It’s been three years since Teresa experienced her first manic episode the summer before college, but her mother still sometimes thinks about how hard it was to get her to ask for help.
Teresa’s other mother had insurance through the Johns Hopkins employer health insurance program, so a stay at Hopkins was covered, but Maria called more than a dozen psychiatrists to find one who accepted her daughter’s insurance and hadn’t had an appointment booked for months.
After Teresa was diagnosed with bipolar disorder and her psychiatrist recommended she see a cognitive behavioral therapist, Maria called back all the therapists who worked with her insurance plan.
“I finally thought, ‘Hey, I don’t care if I have to work until I’m 90,'” Maria said. “I’m going to get her the help she needs and deserves. I still pay for all of her medical expenses out of pocket.” The Baltimore Sun is using Teresa and Maria by their middle names to protect Teresa’s privacy.
According to a report from health policy research nonprofit KFF, the average premium Americans paid for individual health insurance was $8,435 and the average premium for family health insurance was $23,968 in 2023. Health insurance is supposed to make it easier and more affordable to get medical care, but that’s not necessarily the case when it comes to mental health care.
In Maryland, people are nearly nine times more likely to receive out-of-network behavioral health care than primary care, according to a 2019 report commissioned by the Bowman Family Foundation. This disparity is the fourth-largest in the country, but it can’t be explained by a shortage of mental health workers alone: The state is short about 100 mental health providers, but has an even bigger shortage of primary care providers, according to federal data.
Instead, much of the problem can be explained by a decline in the number of mental-health providers who accept insurance: A decade ago, fewer than half of U.S. psychiatrists accepted any form of insurance, and that percentage has only declined since then, experts say.
Therapists across the state said they are not happy that they will now only be paid directly by patients, potentially making it harder for some clients to pay, but some say insurers are forcing them to do it because reimbursement rates have stagnated and they spend time on tedious paperwork.
Deborah O’Donnell, a clinical psychologist in St. Mary’s County, dropped her insurance coverage from CareFirst Blue Cross Blue Shield last year after seven years of caring for covered patients. The costs of operating her practice have skyrocketed in recent years, and the company, Maryland’s largest health insurer, rejected her request to raise her fees.
She said she gets calls every week from people who subscribe to CareFirst but can’t afford the out-of-network rates. They tell her about all the therapists they tried to call before her, and that they either don’t accept CareFirst or are fully booked.
“When you hang up these calls, you can’t help but feel anxious that there’s someone out there who really needs help,” O’Donnell said. “The best they can do is get put on a waiting list.”
“had enough of this”
Hackers breached the nation’s largest health insurance claims settlement center earlier this year, launching what some experts consider the worst cyberattack in U.S. health care history. Change Healthcare, a subsidiary of UnitedHealth Group that processes billions of health care transactions each year, has been dealing with the fallout for months.
Some Baltimore-area therapists say Change Healthcare’s client, CareFirst, owes them thousands of dollars in unprocessed bills, forcing them to make tough decisions to keep their practices afloat.
Brian Wheeler, executive vice president of medical services at CareFirst, said in an emailed statement that the company continued to accept claims through other partners after Change was taken offline, and most providers changed their clearinghouse partner within days. CareFirst offered interest-free advance payments to providers struggling to change partners, he added.
But as of April, CareFirst owed Village Counseling in Ellicott City about $24,000 in unpaid bills, said Amy Phillips, owner of the 30-physician practice. Staff at her office spent hours on the phone with insurance companies for months trying to track down the unpaid bills. Some doctors stopped seeing CareFirst patients because they couldn’t see them without payment. CareFirst patients make up half of the clinic’s patients.
CareFirst has since reimbursed most of the outstanding balance, but Phillips remains unhappy with the insurer: Despite repeated attempts to negotiate higher reimbursements, CareFirst has only slightly increased her premiums since she began receiving benefits in 2015.
“We’re here to help,” Phillips said. “We’re not asking for much, but we’re fed up.”
Wheeler said the company bases its rates on local market and salary data — for example, social workers in Maryland are paid a base rate of more than $100 an hour.
