Viewing Mental Health Care Through a Family Systems Lens

welcome to Mental Health Evolution, a podcast about what's changing in mental health and why it matters. I'm your host, Rachel Harrison, inviting you into honest conversations with people from all perspectives in the field. Clinicians, tech founders, investors, insurance companies, and all the folks in between. Let's explore what's working, what's not, and what's next.

Hey, everyone. Welcome back to the Mental Health Evolution podcast, where we are diving into the changes happening in the mental health industry and looking at it from all angles. We just want to raise the conversation here, and although we regularly have guests today, this episode is a solo episode. I have been thinking about something for a while and wanting to kind of set the stage a little bit and dive into the information about all the different players in the mental health industry. I've gotten some questions and I know there can be a lot to figure out of who does what, how do they do it, all those things. And we're going to talk about it kind of from the lens of looking at each of the players, looking at things that they contribute to the industry and also places that they have some influence, some advocacy, some power to make a difference in their circle. So today's podcast was actually inspired by a Facebook post, a group, a group of therapists posting online. And I see these all the time. This one was discussing therapist income. And if you are not familiar with some of the rhetoric that goes on around this, most therapists feel like their reimbursement rates and. Or their pay is not what it should be, and especially equality with medical practices and things like that. So that was happening in this Facebook group, and the gist was this. There are some making high salaries, there are others making very low salaries, and there are a lot in the middle. As I read through these responses, though, to me what was clear is that this is really part of a larger system. And so part of a larger conversation. This was the therapist looking at the system and what's happening from their particular view, which is valid and important. But I think if we zoom out, we recognize that provider income is really tied to many factors in the industry. It's tied to the economy, and it's also tied to politics. I'm not going to go into the politics and the economy pieces so much in this solo episode, but I did want to talk through all the players essentially in this field. So the lens that I was using as I thought about this more, was the lens of family systems. And for those that are trained clinically. You'll know what this means when a therapist looks from a family systems lens. The idea is that everyone in that system has their own perspective, brings their own strengths and weaknesses, and potentially contributes to whatever is happening that is disruptive in the family unit. And so these are how we kind of look at things. And greater understanding comes from looking at that whole system. So we are going to look at that whole system when it comes to the industry as well. So as always, we like to delve deeper into these topics and provide a little additional reading some articles that we're basing the conversation on. So here are a few that you might find relevant today. The first here is called Exploring Barriers to Mental Health care in the U.S. this article is by AAMC and it highlights systemic geographic and economic barriers to accessing health care, emphasizing disparities among populations and regions. And one of the barriers noted is the difficulty in finding behavioral health care providers covered by insurance. Notably a report in 2017, so this goes back a little ways, analyzed the data from 30 million insurance consumers, so that's a lot of people and found that 4% reported that they had medical or surgical specialists that were out of network, they couldn't find in network care, 3% reported that for their primary care, and 17% reported that for behavioral health care. Which begs to more of the question of what's going on. In a 2015 survey conducted by NAMI, which is the National alliance on Mental Illness, 29% of respondents reported reported that they or their family member had been denied mental health care because their insurance company had deemed the care medically unnecessary. In the Same way, only 14 of those respondents were denied general medical care for the same reason, being medically unnecessary. So that's kind of a disparity there too between what's approved for mental health care and what is approved for medical care. This article goes on to recommend integrative care, increasing technology to help, and also encourage laws and policies that support mental health care. And then I'd like to talk a little bit about this next article which is called how does the US provide mental health treatment? This is from USAFacts. It's actually a great way that just kind of maps out how care happens in the United States, focusing on service delivered coverage gaps and interactions between patients, providers and payers. And lastly, this article is titled actually it was released on the air. It was an audio file from npr. You can also access the written file though on their website and it's called Therapists Are Leaving Insurance Networks. And here's why and this article explores a couple case examples of why providers are choosing to opt out of insurance networks, including things like low reimbursement rates, administrative burdens, and discussing the implications for that access to care. Of note, in that article they do talk about clawbacks specifically, and I want to just define that because it might be something that comes up in the conversation today. Clawbacks are essentially when an insurance company says, hey, there's something that happened in your note. Either we don't think that appointment was medically necessary or the date was wrong, or there was a typo, and for those reasons they will take back that amount of money that they had already paid a provider. And this does happen a lot in the mental health realm. All right, so let's dive in a little bit more to all the players. There are so many, and there are more on the scene now more than ever. So that's part of what I wanted to talk through and describe. There