A 12-year-old boy named Strazh hangs from the monkey bars, staring at the ground. The other kids in the park aren’t interested in him. And he’s not interested in them.

“I just like to play by myself,” he says.

Strazh has autism. Today is a good day. But on most others, Strazh has meltdowns. Something frustrates him and he can’t control his emotions.

“I sometimes end up screaming,” he says. “And I end up yelling and screaming.”

And hitting and banging things, throwing things, adds Strazh’s mom, Natalie Dunnege. As a single parent, she says she bears the brunt of it.

“He told me that I disgusted him,” she says softly. “He tells me he hates me.”

Dunnege puts all her spare money into therapy for Strazh. She says it helps a lot. But Dunnege herself is struggling, feeling depressed and overwhelmed. She decided to look for her own therapist.

“One of the things that I’ve really had to wrap my head around is that I can’t change him. I can only change how I handle the situation,” she explains. “And not that I would want to change who he is. He’s a really good kid, but it’s a lot to handle, especially as a single parent.”

But when she logged onto her insurance website to find a therapist, she realized her copay for a mental health visit was going to be upwards of $75 – more than double her copay for other doctors’ appointments. Under a 2008 federal mental health law, those copays are supposed to be the same.

“There’s no way,” Dunnege says. “It’s out of my budget right now.”

Natalie Dunnege and her son, Strazh.
Natalie Dunnege and her son, Strazh. (Sheraz Sadiq/KQED)

Dunnege lives in a one-bedroom apartment with her son and her father in San Francisco’s Haight district. Grandfather and grandson sleep in twin beds side by side. It’s an awkward walk past those beds to the only bathroom. Dunnege says $75 a week for therapy is impossible.

“My income, I just made lower middle income. Just by the skin of my teeth,” she says. “So I just have to hold off until I’m actually middle class.”

More than 43 million Americans suffer from depression, anxiety and other mental health conditions, according to the most recent federal data. But more than half the people who felt like they needed help last year, never got it. Even people who had insurance complained of barriers to care. Some said they still couldn’t afford it; some were embarrassed to ask for help. Others just couldn’t get through the red tape.

Recent health laws, the 2008 Mental Health Parity Act and the Affordable Care Act, were supposed to fix this. They require health plans to provide benefits for mental health conditions on par with physical health conditions. Under the law, insurance companies can’t charge higher copays or set up separate deductibles for mental health care compared to other medical or surgical care. They can’t limit hospital stays or require preauthorization for mental health treatment if the same limits are not applied to treatment for physical health conditions.

But advocates say insurance companies are still finding ways to keep people who need care from getting it. Some are still not complying with the law. And some have found subtle, technically legally, ways to limit treatment.

Problems with Mental Health Provider Directories

Natalie Dunnege encountered some of these barriers when she tried again to find a therapist. In the last year, she got a promotion at work and moved into a larger apartment. Her employer switched to a better health plan, too. Now she has Blue Shield coverage, and her copay for mental health appointments is only $20.

“Which I was really excited about,” Dunnege says.

But when she looked for a therapist who took her insurance, she struck out.

“I contacted six or seven,” she says.

Only three called her back.

“One of them, they were completely booked,” she says. “And then the other two just didn’t accept the insurance anymore.”

Zero hits out of seven. Had to be a bad draw, right?

To find out, we decided to conduct our own survey and called all the psychologists — 100 in total — that were listed on the Blue Shield website for Natalie’s plan in San Francisco.

Here’s what happened:

mentalHealthTreatmentPost
Lisa Pickoff-White/KQED (Lisa Pickoff-White/KQED)

The end result: 28 psychologists actually had appointments. And only eight of them had slots available outside regular work hours. Eight out of 100.

“Sorry, I wish you the best of luck,” was a common refrain in therapists’ voicemail messages.

For Natalie Dunnege, after seven rejections, she gave up looking.

“It’s hard when you’re feeling sad and you feel like you can barely keep things together,” she says. “It just seemed like way too much at the time.”

Mental health advocates say this is exactly what insurance companies are hoping.

“It’s a way to control cost,” says Keith Humphreys, a Stanford psychiatry professor who served as an advisor to Congress when it was developing the 2008 Mental Health Parity Act. He says while insurers are now required to keep an adequate number of clinicians listed in their directories, they still find ways to sidestep the rules.

“You know the law doesn’t say you can’t put people on there who are dead, or you can’t put people on there who are not taking new patients,” he says. “What that translates into, then, is people have to wait longer for care, which then cuts expenditures for the insurer and reduces access.”

California passed a law last year, SB 137, raising the standards for physician directories. Insurers will have to police their lists for providers who are booked or retired. But a lot of questions remain about how the law will be enforced, especially when it comes to mental health providers, who are largely self-employed, solo practitioners.

The insurance industry says it will be a challenge.

“When you have networks as large as ours and you have as many enrollees as we have here in California, you’re not going to be able to just have everything accurate every single second of every single day,” says Charles Bacchi, CEO of the California Association of Health Plans.

He said the industry is working to make it better.

“But we also need to be realistic,” he says. “We don’t run a mental health provider’s office. They do. And how they handle people calling their offices is their job.”

In a statement, Blue Shield said it tries to make it easy for providers to update changes in their contact information and schedule.

