Readers and Tweeters Have Mental Health Care on Their Minds

Letters to the Editor is a periodic function. We welcome all comments and can publish a range. We edit for size and readability and require full names.


Therapists Aren’t Psychic

Your article on the No Surprises Act supplied readability into some difficulties confronted by therapists and their sufferers in figuring out monetary parameters of therapy (“Mental Health Therapists Seek Exemption From Part of Law to Ban Surprise Billing,” Feb. 3). Most individuals (therapists included) agree that shock payments should not a nice shock. What appears lacking on this in any other case nuanced article, nonetheless, is an articulation of the problem in “estimating” the price of a therapeutic endeavor and the way this, too, is a frequent objection to the act.

A therapist can not often guess on the size or frequency of remedy prematurely of the therapy. It’s unreasonable to say, “It would price you X for the entire episode of care.” To use a template forward of time and say, for instance, {that a} affected person will want 10 periods (or 10 years) of care misses the purpose.

Sufferers are distinctive and their wants will evolve in the course of the course of their therapy. Some will discover they want extra frequent periods. Some will resolve they could desire a totally different therapeutic method. Some need adjustments at a really deep degree; some are hoping for a couple of conferences to make clear an emergent disaster. To supply an upfront price estimation would severely disrupt many evidence-based therapies, together with these therapies that supply an in-depth alternative to get to the intricate roots of advanced emotional issues (issues that may appear deceptively “easy” at first look).

Affected person and therapist make selections collectively. This collaboration ought to by no means be a “shock.” The brand new insistence on an preliminary price estimate prioritizes short-term and quick-fix therapies on the expense of the sort of remedy that many sufferers would possibly need and want.

— Betsy Nettleton, licensed medical psychologist, Chicago



— Ted Doolittle, well being care advocate for the state of Connecticut, Hartford, Connecticut


As a psychological well being supplier, I really feel that journalist Julie Appleby misrepresented our objections to the No Surprises Act. The article implies that therapists need to keep away from transparency and hold prices excessive for shoppers, which is wildly inaccurate.

The very fact is that we’ve got all the time been clear in our charges — that has by no means been a difficulty. Nevertheless, we do have severe objections to the legislation as it’s being utilized to us:

1) It’s unattainable to estimate the price of a “complete course” of therapy, as that is virtually completely as much as the shopper. Companies are fully voluntary, and purchasers pay on the time of the session — there isn’t any scenario, ever, the place they might be shocked with a big invoice, and they’re free to lower the frequency of appointments or discontinue at any time. As a result of this unattainable requirement, some therapists have opted to offer an “estimate” for a full yr of weekly remedy — offering a lump sum, which is each overwhelming and ineffective. Some purchasers could view it as an obligation to decide to a full yr of weekly periods, whereas most don’t want/need that degree of care. This may be dangerous at a time once we are working to construct belief and a therapeutic alliance with the person. Think about struggling to prioritize your psychological well being, after which going through an arbitrary “estimate” consisting of 1000’s of {dollars} — many individuals will probably be discouraged sufficient to forgo therapy.

2) As a result of we’re already offering a doc that lists our per-session charges (along with discussing them earlier than scheduling, throughout consumption, and previous to any periodic will increase), the nice religion estimate creates a redundant administrative burden on us and does nothing to enhance shopper care.

3) Shoppers select to exit of community for numerous causes, together with elevated supplier alternative/specialization, management over their therapy (no managed-care constraints), and privateness. Typically, going out of community signifies that a shopper may be helped instantly vs. being positioned on a waitlist for an in-network supplier, and their insurance coverage advantages should reimburse most or the entire price. The implication that we have to put “price stress on suppliers” on this discipline is just false — therapists are already among the many lowest-paid well being care staff (regardless of the requirement of a postgraduate diploma and persevering with schooling), and we already spend a number of hours per week on unpaid administrative duties, each of which have contributed to a devastating scarcity of psychological well being suppliers throughout a time of unprecedented want. In line with payscale.com, the common psychological well being therapist makes $47,576 a yr — nicely under the common wage within the U.S.

Whereas I assist the intention of the NSA, it merely doesn’t make sense to use it to psychological well being exterior of a “facility” or emergency setting. The tone of this text is biased and needs to be revised to precisely mirror our objections.

As written, the NSA favors insurance coverage firms, discourages out-of-network profit use, and, frankly, is patronizing to purchasers, who’re completely conscious of what every session prices. The one time purchasers are “shocked” is when their insurance coverage unexpectedly doesn’t cowl their therapy or reimbursement. My charges have all the time been crystal clear — the place is the transparency from the insurance coverage firms?

