Carter J. Carter
became a therapist to
help young people
struggling with their
mental health.
Rosanne Marmor
wanted to support
survivors of trauma.
Kendra F. Dunlap
aspired to serve
people of color.
They studied, honed their skills and opened practices, joining health insurance networks that put them within reach of people who couldn’t afford to pay for sessions out of pocket.
So did more than 500 other psychologists, psychiatrists and therapists who shared their experiences with ProPublica.
But one after another, they confronted a system set up to squeeze them out.
Although federal law requires insurers to provide the same access to mental and physical health care, these companies have been caught, time and again, shortchanging customers with mental illness — restricting coverage and delaying or denying treatment.
These patients — whose disorders can be chronic and costly — are bad for business, industry insiders told ProPublica.
“The way to look at mental health care from an insurance perspective is: I don’t want to attract those people. I am never going to make money on them,” said Ron Howrigon, a consultant who used to manage contracts with providers for major insurers. “One way to get rid of those people or not get them is to not have a great network.”
There are nowhere near enough available therapists in insurance networks to serve all of the people seeking care. And although almost all Americans are insured, about half of people with mental illness are unable to access treatment.
The consequences can be devastating.
To understand the forces that drive even the most well-intentioned therapists from insurance networks, ProPublica plunged into a problem most often explored in statistics and one-off perspectives. Reporters spoke to hundreds of providers in nearly all 50 states, from rural communities to big cities.
The interviews underscore how the nation’s insurers — quietly, and with minimal pushback from lawmakers and regulators — have assumed an outsize role in mental health care.
It is often the insurers, not the therapists, that determine who can get treatment, what kind they can get and for how long. More than a dozen therapists said insurers urged them to reduce care when their patients were on the brink of harm, including suicide.
All the while, providers struggled to stay in business as insurers withheld reimbursements that sometimes came months late. Some spent hours a week chasing down the meager payments, listening to hold music and sending faxes into the abyss.
Several insurers told ProPublica that they are committed to ensuring access to mental health providers, emphasizing that their plans are in compliance with state and federal laws. Insurers also said they have practices in place to make sure reimbursement rates reflect market value and to support and retain providers, for which they continually recruit.
Therapists have tried to stick it out.
They have forgone denied payments.
They have taken second jobs.
They have sought therapy for their own support.
But the hundreds who spoke with ProPublica said they each faced a moment in which they decided they had to leave the network.
For Melissa Todd, that moment came after she was pressured to limit the care of a patient in crisis.
A psychologist from Eugene, Oregon, Todd was treating a young woman with a history of trauma whose father had died unexpectedly.
When the patient came to Todd, she was often unable to sleep more than an hour or two for days on end. “She described it to me as maddening,” said Todd, who recognized an array of symptoms that fit a diagnosis of bipolar disorder.
Todd helped her devise safety plans when she felt suicidal and was available after hours, even in the middle of the night.
“I was giving her almost daily updates,” the patient told ProPublica, “because that was what I realized I needed to do if I wanted to survive.” (Her name is being withheld to protect her privacy.)
Longstanding practice guidelines recommend that providers consider a combination of therapy and medication when treating patients with bipolar disorder, so Todd sought a psychiatrist who could manage the young woman’s prescription. Although the patient was covered by UnitedHealthcare, America’s largest insurer, Todd was unable to find anyone who had openings. Her patient had to pay hundreds of dollars for out-of-network psychiatry sessions.
Then, six months into treatment, UnitedHealthcare began to question whether therapy was even necessary.
Todd walked an insurance reviewer through the details of her patient’s fragile state. Even when the woman had periods of calm, Todd said, she knew the disorder was unpredictable. She worried her patient could attempt suicide if care was cut off at the wrong time.
The reviewers responded that the patient needed to be actively experiencing severe symptoms to continue with treatment and suggested that the therapy wasn’t working.
“I felt all this pressure to say the right thing to be able to keep giving my client what she needed,” Todd said.
In the end, the reviewers demanded a date when therapy would no longer be needed.
“I felt all this pressure to say the right thing to be able to keep giving my client what she needed.”
Melissa Todd
Psychologist
Eugene, Oregon
Todd left the network so she could treat her patient without interference. The patient could afford to pay out-of-pocket because of a small settlement after her father’s sudden death. People are more than twice as likely to pay their full bill out of pocket for visits to mental health providers than primary care physicians, according to a ProPublica analysis of federal survey data.
While United did not respond to questions about Todd’s experience, spokesperson Tony Marusic said the insurance company is “committed to ensuring members have access to care that is consistent with the terms of their health plans.”
Like Todd, many providers told ProPublica that insurers frequently interfere with patient care. In addition to cutting off therapy, they are pressuring providers to cap the length of their sessions to 45 minutes, even when the patients require more time. Therapists told us that they have seen their patients sink deeper into depression, suffer worsening panic attacks and wind up in emergency rooms after insurers refused to cover treatment.