Advocates for doctors and nurses also complain about low reimbursement rates, but they typically have more negotiating power than mental health workers, said Matthew Eisenberg, an associate professor of health policy and management at the Johns Hopkins Bloomberg School of Public Health.
Johns Hopkins Medicine successfully raised its fees in 2022 after a standoff with insurer CareFirst that threatened to terminate its contracts with insurers. But most therapists and psychiatrists work independently or in practices that are much smaller than those in the Hopkins Medicine system, Eisenberg said. For insurers to raise fees for mental health clinicians, there would need to be a surge in providers deciding not to accept certain insurance.
Melissa Marineau, a Sykesville therapist who specializes in treating eating and anxiety disorders, stopped accepting Aetna and CareFirst late last year, and says she plans to eventually cancel her health insurance altogether so she can reduce her patient load to avoid burnout and invest in continuing education, such as a degree in nutrition, to better support her patients.
But other therapists say they feel guilty about paying out of pocket, so they sign deals with insurance companies even when it doesn’t make financial sense. Samantha Ross, who runs Grow Through Talk, a private practice in Frederick, knows she’d lose clients if she dropped her insurance policies, but she recognizes that the need for mental-health help has skyrocketed in recent years.
“I don’t make enough money to pay a therapist out of pocket,” she says, “and I don’t want to be in a situation where I have to go into debt to get therapy.”
Parity Paradox
In 2008, two years before Congress passed the Affordable Care Act, lawmakers tried to pressure insurance companies to improve their coverage of mental health and substance use disorder treatment.
Under the Mental Health Parity and Addiction Parity Act, health plans do not have to pay behavioral health service providers the same rates as physical health service providers, but they must remove restrictions that make it more difficult to access mental health services than to access comparable physical health services.
Part of that involves paying providers enough to incentivize them to stay in-network, said Dr. Henry Harvin, a senior adviser to the Bowman Family Foundation and a board member of the Maryland Mental Health Association.
National and local data show that in-network mental health help remains much harder to obtain: In Maryland, people are about 21 times more likely to receive out-of-network inpatient mental health treatment compared with inpatient medical or surgical care, according to a 2019 Bowman Family Foundation report. And the state’s in-network behavioral health clinicians are paid 23% less than other physicians who provide similar services.
“There is not enough enforcement. [of mental health parity laws]”Even states like Maryland, which have done a lot both at the state and federal level, haven’t done enough,” Harvin said. “States need to do more.”
In 2020, the Maryland General Assembly passed a law requiring insurers to submit reports so the state’s Insurance Commissioner can review whether insurers are complying with federal parity laws. But in a report released late last year, the Maryland Insurance Department said it couldn’t determine whether insurers were complying with the law because the documents they submitted for review were “uniformly and grossly inadequate.”
The department fined CareFirst, UnitedHealthcare and Kaiser $250,000, $500,000 and $150,000, respectively, for failing to file reports, according to the report. In emailed statements, all three companies said they have since filed reports.
CareFirst’s Wheeler said it was the first year companies had been required to submit equality reports and there had been “huge confusion”.
Health officials ultimately reduced UnitedHealthcare’s fine to $350,000 and CareFirst’s to $175,000, the companies said. Kaiser also paid its fines, the company said.
Last legislative session, state lawmakers recommitted to improving mental health equity, passing legislation that gave insurance regulators more enforcement powers and removed reporting deadlines imposed in a 2020 law. Insurers will now be required to submit the reports by July 1 and every two years thereafter.
Meanwhile, more than a quarter of Marylanders who need mental health help don’t get it, according to a KFF analysis of census data.
Teresa, who was diagnosed with bipolar disorder three years ago, just finished her sophomore year at the University of Maryland, College Park. She’s doing well academically and is working with the National Alliance on Mental Illness, an organization where Maria volunteers, to start a club for struggling students.
But Maria remains shaken by how hard it was to get her daughter to help. She had good insurance, and because she works as a nurse, she had plenty of connections willing to help her understand the health care system. Still, it seemed nearly impossible.
“That’s always been my question,” Maria said. “What on earth is everyone doing?”
