By Win Milton

Reimbursement.

The term has become almost a cliche in mental healthcare circles. It means payment for services provided by healthcare providers — usually meaning by private insurance companies or Medicaid.

As America shifts to accommodate state-mandated social distancing during the COVID-19/coronavirus pandemic, mental health businesses have largely rushed to register with telehealth platforms.

Telehealth, or telemedicine, means using a videoconferencing platform such as Zoom (though not traditionally FaceTime or Skype, due to HIPAA rules) to log a session with a client. It’s an old trick that hasn’t gotten a ton of use outside rural communities, but for any owners who want to continue turning a profit it’s now the only option.

Naturally, reimbursement has been a concern. Even with a loosening on telehealth-related restrictions and grants by CMS(1) some providers claim to “only” be receiving the equivalent of 75% of usual reimbursements.(3)

The blame for this of course belongs to private insurance companies. Seemingly deciding it’s not enough for the three million newly unemployed Americans to lose their employer healthcare, private payers have also cut back on their reimbursements to healthcare providers.

Regardless, many of the 24,000 (4) behavioral healthcare and addiction treatment locations in the U.S. serve Medicaid clients, who are increasingly covered during COVID-19.2 In fact, Medicaid coverage has largely paved the way for the industry. The inoffensive (5) SUPPORT for Patients and Communities Act of 2018 greatly increased the amount of Medicaid funding going toward treating substance use disorders (SUD), explicitly in response to the so-called opioid epidemic.

Behavioral healthcare does include some big players, such as Fortune 500 company Universal Healthcare Services, the BH segment of which includes more than 300 locations and 50,000 employees.6 However, the majority of the market is fragmented, comprising thousands of local outpatient clinics with five or fewer staff members.

The barrier to entry has never been lower for enterprising owners. The demand is there for treatment — 67,000 opioid-related overdose deaths in 2018 testify to that. (7) And as long as the U.S. refuses a harm reduction (8) approach to SUDs, the narrative is there. And with Congress continuing to wage a War on Drugs, the funds are there.

Entrepreneurs took advantage of the demand, the decrease in regulations, and the increase in funds for treatment of addiction and/or co-occurring mental disorders to make a buck. Some of these facility owners are LCSWs (licensed clinical social workers) or other former counselors, but many are just salesmen with little mental health background who saw an opportunity.

They won’t admit it on the mic, of course.

“I saw what alcoholism did to my brother.”

“I experienced the effects of meth on my community.”

“I treated people with track marks all down their arms.”

With the move toward telehealth-based treatment, this type of owner has added a new spin to their collection: “In uncertain times like these, depression and anxiety will only rise. We have taken steps to provide telemedicine for our clients so that we can continue to support them during this time.” One wonders how much it has to do with the increase in Medicaid and the rapid surge in mental health clientele. Privately they tell their employees to expect an increase in reimbursements and a growth in their business.

None of this is to say that mental healthcare is in itself a scam. Anyone who needs counseling or other treatment should get it, and they should have the means to. This piece’s characterization, further, of the average treatment center founder as an enterprising businessman prioritizing money over the actual consequences of the treatment is surely not one that extends to every treatment organization either. The evil is not in providing support to people with mental disorders; it’s in exploiting it to turn a profit.

To understand the depravity of entrepreneurs benefiting from a global pandemic, one has to weigh the extent of the COVID’s mental health effects.

In Indiana, mental health agencies report an increase of 50%. Addiction hotlines in the area report an increase of 1,100%! (9) In the D.C. area, a doctor at George Washington University said, “You know, we’re seeing certainly in the emergency department increasing numbers of patients coming in with depression and anxiety and even in cases thoughts of suicide relative to COVID-19. And so we’re having to respond to those individuals with ramped up telepsychiatry services as well as outpatient resources that they can utilize to really get through this time.10 In El Paso, the VA prepares for veteran suicides.11 One county in Ohio reported six overdose deaths in a single day last week.12

The United States had a record spike in unemployment last month. Millions of Americans don’t know when or if they will return to work. How they’ll pay their rent. How they’ll pay their medical bills if they contract coronavirus. Whether they’re parents will survive. In the midst of all this anxiety and depression (including but not limited to those who already had it), some see this as a business opportunity.

One might be tempted to allow mental health entrepreneurs a “hate the game, not the player” mindset. After all, it’s the capitalist healthcare system that encourages people to monetize mental disorders and addiction in the first place, not to mention heart disease, cancer, diabetes, Alzheimer’s, AIDS, and — fresh on the market! — COVID-19.

If coronavirus has served as a proof of anything, it’s how desperately universal healthcare is needed in America. Always, but especially now, those that need healthcare should be able to get it (in person or over videoconferencing). And without a price tag. Business owners be damned.

The big winner of COVID-19, other than insurance companies, is probably Eric Yuan, the founder of video conferencing (and data-mining) firm Zoom (founded with $30 million from Triad-linked Li Ka-shing).(13),(14)

No matter what happens next for the world, mental healthcare entrepreneurs can rest assured that the gravy train won’t stop flowing. In fact, thanks to Mr. Yuan, they won’t even have to get off the fucking couch for it.

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Sources and Footnotes:

(1)Centers for Medicare & Medicaid Services

(2) https://www.cms.gov/newsroom/press-releases/president-trump-expands-telehealth-benefits-medicare-beneficiaries-during-covid-19-outbreak

(3) Total reimbursement, including any copay, typically runs about $100–200 for one 30-to-45-minute session. If the session involves a specialist, such as a psychiatrist (a medical doctor, who unlike a psychologist or other counselor can prescribe medications), it can run $300 or more.

(4) See every one of them here: https://findtreatment.samhsa.gov/locator

(5) Opinion of the author: the SUPPORT Act was a net positive but it was too little too late, and the focuses were in all the wrong places (e.g. fentanyl). No bill that actually does something useful passes 99–1.

(6) https://www.uhsinc.com/about-uhs/behavioral-health/

(7) https://www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates

(8) “Harm reduction” refers to approaches to addiction that prioritize eliminating the negative effects of addiction (overdose, infection, HIV transmission, violent crimes, and so on) over minimizing addiction itself. Examples of harm reduction are needle exchanges, safe injection sites, withdrawal-reducing medications like methadone and buprenorphine, decriminalization, and outright legalization.

(9) https://www.newsandtribune.com/news/stay-at-home-extended-state-sees-surge-in-mental-health-calls/article_57821f32-75f0-11ea-b661-ffb1caa054c3.html

(10) https://www.wmtw.com/article/doctor-resources-detail-steps-to-stay-mentally-healthy-during-the-covid-19-pandemic/32038995

(11) https://kvia.com/health/2020/04/01/mental-health-help-available-for-el-paso-veterans-via-telemedicine/

(12) https://www.foxnews.com/us/ohio-coroner-overdose-deaths-amid-coronavirus-social-distancing

(13) https://www.stitcher.com/podcast/grubstakers/e/68142951

(14) https://www.patreon.com/posts/episode-150-eric-35033817