Why I Take Insurance, and I Why I Think More Psychiatrists Should
By: Constantine Ioannou
Tags: Psychiatry, Mental Health, Insurance, Psychotherapy

I began my career in psychiatry in a large urban public hospital. Kings County Hospital Center served all who came whether or not they were insured or had money to pay for services. In order to have enough psychotherapy patients for training we would often take on individuals and charge them low rates (in 1988 this was about $5 a session). This allowed us to treat individuals who did not only require medication management, but would benefit from psychotherapy alone who would otherwise not be able to afford this level of care. I spent a total of 15 years at Kings County Hospital and I am proud that I provided care for individuals who often would not have been treated without us. I never thought that the care I provided was less than what the private sector provided. In certain cases, especially in individuals with severe and persistent mental illness, we provided a broad array of care including individual sessions, medication management, group therapies, art therapies and vocational services, which often could not be provided in a private office-based practices due to the high costs of these services.

My own personal finances were adequate. I made a salary, had wonderful benefits, had paid time off and was looking forward to receiving a pension at the age of 55. Although I made less than my peers in the private sector, there was a degree of security that I enjoyed. In addition to the financial security, I was able to teach and write about my work with patients with HIV, substance abuse issues, and those with dual-diagnoses. I had originally wanted to go into psychiatry to work with cancer patients, and HIV work allowed me to work on issues of death and dying, as well as, working with those with addiction. Addiction was a quiet interest of mine, coming from a long family of alcoholism. Working with the dying allowed me to focus on issues of meaning and individuation which I had always found interesting.

At the age of 39 my professional life changed. I had moved out to Long Island from Staten Island in order to be closer to family who can help with caring for my daughter while my wife and I worked. Commuting back and forth to Brooklyn took at least 4 hours a day and it began to wear on me. Although I loved my job, I had to change and decided to begin a practice. In addition, I took a part-time position as a Medical Director which provided health insurance and a salary. As a Medical Director I was responsible for oversight of a small outpatient addiction service, as well as, providing direct care for those individuals that required psychiatric treatment. All such programs in New York State must have a Medical Director, I asked colleagues who had private practices for advice and was told quite simply that I should not accept any insurance, and that fee for service was the only way to go.

I listened, and waited for those paying customers to come through my door. I printed business cards. I put myself in the telephone book — there was no Google at the time. I did receive some calls. Some internists referred people to me after they heard I worked with addiction. The majority of the people referred did not really want treatment. Some did but were unwilling to pay the full rate. Some paid nothing at all. Many individuals were searching for medication management only. Many wanted to use insurance to pay for their sessions. Due to the lack of patients, I decided to become a member of the medical staff at a local hospital. I felt that this would allow me to meet providers in the community who can then refer to me. In return for being on “staff” I agreed to cover the Emergency Room and Consultations every fourth day and follow individuals who I admitted to the psychiatric inpatient unit. The problem was that I would bill the patient who had insurance and as such, had no obligation to pay. I was working for free, and realized that in order to get paid I would have to be credentialed with various insurance companies

The process is complicated. There are a number of commercial insurance products as well as, public options of Medicaid and Medicare. When one is “paneled” they agree to accept a pre-determine amount for services rendered. The public options paid poorly, but since many individuals with severe psychiatric illness are covered by these I decided to join them and some commercial plans. I decided to take the dive into the insurance world and was pleasantly surprised. Although not a robust fee, I was getting paid, and I was actually making more than I thought I would be in a private practice. I went from perhaps one inquiry a week to almost ten. I did not have to negotiate prices, since these were predetermined by the insurance companies. I filled out a form, sent it to my billing service who charged me based on collections, and waited for the check to come in.

Between my practice and my part time position I was making twice as much as I had at Kings County Hospital. However, I became a single father and, being on call became problematic, as was, working every other weekend. I needed better hours, and I re-entered full time academic and administrative psychiatry from 2003 to the present day. I was guaranteed stable hours and had most of my weekends and evenings off. I was also able to maintain a small practice outside of the hospital and I still take insurance. Every time I mention this to other psychiatrists, they seem shocked. Why would I take insurance? Dr. X charges $300 a session and gets cash. Why are you not doing that? But the real message one receives is that you are thought of as “less than” by your peers since you cannot attract a cash paying clientele. It is easy to fall into that trap. It is easy to ponder why your office is not filled with well-to-do, cash paying patients. The idea of an office with paying clients is a relatively new one in the field of psychiatry. Prior to the advent of psychoanalysis, psychiatrists tended to practice in asylums and sanitariums. With the end of World War II, the need for psychiatrists continued to increase. Psychiatry became a community-based specialty with the advent of medications such as Chlorpromazine and Lithium. Individuals who in the past would be admitted for years, were now treated as outpatients. The divide between more “affluent” clients and those with more severe illness and less money widened.

But the reason I take insurance is quite simple. I believe that individuals in our society have a right to access quality care and as such, physicians (that includes psychiatrists) have an obligation to those who cannot afford care. If people are paying $300 dollars a session and see their psychiatrist weekly this is approximately $15,000 a year that must be paid out. In addition, out of network benefits only pay a small percentage of this so the major cost comes from the individual. If the average person makes $40,000 after taxes, that means, ⅓ of their income will be spent on psychiatric treatment which is untenable for the vast majority of individuals. These individuals pay into their health insurance (an individual plan being over $5000 a year), and as such would hope that this would pay for their needs.

The other argument is around the quality of the provider. A “good” psychiatrist is worth more. An expert in the field is worth more. I am in fact considered an expert. I have been working in the field for 30 years. I have spent a good part of my career focused on the provision of quality mental health care to individuals with severe and persistent mental illness. I have also practice psychiatry in the outpatient setting and teach psychiatric residents the theory and practice of Psychodynamic Psychotherapy. I continued to expand my knowledge base in the field by taking course work in both psychotherapies and the use of medications in treatment. I carry a faculty appointment. I have published. I have been quoted in the media. I feel comfortable stating that I have expertise in this field.

My final argument for taking insurance is a more personal one. Members of my family over the years have sought psychiatric care. They deserve a “good” psychiatrist. They deserve an “expert”. By taking insurance I am able to provide treatments to someone’s child, mother, father or friend. Perhaps the true argument is that everyone deserves quality medical care, including psychiatric care, no matter what the form of payment.

I realize that I am fortunate. I make a nice salary in my “day” job. I work for a public hospital and never have to turn away a patient because they cannot pay. I can afford to provide care for insured patients in my practice because my practice is not my primary source of income. I do not want to shame those who do not take insurance. Although I personally feel the need to care for people with insurance, I understand the financial constraints that the insurance companies place. This is especially true of Medicaid managed care plans who pay a fraction of the amount that even commercial insurance pays. I take insurance because I can afford to take insurance. I believe those of us who are in a similar position should probably take insurance as well. But I also feel that we need to be advocates for our field and demand a reasonable reimbursement for our time. The average employed psychiatrist makes $128/hour with a top range of $200 an hour. Locums psychiatrists can make up to $300. An average fee for a Medicaid managed care appointment of 45 minutes is $90.

There are a number of solutions to this problem. Improving reimbursement is of course always noted, but it is far more complex. The amount of debt that the physician graduates with forces them to seek better income sources. The issue of quality and patient satisfaction needs to also be addressed. Providing a system that rewards brief “medication checks” creates a system where the psychiatrist barely knows their client. In order to allow for the provision of both biological and psychological treatments, payment will need to take into account the time that is required. Finally, we in this country need to view healthcare as something accessible to all, and that includes quality behavioral healthcare.