Thursday, April 09, 2015

Out of Network Care : Why?

I'm still thinking about what I'm going to say in my talk about value in psychiatry from the patients' perspective.
It seems to me that the question of value and getting one's money worth might include the fact that the cost is different in different settings.  So someone who gets care at a student mental health center, a VA facility, or a public clinic may well pay nothing.  And in private practice, many psychiatrists don't participate with insurance plans  and people may choose see a psychiatrist when they have no out-of-network insurance, and thereby assume a cost of hundreds of dollars per session.

So my question for now is quick, and again, it is meant only for people who have been patients.

Why do you see a psychiatrist who is not in your insurance network?  If this costs more than going with an in-network psychiatrist, what makes the extra cost worth it?


Plain Anon said...

My pdoc is out-of-network. It took me a long time to find a psychiatrist that I could work with. She is compassionate and knowledgeable, treats me with respect and is my tireless advocate. Those are qualities I find priceless.

I would say tho that I am financially able to pay her fee easily. I am stable at this point in my life and only see her once every three months, so it is not a hardship. But if that changes and money was a challenge for me, I would give up other expenditures to still see her.

Borderline Med said...

My current psychiatrist is out of network and I was referred to her by my previous psychiatrist. Basically, I see her because she fulfilled my requirements (female, young-ish) and because my previous psychiatrist and her supervisor both agreed she was a good match for me. I barely knew any of the in-network psychiatrists, while the ones I knew were good were affiliated with my med school. So that was a big no. Seeing the out of network doctor was easier than shopping among random people, in my case. Basically, I see my current psychiatrist because I can (thankfully) afford it, she's a good match, and she delivers top-notch quality care. To me the extra cost is worth it because I get to have a doctor who is actually passionate about what she does, and it shows in how she works. Also, I get to choose having a doctor who actually listens and has time to discuss my issues, not just for med-checks. I simply refuse to see a doctor who has no time for me. It came with a hefty price, but it's the best decision/investment I have ever made and the results so far have been great.

Anonymous said...

I'm still on my parents insurance, and I don't really want to have to explain to them why I want to be in therapy, so I pay out of pocket. Worth it, on my opinion

Anonymous said...

I've paid out of pocket for a few reasons:

1. Better providers in my area either are OON or don't take insurance (allow pt to submit but they don't)

2. Related to #1, personal crummy experience in network. When I was seeing a psychiatrist years back, so few in network options, tried 2 times both times got providers who didn't inspire confidence - did half baked assessments and tended towards crazy short (average 5-10 min) visits. Both times was not satisfied the recommendation was appropriate to me as much as easy for doc and they seemed annoyed when I asked about options - one suggested newest greatest SNRI as first line for depression are 20 min "eval", in general when 1st recommendation = latest commercials I wonder if its drug rep visit/popular demand or provider honest belief its best match - in which case why bother with specialist anyway. When I asked why that med vs others (didn't really have an opinion at that time, was just curious as I knew there were tons out there, PCP had suggested I see a shrink to get best fit to start with due to wanting to treat depression aggressively, known family hx of recurrent and debilitating depression) was told b/c he had samples so why not, they are all the same. Second guy at same practice I went to 1x for a refill for antidepressant that was working fine, he asked about anxiety, stated I was working on anxiety in therapy and it was slow but helpful, he pushed Klonopin, within 30 sec suggested it and was adding to the script "it works faster and is easier and people like it" type reasoning (If he had bothered to ask or look at notes he'd see I'm not a big med fan, was fine with antidepressant but prefered therapy for coping/long term recovery - annoyed that I felt like I had to defend myself for wanting to learn to cope with anxiety w/o benzos, he seemed annoyed I knew Klonopin was a benzo (mind you, one that is very appropriate for some symptoms/folks, not me). That was it for in network in that phase of my life.

3. Working w/ therapist on trauma hx, appreciate the option of seeking mental health care outside of EMR system where I work or have close colleagues - healthy paranoia from being aware of how common notes are accessed at least where I worked at the time - I don't want to worry about provider writing whatever would be helpful for her or on flip side censoring myself w/ provider due to not wanting it in my medical record in a specific system. The age of having public and private tx notes is ending IMO because of time constraints, and again, just not something I want to worry ab. Folks who don't do insurance or are mostly out of network are more likely to keep notes/records locally rather than on a bigger EMR system, & I'd rather submit OON form with a code vs. having provider having to share detailed info or notes and create often useless tx plans to satisfy managed care network reviewers.

Enjoy your blog, BTW, have read on and off for a few years, just usually on my phone where I'm not inclined to comment using the text sized keyboard :-) A bit of a ludite when it comes to typing, give me my normal keyboard.


Jen said...