are so many things that we can look at here. So let's go ahead and start with the client or the patient. They're called different things depending on who your provider is. Psychologists and psychiatrists tend to call them patients, counselors, therapists, marriage and family therapists, art therapists, social workers. That group tends to call them clients. So you will hear me use both of those words, and those are kind of interchangeable for the point of this discussion. But access to mental health services is not equal in depending on where you live. So some of these articles that I highlighted above will point out that different things really influence these how many providers are actually working in any given service area depends on access to care. So they estimate around 28% of clients or patients are actually able to access the care that they're looking for in certain like 20% of regions. Right. They're able to access that care. And others face long wait times, high out of pocket costs, or traveling long distances to get care. Some of that has eased and changed with the introduction of telehealth. Certainly that has made at least the travel pieces potentially easier. But healthcare providers are also limited by state licensure. So if you live in a state that has a lot of other states that are close by, it's very possible that your provider can't practice in one of the close by states and can only practice in a specific state. But clients and patients do have influence in the system because they can reach out to their insurance companies. They can voice their needs, they can highlight care that is needed. They can also request special care agreements in some cases and if a client is paying out of network or out of pocket services, they also have the power to invest in what they're valuing, just like we do with any product that we're buying. In this economic model, the clients and patients are the consumers. And where they choose to spend their money, whether it be copay or whether it be out of network services, does determine the health of the business or the individual provider that they are supporting. Larger companies tend to have more backing by other funding sources. And so that's a little bit of a different piece there. So next, let's go ahead and look at individual providers. Income for individual providers is directly influenced by reimbursement rates and administrative burdens and the type of practice setting. There is a 2025 US therapist salary report that you can look into that shows how private practices, group practices, and network participation affect earnings. Many therapists are making decisions about joining insurance networks or staying out, as talked about in that NPR article. And that's just because there are so many different complicated pieces to consider. The organizations that house these providers can be small businesses, nonprofits, and also larger companies. But they also have operational structures that influence how therapists are paid, and they are really still dependent on insurance, if that is something that is provided. For example, small independent practices may have more flexibility than some of these larger groups, but they may have fewer resources for administrative support. And then the larger organizations may have more stability, but also have more bureaucratic oversight. Of these organizations, about 60% are private practitioners, which means either small groups of practitioners or individuals. The smaller the group, the less influence they have over insurance reimbursement rates, as well as resources to cope with clawbacks and those audits that we talked about earlier. The larger companies may be able to acquire other funding sources to help offset the cost, and they're going to have bigger systems to manage all the details of insurance billing collections as well as referrals. One thing that has been said about larger companies that provide these services is that they can sometimes struggle with quality of care. Providers, I would say, have leverage in this system primarily through their professional organizations such as APA, NBCC, NASW, etc. That lobby for their interests in policy and law. And that is a very helpful resource for providers, but they also have leverage in maintaining rates because it's a very interesting cycle that happens. If you're not familiar, insurance companies actually take an average of what providers are charging in a certain area, and they take a percentage of that, and that determines what they're willing to pay the provider. So if Providers reduce their rates, then the insurance rates are going to go down. If providers raise their rates, then the insurance reimbursement rates are going to go up. And now this has to be done collectively. If there's just a one group or practice that's doing this, it's not necessarily going to impact the entire network in that area. But that is one reason why reimbursement rates vary dramatically from county to county. I can tell you from different states that I've practiced in, each county has their different rates and they can vary by a large percentage of the total rate. All right, next element. You ready for this? This is the new player on the scene. These are tech companies and managed service organizations. We're going to kind of loop those two together. They, they can do different things and sometimes they do similar things. So a managed service organization is a group that brings together providers but provides all of the back end services. So they own the credentialing, the billing and all of that for their providers so that the providers can do the providing and they pay these providers. Tech companies also have. There are so many different options, right? Some of the tech companies have apps, some of them are actually providers. Like there are groups of providers that are housed within the tech company and they're doing virtual platforms. There's also some different types of therapy that's happening like texting and emailing and potentially AI. So these organizations are playing a growing role in shaping workflows, scheduling, billing and even virtual care access. Venture capital backed companies, which several, I think most of these are, are entering this space and creating platforms that streamline some processes, but they also