Solving Mental Healthcare Access And Championing Insurance Reform With Dr. Carrie Singer

[00:00:00] John Cordray: We're gonna talk about something in this episode. That is really a topic that I haven't talked about yet. But one that I think is so important, especially right now with what's going on in the mental healthcare space. And with me today, I have Dr. Kerry singer and we're gonna be talking about solving mental healthcare access and championing insurance reform.

[00:00:27] Welcome to the mental health today. Show my name is John Cordray and I'm a licensed therapist and the host of the mental health today show I'm so happy that you're here with us today. With me today, I have a very special guest.

[00:00:41] Her name is Dr. Carrie singer. She is a clinical psychologist and owns a 40 provider group mental health practice in the Washington DC suburbs, which grew to $7 million annual revenue in five years. Her business [00:01:00] passions include solving mental healthcare, access problems, channeling insurance reform, and educating physicians on behavioral health integration.

[00:01:11] Dr. Carrie singer. Welcome to the show. Thank you for having me, John. You're very welcome. And, and I, this is a, a topic that is very interesting to me, obviously, cuz I've been in the field for quite a while, but I know that a lot of people. They know that something's wrong because they either try to, to find a therapist and they can't, or they might see in the headlines that there are a lot of mental health companies these days that are downsizing and letting people go.

[00:01:44] And, and so there's probably some confusion and some concern at the same time. And I know that people have frustrations with their insurance. So I'm really interested of learning a little more about both the [00:02:00] mental health care access and insurance reform. So can you just tell us a little bit about that and, and tell me a little bit about how you got into that and your interest in that.

[00:02:12] Sure. 

[00:02:12] Dr. Carrie Singer: Thank you. Well like you mentioned, I did grow my group practice pretty quickly because we do take insurance and not many people in our DC Metro area do. And a lot of them are charging 200 and visit a of middle class folks just can't afford. So we were able to grow quickly, but we still have 1400 clients on a wait list, which I feel devastated about.

[00:02:34] I think the pandemic has really amplified and accelerated the distress. You know, that people are feeling, you know, people are isolated. Some people have had financial impacts, health impacts, you know, grief and loss issues. Divorce is on the rise. You know, substance abuse is out of hand and just, you know, suicide rates are at an all time high, like, you know, political tensions, racial tensions, just like a, a melting pot of you.

[00:02:58] Breeding ground for all these [00:03:00] issues popping up. And I think the CDC was estimating that earlier on in the pandemic, 40% of Americans were meeting clinical criteria for anxiety and depression, which normally before the pandemic, that was more like 25%. So the need has almost doubled, but the amount of therapists has not doubled.

[00:03:17] If anything, in some. Going down, you know, fewer people are going to school because they see the massive student loans they're gonna take on. And the potential for income is not as high as if they had, you know, a graduate degree in a different field. So you have this huge supply demand imbalance that leads to this huge mental healthcare access issue.

[00:03:36] And so in the light of that, you know, people have rushed in with these digital solutions where maybe they're going to integrate kind of paraprofessionals like behavioral health coaches. Which maybe, I don't know what kind of training they even have or sometimes kind of peer support options, group therapies, just ways to solve problems at scale.

[00:03:55] I think a lot of kind of investors and venture capitalists saw this windfall of, [00:04:00] oh, look at the demand in this field. Like this is something we can capitalize on because mental health is not well structured and organized and we can make it more accessible because if you Google. Find a therapist near me, the first things that are gonna come up are gonna be talk space and better help.

[00:04:15] And you go and you click on there and look at that. They can get me seen for an appointment in the next couple of days. So, you know, that is not the way the mental healthcare system has been designed in the past. It's been fragmented and siloed and you know, you go to your physician and you say, can you recommend a therapist for me?

[00:04:30] If you're even brave. To bring up that conversation with your doctor. And if they're even savvy enough to say, that's a good idea, why don't you take care of your mental health? And, you know, we can talk more about that. Some of them are uncomfortable having those conversations, but more and more they've become the frontline of kinda the gate keeping function.