I am in treatment for severe, recurrent MDD. My insurance does not cover any psychiatrist who also does therapy. I see my psychiatrist, who accepts no insurance, because he is excellent psychopharmacologically, and easy to talk to. I have a strong relationship with him and feel comfortable with him, whereas in general I find it hard to talk to shrinks. When I began seeing him, I had an excellent job with great out of network benefits and paid his full fee ($450/session) getting reimbursed about 70%. When I changed jobs (and insurance) to a much lower paying job in the public sector, we had been working together for several years and had a strong rapport. At that time, he slid his fee so that I only pay $15 more then what a copay would have been. There's no way I could have afforded it any other way, and I would have had to go back to medication management through my insurance. I have learned the hard way that isn't often ideal.

I want to be VERY clear that if he had not slid his fee so heavily, there is no way I would have been able to continue seeing him and I would have switched to medication management only through someone on my insurance. As much as we talk about the importance of good psychiatric treatment, all things said, you can only afford what you can afford. FYI - I live in a major metropolitan area with a plethora of shrinks of all kinds.

Josey Quinn said...

I started seeing my psychiatrist 7 or 8 years ago. in that time, we've been through a suicide attempt and three hospitalizations together. He never, ever gave up on me or "punished" me for at times being a difficult patient. Two years ago, he was removed from my insurance network. For about two seconds, I considered switching to an in-network provider. I realized, though, that the reasons he was booted from the network were the very reasons he was the right doctor for me. He works hard to find a medication cocktail that works for his patients individually. He doesn't blindly follow insurance company guidelines or put all of his patients on the newest drug. He saved my life, and he continues to help me remain stable. The extra money I pay is worth it many times over.

Anonymous said...

Out of interest, what does 'out of network' health care cost?
In Australia private health insurance doesn't cover outpatient doctors visits so you only have the government rebate (medicare).
Public (or 'bulk billing') psychs are as rare as hens teeth.
For a private psych you are paying anywhere from $70-150 out of pocket for a 20-50 min appointment.
Totally worth it in my mind. But I did struggle to pay when I was too ill to work.

Anonymous said...

My pdoc does not take insurance and does medication only. Because he does medication only and appointments are short, it's not too expensive. As I have mentioned before he also lives several hours away from me. Why do I see him as opposed to someone who takes my insurance (and someone who actually lives in my city)? The most important thing to me was that the pdoc was recommended by someone I respected who really knew him as a person. I had had bad luck with a few previous pdocs who took my insurance and when I was without insurance those who provided indigent care, and I ended up worse then when I started. So, what mattered to me more than cost was that I had some idea that the pdoc I was going to see was good at their job, was well regarded in the community, and patients felt they received respectful care. My therapist (actually my former therapist as I have since graduated from therapy) who referred me to my pdoc was able to tell me that she had referred a number of patients to this pdoc and that not only did patients get a lot better they really liked him and felt respected by him. He has turned things around for me, and I am lucky to have him as my physician. I am doing so well that now I only talk to him once every 3 months by phone, and see him in person once or twice a year.


Anonymous said...

I would also add that even though my pdoc does medication only and does not take insurance, he is available by phone in an emergency and does not charge for it. I have only called him outside of an appointment twice in three years, and there was no charge.


Anonymous said...

I don't have out-of-network coverage. I see my doctor quite frequently for analysis for a very reduced fee. The fee is really more symbolic than anything else. I've seen him since he was a resident, and he chose to keep me on afterwards even though I wasn't employed.

I see him in his private practice, but he still has an affiliation with the hospital where my PCP is, so that's convenient. I wouldn't seek out someone out of network for anything other than something short-term, e.g. couples therapy. It's just not affordable to me.

There are some insurances that will do case-by-case exceptions, especially for children, if the patient's insurance changes and there is an existing relationship.

I think that there are patients for whom it's important to have a team of people working together, e.g. some with "serious and persistent" mental illness, who may well have a case manager and complicated medical conditions. So, making sure that a cardiac workup happens for someone taking Geodon is a big deal and having a nurse or nurse practitioner provide wrap-around care is very important. This is very common among those on Medicare and Medicaid, the so-called dual eligibles. They don't have any money to go out of network. Occasionally you'll see a provider who has kept someone on essentially pro bono.

clairesmum said...

In talk therapy and psych doc meds for 30 years in MA. At the start I had good insurance and most providers were in network. Over time, the good psychopharm docs went out of networks, but I was able to self pay and get some reimbursement. Good psychotherapists slowly came out of network - reimb rates got down to $45/session with a 'good' insurance plan. The ones with social justice values tended to stay in the longest.
Relocated to Bay area recently - private paying both MD and talk therapy. Rates same as East coast, BUT insurance reimbursement much less. Our plan does not consider the costs paid for MH care to be applied to deductible or coinsurance maximum, and will only reimburse you for 30 sessions/yr. (Talk q o wk and MD q 3 months.)
Hopefully will be able to continue to get what is needed from good providers and afford to pay for it. Paying for care does help keep records out of the big health care system computers. Generally the folks who are good can support themselves with a self pay practice as patients won't stay with them if they are not getting better. The folks who are mediocre but credentialed can't make it in the patient pay marketplace and rely on the flow of 'network' customers who have few choices.

