The frustrations of insurance
I have so many mixed emotions regarding insurance, accepting insurance, and providing quality care. Before opening my private practice, I worked in one non-profit in which I saw families primarily on Medicaid, and one in which most families were on private insurance plans. My work was incredibly meaningful, and I was fortunate in both environments to not have to work directly with insurance companies. All of my billing was completed for me.
Despite not dealing with billing directly, every bit of my job was shaped by insurance companies, from the norm of 30-minute sessions to the lack of time to prepare sufficiently for each patient. Unfortunately, speech-language pathologists are reimbursed by the session, not by the time spent with a family. In other words, the companies I worked for made the same amount of money whether I saw a patient for 30 minutes or 60 minutes. In addition, the reimbursement from insurance companies, particularly medicaid, is problematically low (though advocacy groups worked very hard to have it raised slightly in 2023!).
Financially, there is massive rationale behind jam-packing schedules with 30-minute sessions. However, there is another factor that leads larger nonprofits making these scheduling decisions: the waitlists. Waitlists for speech therapy have become increasingly long, particularly following the pandemic in 2020. Typically the families I worked with waited 6-9 months following their evaluation to start therapy. If they had time constraints (e.g., only after school sessions), they sometimes waited a year. SO much happens in 6-12 months of childhood when it comes to speech and language development. By doing 30 minute sessions, we can see almost double the families. This means we can get kids off waitlist faster.
In my eyes, all of these details come down to one main question: Are we prioritizing the amount of time spent with the child in front of us, or are we prioritizing the reach that we can have in the community? To be perfectly honest, if I were in charge of rehab department at a large nonprofit, my priority would be the community. Looking at the big picture, I understand the value behind seeing almost double the amount of children, providing them with 30 minutes of quality care, and remaining viable as a company in order to continue serving the community.
As an individual clinician, however, I want to focus on the families in front of me. I want to prepare for my sessions, and give each child exceptional care, with time and scheduling based on that child’s exact needs. I want to evaluate a child when we start therapy, so that the results are directly guiding our work and our goals. I want to give each child time to build rapport with me, to play freely, and to feel comfortable - this is, after all, what enables the most communication! I want to answer every question a caregiver has without worrying about being over time. I want to have time to call a child’s school teacher to collaborate and see how I can help across environments. I want to have time to write detailed evaluations without pre-written dot phrases that go in every child’s evaluation. I want to write evaluations that describe your child's strengths and areas of need, without the obligation of detailing enough “deficits” and “disorders” to be sure insurance will cover therapy. I want the flexibility to perform dynamic assessments across sessions.
I want to spend more time with the child in front of me, and make sure I am meeting their every need with my best attention and most informed, up-to-date evidence-based practice.
As a parent, I would want my son to have an unhurried, hour long session with a clinician who knows and cares for him. I want this to be the reality WITHOUT that clinician being pushed to burnout. While I have seen first hand how hard some clinicians work to make this the reality within the constraints of insurance reimbursements, it is unfortunately the exception and not the norm, and these clinicians are often the first to burn out.
There are so many problems with this system. The reimbursements, the waitlists, the effectiveness or our care, the burn out of our healthcare providers. This didn’t even dive into the testing and goal writing. While I do not currently accept insurance, I do work with my families to ensure that my services are reasonable and affordable. I am happy to talk through any pricing with families, and I do offer a sliding fee scale for eligible families. If you have any questions about this, please do not hesitate to ask. It is something that is often at front of mind for me, and I am always open to hearing other sides of this issue.