[00:04:47] Somebody comes in for their annual visit. You know, you should be asking about anxiety, depression, suicidal thoughts, and substance abuse. And so they might say, look, I, we have this list of four people. We, we refer to, we've heard they're pretty. So you might [00:05:00] call those four people. Majority of them are probably no longer accepting new patients have left insurance panels.

[00:05:06] Or if they do have openings, maybe they don't have the specialty you need treated, or they don't have after school evening or weekend times that are gonna be convenient for you. So it's kinda okay, great. Back to the drawing board. It can be very frustrating from a client perspective and hearing the stories of the people on our wait list.

[00:05:22] I'm just intimately familiar. People will say I've made. Almost a hundred calls, you know, and hardly anybody answers their phone or gets back to me. And it's just, I, I didn't think it would be this hard and I'm already feeling like maybe I don't deserve help and you know, they're depressed and they're nervous.

[00:05:37] So they're maybe sluggish and it's hard for them to coordinate that search effort. And it, it just. So they give up and then eventually their problems get worse. Maybe they end up going to the emergency room because they're having a panic attack or suicidal thoughts. And that ends up costing a healthcare system so much more money than if we had a better design that allowed for preventative care.

[00:05:58] John Cordray: That is so true. [00:06:00] And we are in, as you mentioned, a mental health crisis, like never before. And so it's the worst time to be experiencing this. We should be doing everything that we can to create better and easier access to everyone. But that's not the case, like you mentioned. And I, I think you are right on with wanting to educate physicians because.

[00:06:24] Not all physicians are trained in behavioral health. No. And many of them are, like you said, are not quite equipped to talk much about that. And so that is really important as well in this is to educate physicians. So along those lines, what would, if, if a physician is listening to this and, and maybe they're agreeing with this and say, yeah, I have a lot of patients that come to me.

[00:06:49] And they talk about depression or anxiety or, or even thoughts of suicide. I have a list of therapists that I can refer to. But what [00:07:00] else would you recommend to physicians who are wondering, what else can I do for my patients? 

[00:07:07] Dr. Carrie Singer: Well, and I feel bad for physicians for especially primary care doctors. You know, they only get a 10 minute visit sometimes with a patient for a follow up and they have so many other metrics that they're supposed to be tracking outcomes.

[00:07:18] They're supposed to be reporting on that. Sometimes behavioral health falls to the bottom of the list. And I'm in part of an integrated medical group right now where I liaise with physicians quite often. So a lot of them say, I don't have time to open that can of worms, cuz this may starts crying. I.

[00:07:34] It's hard to say, sorry, you gotta get outta here. My next patient is waiting. So how to get insurance to pay for longer appointments or maybe annual mental health wellness visits, instead of just, you know, physical health visits and talking to physicians about, you know, giving anxiety and depression screenings.

[00:07:50] Annually when you're seeing these patients and following up on the results, if they're, if they're clinically significant or at risk, I think that they just don't feel equipped staffing wise and sometimes [00:08:00] training wise. And there's a lot of free continuing me medical education events they could attend because oftentimes now primary care doctors end up being psychiatrists.

[00:08:09] Because there are so few psychiatrists, there are more psychiatrists dying and retiring every day than there are entering the field of medicine. So physicians have to be very well versed in all the different psychiatric medications, which often they're not, they, they always say, tell me the one or two SSRI I should be using.

[00:08:25] Like, they just want something like to default to, but it's not that easy, you know, really depends on the individual's unique biology and there's genetic testing they could be using. And they're they Don. They don't have the specialty knowledge. Most of them will say I only got two days of psychiatry training during my residency.

[00:08:40] So you have people who have the, probably the least amount of specialty experience doing the majority of the prescribing. 

[00:08:46] John Cordray: And that's a problem. I think we can all agree. That is a problem. So yeah, I think the, the more that we can do to educate physicians in for those of us in the mental health field, who are professionals.[00:09:00] 

[00:09:00] We can, we can do that. We can help physicians. And if you are a physician listening, I would encourage you to reach out to a therapist in your area and ask don't be, I mean, you're a doctor. Yes. But you don't know it all. And a mental health therapist. That's all we do. 

