Paying for Therapy Services

• Why Choose Self-payment?
• Managed Care / Self-Payment Cost Comparison
• Considerations When Using Managed Care Benefits

Why Choose Self-payment for Psychotherapy?

You Want Privacy

Whenever insurance is used, some information (such as your diagnosis) is available to the insurance company and sometimes to employers. Managed care companies often ask for detailed personal information about clients in order to make payment decisions. This can undermine the sense of privacy necessary for effective psychotherapy. When clients pay for therapy out of pocket, there is significantly more privacy.

You Want to Choose Your Own Therapist

Insurance companies often require the client to choose a therapist from a list of "preferred providers." Many clients find this limitation unacceptable. Instead, they prefer to work with a therapist who comes highly recommended by someone they know.

You Want to Choose the Type and Length of Treatment

Many managed care companies make unilateral decisions about important aspects of treatment: type or length of therapy, use of medication, and referral to self-help groups instead of professional services. Frequently, companies provide only ultra-brief options for therapy.

You Don't Want Managed Care to Control the Course of your Treatment

When you use a managed care provider, your therapy sessions must usually be pre-approved by the company. A managed care employee evaluates the severity of your problem, your motivation and your progress, then makes a decision about the number of sessions and type of treatment. This "gatekeeper" often has less clinical experience and certainly has less information about your situation than your therapist.

You Don't Want to be Labeled "Sick"

Whenever insurance is used for psychotherapy, the treatment must be "medically necessary," which means that the therapist must give you a psychiatric diagnosis. When you pay directly, you may seek consultation from a mental health professional for any reason you choose. People use therapy for personal growth, for help coping with stressful life situations, and for marriage and family difficulties, as well as for chronic and serious psychological problems.

You Don't Want to Compromise Your Ability to Get Insurance in the Future

Using your insurance means that at least your psychiatric diagnosis and the length of your treatment will be part of a computer database. When managed care companies require therapists to provide even more details about a client's history, symptoms, and progress, this information may also be transmitted to medical data banks which are available to other insurance companies providing health, life, or disability coverage.

You May Want to Keep the Money You Pay Within Your Community

Insurance companies are in the business to make money. They are most often not based in your community, and their profits are taken from your community and distributed to their shareholders.

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Comparison of Managed Care and Self-payment

Treatment Under Managed Care	Self-payment
The insurance company provides a small list of therapists' names without much information.	Clients are free to choose their own therapist.
The therapist has a contract first with the insurance company and second with the client. There is a conflict when the client's wishes do not match the insurance company's decisions.	Clients contract with their own therapist.
The insurance company requires information about a client's most dysfunctional behavior. The insurance company does not tell the client who has access to this information, if the information is in a data bank, or how the information may limit the client's future choice of insurance.	Client confidentiality is a highly respected element of the therapeutic relationship.
The length of treatment is decided by the insurance company. Economics and internal regulations may influence treatment decisions.	The length of treatment is decided by the client and therapist together.
The insurance company is apt to choose a treatment approach based on cost rather than the individual's needs.	Clients choose the type of psychotherapy that fits their personal needs.
In some cases, a disproportionate amount of the health care dollar goes to marketing and shareholder dividends instead of direct care.	The health care dollar goes directly to providing health care.
Profit margins ultimately drive treatment decisions.	Individual providers have an investment in the cooperative relationship between client and therapist.

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Considerations When Using Managed Care Benefits

Because of the rapid increase in the cost of health care, most insurance plans are using Health Maintenance Organizations (HMOs) or "Managed Care Companies" to control costs. These companies promise to control costs by cutting waste and lowering rates. Problems occur when a managed care company does not approve the choices the consumer wants to make. Treating therapists can also be in a bind because they may risk losing their contracts if they do not follow company directives.

There are many good therapists working for managed care, and many clients receive good treatment from these providers. However, managed care therapists are working for both you and the company. It is important to know about the therapist's obligation to the managed care company and how this may influence your treatment.

Questions You Can Ask a Managed Care Therapist

• Ask about the limits of confidentiality. What information about you will the managed care company require?

• Ask your therapist if he or she would make different treatment recommendations if you were paying directly.

• Ask what kind of arrangements your therapist has with the managed care company. Psychotherapists have codes of ethics that require them to be honest with their clients and reveal information about how managed care companies are involved in treatment.

• Ask specifically about financial arrangements where the therapist makes more money by seeing you less. One of these is called a "capitated contract" where the therapist is paid a certain amount regardless of the number of times you are seen. Under these contracts the therapist has no financial incentive to see you after the first meeting. Sometimes there are bonuses for quickly discharging clients.

If the answers to your questions about your treatment are not satisfactory, you have a right to a second opinion. Good therapists will be open and honest about the involvement of managed care in your therapy. You have a right to know about alternative types of treatment and how the managed care company influences your personal mental health care decisions.

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