Advocating for Mental Health Insurance Reform | Lisa R. Savage of the Center for Child Development

Delaware is a small enough state that we can create change. It's not like California or New York where the systems are just impossible to navigate. Delaware is a small enough state. We could get the ears of people. Like, it was easy to get coons. It was easy to get blunt. Rochester's people. I email the director of Medicaid all the time, and he is so responsive. And I think he listens, I think he gets it. But as a sole person doing this, you can't do it alone. There's power in numbers. And when we're all being impacted by the same thing, we need to speak up. We need to use that power. It's an ongoing thing. There's systems that are going to be difficult to change. There are politics at play. You know, there's money at play. There are lobbyists. Insurance companies have expensive lobbyists. I am a little, teeny, tiny tadpole in this big city. But I like the fact that people like me, you and some of the other therapists in Delaware have said, enough is enough. We need our voices heard. We're in the trend.

Welcome to the Mental Health Entrepreneur Podcast. We are here to inspire creative ideas and connections for entrepreneurs and advocates working to address our mental health crisis. As you listen, I hope you will experience new ideas and motivation to innovate in your business, your community, and in your life. Welcome. Welcome, everyone, to the Mental Health Entrepreneur Podcast. I am so excited today to have our guest with us, Lisa Savage, who is a social worker and also a group practice owner in the state of Delaware. Lisa is also doing some grassroots kind of advocacy for our field and for insurance reform. And I'm excited to have her here to talk today about all things entrepreneur journey and also the advocacy that we can do for ourselves in this field. So, Lisa, welcome.

Thank you, Rachel. It is a pleasure to be here with you. I've heard your name over the years I've crossed on social media, but it is absolutely a pleasure to sit here and be a part of your podcast today.

Ah, thank you. Same here. I've been watching your work and I'm just really excited to have people hear more about you and what you're doing. So let's start with that kind of journey. I know you have a group practice in Delaware and you've been around in this field a long time. I'd love to hear a little bit about what that process has been like. How did you get here?

Yeah, I love that question. I have been around for a long time. When I think about it, it's been years. So I started like most people. I was working for other people for a long time. After finishing graduate school, I joined a group practice, which at the time was a pretty popular group practice. It was owned by psychiatrists. And they invited me to join them. And I did because I knew I knew at least one of the psychiatrists and a great deal of respect for him. It just started to get really tough being there. Like, I was super young. I didn't really know a lot about in practice. But it started to get really challenging there. Lots of things were changing and I decided I needed to figure out how to do this on my own. So I took a full time job with Christiana Care, with coordinated wellness centers at high schools. And yeah, so I did that for several years and absolutely loved providing mental health services in the school. While I was doing that, I started seeing clients on my own. I started getting referrals to. I had a little teeny, tiny office where literally we are in the same building that I started in in 1998. We are in that same building. We just had a much larger space. So I started seeing people and then started getting busier. And I started getting busier with referrals of children and adolescents. And I always enjoyed working with kids and especially teens. So as my practice grew and I got busier, I decided to leave Christiana Care and open my own practice full time. It was terrifying because at the time I was single, I had a house, I had a car note. But I'm the kind of person who likes to just take risks and jump into things. And so I did being completely foolish. And if I was being honest, looking back on it, I certainly would have done things differently. But here I am. I survived. So in that time, as I was working with children and teens, where I realized, Rachel, was that the teens and the kids and the families that I wanted to work with the most would not be able to get to my office in Newark. I was thinking, so how do I create a model of service that people that I want to be seen can have access to my services without causing them a great deal of difficulty and challenging to get to the suburban office? So I approached the school. At the time, it was Martin Luther King elementary School in Wilmington that had a couple of kids who were. Who were students there. And I said, hey, I have these kids who are students at your school. I'm working with them. Their parents would love for them to be seen in the school. That. Okay. And the principal immediately said, yes, absolutely. And then she says, by the way, could you see a Couple of other kids. Sure. Absolutely. So I started there at Martin Luther King School, and then I went to Christina School District and said, I'm really curious if this is something that you all would be interested in. And so the person in charge at that time said, well, we have four middle schools. I would love to kind of get you in there and just see if this takes off. Well, the first year that I was in the middle school, and I covered the four middle schools in Christina.