— Michelle Stevenson, Syracuse, New York


— Kevin Frick, Baltimore


Psychological Well being Care: Entry vs. High quality

A high problem in behavioral well being is shifting focus from entry to care to high quality of care largely because of the elevated demand for companies all through the pandemic. And high quality begins and ends with evidence-based knowledge. The query has been: How can we offer behavioral well being companies to everybody who wants it, no matter location? Whereas this could and can stay a precedence in 2022, there will probably be a further focus shifting ahead on high quality of care. In spite of everything, what’s the goal of offering entry to care if the standard of care isn’t addressed? Suppliers have to be asking themselves: Are folks truly getting higher via our behavioral well being companies, can we scale back readmissions, can we get rid of therapy failures?

To make sure high-quality care, behavioral well being organizations will more and more depend on measurable knowledge to trace affected person and inhabitants outcomes. Knowledge, derived from evidence-based assessments, consumption kinds, together with social determinants of well being insights, is in the end what’s going to inform medical and operational executives if their applications and therapy plans are working. This info can also be important in figuring out find out how to make significant enhancements to ship the simplest and environment friendly care.

Delivering high-quality care begins and ends with knowledge. Measurement-based care (MBC) — outlined because the follow of offering medical care based mostly upon shopper knowledge collected all through therapy — will acquire reputation as extra behavioral well being organizations depend on this technique to enhance the standard and consistency of care. With their final enterprise aim to enhance medical outcomes, hospitals and well being programs will additional acknowledge that incorporating MBC into their practices is one of the simplest ways to verify and doc affected person progress.

So far as value-based care: Worth-based care fashions middle on affected person outcomes somewhat than the variety of companies or visits. Not like the normal fee-for-service mannequin, value-based fashions align payer and supplier incentives towards nicely care somewhat than sick care. Underneath this mannequin, the main target is on high quality and outcomes efficiency somewhat than affected person/member utilization of companies.

The yr 2022 will usher in outlined milestones and clear progress towards value-based care in behavioral well being. There will probably be extra pilots and applications of value-based reimbursement contracts between payers and suppliers.

— Eric Meier, president and CEO of Owl, Portland, Oregon


— Ron Howrigon, Raleigh, North Carolina


No Shock the Legislation Is Complicated?

The outline for the podcast “‘An Arm and a Leg’: Know Your ‘No Surprises’ Rights” (Feb. 2) says the No Surprises Act applies solely to hospitals. It additionally applies to unbiased free-standing ERs. And the protections in opposition to stability billing at an in-network facility apply to each hospitals and ambulatory surgical facilities.

— Kathy Bakich, Bethesda, Maryland

[Editor’s note: Thanks for your sharp eye and insight. The article has been corrected.]


— Dr. Cedric Darkish, Houston


Dietary Fundamentals and Fundamental Rights

Thanks for the crucial column by Chaseedaw Giles on the issues of high quality meals availability in sure city neighborhoods (“What Does It Say About Your Neighborhood If the Supermarket Isn’t So Super?” Feb. 16). Boston is significantly better off in that regard than most different cities, however it’s the rural areas that undergo probably the most. Most small cities throughout the nation have very low-quality meals selections; Greenback Generals and different related shops — with their meals (if one can name it that) that’s excessive in refined sugar — dominate the obtainable shops. That is simply another reason that rural America is struggling a lot with power way of life ailments, unemployment, and substance abuse. We’d like extra reporting and motion to resolve this existential drawback.

— Alan Wright, Roslindale, Massachusetts


— Julian Agyeman, Cambridge, Massachusetts


Checking Up on Kaiser Permanente

I have to say I’m biased almost about Kaiser Permanente (“California Inks Sweetheart Deal With Kaiser Permanente, Jeopardizing Medicaid Reforms,” Feb. 3). It’s the worst well being care supplier ever. Docs should not obtainable, not sufficient areas, unhealthy medical companies division, telephone service, maintain instances, wait instances for appointments, the pharmacies are a joke.

The truth that Kaiser Permanente and Gov. Gavin Newsom are having backroom offers irks me to no finish. KP’s aim is to personal the Medi-Cal system in California. Poor Newsom has a lot cash in California, because of overtaxation, he gained’t pay to have the poor, aged, and disabled correctly cared for.

Sure, I plan on sharing this data with all. This is rather like the mob. No joke. Each needs to be ashamed and humiliated by these actions. I might see these unhealthy practices prolonged to all cities within the U.S., known as socialized drugs. Terrifying.

