Navigating the Intersection of Work and Mental Health
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Working Better and Stressing Less

Ideas on work and mental health

Running a business and a family in parallel
Not so tiny anymore...

Not so tiny anymore...

My blog’s theme is generally, “behind the scenes in counseling.” I don’t often post my personal operational updates here and usually speak in broad terms on counseling issues. However, as I began the process of making my practice and schedule work with my son’s Fall, 2017 kindergarten schedule, I started wondering, “would it be useful to share the complexities of this exercise with my colleagues, community, and clients?” Useful or not, I want to share it here just in case it’s helpful to anyone either going through this transition themselves or who wants to learn about my practice.

For those of you who don’t know, I left the software and technology world in 2010 to go back to school for a master’s degree in counseling psychology from Pacific University. I got married in the spring of my first year in graduate school and my son was born midway through my second year. I graduated, started a private practice as a registered intern, and then had my daughter, 21 months after my son was born. With two children, I was only able to practice a few hours a week and constantly reorganized childcare until they both entered the same preschool in 2014. I dabbled in consulting/software projects and continued with my private practice until I became fully licensed in the spring of 2016. Other than the usual sick days and snow days, in the last year, my schedule has finally really smoothed out.

Calm seas don’t stay that way forever though. In August, my oldest starts kindergarten and with it, a 8:45-3pm school schedule each day. This is challenging because my most popular client appointments are from 3pm-8pm. Herein lies the conundrum. My husband and I feel like it’s going to be challenging for our son to transition from a 12-person preschool classroom to a 25-person kindergarten. While the aftercare program at school is great, we have a feeling that at least for the first year, it’s probably a best fit to bring him home right after school. For the record, I want to acknowledge that having the ability to make this decision is a marker of incredible privilege. That privilege is also why I’ve felt so guilty thinking of cutting back those after-school/after-work hours. Part of why I’ve been so dedicated to keeping them for all of this time is because I believe providing mental health care is one of the few things I feel qualified to do in the social justice arena. And unless you have a non-standard schedule, enough seniority to leave work mid-day for a weekly appointment, or a very flexible employer, after work is when you need appointments.

It is only a season though. It won’t be long before my kids feel too cool to hang out with mom and choose spending time with their friends instead. I hope my clients will understand when my hours shift and I hope my colleagues keep inviting me to networking events and happy hours that occur during times and in places I can’t go, at least for awhile.

So all this to say, my schedule will be shifting in August and I’m starting a very slow transition now. Eventually, my availability for regular appointments will look something like the screenshot below and I’ll have occasional appointments available on Mondays and Friday early afternoons for those who can’t fit into my regular calendar. Mondays and Fridays are frequent in-service and holiday days for Portland Public Schools and so I’ve decided to leave them off my regular calendar. 

Schedule beginning in late August, 2017

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Interim schedule beginning Spring/Summer, 2017

So then there’s the question of how to get from here to there. Right now, I have afternoon appointments five days a week but don’t begin seeing clients until around noon. In order to begin the process of moving folks from the current schedule to the new one, I need to open up a lot of new times and maintain older ones.

It’s always something and maybe that’s ok

I teach people to be more flexible in order to manage the changing circumstances and seasons of their lives. I strive to live what I teach. Yet, there is part of my brain that is so in love with a mythical ideal of a final, perfect form of my business. “Yes – I have you scheduled in the 2pm spot for the next five years,” would feel stable. Yet, I also don’t do that type of therapy. I’m not a psychoanalyst that believes in clients being in therapy for years and years on end. Sure some folks need long term therapy but even they can’t predict that they can keep the 2pm spot for five years either. Part of my practice is to teach people to adapt to change and organize their work lives in a way that serves their WHOLE lives. Most therapists agree that you can’t take clients places you haven’t been. Asking for what you want is hard. So here I am, asking: can we find a time that works with both of our schedules?

 

 

 

Katie PlayfairComment
If you're having trouble finding a therapist...