[00:09:18] Dr. Carrie Singer: And there are different insurance codes.

[00:09:20] Now that can be billed for physicians who want to use integrated behavioral health in their practices. So you get paid for the screenings that you do. You can have behavioral health consultant available to your team and a psychiatric consultant to kind of give second opinions on difficult cases and to kind of deliver case management services to some of your more complex patients, because all the research shows that if you have a behavioral health condition, You're likely to experience more health problems and to not take care of them as well.

[00:09:49] It 

[00:09:49] John Cordray: makes a lot of sense. And so that's good. That's good that there are some codes that physicians can get compensated for, cuz it does take time to do these things. [00:10:00] Sure. So I, I wanna kind of transition just a little bit it's related, but insurance reform. So this might sound like to some, oh, this is boring.

[00:10:12] Don't turn it off. Don't turn these efforts at off, because this is important because it relates to you because everybody just about everybody has insurance. And so to use insurance for therapy or counseling, that sometimes it could be tricky. And so. Carrie. Tell me a little bit about insurance reform and where do you see the problem in?

[00:10:37] Do you have an idea of trying to fix the problem? 

[00:10:42] Dr. Carrie Singer: Well, I think in for insurance reform is a huge problem. That's hard to, to tackle once, but to maybe chip away a little bit at it. And I think the Biden administration has made actually some good progress in that area in terms of mandates for insurance companies.

[00:10:57] More transparency with [00:11:00] rates and what they're paying different facilities for different procedures. So patients can choose to use a lower cost provider. Maybe that'll save them a little bit on their deductible, their copays, but it is a complex issue. And I can say from the patient's point of view, like when you go to find it.

[00:11:14] A cardiologist, for example, you think, well, I'll just look in my insurance directory, I'll call the first three people and I'll take the one that has the first available appointment, but that's not really how it works with mental health. A lot of times the directories haven't been updated in years. They keep providers on who have left the panel or retired because they want it to look like they have a full network where maybe really they don't or more likely they're just understaffed and they haven't been updating.

[00:11:37] Properly. So giving patients the correct updated information about specialty availability, openings, even reviews aren't made available to patients most of the time, like how have other people felt seeing this provider? So that's a little bit of a problem, but I'd say in general, People feel like insurance does not reimburse therapists nearly as much as they do medical professionals for say [00:12:00] an hour of their time.

[00:12:01] And so a lot of professionals in my area, you know, Hey, I can make 200 to $250 an hour on my own, or I can make less than half of that taking insurance. And then I also have the headaches of. Figuring out how to file the claims. And if they get denied, I have to appeal them. I have to sit on hold for two hours to even figure out what's going to be covered, not covered.

[00:12:19] They don't wanna take that risk. And they don't like that administrative hassle. So they're leaving panels. I think the statistic is something like 70% of patients have to seek out of network mental healthcare. And it's not nearly that high. When it comes to physical healthcare, you would never think of using a, a hospital or a provider outside of your, your network if you had a medical condition, but it's just a way of the world.

[00:12:40] And. Clients are initially surprised by that. And they're not prepared for those out of pocket costs. And so they might go on to debt and sometimes they might think, have a few sessions and then even find out it wasn't the right fit or it didn't solve their problem. So it's hard for clients to get the right information about the care that they need.

[00:12:57] And insurance companies should have care [00:13:00] managers who are helping clients kind of through the process. Okay. Let's think about what services you need. Who's in our network, where can you find them? But oftentimes they're just so overwhelmed again, by the sheer amount. And patients don't even know that that help is available.

[00:13:12] It's just a big disconnect, I think, between patient needs and the insurances companies ability to facilitate meeting those needs. So I think some of it has to do with rates. Some of it has to do with administrative procedures. But during the midst of this mental health crisis, you know, a lot of insurance companies will say that they are trying to increase access.