Anonymous said...

Weird, my first post didn't post. Oh, well I didn't say anything really profound so no big deal.


Elisha said...

Extremely important to note that a lot of this is subjective. There have been periods where paying a copay for my antidepressant was too expensive -- no chance of seeing an out of network or even in network therapist. It may an excellent investment, but when you're unemployed and supporting a family and you don't have money to pay, you don't have money to pay. And that's all there is to it.

That said, as far as "getting your money's worth" I happen to think it's a lot more about supervision, consultation, medical competence, ethical behavior -- I saw a private practice no insurance psychiatrist who did therapy at $350/45 minutes twice a week for years -- she didn't believe in supervision or consultation, misdiagnosed me and didn't monitor my lithium levels or kidney function for a year and a half and I wound up extremely ill and hospitalized in the ICU. Definitely did not get my money's worth there. Precisely because she was a private practice no insurance shrink, there was no oversight and nothing to ensure she practiced with competence.

The best care I ever received was actually a mix of therapy and medication management from a resident in a resident's clinic, where I paid nothing. So I guess I got my money's worth for that one. And prior to both of those, I saw an in-network psychiatrist who did a mix of therapy and medication management and also received excellent care for several years until she passed away. I'd say that was worthwhile, too. Currently see an out of network psychiatrist for therapy and meds with a huge sliding scale. Her regular fee is $550/session, which allows her to work with those with low paying jobs like me, who pay virtually nothing. Fair? I don't know.

Extremely important to recognize, Dinah, that for many people, I'll even say most, out of network vs. in network isn't even a consideration. You're talking about a privileged minority. Equally important to recognize that while some in network psychiatrists suck, whether because they suck based on who they are or because they are bound by all the terrible insurance restrictions unfairly placed on them, others are excellent, and do provide both therapy and meds, and do a great job; I'm not just chirping: I've worked with and benefited from them. It's not as black and white as it's being made out to be.

Anonymous said...

I appreciate what Elisha says. Just FYI.

bigred5 said...

I see a therapist out of network because I wanted someone who was also a Christian. I was struggling with the stigma (mostly my own) that good Christians don't need therapy. It was my mental compromise. My therapist is licensed. I find them to be compassionate and unjudgemental. I am also comfortable talking with them regarding faith issues. I am diagnosed with general anxiety and ptsd.

Nathan said...

It can be tough for folks as some of people's worst times are happening when they are unemployed or lack insurance. I sought treatment at a time when I took some leave from grad school, and didn't have insurance. I thought it would be worth it to invest in care, but it turned out that I just lost a lot of time/money/whatever stability I had remaining when I was already pretty stressed about lost time and debt. Now that I have pretty good in- and out-of-network coverage, I am too skeptical and angry to seek mental health care (but to be fair, have been told by more than one psychiatrist that if I have any skepticism that care isn't for me anyway, ex. "Of course you have to believe that meds work well for them to work well!").

james hetger said...

I've been seeing my Pdoc for one year, since summer 2015. He has been warning me since Feb. that he was going out of my network. I've only had insurance for two years so this is the first time I've had insurance pay for therapy. I really didn't know what out of network meant but he said my payment would increase, and kept encouraging me to contact my insurance company to find out what they would pay. I didn't want to think about it, as I was coming in because my wife died and I was having problems coping. Before I had insurance I was self-employed without insurance and I paid out of pocket for about six previous therapists over twenty years for a total of about 7 years of therapy. None of them, I think, helped me much. Before this therapist I hadn't gone for about 12 years.

Yesterday he told me that I owed full price for the last seven sessions, and that my OON cost will basically be me paying out of pocket six months of weekly therapy of me paying full fee (@200/hr), until a super high deductible is met. After that my insurance would pay half and I would pay half. He offered to find someone for me in my network.

Frankly, I'm a little in shock. I would like to continue with him, but don't know where I would come up with $200 a sesh overnight. Hmm.

I'm not so upset about the big bill yesterday, the fact that I'd have to pay full cost for the rest of 2016 (Aug. - Dec.) (because now I realize that I should have called my insurance comp. to find this out myself) or the fact that he offered to find another therapist for me, but just I guess that it all happened in the space of 5-10 minutes and then he asked me what I wanted to do about it. :) Uhhhhh.... think about for a day or two? :)

Funny thing is that at this point I'm doing pretty good and was thinking about ending therapy, but I did think that I could increase my level of functioning more and more, and this is what I wanted help with. Well, huh. I don't have he money to come in every week. Even once a month is a luxury on my budget, but that is probably what I will do.