Wow, that's a lot of schools.

It was a lot. And it was just me at the time.

That's what I'm thinking.

Wow. It was huge. And so the second year, the first year, you know, it was really busy. I decided to hire someone and again, had no clue what I was doing, but I knew I needed some help. Hired Rebecca, who was still with me, and she took on the elementary schools in the district because she loves working in early childhood mental health. And from there, we started to grow. That was 2007, when I brought Rebecca on, and we currently just hired our internal 81st employee yesterday.

Wow.

So quite the evolution. Yeah, we are. And I'm proud of what I built. I feel like we do exactly what I envisioned, which was helping children and adolescents. The time that I started, there were very few services for kids in the States, so I knew I needed to fill that gap as an entrepreneur. I was thinking, okay, what are the needs of my community? I feel like I've lived that vision that I had way back when, but I did not think that it would get this big this quickly. And here we are. It's a passion of mine. I love what I do. I love what I've created, But it is also so very hard at times.

Yeah. Yeah, definitely. So I'm curious. What do you feel like you have been, like, maybe one or two of your big learning points along the way as an entrepreneur?

Oh, man.

I know. Big question.

I think one of the biggest lessons that I've learned is that being on this journey as an entrepreneur, you need a support network. You absolutely cannot do this alone. It is a roller coaster. And I think anybody who's been an entrepreneur in any field will agree with that. It can be a roller coaster. You can also feel very isolating, because when you're at the top, you're the leader. Everyone's looking to you. So what I did was I built an infrastructure in my practice where I put other people in leadership positions. They became my circle of folks that I could rely on, that I could delegate some responsibilities to. But I also Built networks outside of my practice too, because, I mean, obviously when you're the leader and even though you have people who are on your leadership team, there are other things that you need to process that wouldn't be appropriate to do that with people who are part of your team. And so I built a network of people, social media in real life, that understand what it is to be an entrepreneur and a mental health entrepreneur. That was a big lesson. The other lesson that I learned too, is that what you build today is going to transform over the years. It's not going to look the same as it did when you first started out. And so you have to allow space for things to change and things to grow. I created an infrastructure when I first started. Okay, this is what I wanted things to look like. And that was my first iteration. But it has changed and evolved and evolved over the years. And so when I'm consulting with folks about creating their private practice, it's the first thing I tell them. Create a shell of an infrastructure, but be prepared for that to change, because as your practice grows, as you begin to scale, you need to make space mentally, emotionally, but also logistically in terms of how you're going to accommodate the growth and the change in your infrastructure. So those. That might be two of the big lessons that I've learned.

And I definitely see that internally, like the change of infrastructure. But I think it's interesting too, in our field, how much has changed externally. I know I did a solo podcast talking about when I started in this field, we could just sit down and see our clients for a 50 minute session and write our notes in our little folder and file that away and go home. And so many things have changed in the landscape of mental health care. I'm curious what some of the things are that you've seen that have shifted and evolved.

I remember sitting in my office one day back when I was a solo practitioner, you know, and I was doing like you did, wrote notes in between sessions and, you know, was able to have some downtime and I didn't have clients and that kind of thing. I've seen that the pressure change from the simplicity of being in private practice to it becoming a very complicated process. So things like just getting credentialed with insurance companies is a freaking nightmare. It's such a process getting other people credentials. So you hire a licensed person. The credentialing process can take quite some time. It's got a little bit better with some insurance companies, but you can't start that person until they're credentialed. I know. What do you do with that person in the meanwhile? Do you say, hey, stay with your old job until you. Until you get credential? That's become a challenge. The other thing is, I had never experienced clawback when I was a solo practitioner. The first clawback that I had was from a big insurance company. We shall remain nameless. But I strongly dislike them. They're no longer in Delaware, but I strongly dislike them. And so they did an audit of our chart. It took about six months before they got back to us.

Wow.

