This Marylander had insurance. Why was it so hard to get her daughter mental health help? [Baltimore Sun]

It’s been three years since Theresa experienced her first manic episode the summer before she went to college, but her mother, Maria, still sometimes thinks about how hard it was to get her help.

Theresa’s other mom had insurance through Johns Hopkins University’s employer health program, so her stay at a Hopkins hospital was covered. But Maria called more than a dozen psychiatrists before finding one who took her daughter’s insurance and wasn’t booked for months.

After Theresa was diagnosed with bipolar disorder and her psychiatrist suggested she see a cognitive behavioral therapist, Maria again called every therapist she could find who worked with the insurance plan.

“Finally, I was like, ‘You know what? I don’t care if I have to work until I’m 90,’” Maria said. “I’m going to get her the help that she needs and deserves. We pay completely out of pocket — still — for her therapy.” The Baltimore Sun is identifying Theresa and Maria by their middle names to protect Theresa’s privacy.

In 2023, Americans paid an average premium of $8,435 for individual health care coverage and $23,968 for family coverage, according to a report from the health policy research nonprofit KFF. Health insurance is supposed to make getting medical care easier and more affordable, but that’s not always the case when it comes to mental health care.

In Maryland, people are nearly 9 times more likely to go out of network to get behavioral health care than to get primary care, according to a 2019 report commissioned by the Bowman Family Foundation. That disparity — the fourth worst in the country — can’t just be explained by a shortage of mental health workers. Even though the state is short about 100 mental health providers, according to federal data, it’s short even more primary care providers

Instead, much of the problem can be explained by the shrinking number of mental health providers who accept insurance. A decade ago, less than half of U.S. psychiatrists accepted any form of insurance — a share that experts say has only decreased since.

Therapists across the state said they don’t relish only accepting payments directly from patients and potentially becoming unaffordable to some of their clients. But with stagnant reimbursement rates and the time suck of tedious administrative tasks, some say insurance companies forced their hand.

Last year, Deborah O’Donnell, a clinical psychologist in St. Mary’s County, stopped accepting CareFirst BlueCross BlueShield after seven years of caring for patients covered by the insurer. The costs of running her practice had skyrocketed in recent years and the company — Maryland’s largest health insurer — denied her request for a rate increase.

Each week, she said, she gets calls from people who have CareFirst and can’t afford her out-of-network rate. They tell her about all the therapists they tried calling before her, and how they also don’t take CareFirst or are booked.

“I have to leave these calls with the unsettled feeling of knowing that there’s a person out there who very much needs help,” O’Donnell said, “and the best they can do is get on a waiting list.”

‘We are tired of it’

Earlier this year, hackers snuck into the nation’s largest clearinghouse for medical insurance claims and unleashed what some experts consider the worst cyberattack in U.S. health care history. For months, Change Healthcare — a United HealthGroup subsidiary that processes billions of health care transactions every year — dealt with the consequences.

Some Baltimore-area therapists said CareFirst, a Change Healthcare customer, owed them thousands of dollars in unprocessed claims, forcing them to make tough decisions to keep their practices afloat.

In an emailed statement, Brian Wheeler, CareFirst’s executive vice president of health services, said the company continued accepting claims through other partners after Change went offline, and most providers switched clearinghouse partners within a few days. CareFirst offered interest-free advances to providers who struggled to switch partners, he added.

But as of April, CareFirst still owed Village Counseling in Ellicott City about $24,000, said Amy Philips, owner of the 30-clinician practice. For months, her office staff spent hours on the phone with the insurer, trying to track down missing payments. Some of the clinicians stopped seeing CareFirst patients — who make up half of the practice’s caseload — since they couldn’t afford to offer sessions without payment.

CareFirst has since caught up with most of the missing payments, Philips said, but she’s still frustrated with the insurer. Despite many attempts to negotiate a reimbursement increase, CareFirst has bumped her rate up only slightly since she started accepting it in 2015.

“We are helpers,” Philips said. “We don’t ask for much, but we are tired of it.”

Wheeler said the company’s rates are based on market and salary data in the region. For example, he said, a social worker in Maryland would be paid more than $100 per hour as a base rate.