If you're having trouble finding mental health help (especially in Portland), you are not alone. I've been receiving calls and emails each day from people looking for a therapist with certain skills, appointment availability, and insurance paneling or ability to bill third parties. Many of my colleagues are in the same boat and those I've talked with feel terrible about it. We got into this business to help people who want help - not to turn them away. So what's going on? 

Here are some things I imagine you might be wondering if you're struggling to find a therapist and my best attempts at answering them:

Why don't you notify insurance companies when you become unavailable? 

The switches from available to unavailable happen so fast that we can't keep up. A lot of times "open" means we have one or two spots available and when those are filled, we're again closed. Second, a lot of insurance companies really bury that "accepting new patients?" button where it's hard for us to find it. I had to call technical support with one of my carriers to figure out how to switch myself to "unavailable." 

I saw your directory listing - it didn't say you weren't accepting new patients. 

True. I cancelled one of my directory listings last week and another, I'm trying to figure out where to put "no" on accepting new clients. I did update my voicemail and website but not everyone sees that before calling or emailing. This is a symptom of the same problem above; when you go from closed to open and back again in the course of a week, it's very hard to toggle those available indicators on and off with precision. 

My doctor referred me, so you must be open. 

These situations are the worst because we're letting not only YOU down, but also the professionals who referred you to us. Full time primary care physicians have panels of up to 2,000 patients at any given time. Full time counselors may have 20-40 patients at any given time, depending on how frequently they're meeting with those clients. Physicians may see 24 patients in a day while counselors see four to six. Assuming that 10% of a physician's practice needs mental health care at any given time (just a guess), a doctor would need five to 10 counselors to meet the demands of a single physician's panel. Unfortunately, there aren't that many mental health practitioners in our community. As we begin to talk more about the importance of mental health care to general health and wellness, we're missing the manpower necessary to meet demand, hence why many practices are full. 

What am I supposed to do then?

1. Call a counselor who appears to be open and who appears to meet your needs. If they can't meet your needs, ask them for referrals. Although not every counselor you call can give you personalized help with finding someone open, many counselors can and will. Many counselors also have referral lists. 

2. Consider how flexible you can be to come to appointments during regular business hours. Many folks want evening/weekend appointments and there aren't enough to go around. If you can come to counseling during the day, you'll have more options. 

3. Consider seeing an intern. Registered Interns in Oregon are qualified mental health practitioners who have graduated from programs, often passed their board exams, and are simply accruing hours toward complete licensure. "Intern" in the title doesn't mean they're not good or qualified. It means they're just earlier in their careers and they may be able to slide lower on cash-pay scales than other fully licensed practitioners. 

4. Research your "out of network" insurance benefits. Insurance plans vary considerably in how they cover clinicians who are not paneled with them. When I recently cancelled my contract with an insurance company, I found that many of my clients had out of network benefits that made the cost of seeing me similar to their cost when I was in-network. 

5. Look into therapy groups. Therapy groups can be less expensive and more available than individual therapy. Groups may not fully meet your need for personalized individual therapy but they can be surprisingly healing and can at least get you immediate support while you look for a personal therapist. 

6. If you have employer-sponsored insurance and feel comfortable enough to share, let your HR department know if your mental health benefit isn't as easy to use as they said it would be. Your HR staff may have been sold a great-sounding plan that isn't actually so great after all. They need that feedback. 

Most of all, don't give up

Taking care of your mental health is a lifelong process. You may be most motivated to seek out help when you're in high distress but if that acute distress passes before you find someone to help, don't stop looking. It's easier to get into a practitioner if you've already worked with them in the past. It's also fair to work on your mental health when you're in low to medium distress, so you're practiced when the pressure increases in the future. Stay motivated and make that connection now so you have it in the future. 

Katie PlayfairComment
Shining light in dark places

Much of therapy is about getting painful things that live in our brains, out into the "real world," using language. Darkness can't stand being spoken. Words are light and shared words are bright light. 