And they got back to us. They sent me a certified letter demanding $25,000 be returned. This was. This is like 2010, maybe. Again, as a practitioner, I didn't have $25,000 sitting around in my bank account because guess what? The profit margin in this business isn't that great. So itty bitty. Yeah, exactly. I panicked. And then I was like, oh, no, you're not going to panic, you're going to fight. So I called them up and said, like, what is this about? It turns out they. This is before electronic health records. This is when we were still doing handwritten notes. The therapists who are working for me, again, all new to the field, all new to private practice. A lot of them had not documented the start in the end time on their notes, even though the quality of their sessions was amazing because they were great providers. So that's what we got pinged on. So I fought tooth and nail with this company and I was able to get the penalty reduced. But again, these. This is an ongoing issue. Do we deserve that penalty? $25,000 is steep. We did not document the start and end times on the notes. So I took the slap on the hand for that. But a lot of times these clawbacks are unfair because the other thing I. My other argument with them was that these are new practitioners. Like, nobody tells us this is what you need to do. Can you give us some grace for this? We learned a lesson. If you come back and you audit us in six months and the issue is still an issue. We have our hands in finance. I get it. So that led to. I got the fine, the penalty reduced significantly, which is great. So that led to us using electronic health records because that became like a mandate from insurance companies, like, you gotta do this, you gotta do this. And so those are ongoing challenges. Fortunately, we have not experienced any clawbacks like that since that time, thankfully. But we have faced tremendous bodies one day and literally just gotten back from vacation. I had been in Europe for three weeks Literally, I'm sitting in my office the first day back, and it was a loud pounding on my door. And I was like, who the heck is this? Inception with a client.

Oh, geez.

Opened the door. I was livid. Like, who's interrupting me? It was representative from an insurance company that came to my office, and I said, listen, I'm the client. And they said. They gave me a letter that said, we want all of your charts, all of your notes since, I don't know, like, for the past year. I was like, excuse me, and we want them now. And I said, well, first of all, they're all contained in electronic health record, and I'm not going to sit here and print all those notes. And I have a client. And they said, we don't care, we don't care. We'll be back in two hours, so finish with my client.

Oh, my.

And I called my providers, and I was like, anybody who can come in to help me print records, Rachel. It took hours. And even when they came back, we did not have those notes printed. We didn't have all of them printed because it was a year's worth of notes.

Yeah.

So they gave us until that Monday. This is a Thursday. My office manager and I spent the entire weekend printing. There were boxes and boxes of notes. We sent them in again. Six months later, they sent me a letter and said, oh, your records are fine. Yeah, completely unnerving.

Right? And. And working against the very clients they're trying to serve, right in. In the middle of a session. Like, there are other ways this could have been handled.

Absolutely, there were. I said, like, is something going on? No, this is just what we do. And you signed a contract stating that we could come in and look at your records at any time. And so I didn't worry so much that our records, that we would be fined for anything. I knew our records because at that point we had started doing our own internal audit. So I knew our records were clean. But for them to come in, the audacity to come in, interrupt the session, and then demand within hours that we produce these records and then wait six months, and then they say, oh, you know, things are fine, you know, thank you for cooperating. So it's those kinds of things that never used to happen before that are happening. We have not been through an audit like that since then. I don't worry so much about audit because I know that we have checks and balances in place, that we were fine. But just the thought of that always looming over you, that you could be audited at any second. It's unnerving. And I don't know too many fields that this happens in. I know that companies go through audits, but that the way that we go through audit and the fact that we have release private personal information to insurance companies, it's not fun. It is not fun.

And what sticks out to me in that is that while your whole staff was working on printing records in a very short period of time, whereas if they would have said, hey, we're coming to get these, you need them by X date, then you could have like planned accordingly. Really, the people that suffer are the clients because everybody's working on this paperwork thing and we have to what, cancel client sessions or.

Exactly what we did, right. Shut the office down for that night. It was, it just was so disruptive, so stressful. You know, fortunately I have a great staff and they were like, okay, let's roll up our sleeves. And we were printing and, and I asked the insurance company, I said, are you going to pay for us to send all these things? Because it was boxes and boxes. And they said, nope. What about the printing? Nope. Oh, well, it's on you. It just like, where do they take some responsibility? I get it, like you can audit our records, but to do it in that manner was really egregious to me. My husband, who's a business owner too, he said, if that were me, I would have opened my door up and I would have marched him right in and told them absolutely not. You know what? Most mental health professionals are intimidated by insurance companies. I was intimidated at the time. Yeah, this is my livelihood. And I didn't know that I had the ability to say, I'm not doing this at this time. Give me some notice. And now, like, I would handle that differently. I feel more empowered knowing what I know now. But it was, it was pretty unnerving. So there's a lot of changes, but some of the changes feel really difficult and insurmountable and unfair.

