There are many topics on which I cannot claim to be an expert. I cannot solve the issue of gun violence, I don’t know what will “fix” the current societal crises, and I have no idea what will happen in the future regarding climate change.

There is one topic that seems to be coming up with more frequency and regularity, and I am qualified to speak on that. The shortage of mental health professionals, and the relatively few mental health professionals who accept insurance.

I could probably write for days about the problems inherent in the insurance system, as likely all of us who work in health care could.

While there is more discussion and acknowledgment around mental health issues than ever before, potential patients face so many barriers to receiving quality care that many just give up. And that’s just the first layer of this very complex issue.

After acknowledging that one has a problem and wants help, which is difficult and unfortunately still shameful for many, potential patients call their insurance for a list of “providers” (we have long discussed the problems inherent in being referred to as “providers” and maybe I will take that up in a later post). They are then most often emailed an outdated list, full of names of people who may be dead, retired, not accepting new patients, or do not have training in the area in which the potential patient needs help.

So potential patient starts contacting provider after provider. Potential patient either does not get any responses at all, or is told that the therapist is not accepting new patients. Ghost network in action.

There are multiple reasons for this on the professional side, and I understand and empathize with potential patients who are desperately looking for in-network therapists and cannot find anyone to help them. I list just a few of the reasons below.

Inadequate payment. I have 17 years of experience, have invested more money in continuing education than I can tally without projectile vomiting, and yet I would be paid the same amount as a professional with 6 months of independent licensure and no post- graduate training. The contracted amount is also far below customary rates, and below what most anyone can possibly accept and (quite literally) keep the lights on in his/her office.

Insurance company clawbacks. At any point, the insurance company can demand all session notes, and if they arbitrarily decide that the therapist didn’t code or adequately document something the exact way they decide it should be documented on a random Tuesday at 3:14 PM, the company can then demand all the monies back from the professional. I personally know of multiple therapists who had to return mid-five figure sums to companies after therapy was rendered and the patient was clearly benefitting from treatment.

Lack of parity enforcement, compounded by shame. It is a fact that insurance companies demand ongoing treatment reviews to approve (or more frequently, deny) additional sessions. Patients ostensibly have options in these situations. However, because therapy involves private and deeply personal information (unlike a visit to an orthopedic surgeon) patients are less likely to pursue additional avenues of recourse because they don’t want anyone other than their therapists knowing the personal details of their lives. Insurance companies are quite literally banking on our shame. Our shame as a society in which a broken leg is cast without question, but a patient’s debilitating depression is still viewed as a weakness and help is often denied.

Lack of accountability. Insurance companies will say that they are not making “treatment decisions.” They are merely making “coverage decisions.” Coverage decisions, for most people, are treatment decisions, given that without insurance coverage, many cannot afford to pay out of pocket for therapeutic services. Countless lives have ended when patients are denied substance abuse and/or eating disorder therapies, the two mental health disorders with the highest mortality rates. We will never know the full impact these “coverage decisions” will have for the surviving family members and other loved ones.

As I said earlier, I could write for days about this. And I want to. I hope you’ll join me. Lives depend on it.

Zoe M. Crawford is a social worker.

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