Diabetes Self-Management Blog

I have written a few blog entries lately related to barriers to getting the mental health therapy you need. But I haven’t yet touched on one of the biggest obstacles to getting treatment—the price tag.

For many people who are in need of help, the idea of spending $20, or $65, or $150 an hour for treatment is prohibitive. So before a person can think about finding the right therapist, the answer to the question “Should I seek treatment?” is already “No” with a capital N, because it costs too much.

This is not just an issue for the people who seek therapy. Years ago, when I first worked for the American Diabetes Association, I suggested that we not charge patients who needed therapy (cost was an issue for me), so we didn’t (we had a United Way grant). This was only partly effective, however—it certainly helped some people who were in need of counseling and those who were looking for group support, but we also found that a lot of people didn’t show up for their appointments. There was something about the perceived value of free therapy that led some people to believe that they didn’t have to keep their appointments. So we started charging $10 for individual appointments, and our no-show rate fell by quite a bit.

Unfortunately, the grant ran out and we had to begin to pay for the office space, the scheduler, and the therapist and his benefits out of what he brought in through his therapy practice. We didn’t make enough money, and the social work position was eliminated.

Providing therapy is expensive. Properly trained therapists have had many years of schooling and of experience. They need to have a private office space and a means of billing, scheduling, and documenting what they do. They may need a license, and they all need insurance. The bottom line is that the therapist’s expenses are necessary and important.

The following is a rundown of a few different models of practices and fees that you might encounter when seeking mental health therapy.

When a therapist works as part of a group of mental health care providers, his operational expenses are shared with other members the group, and if the group is small enough and is able to file for insurance reimbursement, its members can afford to charge lower fees. The average fee in this situation is probably about $80 per session for individual therapy. Most smaller groups will also have a system called a sliding fee scale, which determines the cost of a person’s therapy sessions based upon the amount of money he makes and how much he can afford to spend on therapy.

Larger, multispecialty clinics are unlikely to use sliding fee scales because it is simply too complicated—allowing different patients to pay varying fees would make the bookkeeping too challenging and open the system to the possibility of abuse. Therapy sessions at these organizations are likely to be the most expensive, but these organizations are also most likely to file for insurance reimbursement for you. They are also likely to have arrangements with insurance companies to discount the therapist’s fees. This means that, while the therapist might usually charge $250 for an hour of therapy, the insurance company would only pay him $80. This also means that if someone sees the therapist and pays out of pocket, he will pay $250.

Private practice is another concept altogether. Some therapists belong to insurance company panels. These therapists are similar to the multispecialty folks in that the insurance companies will discount most of their fees and the therapists sign a contract to take what the insurance company offers. The therapists cannot take any additional money from their patients, only their co-payments and whatever the insurance company has agreed to pay.

On the other hand, some therapists in private practice choose to run a cash-only business, which means that they decide what fees to charge. They usually charge a set amount for therapy sessions and have no agreements with insurance companies, although with proper coding and billing information, patients can submit their own bills and may be able get reimbursement from their insurance companies. Private practice providers may or may not offer sliding fee scales—it depends on the individual practitioner. In my own practice, I have worked with certain patients to come up with an appropriate fee so that they can afford to see me.

If you feel that you cannot afford treatment, please speak with the therapist you want to see about whether he offers sliding fee scales. Or ask your physician if he is associated with a therapist who might see you as part of your visit. Therapy is often easier to bill insurance for if it is associated with a medical visit, especially if a person has a chronic medical condition. If it won’t work out to see an individual therapist, seek support from a group or potentially from a local hospital, where support is often free of charge.

As you can see, the costs of therapy are not easily dealt with. It’s not easy to ask for help, and if on top of that we need to ask for help paying for it, we start out with a big dose of shame. I hope that you can work through these initial issues and talk with the people in charge of billing at your potential therapist’s office, or at least call your health insurance company to seek its help in finding affordable care. Meanwhile, those of us who work in mental health care have been trying to get legislation passed to require parity, or equality in how insurance companies cover both physical and mental health issues. At the very least, such a move would make some difference in how a person’s therapy gets paid for.

I suspect that this post may inspire a variety of reactions from people, so please let me know what your feelings are about this issue by leaving a comment below.

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