Advocates for doctors and nurses also have complained 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 in the Johns Hopkins Bloomberg School of Public Health.

In 2022, Johns Hopkins Medicine successfully negotiated a rate increase with CareFirst after a standoff in which it threatened to drop the insurer. Most therapists and psychiatrists, however, work independently or in practices that are much smaller than the Hopkins system, Eisenberg said. It would take a surge of providers deciding to no longer accept a certain insurance to drive a company to increase its rates for mental health clinicians.

Melissa Mullineaux, a Sykesville-based therapist who specializes in treating eating disorders and anxiety, stopped accepting Aetna and CareFirst at the end of last year. Eventually, she said, she plans to drop all health plans. That will let her work with fewer clients, avoid burnout and invest in continuing education, like a nutrition degree to better help her patients.

Other therapists, however, said the guilt they feel about going self-pay keeps them in-network with insurance companies — even when it doesn’t make financial sense. Samantha Ross, a solo practitioner in Frederick who runs Grow Through Talk, knows she could take fewer clients if she stopped taking insurance. But she’s aware of how much the need for mental health help has surged in the past few years.

“I don’t make enough money as a provider to pay my own therapist out-of-pocket,” she said. “I don’t want for people to have to go into debt to have therapy.”

Parity paradox

In 2008 — two years before Congress passed the Affordable Care Act — lawmakers tried to push insurance companies to improve coverage of mental health and substance use disorder treatment.

Under the Mental Health Parity and Addiction Equity Act, health plans aren’t required to pay behavioral health providers the same amount as physical health providers. However, they are required to eliminate restrictions that made it harder to access mental health care than to access comparable physical health care.

Part of that means paying providers enough to incentivize them to stay in-network, said Dr. Henry Harbin, senior adviser to the Bowman Family Foundation and a board member for the Mental Health Association of Maryland.

National and local data shows it’s still much harder to get mental health help in-network. In Maryland, people are nearly 21 times more likely to go out-of-network for inpatient mental health treatment compared to inpatient medical or surgical treatment, according to the 2019 Bowman Family Foundation report. And the state’s in-network behavioral health clinicians are reimbursed 23% less than other doctors performing similar services.

“There’s just not been enough enforcement [of mental health parity laws], either at the state or federal level — even for states that have done a lot, like Maryland,” Harbin said. “They’re going to have to do more.”

In 2020, Maryland lawmakers passed a law requiring insurance companies to complete reports that would allow the state’s insurance commissioner to check their compliance with the federal parity law. However, in a report released late last year, the Maryland Insurance Administration said it couldn’t determine whether insurance companies were following the law because the documents they submitted for review were “uniformly and significantly inadequate.”

The agency fined CareFirst, United Healthcare and Kaiser for failing to submit completed reports — $250,000, $500,000 and $150,000, respectively — according to the report. In emailed statements, all three companies said they had since submitted completed reports.

It was the first year companies were required to submit parity reports and there was “significant confusion,” CareFirst’s Wheeler said.

The insurance administration ultimately reduced United Healthcare’s fine to $350,000 and CareFirst’s to $175,000, the companies said. Kaiser also settled its fine, the company said.

In the last legislative session, state lawmakers took another stab at improving mental health parity. They passed a law that gave the insurance administration more enforcement authority and removed a sunset on reporting requirements established in the 2020 law. Insurance companies will be required to complete reports by July 1 and then every two years moving forward.

Meanwhile, according to an analysis of census data by KFF, more than a quarter of Marylanders who need mental health help aren’t getting it.

Theresa, who was diagnosed with bipolar disorder three years ago, just finished her second year at the University of Maryland, College Park. She’s doing well in school, and is working with the National Alliance on Mental Illness — an organization Maria volunteers with — to start a club for students who are struggling.

But Maria remains rattled by how hard it was to get her daughter help. She had good insurance and, since Maria works in nursing, plenty of connections eager to help her navigate the health care system. And it still felt nearly impossible.

“That’s always my question,” Maria said. “What in the world does everybody do?”

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