[00:13:30] They're trying to draw new providers into their network, but the way that they're doing it is they're partnering with these digital health companies that have met, you know, quickly brought on all these different providers. A lot of whom are trainees. Some of them are coaches. Some of these digital health companies have had complaints about improper prescribing practices.

[00:13:48] You know, they're startups. And so instead of, you know, partnering with the, the clinicians who've been in their network sometimes a dozen plus years and giving them a rate increase instead of they're directing their, their money and their efforts toward working [00:14:00] with digital health companies, which I know as a practice owner and psychologist has been very frustrating for us.

[00:14:05] You know, it, it feels like everything is becoming consolidated and this umbrella, like kind of how a lot of hospitals would buy medical practices, it feels like that's kinda happening with mental health too. So now, you know, a lot of the mental health services in the country are. Walmart, Google CVS. And that's a little bit scary to think about how they're, they're using your healthcare data.

[00:14:24] Mm-hmm . 

[00:14:25] John Cordray: Yeah. And that's a whole topic for a different episode is how these humongous companies have access to our personal health information. Yeah. That that's a, a totally different topic, but I really appreciate you bringing out the problem. The problem is even if you can, a a, a client can find a therapist in their network and to, to be able to go and use their insurance.

[00:14:55] Let's say it's a, maybe a $20 copay, maybe $30 [00:15:00] copay, but the therapists themselves are not really compensated. And that's what most, I would say most people don't realize that if your therapist accept insurance more than likely the insurance is not gonna give the therapist a really good reimbursement.

[00:15:18] And so they have to drastically reduce in order to find people to accept insurance. So when you pay a 20 or $30 copay, the therapist is not gonna get a whole lot from the insurance company. And but it helps you as a client, but with a, a therapist, I know this cuz I had a private practice. I accepted some insurance.

[00:15:44] If I had the choice of not offering insurance and just doing private pay, I would get paid more. But the problem is the other side. Then a lot of, like you mentioned, clients are not able to afford the, the right care. So there are some [00:16:00] highly qualified therapists that are in practice, but they're not using their insurance.

[00:16:07] Clients are not able to access because of the financial burden. And so that is a huge problem. And what would, what would you say Carrie would be a solution or a something that could help with that barrier? 

[00:16:25] Dr. Carrie Singer: Well, and a lot of the people who don't accept insurance are people who provide specialty mental healthcare.

[00:16:30] So if you have an eating disorder or if you need a treatment called D B T, like these are things that therapists have to go and get a lot of extra expensive educational training to be able to provide well. So they feel like insurance doesn't compensate them for their expertise, which they don't insurance covers.

[00:16:45] The same amount, whether you have one year of experience, 20 years of experience, no matter what specialty training you have. I really think that just like if you're working another type of job and qualifying for raises, they should really base it more on years of experience, level of specialized [00:17:00] training, you know, patient satisfaction scores, even if you want, you know, there's, there's no differentiating and it's very hard to negotiate for, you know, rate increases even over time, loyalty to the network.

[00:17:11] John Cordray: Yeah, that's very, very good point. And you're right. So these specialty services that a lot of therapists have, it is expensive. And that's another problem because there, I know that there are a lot of therapists, especially those who are just getting licensed. And just get outta grad school there's debt and they're they're in debt, just like other professions, whether you're a dentist or a doctor or a chiropractor, you, you go through your schooling and you have debt.

[00:17:37] And then if you want to continue specializing, you go into more debt a lot of times. So this, this is a problem. And yet it, there are some things that we can work on and there is hope. So this is not doom and Gloo. With mental healthcare access. And you mentioned that there are a lot of [00:18:00] mental health tech companies that are available now as well.

[00:18:03] And I know a lot of them are able to accept insurance and it's a fairly new. A new phenomena, if you will, because there are just seems like hundreds of different mental health companies tech companies coming out all the time. And I know that there is a huge. Plus of using that because it does open up more access to therapists and to clients and to match them.

[00:18:32] But there's also a problem with that. If the tech companies are growing too big and too fast, then as we, you mentioned, you alluded to it earlier, there have been a lot of layoffs and that's a concern and that does not look good to the public. With the mental health world, but there are a lot of good things that are happening as well.

