids, gives them his all, and just when he needs them, they're gone.

I have bad memories of us, and they haunt me (this is called chipping denial, you're not accusing him of anything). I have to work through things, mostly negative thoughts about myself, nobody else. You did the best you could. You tried to parent the best you could.

I feel like a bad person, a failure, for not meeting your expectations.

I'm in therapy, working on my own set of expectations, and how I'm going to live with myself when you're gone.

Maybe I'll get it together soon. Who knows? I don't expect you to forgive me for this or to really understand me. But despite your take on mental illness, I think everyone gets depressed sometimes. Maybe even you.

And then the identified patient stops talking or signs off (he doesn't have to write "Love" that's up to him) and hopes his father begins to talk about his own feelings, his own depression, his own childhood abuse, knowing he probably won't.

But he might. They sometimes do.

This is a strategic intervention, full of lies. The identified patient is not remorseful, probably doesn't even believe his father did the best that he could. The identified patient may never regret not talking to his father, cutting him off.

With good therapy, he will live with himself just fine once his father has passed on. He probably won't care. Some celebrate. It is survival we're talking about here. And you can't always sleep with a person you perceive as the enemy. You can't always go home just because they're ringing the dinner bell.

The therapy, surely, is about changing that perception, the one that identifies the parent as the enemy. If that's possible.

To do that, you need history. You need the extent to which the parent suffered abuse during childhood. If the identified patient doesn't know the history or denies transgenerational abuse, I make finding out a therapeutic objective. It's there.

He was criticized, abused, shamed. Not loved. Abandoned. The child who cuts him off finishes the job. It's the unkindest cut.

In family therapy you want to get to a point with an abusive parent that you can admit you're not so tough. You don't know how he survived his childhood. How did he do it?

Families can toughen us up or wear us down. The resilience variable is having a healthy adult around who counters the abuse, one who puts a hand on the abused child's shoulder and says, "You're a good kid, a wonderful kid. You'll grow up. You'll get out. Talk to me any time. Tell me everything."

We can get into calling authorities about child abuse another day. In a word, Yes. Call.


therapydoc

*Those questions include:

Did (your father/mother/guardian) call (you) lazy?
Retarded?
A loser?
A fool?
Stupid?
With gusto? With sarcasm? With hate? Disgust?
Were there tirades directed at making people feel badly about themselves?