Yeah, yeah, I agree. I think too there have been so many new players, if you will, on the scene of mental health. Like certainly we have these restrictions from insurance companies and they're moving toward value based care, which is going to be a huge change for our field. And then we also have tech companies that have come in and created spaces for people to have therapy, which can sound really great on one level, but it also changes the type of work that we do. I mean, I don't know that emailing somebody can be necessarily the kind of therapy that we actually do in Our

offices and texting people.

Yeah.

That goes against everything that makes sense to me as a very relational person and as a person who knows that having that relationship with that person is more important than any modality that I'm trained in, I can't imagine how effective this is.

I agree.

Yeah. The other thing that is really bothersome to me about these tech companies is that they're predatory in a lot of ways. They're predatory on professionals. You can say, well, tell a professional. And I've seen these ads come through my Facebook page, my social media. You can make $100,000 working for us. But what they don't say is that you've got to sacrifice and you're going to have to work to earn this money.

Yeah. And you have to work a lot to earn that money. Yeah.

Yeah. I've heard horror stories about these tech companies sharing private information, not protecting clients information. And that's of concern for me as well. The other thing that really bothers me is that as a mental health professional, but also as a mental health advocate, when insurance companies give pushback to providers and paying them, giving them an increase in their rate, is that there are other companies that contract with insurance companies and then they contract with providers to pay them a higher rate because they're getting paid more from the insurance company than we do as individual entrepreneurs. Like, make that make sense to me because that's not making sense. How are you paying this company X amount of money but you can't pay providers? So we have to then end up. And I have not done this, but I get why providers do, but then we have to end up partnering with these companies, credentialing with them, so that we can get paid a higher rate.

Yeah.

I don't know. It's bothersome to me because it's a huge shift. I just don't know what it's all going to mean for the field of mental health. I just don't know what it's going to mean.

I agree. And I'm definitely seeing signs that we need more and more of this advocacy, which is how I even came into contact with you. Can you talk a little bit about what you've been doing with a group in Delaware to, to start kind of raising our voices to be heard.

Yeah. Yeah. So for me, started after the change health incident where they were, they were hacked and gosh, some ungodly number of all mental health claims go through this insurance company or this, this clearinghouse, Change Health. So we were significantly impacted when that happened. We were not Able to get claims sent out, and we weren't able to get payments coming in for the first couple of days. I didn't really know how it was going to impact us. Well, okay, you know, it's not a cyber attack. And then it hit me. Oh, we're not able to get claims up. We can't get paid. So the first week, I could not pay my employees. I paid my people a salary, couldn't pay them. We scrambled, we pivoted, we tried to find other ways to get paid, and we were. We were successful. So they. Their pay was delayed by. They usually get paid on Friday. So about three business days. The hardest thing I've ever had to do as a practice owner was to have a meeting with, like, all these people and say, I'm sorry, guys, we can't afford to pay you. Some people understood. Some people did not understand. And I get it. I get both sides and said, listen, I know you're going to have big feelings about this. Please come talk to me. Like, I get it. We survived that. So. But it made me angry because what I realized, Rachel, was that we are operating with such a slim profit margin that when crises like this happen, we have no money in the bank. There is no money in the bank to pull from because we are. Most of my revenue, if I'm being completely transparent, goes to pay the salary and benefits of my employees. I am capitalist, which you're going to have a little bit of money in the bank so that when there is a crisis, I know that I can take care of my responsibilities. I was not able to do that when this change health thing happened. So I thought, you know what? I'm not powerless anymore. But I knew I couldn't do this alone, so I did. I made a TikTok video.

I haven't seen that yet. Okay.

