Thursday, September 6, 2012
For many Americans, access to mental healthcare is a matter of necessity, not a luxury. And for most of us, it's not free. Like other needs, such as food, water, clothing, and shelter, quality healthcare comes at a cost. Impoverished Americans are typically eligible for Medicaid or CHIP programs (Children's Health Insurance Programs), retirees have Medicare, and the wealthy can typically afford their care. So that pretty much leaves middle class Americans of working age to grapple with the burden of affordable mental healthcare. In this post, I'm offering you 7 tips for making your mental healthcare more affordable. I hope you find them helpful.
1) If you take medication, ask about generics.
I am surprised to find how many of my clients are unaware that many of the medications they are being prescribed are available through generic drug discount programs at major retailers, like Walmart and Target. Some of the most commonly prescribed medications for depression, anxiety, Bipolar Disorder, and psychotic disorders are available for $4 for a 30-day supply or $10 for a 90-day supply. For most of us, buying medications through generic drug programs is less expensive than purchasing through insurance, and for those of us without insurance, these programs are a godsend. Ask your prescribing physician if there is a generic available for any name-brand scripts. Make sure that your physician knows that you prefer generic medications when appropriate and that your pharmacist knows that you consent to receiving generics when they are available. Your physician may determine that a generic medication is not the right fit for you, and many medications are not available in a generic form, but you may never know if you don't talk about it.
2) If you don't have health insurance and can't afford your medication, consider applying for a prescription assistance program.
Many pharmaceutical companies and charitable organizations offer free or discounted medications to uninsured patients. You can apply for assistance through the Partnership for Prescription Assistance. Fortunately, many clients I've referred to this resource over the past 7 years have been able to get help.
3) If you don't have health insurance, start shopping.
Signed into law by President Obama on March 23, 2010, the Affordable Care Act requires most Americans to purchase health insurance beginning in 2014, a requirement known as the individual mandate. By 2016, the penalty for noncompliance will be $695 per adult and $347.50 per child with a maximum penalty of $2,085 per family. Purchasing health insurance is not just just a good idea; it's now the law. Treat the purchase of health insurance just as you would any other significant investment, like a car or a home. Comparison shop with multiple companies and plans. An insurance agent or underwriter may be helpful in customizing a plan that works for you. Ask friends and family members what insurance they've purchased and whether or not they're happy with their plan. If you keep getting denied coverage because of pre-existing conditions, understand that beginning in 2014, insurance companies will be prohibited from denying coverage. In the meantime, you can obtain insurance either through a federal pre-existing insurance plan or a state high risk pool.
Even without a pre-existing condition, health insurance can be expensive depending on a range of factors, such as age, gender, body mass, lifestyle habits, and place of residence. And those of us who are self-employed or whose employers don't offer a health plan miss out on three advantages of employer-based insurance plans:
(1) We have to pay for the entire premium ourselves instead of splitting the cost with our employer;
(2) We can't purchase our plans with pre-taxed earnings as companies can; and
(3) We don't get a discount for buying in bulk.
But there are some ways to compensate for these drawbacks. If you are the member of a professional association, see if your association works with an insurance company that offers reduced rates for members. When I transitioned into private practice, I was afraid that I'd have to pay hundreds of dollars a month for insurance, but by going through the American Counseling Association, I found a good plan with a $1,500 deductible and a 40% coinsurance rate for just over $80 a month. Consider a plan with a higher deductible, often known as catastrophic coverage. These high-deductible policies may be more affordable and will generally work well for more expensive and serious medical costs, but you will have to pay for smaller expenses until you meet your deductible. The good news is that the rate you pay for these expenses will be discounted, as the provider will bill you for the same contracted rate that your insurance company would typically pay for. Nonetheless, the steeper your deductible, the greater the possibility that you will be paying for a lot of out-of-pocket expenses. And that brings me to my fourth tip.
4) Put money aside each month for out-of-pocket medical expenses.
I know this is easier said than done. Everyone plans to put some money aside, but few of us ever seem to get around to it. I recommend that you start off by completing a household budget. Based on the income you have left after your expenditures, decide how much money you can reasonably invest in healthcare savings. If you don't have enough left over to invest, then the next question becomes, "What can I cut in my budget to make my health a priority?" If I'm not saving up money for my health expenditures, but I have the newest iPhone and a premium cable plan with so many channels that I could watch a new one everyday of my life for 5 years, then I might want to question my priorities. Think about it this way: The typical American family spends about 5% of its income on healthcare, which is a little more than half of what it spends on food, another basic necessity. Some cost-saving measures can be as simple as making coffee at home instead of buying it at a restaurant or preparing more meals at home instead of eating out.
If you're like me, you may need a little extra help in staying disciplined enough to put some money aside, so I'll offer three options that may help you:
(1) If you are not self-employed, consider a flexible spending account (FSA). FSAs allow you to put aside a little money every month to save for healthcare expenses, and since that money is pre-taxed income, you're saving on your healthcare expenses. But be careful; FSAs operate on what's called a "use it or lose it" principle, meaning that you lose anything left over in the account by the end of the year. For this reason, it's best to base your estimate on a typical year's worth of healthcare expenditures.
(2) Regardless of whether or not you're self-employed, health savings accounts (HSAs) tend to be a good strategy if your insurance plan is a high deductible health plan. Like FSAs, HSAs allow you to put aside some pre-taxed money every month for healthcare expenses. But unlike FSAs, you don't lose money that you don't spend by the end of the year. The bad news bout FSAs and HSAs is that the Affordable Care Act (ACA) places some significant limitations on the use of such programs. For example, people with FSAs used to spend their remaining funds on routine over-the-counter (OTC) healthcare supplies at the end of the year to avoid losing their balance, purchasing common household items like vitamins and cold and flu medications. But under the ACA, OTC expenditures are no longer permitted for both FSAs and HSAs. The ACA also cuts in half the amount you are allowed to invest in FSAs from $5,000 per year to $2,500 effective in 2013. Nonetheless, there are still many benefits to HSAs and FSAs.