impact how revenue flows and which providers are prioritized. So the bottom line with that is they have a pretty heavy influence and are often getting different rates than maybe some of the practices that have been around for a while. These organizations and tech companies tend to talk about trying to improve access to care with their virtual platforms and their strategies to provide care outside of state lines where other providers can be fined for this or even lose their licenses. Some of these organizations are funded by venture capitalist groups looking to acquire market space and many also sell the data of their patients in order to supplement their income. These organizations are marketing powerhouses. You have probably heard their ads on podcasts. If you listen to a lot of podcasts, they are leveraging all their big teams in marketing, legal, HR recruiting, etc, in order to grow in this space. And by all accounts, it is a bit of a race right now to see among these tech companies who can get the most Market space. These companies are changing the way that therapists operate when they hire them in regard to confidentiality, licenses being bound by state lines, modality of therapy, such as text, email and AI. They are disruptors in the system and they are changing how the system operates. And that is sort of their role. And honestly, when you look at things like access to care, it really has been an issue. And these tech companies are coming in to try to solve that accessibility issue. They are also pointing out what many of the smaller businesses have long known, that to follow the rules and ethics of our profession, it is challenging to grow a larger business. So they are hiring legal teams and they are challenging some of those marketing ethics that we have and things like that. These companies are acting as disruptors, challenging the status quo and offering new perspectives. Disruptors aren't always a bad thing, I might want to add, because it does help us take a lens and look at what we're doing and look at the industry and look at what needs to remain the same, where our ethics need to prevail and where, if any, there might be changes or things that we can do to make access to care better. The next layer is the famous, I've already alluded to them, insurance company and they remain very important. They do set the reimbursement rates based on the area that they're in. They determine which providers are in network and they influence which services are covered. Things like policies, parity, regulations and state specific rules can change the way that care is delivered and accessed. For example, a provider's decision to leave an insurance network can ripple through the system affecting patients, other providers and even policy enforcement. You may have even had this happen. If you have a provider that you're using and suddenly they decide they're not taking your insurance anymore, you've got to find somebody else. It can be complicated, can be difficult to transfer medical records, all of that. Insurance companies do have a lot of power in this industry and they are often the focus of negative viewpoints. But the other side of this is true too. Insurance companies are a business and they are challenged to be able to do right by all of their participants with all of their needs. I don't know that I would want to be the person trying to make a decision about what is covered and what is not. And they are influenced by economic factors just like everyone else in this system. So while yes indeed they have a lot of power, they also have their own rules and regulations and things that they need to do to stay afloat and to provide care to people. At lower rates, at just paying a copay, or no co pay at all to provide that access to health care, which is different than if someone has to go out of network. And finally, I want to talk about advocacy groups and professional organizations. They shape the regulations, they set the standards and push for systemic improvements. They provide a very important critical voice that influences legislation, workforce policies and the overall quality of care. When all of these players interact, hopefully what happens is we get a healthier ecosystem. Decisions by one group, such as insurers, can impact everyone else in the system. And technology is also a platform that is already changing everything else in the system. And that is a lot about what we're talking about here on this podcast is that all of these players have a role. Everyone impacts the other. And the decisions made in these individual businesses can impact other businesses, but also the economy overall, also the health and well being of the clients and patients that are wanting to be seen or to have mental health care. I think there's a clear need for ongoing dialogue so that everyone, whether you're a provider, a policymaker or a patient, can better understand how to make choices that affect the broader system. This is where advocacy and informed discussion hopefully can make a tangible difference. So I want to thank you today for listening to this episode. I also want to say that I may have missed things. I am just one person trying to step back and look at the system, trying to look at it from the perspective of what are the challenges of each of these pieces, each of these players, and what are the benefits that they potentially bring? What is the influence that they have on the rest of the system? But I'm only one perspective. I do a lot of reading and listening on these topics. I shared with you a lot of those things from articles and different things I've read. But I probably missed something. So that's my caveat for you. If you are thinking and you have an idea and you're like this was missed. This is something important we need to talk about, reach out to me. I'd love to hear about it. Also, we will continue to bring on guests that are going to elevate this conversation even more and give us their perspective. So with that said, we're going to call it a wrap for this solo episode here. As always, we'd love to hear from you. Any feedback, anything you'd like to hear more about on this pod. And we will be back next time with more perspectives on the mental health care industry with the Mental Evolution podcast. Thanks for being here everybody.