“We understand that there are a number of issues that impact a provider’s availability to take new patients, such as administrative limitations and fluctuating numbers of patients based on their individual needs. When those instances arise, the provider is required to notify us so that patients have access to the most up-to-date information about who is available in their area.”

The industry also says it’s facing another challenge: a nationwide shortage of mental health providers, further exacerbated by the millions of people who signed up for insurance under the Affordable Care Act.

In California, there are “around 4 to 5 million more people with coverage, just in the last two years,” Bacchi says. “And that’s creating a strain for everybody, plans and mental health providers.”

But is it really just a supply and demand problem? Is it that there aren’t enough therapists, or is it that there aren’t enough therapists who are willing to work under the terms and rates set by the insurance companies?

This story was originally published on May 23, 2016. The video will be broadcast on KQED Newsroom July 15, 2016. 

 

  • VWFeature

    “When you have networks as large as ours….(and you don’t give a hoot about people, just money)” says Charles Bacchi, CEO of the California Association of Health Plans.

    There. Fixed that for you.

  • VWFeature

    Treating mental health problems REDUCES the overall cost of care. But insurance companies’ profit is a percentage of the total, so the higher the costs are, the more they profit. If costs go up, they just increase their rates next year. They can’t lose. All the crocodile tears about ‘losses under the ACA’ are designed to get premium increases.

  • Elspeth

    Know your rights. Know who the regulators are. Appointments have to be available within certain time frames by law, which can be located on the Department of Managed Health Care’s website. If you cannot readily find a provider who will see you within 10-15 business days of calling for an appointment, call your insurance company and remind them that THE INSURANCE company has the LEGAL DUTY to find and provide access to the provider. Make them make the phone calls for you, its their job to have sufficient providers willing to see covered patients at any given moment, so it shouldn’t be hard for them to identify providers. If they cannot, or will not, file a complaint with DMHC. No it doesn’t fix the problem overnight, but generally, once the complaint is file the insurance company will make certain that you get seen. Blue Shield has the absolute worse compliance rate and 80+% of their interaction with DMHC are resolved in favor of the patient. This includes issues with the co-pays being charged being different than for other appointments.

    If it is an emergency, go to the emergency room. But as with any other health care issue, expect to have to be seen during regular business hours if it not an emergency. That the woman in the story refused to see someone during business hours is ridiculous. If she truly is ill, she would go get help when help is available, whining that there are no after hours apts seems an awful lot like attention seeking and not truly a need issue.

    • Kimmi Tyler

      How do you have a job and see a therapist during your work schedule? While employers are supposed to accomodate medical appointments, it doesn’t mean they do in practice. And if you are a low wage hourly employee with an irregular schedule, good luck. I’ve had therapists where I didn’t have a set appointment time every week and it was incredibly difficult to make my irregular work hours and my therapist’s appointments match up. And if she is someone, like a receptionist, if she is not at work then the whole business suffers and it causes major problems so she may not feel comfortable putting everyone in that position. Its not like everyone can just not be at work for 2 hours every week and not deal with any repercussions.

  • Curious

    Obamacare fixed all this.

  • Chocolate

    It’s time to get the insurance companies out of the health business, period. This is a travesty, a completely broken health industry dictated by insurance companies.

  • Su

    I tried to get specific therapy for my child. I could not find anyone. I called 25 people on a list the insurance gave me. None were available or did that type of therapy required for the diagnosis. I called insurance again and they said they would give me another list of 180 people. I tried to get them to pay out of network, they wouldn’t. I appealed, still they wouldn’t. I appealed to the state managed care, it was denied based on the insurance providing the names of several people to them. I called those people and they would not get back to me. I called the state again and asked if they had ever called those few names to see if they were available and they said they had NOT, that the insurance only had to provide the names to them as proof. I think th state didn’t really do their job, they should have followed up with a phone call to the providers to see of the insurance was lying or not, but they didn’t so it put me back to where it all started, only 3 months later. I think neither the insurance or the state did their jobs correctly.

  • Mary

    I highly recommend neurodevelopmental pediatrician Dr. Sanford Newmark and child psychiatrist Dr. Kimberley Tompkins at UCSF Osher Center for Integrative Medicine for this family:
    http://www.osher.ucsf.edu/patient-care/treatments-services/pediatrics-2/neurodevelopmental-pediatrics-autism-adhd-and-related-conditions/
    and
    http://www.osher.ucsf.edu/patient-care/our-practitioners/kimberley-tompkins-psyd/

    • FailureIsYourOnlyOption

      Troll

Author

April Dembosky

April Dembosky is the health reporter for The California Report and KQED News. She covers health policy and public health, and has reported extensively on the economics of health care, the roll-out of the Affordable Care Act in California, mental health and end-of-life issues.

Her work is regularly rebroadcast on NPR and has been recognized with awards from the Society for Professional Journalists (for sports reporting), and the Association of Health Care Journalists (for a story about pediatric hospice). Her hour-long radio documentary about home funerals won the Best New Artist award from the Third Coast International Audio Festival in 2009.

April occasionally moonlights on the arts beat, covering music and dance. Her story about the first symphony orchestra at Burning Man won the award for Best Use of Sound from the Public Radio News Directors Inc.

Before joining KQED in 2013, April covered technology and Silicon Valley for The Financial Times, and freelanced for Marketplace and The New York Times. She is a graduate of the University of California at Berkeley Graduate School of Journalism and Smith College.

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