Letters to the Editor is a periodic feature. We welcome all comments and will publish a selection. We edit for length and clarity and require full names.
Therapists Aren’t Psychic
Your article on the No Surprises Act offered clarity into some difficulties faced by therapists and their patients in determining financial parameters of treatment (“Mental Health Therapists Seek Exemption From Part of Law to Ban Surprise Billing,” Feb. 3). Most people (therapists included) agree that surprise bills are not a pleasant surprise. What seems missing in this otherwise nuanced article, however, is an articulation of the difficulty in “estimating” the cost of a therapeutic endeavor and how this, too, is a frequent objection to the act.
A therapist cannot usually guess at the length or frequency of therapy in advance of the treatment. It is unreasonable to say, “It will cost you X for the whole episode of care.” To apply a template ahead of time and say, for example, that a patient will need 10 sessions (or 10 years) of care misses the point.
Patients are unique and their needs will evolve during the course of their treatment. Some will find they need more frequent sessions. Some will decide they might want a different therapeutic approach. Some want changes at a very deep level; some are hoping for a few meetings to clarify an emergent crisis. To offer an upfront cost estimation would severely disrupt many evidence-based treatments, including those treatments that offer an in-depth opportunity to get to the intricate roots of complex emotional problems (problems that might seem deceptively “simple” at first glance).
Patient and therapist make decisions together. This collaboration should never be a “surprise.” The new insistence on an initial cost estimate prioritizes short-term and quick-fix treatments at the expense of the kind of therapy that many patients might want and need.
— Betsy Nettleton, licensed clinical psychologist, Chicago
— Ted Doolittle, health care advocate for the state of Connecticut, Hartford, Connecticut
As a mental health provider, I feel that journalist Julie Appleby misrepresented our objections to the No Surprises Act. The article implies that therapists want to avoid transparency and keep costs high for consumers, which is wildly inaccurate.
The fact is that we have always been transparent in our fees — that has never been an issue. However, we do have serious objections to the law as it is being applied to us:
1) It is impossible to estimate the cost of a “total course” of treatment, as this is almost entirely up to the client. Services are completely voluntary, and clients pay at the time of the session — there is no situation, ever, where they could be surprised with a large bill, and they are free to decrease the frequency of appointments or discontinue at any time. Due to this impossible requirement, some therapists have opted to provide an “estimate” for a full year of weekly therapy — providing a lump sum, which is both overwhelming and useless. Some clients may view it as an obligation to commit to a full year of weekly sessions, while most do not need/desire that level of care. This can be harmful at a time when we are working to build trust and a therapeutic alliance with the individual. Imagine struggling to prioritize your mental health, and then facing an arbitrary “estimate” consisting of thousands of dollars — many people will be discouraged enough to forgo treatment.
2) Because we are already providing a document that lists our per-session fees (in addition to discussing them before scheduling, during intake, and prior to any periodic increases), the good faith estimate creates a redundant administrative burden on us and does nothing to improve client care.
3) Clients choose to go out of network for a number of reasons, including increased provider choice/specialization, control over their treatment (no managed-care constraints), and privacy. Often, going out of network means that a client can be helped immediately vs. being placed on a waitlist for an in-network provider, and their insurance benefits may still reimburse most or all of the cost. The implication that we need to put “cost pressure on providers” in this field is simply false — therapists are already among the lowest-paid health care workers (despite the requirement of a postgraduate degree and continuing education), and we already spend several hours per week on unpaid administrative tasks, both of which have contributed to a devastating shortage of mental health providers during a time of unprecedented need. According to payscale.com, the average mental health therapist makes $47,576 a year — well below the average salary in the U.S.
While I support the intention of the NSA, it simply does not make sense to apply it to mental health outside of a “facility” or emergency setting. The tone of this article is biased and should be revised to accurately reflect our objections.
As written, the NSA favors insurance companies, discourages out-of-network benefit use, and, frankly, is patronizing to clients, who are perfectly aware of what each session costs. The only time clients are “surprised” is when their insurance unexpectedly does not cover their treatment or reimbursement. My fees have always been crystal clear — where is the transparency from the insurance companies?
