Before I get into this, let me say that I am (more or less) all right. I wasn’t for a while but I am right now. So this is not particularly about me but if you have other therapists in your life, you might want to check in on them.
If you’ll recall, over Covid talking about mental health became more of a thing, which is great. Lots of the self care articles begin and end with “go see a therapist!” but of course therapy is not accessible for everyone and folks rightly began to push back about it. Unfortunately the conversations threw therapists under the bus:
- People thought therapists should make themselves more accessible — offer more sliding scale slots, get on more insurance panels, flex their schedule for more evenings and weekends. In other words, individual therapists should fix the problems of capitalism.
- Venture funding realized mental health might be lucrative and began to exploit therapists (and their clients) in order to line their pockets.
In practice, this meant that a whole lot of shady companies came out of the woodwork and at first set up business practices that looked like they’d help therapists with all of these accessibility problems.
Now therapists do not make a lot of money. Some do; most don’t. One reason I get super annoyed watching therapy on TV is the therapists all live like Frasier Crane.
As if.
You may think your therapist is rich because you know how much they charge but their hourly rate is not an actual 40-hour a week hourly rate. Not for any single therapist! No therapist whose Psychology Today profile says they make $150 an hour is making $6000/week!
Ok so your therapist is not rich especially if they’re taking insurance.
You need to know that insurance is a goddamn NIGHTMARE. Insurance companies are predatory and are not interested in your well being or in your therapist’s well being. Insurance companies want to CUT COSTS and they do this by controlling how much your therapist gets paid, when they get paid, and whether or not they can justify what they’re trying to get paid. (Look up clawbacks — therapists live in terror of clawbacks!)
You have to watch this, too. Because UHC (Optum) is buying up group therapy practices, too. They OWN therapists (not all of whom know that they are working for Optum). They also own all the records. That’s right — your private case notes, your hopes and dreams, your secret confessions. Yup.
Insurance controls the course of your treatment. Most companies are not super awful about this but they will come and yell at your therapist for charging for a 90837 (53+ minutes) instead of a 90834 (38 to 52 minutes). The difference in what the therapist earns is significant but insurance companies HATE to pay for 53+ minutes.
(When I was taking a particular Medicaid their rate for 90837 was $89. For 90834 was $67. I see most of my clients for 55+ minutes so that’s what I charged and I got a nasty letter about it. I quit soon after because they cut the telehealth fee to $72/hour for 90837 WITHOUT WARNING.)
How insurance works is they say to therapists, “Sign a contract with us and we’ll send you clients but our clients get a deal and can see you at a percentage of your hourly rate.” This is one reason why therapists have a higher rate — because they need to have one that’s MORE than insurance will pay because insurance will look at what a therapist is making and mess with it. Like Insurance A pays $85 and Insurance B pays $65 and Insurance A gets wind of it and says, “Hey! I see you’re accepting a much lower rate for this other company so we’re going to pay THAT rate!” Or they’ll say, “We hear tell that other therapists in your area are charging $100 and we’ve been paying you $105 of your $125 fee but to heck with that; we’re dropping you to $100, too!
Insurance is also often screwing YOU as the buyer. Most alarming is that some companies are now demanding your records (really theirs because you sign away your HIPAA rights to use insurance) to train their AI meant to put therapists out of business.
Historically most insurance companies didn’t request records beyond your diagnosis so they could decide how many sessions they’d pay for but they are starting to demand them more and more often. Several insurance companies have stated clearly that they are moving to a new structure which goes like:
- Oh are you depressed? Why don’t you use our free app and talk to our AI bot to see if that helps you manage your depression!
- Oh it doesn’t? Why don’t you use one of our Mental Health coaches (NOT a therapist and they pay them much less) and see if that helps!
- Oh it doesn’t? I guess you can see a therapist. For now. Here’s a list of 42 therapists in your area who take our insurance, 29 of whom aren’t taking new clients and 12 retired therapists that we haven’t bothered to remove from the list. So that leaves that one, who we’ve decided to pay 10% of their normal rate. Good luck.
So that’s one way we’re all getting screwed.
The other way is that therapists are allowing Trojan Horses into their practice because they’re overworked, overwhelmed, and just trying to make a living. (We get into this work because we like people not paperwork and many of us suck at paperwork.) So at the front of Covid a whole bunch of therapists I know started working with these huge credentialing companies. These companies were like, “Hey! Sign up with us and we’ll get you paid by credentialing you with all the insurances [a tedious, bureaucratic chore that isn’t always effective] AND we’ll make sure you get paid more! So insurance X usually only pays $85/hour for your area? We’ll get you $95!”
I mean, who wouldn’t sign up? (Me, I did not sign up. Because I’d seen Silicon Valley and knew this was the pizza episode all over again.)
Let’s step back into the Time Machine.
In 1999 I paid for Noah’s entire xmas haul with fake money. For those of you who weren’t around in those heady days, there was no Amazon. No one was shopping online. But investors could see that if they could get people to shop online, it’d be a windfall. So there were all of these insane coupons like $99 off $100 plus free shipping. And you could stack coupons so I got Noah a train table, a wooden Brio train set with all of these Richard Scarry people, a real doctor’s stethoscope and various stuffies and clothes for basically nothing. It was the best xmas ever!
All of those companies were using venture funding to finance our shopping but obviously it was not sustainable. So many of the starts up went under but the ones that remained made bank. (And paved the way for Amazon but I digress.)
Venture funding funds ALL of these mental health start ups, too, and some of them will make it and some won’t but their shady practices will remain.
(Here is a list of start ups. Read between the lines of what they’re offering and remember their goal is to MAKE MONEY. Note how many of them are about making mental health care more affordable — that will mean paying therapists less or easing them out of the process AND it will mean somehow getting money from clients, which means making money off of your information or of decreasing services to you.)
That’s what was happening with these credentialing companies. They were tricking therapists into using them — into becoming dependent on them — and then when the therapist was all in they changed the business model. Obviously they could not continue paying people MORE than they were getting paid (they were using venture funding to make up the difference) so they dropped the fee AND took a cut.
Of course.
PLUS those companies were USING the therapists by recording sessions or demanding case notes to train their AI to build those bots to replace therapists.
That’s right — some of you may not realize that your therapy sessions (perhaps anonymized! Who knows!) are being used to train AI. Nightmare fuel, right?
This is all to say, it’s not great out here for a therapist. It’s a really really really hard job. I mean really hard. I love it but it takes A LOT out of me. It’s getting harder and harder to get paid and the culture is still, “Therapists are rich! Ask them to make it more accessible!”
If we take insurance we are giving up autonomy and opening our practices up to exploitation (now more than ever). If we are using these credential services or AI note taking (that’s a thing! so wild!) or are working with a company owned by Optum, who knows what’s happening.
The way I feel about the field of therapy now is how I felt in 2008 watching the internet change journalism. Watching print fold and compensation drop. That’s what it looks like to me right now.
I do not worry so much for myself because I’m already established and because I am actively trying to build out something else to supplement (although lemme tell you, that has been much harder than I thought!) but I don’t know if I’d encourage anyone else to be a therapist right now. It’s a lot of debt and I’m just not sure what the future holds.
Anyway. Go hug a therapist. They probably need it.
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