Our society feels dark to many of my clients, friends, and neighbors right now. Shine your light to help drive out the specific darkness that most bothers you. Don't stop speaking. 

Katie PlayfairComment
The struggle (and strength) of accepting the unexpected

My practice is in Portland, Oregon and I was born here. I know a lot of things about Oregonians and one of them is this: We don't do snow well.  It's snowed three times in December and January this winter and each time, it's been less than two inches. School's been called off approximately five days thus far. I've been a counselor for about as long as I've been a mother and after six years of having both roles, I still don't do snow days and sick days as gracefully as I would like to. Accepting the unexpected, the unplanned, the unwanted is still not my greatest strength. Based on my Facebook feed, it isn't the strength of most of my parent friends either. At least I'm not alone. 

Someone posted this awesome infographic to my Facebook feed. It was created by someone named "Sarala" and if you know him/her, please have them email me so I can give credit for the humor and the truth. 

Someone posted this awesome infographic to my Facebook feed. It was created by someone named "Sarala" and if you know him/her, please have them email me so I can give credit for the humor and the truth. 

Days like this, sick days, snow days, or other unexpected impediments are struggle and they may even be some suffering (especially if your boss doesn't understand you're stranded at home and if school is closed and you're out of sick days). They also provide some interesting material to work with to help increase your psychological flexibility. 

Let me be clear: I'm not suggesting that you APPROVE of these unexpected upheavals to your best laid plans. I can enumerate the ways in which I'm behind - I cancelled three client appointments today, I'm behind on two continuing education courses I was supposed to finish before the end of 2016, and that career development course I've been working on - forget it. I haven't touched it since the snow day before Christmas. I completely disapprove of this weather (and my kid's pinkeye right before holiday break). But ACCEPTING the interruption is the difference between struggling and suffering. It's the difference between spending the day at 3/10 frustration and anger and 9/10. It can be the difference between creating meaningful memories of whatever situation you're faced with and creating horrible ones. 

Accepting means allowing yourself to experience anxiety and worry about the interruption and doing necessary planning while also allowing time to refocus on the most important things around you. Today it meant focused task-switching between rescheduling clients, answering emails, playing with children, doing housework, and then editing resumes.

Accepting means acknowledging your frustration about disappointing people, having to renegotiate deadlines, and watching your to-do list grow while also noticing that the struggle of fighting against things not under your control creates more suffering than letting go. 

Acceptance is difficult and active and requires a lot of attention. It gets easier with practice but I'm not sure it ever gets easy. I yearn for the day when acceptance is reflexive for me. For now, all I can say is that it's been my experience and the experience of most of my clients that acceptance is a skill that becomes easier each time you practice it. 

Human resources, benefits, and financial leaders - We need your help!

It’s January and for many of us (me included), it will be the first time we put our new health insurance to the test. Unfortunately, many folks who choose to use their health insurance for mental health services will be in for some unfortunate surprises. Here are some I’ve heard from folks who’ve called my practice in the last week:

1.     I can’t find any therapists who specialize in what I need help in, who are in-network with my insurance.

2.     I thought I had good out of network benefits because it said 60% would be covered. I went to a therapist out of network and I thought insurance would pay $60 and I would pay $40. It turns out insurance only paid $30 and said that was 60% of THEIR allowed amount ($50). Now I owe my therapist $210 because I went three times before finding out how my insurance would actually pay!

3.     I work in benefits for my company and I’m desperately looking for therapists to see our employees! I’m so glad you take our insurance. Wait… you’re full? Oh… you and everyone else.

4.     My insurance company and therapist agree that I need 90-minute exposure therapy sessions but the most my insurance pays for is 60 minutes. Can they really deny me evidence-based services?

There are a lot of things consumers can do to minimize their insurance surprises but I will talk about that in a later post. Today, I want to make a call to action for people who can actually change this problem for patients who need mental health services: HR professionals, benefits professionals, and CFO’s, I’m looking at you.