(3) If you don't have an HSA or FSA, consider creating a separate savings account just for your healthcare expenses. You can also arrange to have money automatically transferred from your checking to savings account on a bi-weekly or monthly basis to help you stay disciplined. Remember that healthcare is a need, not a luxury. It may not be fun to spend money on quality care, but our challenge is to make it a priority.
5) If you're struggling with the cost of your care, communicate with your provider.
Few if any of us relish the idea of admitting that we're having a tough time paying our bills. But if you talk to your providers about your difficulty, they may be able to offer help that could mean the difference between accessing appropriate care or not. First, some practitioners offer sliding scale fees for those who genuinely lack the ability to pay the full rate. Second, some providers offer payment plans that allow you to pay your bill in installments. Third, some practitioners may offer you a discount if you pre-pay for services or pay at the time of your appointment. Fourth, your provider may be able to refer you to an appropriate community resource to help you reduce your expenses. In my area, I know of programs that will provide free psychiatric care and counseling for individuals with a limited income and no health insurance, but clients are often unaware of such resources. Finally, some providers offer free or pro bono services in the rare event that a client is both ineligible for public assistance and realistically unable to pay even a sliding scale rate.
Asking for help is easier said than done. Many of us highly value our independence and autonomy. We like to think of ourselves as self sufficient--of being able to handle our own expenses. Consequentially, the idea of using a community resource or charitable program is an uncomfortable one. But if it means the difference between taking care of yourself or not, then it makes sense to accept a little help. You can always remind yourself that such help is temporary and that you can donate to a charitable program in the future when you find yourself in better circumstances as a form of compensation.
One more note on asking for help; If you are experiencing a true psychiatric emergency (i.e. suicidal thoughts or plans, thoughts of harming others), you can be admitted to an ER, an inpatient psychiatric program, or a crisis stabilization center immediately regardless of your ability to pay. In some cases, your costs will be covered by local, state, or federal funds or by charitable funds. In other cases, you may be billed for the services with the option of a payment plan, but the bottom line is that getting help is more important than ability to pay. It's crucial that you get the help you need immediately.
6) Supplement your treatment with healthy lifestyle choices and therapy assignments at home.
You can maximize your progress and minimize the potential for a costly relapse by supplementing your therapy with changes in your day-to-day behaviors. If you're taking medication, be sure that you take it regularly and on schedule so that it can do its job. Learn about and implement a diet that gives your body the resources it needs to preserve your mental health. Regular exercise can stimulate mood-enhancing neurotransmitter regulation, boosting your mood. Completing therapy homework assignments between sessions is associated with greater symptom relief, so if your therapist is giving you something to do between sessions, do your best to follow through. And if you're not being given therapy assignments, then ask about it. And while you're at it, ask your therapist about recommended self-help books. Consider supplementing your therapy and self-help work with participation in a community support group, most of which are free. If you're only relying on medication for mental health treatment, then I strongly recommend that you meet with a psychotherapist for counseling. Study after study shows, for example, that depressed patients who participate in cognitive therapy show greater improvement. Finally, avoid heavy alcohol consumption and the use of illicit drugs. All substances that produce euphoria also interfere with brain chemistry, and such interference can counteract the therapeutic effects of medication, interact in harmful ways with medication, or make it difficult for your physician to assess whether or not a medication is helping.
7) If you can't afford to see a psychiatrist, consider visiting a community mental health center (CMHC), a Psychiatric Advanced Registered Nurse Practitioner (ARNP), or a primary care physician (a.k.a. general practice, family doctor).
CMHCs typically receive public and/or charitable funding to assist individuals with limited income who don't have health insurance. While there are certainly exceptions, care at CMHCs may come with a few drawbacks. CMHC providers are often less experienced, and there may be lengthy waiting lists or limits in the frequency of appointments. You may not be able to access psychotherapy to supplement your medication maintenance, and in some cases, the CMHC may not charge you much less than you would pay for some private providers in the community who use a sliding scale. Nonetheless, many people receive quality care at a reduced rate through CMHCs. ARNPs who work in private practice are nurse practitioners who can prescribe medication under the supervision of a psychiatrist. Because they receive less training and education than a psychiatrist, they sometimes charge less than a psychiatrist, and many of them are excellent providers (I refer to a local ARNP frequently). Some primary care physicians are comfortable with prescribing mental health medication, especially in the case of milder depression and anxiety. At the very least, they may be a good resource until you can afford to see a psychiatrist. Some retail health clinics and convenient care clinics may prescribe common antidepressants at an affordable rate, especially if you are between insurance policies and just need a refill of a medication that's been working for you. To be clear, I generally recommend that clients work with a psychiatrist, as they are the most trained and qualified professionals who prescribed mental health medications. But it would be dishonest for me to deny that many clients receive appropriate care through a PCP, especially in cases of common, simple, and mild mental health conditions.
The bottom line...
I can condense these 7 tips into 4 strategies for more affordable mental healthcare: (1) Communicate with your provider; (2) Supplement your treatment with healthy lifestyle choices; (3) Be an informed consumer when it comes to insurance and healthcare costs; and (4) Budget and save for out-of-pocket expenses. I have seen all 7 of these strategies work for clients who I've personally provided care for, and I hope they can be helpful for you, too. If you have any other tips or resources, feel free to post a comment and share them.