— Michelle Stevenson, Syracuse, New York
— Kevin Frick, Baltimore
Mental Health Care: Access vs. Quality
A top challenge in behavioral health is shifting focus from access to care to quality of care — largely due to the increased demand for services throughout the pandemic. And quality starts and ends with evidence-based data. The question has been: How can we provide behavioral health services to everyone who needs it, regardless of location? While this should and will remain a priority in 2022, there will be an additional focus moving forward on quality of care. After all, what is the purpose of providing access to care if the quality of care isn’t addressed? Providers need to be asking themselves: Are people actually getting better through our behavioral health services, can we reduce readmissions, can we eliminate treatment failures?
To ensure high-quality care, behavioral health organizations will increasingly rely on measurable data to track patient and population outcomes. Data, derived from evidence-based assessments, intake forms, including social determinants of health insights, is ultimately what will inform clinical and operational executives if their programs and treatment plans are working. This information is also essential in determining how to make meaningful improvements to deliver the most effective and efficient care.
Delivering high-quality care starts and ends with data. Measurement-based care (MBC) — defined as the practice of providing clinical care based upon client data collected throughout treatment — will gain popularity as more behavioral health organizations rely on this methodology to improve the quality and consistency of care. With their ultimate business goal to improve clinical outcomes, hospitals and health systems will further recognize that incorporating MBC into their practices is the best way to confirm and document patient progress.
As far as value-based care: Value-based care models center on patient outcomes rather than the number of services or visits. Unlike the traditional fee-for-service model, value-based models align payer and provider incentives toward well care rather than sick care. Under this model, the focus is on quality and outcomes performance rather than patient/member utilization of services.
The year 2022 will bring in defined milestones and clear progress toward value-based care in behavioral health. There will be more pilots and programs of value-based reimbursement contracts between payers and providers.
— Eric Meier, president and CEO of Owl, Portland, Oregon
— Ron Howrigon, Raleigh, North Carolina
No Surprise the Law Is Confusing?
The description for the podcast “‘An Arm and a Leg’: Know Your ‘No Surprises’ Rights” (Feb. 2) says the No Surprises Act applies only to hospitals. It also applies to independent free-standing ERs. And the protections against balance billing at an in-network facility apply to both hospitals and ambulatory surgical centers.
— Kathy Bakich, Bethesda, Maryland
[Editor’s note: Thanks for your sharp eye and insight. The article has been corrected.]
— Dr. Cedric Dark, Houston
Nutritional Basics and Basic Rights
Thanks for the very important column by Chaseedaw Giles on the problems of quality food availability in certain urban neighborhoods (“What Does It Say About Your Neighborhood If the Supermarket Isn’t So Super?” Feb. 16). Boston is much better off in that regard than most other cities, but it is the rural areas that suffer the most. Most small towns across the country have very low-quality food choices; Dollar Generals and other similar stores — with their food (if one can call it that) that’s high in refined sugar — dominate the available stores. This is just one more reason that rural America is suffering so much with chronic lifestyle diseases, unemployment, and substance abuse. We need more reporting and action to resolve this existential problem.
— Alan Wright, Roslindale, Massachusetts
— Julian Agyeman, Cambridge, Massachusetts
Checking Up on Kaiser Permanente
I must say I am biased with regards to Kaiser Permanente (“California Inks Sweetheart Deal With Kaiser Permanente, Jeopardizing Medicaid Reforms,” Feb. 3). It is the worst health care provider ever. Doctors are not available, not enough locations, bad medical services department, phone service, hold times, wait times for appointments, the pharmacies are a joke.
The fact that Kaiser Permanente and Gov. Gavin Newsom are having backroom deals irks me to no end. KP’s goal is to own the Medi-Cal system in California. Poor Newsom has so much money in California, thanks to overtaxation, he won’t pay to have the poor, elderly, and disabled properly cared for.
Yes, I plan on sharing this info with all. This is just like the mob. No joke. Both should be ashamed and humiliated by these actions. I could see these bad practices extended to all cities in the U.S., called socialized medicine. Terrifying.