[00:18:55] It's easy to focus on the problems, but we also wanna talk [00:19:00] about, there are a lot of great things going on right now, more so than ever before, in my opinion. There's a lot more, 

[00:19:07] Dr. Carrie Singer: there's a lot more acceptance. I think of seeking mental health help. You know, there's lots of therapists on TikTok that have huge followings.

[00:19:14] Like people are not ashamed anymore, certainly to speak up about these issues that they're having. And so many people are having them they're they're easily relatable. So that's a great thing. I think in terms of parody law, though. You know which past, I dunno, 2008, you know, that insurance companies should provide equal coverage for mental health and physical health treatments.

[00:19:32] I still think we have a long way to go. I mean, and even in all those years, there's only been a few lawsuits that have actually come to fruition against insurance companies where the adequate coverage didn't exist. So the Biden administration has made that their priority to crack down on. They've also come up with a lot of student loan assistance programs for therapists.

[00:19:49] I know the therapists in our practice get up to $50,000 of forgiveness after two years of working with us full time, which is. 

[00:19:55] John Cordray: Well, that's fantastic. Yeah, that's excellent. Well, [00:20:00] we've talked about mental healthcare access and insurance reform and educating physicians. I'm really curious to learn a little bit more about you personally.

[00:20:12] And in particular, I, I noticed that you growing up as a teen, you went to boarding. Geez. How'd you find that out? 

[00:20:26] Dr. Carrie Singer: yeah, so I certainly had my own mental health challenges. As a teenager, my parents were divorced, you know, I had problems with alcohol and drugs and I got kicked outta three high schools. So finally my parents sent me to a wilderness.

[00:20:38] Program and escort pulled me outta my house in the middle of the night to take me there, kicking and screaming. And then from there, I went to an all girls therapeutic boarding school in Montana for two years where I'd say they used some unconventional therapeutic practices, like having a shovel horse manure a lot of the times build fences.

[00:20:54] I learned how to drive a tractor before I learned how to drive a car. Sometimes they'd wake us up in the middle of the [00:21:00] night to go on mile and mile long skis. And when there would be a, a girl who had an eating disorder who didn't wanna finish their lunch, we'd all have to run laps around the dining hall until they did.

[00:21:09] So that place got shut down. A few years ago. So but I will say that it did put me back on the, the right track again, and I knew what kind of a bad therapeutic experience was. And I wanted to do something a little bit better, you know, certainly for the teens and families that I've been able to serve.

[00:21:26] John Cordray: Yeah. So I I'd love that. Thank you for sharing that. And I know that there are parents who are listening to this that may have a child. In that same position, maybe they're acting out and they're trying to figure out what to do. And I think you just sharing your own experience, even though it wasn't all positive, it ended positively, it was ended in a good way.

[00:21:50] And I know that it's a very difficult decision. For a parent to think about having their child go to a boarding [00:22:00] school or to go to a treatment center. Like it's scary. 

[00:22:04] Dr. Carrie Singer: Its and educational consultants can help there's so programs, it's hard ones. You're right. Like, like any program though, you know, when you get out is when the real work begins, you know, the community reintegration, you know, especially with substance abuse, the relapse rates are pretty high.

[00:22:20] Like, you know, find a 12 step program, get connected, you know, build your. 

[00:22:25] John Cordray: Yeah, and I, and that's, that's the key is your support network, who, who in your life that can be a support and, and help, and that can help so many different struggles. And I definitely agree with that. So, We have a few minutes left.

[00:22:43] Are there any final words that you would like to leave us with in regards to either mental healthcare access or insurance reform, or even going back to educating 

[00:22:55] Dr. Carrie Singer: physicians? Well, I think a lot of the power does lie in the [00:23:00] patient's hands and, you know, telling your employer, your HR department, look, you don't have coverage for these services that I need.