No, it’s not fair. Insurance regulators and legislators should have your back in making sure that the coverage you purchased for your employees actually works how the insurance company sold you on it working. However, regulatory and legislative change are slow. Fixing this problem with any speed depends on YOU.  

Why should you care? Mental health problems are costing your organization a LOT of money and most insurance companies are lying to you when they say mental health services are getting covered just like any other medical condition.

First, the cost: The true costs of untreated or undertreated mental health issues are hard to measure. You can get your arms around some of it by looking at studies. Partnership for Workplace Mental Health provides stronger data and business cases for why organizations should care about treating their employees’ mental health concerns than I can create independently. Please peruse their Business Case section and Cost Calculators for more information on how these costs may affect you. Data coming from the WHO suggests that every dollar spent on mental health care results in about four dollars of increased productivity. Hopefully I have your attention about why mental health care matters. Now, let’s discuss access to it.   

“Yes of course we address mental health! We have health insurance and it covers mental health care,” you say. But does it, really? Your insurance company might be lying to you about providing parity between mental health and physical health coverage. Up until recent years, many health plans excluded mental health coverage from their plans but thanks to various state laws like Oregon’s 2005 mental health parity law and the Affordable Care Act (ACA), insurers now have to cover mental health and meet particular standards of how they do so. To comply, some insurers adopted Coordinated Care Organization (CCO) models that allocate healthcare dollars to mental health care in order to reduce overall spend on health care. Other insurers added mental health care to their benefit plans and outsourced mental health coverage and services to “mental health care management” organizations, incentivizing them to control costs on mental health diagnoses ALONE and not on overall healthcare spend. Still others added mental health care to their list of covered services and started bringing mental healthcare providers in network as any other provider and needed to adjust rates based on their experiences paying for the services.

In fairness to the insurance industry, it was probably a big cost impact to suddenly have to pay for services that were previously excluded from health coverage. The savings from providing people with improved mental health care is long-term and insurance company shareholders care about quarterly and annual performance – not how a company profits in five years, ten years, or a generation down the line. So many companies adopted the following strategies to cope with the increased costs: 

1.     Decrease reimbursement rates to in-network providers and decreasing “allowable amounts” or “usual and customary rates (UCR)” for out of network services, to levels below what providers in the community were previously being paid.

2.     Design plans with no out of network coverage, thus ensuring that all services reimbursed are delivered by practitioners who are both willing to accept rates and medical necessity rules dictated by the insurance company (rationing).

3.     Severely limit the number of in-network providers, thus rationing client care using a scarcity of approved providers (“I can’t find anyone in network because the network’s too small or not qualified to treat my condition”).

4.     Offer unusable sales carrots to corporate customers like, “No copays for in-network mental health services,” knowing that they have an insufficient network to handle the demand.

5.     Bullying providers by denying claims, instituting intimidating medical necessity reviews, burying key terms of provider contracts in difficult-to-access provider manuals, dropping rates after providers are contracted and have clients in-network, and making it difficult for providers to leave the network.

Although physicians and medical providers are certainly suffering from decreasing rates too, most of the techniques listed above are used mostly to limit mental health care alone. Many insurers are getting sued for unfair parity practices but these lawsuits take time and you, as HR, benefits, and finance professionals can make change sooner! 

What you can do:

1.     Talk with your employees and find out what they need and whether those needs are being met. If you are concerned about getting too personal with them, conduct an anonymous survey to find out how your current coverage is or isn’t working for your employees. If you’re worried that your online survey is traceable and has privacy issues, get employees to type feedback out on paper and put it in a box. You need to learn what they need so you know what to ask for.

2.     Identify specific barriers to good care on your insurance plan so you know what to ask for from your broker or insurance company.    

a.     Can employees easily find someone in-network?

                                               i.     If not, they don’t “really” have in-network benefits because they’re not easily useful.

b.    Can they afford to use out-of-network benefits? Do out-of-network benefits cover the same or similar dollar amount (allowed amount) as in-network benefits?