If you are young and have a family, it’s just great. But don’t age or fall prey to some terrible disease for which you need proactive care. You won’t get it.
— Kim Carrasco, Folsom, California
— Chris Friese, Ann Arbor, Michigan
Poaching of Staff Is Widespread
Great article on the effects of staffing shortages on rural hospitals (“Bounties and Bonuses Leave Small Hospitals Behind in Staffing Wars,” Feb. 7). I am concerned that all the press focus has been on hospital effects because they have great teams that can provide support for getting the article written. However, I work with safety-net clinics that are not federally qualified health centers. Our clinics that predominantly serve uninsured and Medicaid community members are also being affected and that is reducing access to care for these underserved communities.
Employees don’t even have to have certification to be poached, they just have to have done their practicum (they can use an oximeter, blood pressure cuff, and understand loading data into an electronic health record) and they can get an $8,000 bonus just for showing up at the hospital down the street. That means our clinics are doing the basic training for hospitals and losing all that benefit in communities most in need. Some of our clinics are having to reduce hours because they simply don’t have the staff to provide care to uninsured/Medicaid patients. This is incredibly frustrating and painful for underserved communities to face this, just as in rural communities. I hope we will not forget these communities in our efforts to explain the challenges in health care today.
— Phyllis Albritton, Colorado Safety Net Collaborative, Westminster, Colorado
— David Balat, Austin, Texas
‘Rapid’ At-Home Tests: Too Little, Too Late
I, like many others, on Jan. 19 signed up on the government site for the free at-home tests. I waited weeks for any word of delivery — nothing. They finally showed up on Feb. 15. Still, two kits for four (!) at-home tests per family are ridiculously inadequate. Especially for a family of over, say, two members.
I grade this effort by the government totally inadequate. Too little, too late. Sound bites vs. actual results.
— Evan Hassiotis, Roswell, Georgia
— Dr. Ali Khan, Omaha, Nebraska
Free But Unpatriotic
Regarding the article “What Are Taxpayers Spending for Those ‘Free’ Covid Tests? The Government Won’t Say (Feb. 11): Why did the government buy kits from another country instead of ones made in the USA? Is there a reason why the United States government can’t spend the taxpayers’ money on U.S.-made products? I am now wondering if the N95 masks that are going to be free to us from the government will be purchased from U.S. companies. We have not been able to find any in our area.
— Beverly Neibert, Marysville, Pennsylvania
— Chris Vanderveen, Denver
Strengthening the Foundation for Home Health Care
No patient in need should be left without care — period. Home health agencies must have the resources they need to meet the demands of today’s health care workforce. As demand for home health care continues to grow, Medicare must address the way it reimburses agencies for care in order to help us meet patients’ current and future needs through the recruitment and retention of a skilled workforce (“Pandemic-Fueled Shortages of Home Health Workers Strand Patients Without Necessary Care,” Feb. 3).
Home health care, which has always been a popular option for seniors and families, has shown its value during the pandemic. That’s because it has helped many seniors recover from serious illness and injury without needing to be admitted to skilled nursing facilities, which have been challenged with covid-19 outbreaks. According to analyses, the demand for home health will increase rapidly in the years ahead as America’s Medicare-aged population continues to surge.
Unfortunately, Medicare policy contributes to serious labor shortages because Medicare’s payment adjustments have not been reflective of labor and administrative price trends in the home health sector. Though the pandemic and creeping inflation have both caused labor costs (including wages, benefits, hiring, and retention) to jump sharply, annual home health payment updates declined from CY 2019 to CY 2022. This trend is simply unsustainable: If the annual payment rate update continues to fall below rising workforce, labor, and care delivery costs, Medicare risks undermining the sustainability of America’s home health system.
By keeping pace with rising labor costs, Medicare and other payors can ensure home health agencies are better prepared to meet the demands of more American seniors who want to be cared for at home.
— Joanne E. Cunningham, executive director of the Partnership for Quality Home Healthcare, Washington, D.C.
— Beatrice Westrate, Chicago