[00:23:09] Like, we even take some health insurances where they don't cover family or couples therapy, cuz they say that's not medically necessary. Some of them deny autism services coverage. It's like who's making up these policies. Like you need to be your own champion to say like, I need this. I'm entitled to this.

[00:23:23] You need to push back because insurance companies listen to employers because those are really their customers. You know, who's gonna bring them the biggest contracts. And if you're unhappy with things, you know, there's an insurance commissioner. There's, you know, legislators just make your voices heard when you can't find the care that you need, because that's really unacceptable.

[00:23:40] I agree. 

[00:23:41] John Cordray: I agree. And, and so if somebody wanted to reach out to those who are in authority, where would they go? To contact someone. 

[00:23:53] Dr. Carrie Singer: That's a good question. I, I'm not actually sure. Who has the power to make a difference aside from writing to your Senator, your governor, but I would start small [00:24:00] really at the employer level, which is hard to say, you know, you don't wanna open up sometimes that you're having a problem, but a lot of employers do have what they call an EAP or an employee assistance program.

[00:24:09] They probably have some mental health benefits that they've paid into that they want their. You know, people to be able to use, to, to retain them. And if those people are not able to use those benefits, because there's a short supply of providers, not enough openings, you know, poor reimbursements, then that's something that can be addressed.

[00:24:25] You know, I think insurance is this necessary middle man. You know, I don't think that they're always our opponents. You know, I, I would hope that most of them want to do good, but they are governed by business people who want to see good margins, good returns. 

[00:24:40] John Cordray: Yeah, so great. Great. If I start with your employer and, and look to see what type of E I P pro benefits that you have for mental health.

[00:24:49] I think that's a very wise thing to offer. Well, I wanna say, doc, I've been calling you Carrie the whole episode. Right. But it should be Dr. Singer. Don't worry about it. , you've [00:25:00] earned it. So I want to thank you address you that way. Dr. Singer, one of the things I like to ask all my guests is talking about self care.

[00:25:08] That's something I do promote a lot. And I'm really curious, cuz you're busy. You, you have a huge group, mental health practice. You have a lot of things that you're working on. I'm really, and I know you have children. What, what, I'm curious, what you do for self care. 

[00:25:26] Dr. Carrie Singer: Honestly some days it has not been great.

[00:25:28] And I'll say, especially over the pandemic with the kids being at home, we're working from home or, you know, we got a new puppy, you know, whether that was a good idea or not, remains to beeen, you know, life is really busy. So trying to pause and take those moments to just even take a lunch break, you know, try to get some fitness and some, some relaxation.

[00:25:46] We've been going to the beach quite often, which has been really nice. It makes me wonder why we choose to still live in a place that is cold and rainy half a year. . Maybe make some differences there, but to delegate and outsource as much as possible. So when it comes to business, [00:26:00] hiring people who can help me, I can't wear all the hats.

[00:26:02] I can't do it all. When it comes to life, get a nanny escalated to clean the house. If you can afford to like, these are things, sometimes I should be able to do it all. I don't need to get help for that, but like, it's so much better if there's things that you don't enjoy it, somebody else can do for a decent price.

[00:26:15] Let them do it. 

[00:26:17] John Cordray: Sage advice. Very, very good. So don't fall into the trap of saying to yourself or thinking to yourself, I can do it all because if you do it all, you're gonna burn out and you're gonna shut down. Yeah. And that's something I've talked about before as well. Well, Dr. Singer, thank you so much for coming on and just spreading the awareness to mental.

[00:26:40] Access in insurance reform and, and also educating physicians and talking about that very important. And also those who are wanting to learn more from their employer benefits I think that's, you bring up a great awareness and I hope a lot of people get a lot of value. Out of this [00:27:00] episode. So I really appreciate you coming on my show.

[00:27:03] Sure. Thank you so much for having me. You're very welcome. And so that's it for this episode of the mental health today show, I am very delighted and happy that you are tuned in and don't forget, you can check out the website at mental health today. Show dot. Again, that's mental health today. show.com and thank you and take care of yourself.

[00:27:27] And we've been your mental health since 2015. Take care.