In our mental health circle. And she was like, we got. We got to connect. So she started messaging me. She's in California. Lovely, lovely person. Love her to death. And said, you know what? Let me try to see if I can get folks rallied in Delaware. And then there were some other things going on in the Delaware Facebook group. And so I messaged those people, let's, let's do this. And that's kind of how things started. Very grassroots, but it's also very passionate because all of us have been impacted by change health. Whether or not to what degree or another degree, we were all impacted, and it was just a nightmare. The other thing that made me angry was that I reached out to several people in the State of power. Only one person got back to me, and that's because she's a personal friend of mine, and that was Congresswoman Blunt Rochester. She got back to me. No one else in a position of power got back to me. So that was where things really started to kick off. And I was like, this is not fair. And so very fortunate that there are other mental health professionals in Delaware who want to coalesce, who want to work together, don't see each other as competition.

Yeah, yeah, we got to stop that. We got to.

Yeah, that doesn't make any sense at all. But who want to coalesce and who want to create change? So a couple of folks got Senator Coons office involved and his office has been amazing. They've been responsive. They get it. We met with the insurance commissioner, who has he heard us. And I feel like he's doing some things behind the scenes on our behalf. We're going to meet with the director of Medicaid. I like to convey to these folks, we're not trying to beat you guys up. Understand some things. And we also want you to understand what we're dealing with as well.

Yeah.

Delaware is a small enough state that we can create change. It's not like California or New York where the systems are just impossible to navigate. Delaware is a small enough state that we could. We could get the ears of people. Like, it was easy to get coons. It was easy to get blunt Rochester's people. I emailed the director of Medicaid all the time, and he is so responsive. And I think he listens, I think he gets it. But as a solo person doing this, you can't do it alone. There's power in numbers. And when we're all being impacted by the same thing, we need to speak up. We need to use that power. It's an ongoing thing. There's systems that are going to be difficult to change. There are politics at play.

Yeah, for sure.

There's money at play. There are lobbyists. Insurance companies have expensive lobbyists. I am a little teeny, tiny tadpole in this big thing. But I like the fact that people like me, you and some of the other therapists in Delaware have said enough is enough. We need our voices heard. We're in the trenches. And if we're going to survive, we gotta. We gotta take this cause up. Like this is what we have to do.

Yeah.

So I'm really appreciative of the colleagues that have kind of coalesced to sound the alarm that this is what we're dealing with and this is what we need.

I really appreciate that because I think for listeners, if you haven't given this a thought and you are a mental health provider, and even if you're not, if you can advocate for mental health, I think we're dealing with a quality of care issue here, that there are a lot of corporate business venture capital pieces at play that are really kind of working toward maybe squeezing out the little guy, if you will. And the little guys are us who have had all of our training, who really want to provide excellent care. And I think at a certain level, the care and the choices for mental health care are what start to suffer. So the people who want to go and receive support and need support are ultimately going to suffer. If these smaller practices or individual practitioners are sort of eked out of the

market, and particularly in a small state like Delaware, I feel like we are at risk. The one thing, that, you know, people may not realize in Delaware is that there's a provider shortage. You and I know that because, you know, our phones are ringing off the services, the mental health needs haven't decreased at all. And I feel like in Delaware, if we allow things to be taken over by corporate interest and venture capitalists feel like we've done our community a disservice. Therapy is so much more than about the modality that you're trained in. It really is about that connection. It's about the kids that I work with feeling safe. It's about being consistent and showing up for them. It's about understanding cultural nuances that often meet us in our offices. So in tech companies, meet those needs. I would venture to say no, they absolutely cannot. I want to be part of that voice of defense. We've got to be the voices for the voiceless and for the clients that we know. And for the sake of our industry, we've got to be the ones speaking up. Nobody else is going to be doing it for us.

I love that.

Yeah.

I just want to encourage everyone that if you would like to get in touch with Lisa, we'll have all of her links and ways to find her and the work that she's doing available in the show notes. And if you are a therapist listening to this, please find a way to help advocate. And if you are a business person or just a person who values mental health, I encourage you to support your mental health practitioners as you can. Thank you, everyone for being here. Thank you, Lisa, and we'll see you next time.

My pleasure.