                                               i.     If out of network benefits pay a fraction of in-network, they’re also not useful.  

c.     Do employees have necessary skills to negotiate with out of network providers to match or come closer to network rates, thus reducing out of pocket costs for them?

                                               i.     Let’s say the “allowed amount” for out of network benefits is $50 per session. If an out of network provider charges $150 per session, your employee can talk with them about accepting less to decrease out of pocket costs.

3.     If your company cannot afford an insurance plan with excellent mental health care, consider alternate ways of helping employees pay for mental health care:

a.     Set up and contribute to an FSA or HRA specifically for use to fund mental health care.

b.    Educate your employees on how to negotiate with community mental health providers for lower rates.

c.     Negotiate for your employees with a group of mental health providers who put their name on a list to provide some discounted services to your employees.

d.    A local EAP may be able to do some of this for you but if you have a large national EAP, it’s likely they have most of the same problems as large insurers (listed above).

4.     Advocate for real mental health access when you purchase benefits. Ask hard questions and demand plans that are structured to provide quality mental health care.

a.     If your insurance company has outsourced behavioral health to another organization, warnings flags should go up. Those organizations are not incentivized by improving overall health of your employees but rather by “cost control” of mental health services.

5.     Write your legislative and regulatory agencies. Let them know you’re concerned.  

 

In the world of health care coverage, organizations are key consumers and you as HR, finance, and benefits professionals hold the keys to unlock big changes quickly. If you are losing money and productivity because of untreated or undertreated mental health concerns or if you simply want to support your employees to be happier, more effective people in their lives and work, please consider standing up and demanding fair access, transparency, and ethical behavior in mental health. As counselors and as clients, we’re counting on you to help.  

Katie PlayfairComment
The ethics of insurance companies influencing access and care

Should insurance companies dictate the duration of appointments your counselor offers? I'm not sure but right or wrong, many are now doing that. Two of the major insurers I contract with have largely stopped paying for hour-long therapy visits (Code 90837) in favor of 45 minute visits (90834) except in cases of medical necessity. 

I structured my entire practice around offering full hour-long visits and I scheduled myself 30-minute breaks between appointments so I could allow appointments to run over time when needed. I often found myself needing more like 75 minutes for some clients and I really didn't mind that insurers would only pay for 60 minutes. However when some companies started limiting visits to 45 minutes for most clients, allowing 90 minutes of time for 45 minutes of compensation became unsustainable for my practice. 

I don't like making business decisions based on financial factors. I just want to deliver what I think is the best care but ultimately, counseling is my source of income and I have to be responsible to my family by running it well. At first, I was angry to be making the decision to offer two days a week of 45 minute visits (followed by 15 minute breaks). But structuring my schedule this way solved another problem I'd had in my practice: Limited access. 

Access is as much an ethical issue as appointment duration. By adding two days of 45-minute visits, I was able to see more people - people that the week prior to making this change, I was referring out, sometimes with no clinicians to accept them within their insurance panel. I was able to say yes to taking on more clients. 

This is the conundrum of having more access to care via the Affordable Care Act (ACA) - more people have insurance but there aren't always enough providers to care for them. Agencies are having to take on so many clients that they sometimes clients only get seen once every six weeks. Private practitioners like me are having to turn more people away. 

At first I was angry at being told by insurance companies that I could only provide 45 minutes of care per visit but now I'm not sure how I feel. I'm able to care for more people. Most are getting adequate care at 45 minutes. I put some people in my 60/90 minute spots who really need it when their insurance refuses to pay and I absorb the cost. I still have more flexibility than agency counselors who are way overloaded, but I'm also doing my part to see more clients. 

I keep asking myself, which is the lesser of two evils; limiting visit duration for some clients but being able to take on more clients who need help or having full hour visits for everyone while turning away more clients in need? I don't know so I guess I'm splitting the difference by offering both durations in my practice.  

 

Katie PlayfairComment