In case you are younger and have a household, it’s simply nice. However don’t age or fall prey to some horrible illness for which you want proactive care. You gained’t get it.

— Kim Carrasco, Folsom, California


— Chris Friese, Ann Arbor, Michigan


Poaching of Workers Is Widespread

Nice article on the consequences of staffing shortages on rural hospitals (“Bounties and Bonuses Leave Small Hospitals Behind in Staffing Wars,” Feb. 7). I’m involved that every one the press focus has been on hospital results as a result of they’ve nice groups that may present assist for getting the article written. Nevertheless, I work with safety-net clinics that aren’t federally certified well being facilities. Our clinics that predominantly serve uninsured and Medicaid group members are additionally being affected and that’s decreasing entry to look after these underserved communities.

Workers don’t even need to have certification to be poached, they simply need to have performed their practicum (they will use an oximeter, blood stress cuff, and perceive loading knowledge into an digital well being report) and so they can get an $8,000 bonus only for displaying up on the hospital down the road. Meaning our clinics are doing the essential coaching for hospitals and shedding all that profit in communities most in want. A few of our clinics are having to scale back hours as a result of they merely don’t have the employees to offer care to uninsured/Medicaid sufferers. That is extremely irritating and painful for underserved communities to face this, simply as in rural communities. I hope we won’t overlook these communities in our efforts to elucidate the challenges in well being care at this time.

— Phyllis Albritton, Colorado Security Internet Collaborative, Westminster, Colorado


— David Balat, Austin, Texas


‘Speedy’ At-Dwelling Assessments: Too Little, Too Late

I, like many others, on Jan. 19 signed up on the federal government web site for the free at-home exams. I waited weeks for any phrase of supply — nothing. They lastly confirmed up on Feb. 15. Nonetheless, two kits for 4 (!) at-home exams per household are ridiculously insufficient. Particularly for a household of over, say, two members.

I grade this effort by the federal government completely insufficient. Too little, too late. Sound bites vs. precise outcomes.

— Evan Hassiotis, Roswell, Georgia


— Dr. Ali Khan, Omaha, Nebraska


Free However Unpatriotic

Concerning the article “What Are Taxpayers Spending for Those ‘Free’ Covid Tests? The Government Won’t Say (Feb. 11): Why did the federal government purchase kits from one other nation as a substitute of ones made within the USA? Is there a cause why the US authorities can’t spend the taxpayers’ cash on U.S.-made merchandise? I’m now questioning if the N95 masks which might be going to be free to us from the federal government will probably be bought from U.S. firms. We’ve not been capable of finding any in our space.

— Beverly Neibert, Marysville, Pennsylvania


— Chris Vanderveen, Denver


Strengthening the Basis for Dwelling Well being Care

No affected person in want needs to be left with out care — interval. Dwelling well being companies will need to have the assets they should meet the calls for of at this time’s well being care workforce. As demand for dwelling well being care continues to develop, Medicare should tackle the way in which it reimburses companies for care as a way to assist us meet sufferers’ present and future wants via the recruitment and retention of a talented workforce (“Pandemic-Fueled Shortages of Home Health Workers Strand Patients Without Necessary Care,” Feb. 3).

Dwelling well being care, which has all the time been a preferred possibility for seniors and households, has proven its worth in the course of the pandemic. That’s as a result of it has helped many seniors recuperate from severe sickness and harm while not having to be admitted to expert nursing services, which have been challenged with covid-19 outbreaks. According to analyses, the demand for dwelling well being will enhance quickly within the years forward as America’s Medicare-aged inhabitants continues to surge.

Sadly, Medicare coverage contributes to severe labor shortages as a result of Medicare’s fee changes haven’t been reflective of labor and administrative value developments within the dwelling well being sector. Although the pandemic and creeping inflation have each caused labor costs (including wages, benefits, hiring, and retention) to jump sharply, annual dwelling well being fee updates declined from CY 2019 to CY 2022. This pattern is just unsustainable: If the annual fee charge replace continues to fall under rising workforce, labor, and care supply prices, Medicare dangers undermining the sustainability of America’s dwelling well being system.

By protecting tempo with rising labor prices, Medicare and different payors can guarantee dwelling well being companies are higher ready to satisfy the calls for of extra American seniors who need to be cared for at dwelling.

— Joanne E. Cunningham, government director of the Partnership for Quality Home Healthcare, Washington, D.C.


— Beatrice Westrate, Chicago

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