E6 EZ EE THE WASHINGTON POST.TUESDAY, FEBRUARY 22 , 2022
Haunt them backDon’t let the phantoms bring you down.
l Take careful, thorough notes anytime you need to search for a provider.
l If you’re calling numbers on a list, don’t wait for one provider to call back. Call and email many at once for
the best chance of a quick response. Write a few paragraphs outlining what kind of care you need.
l If you or a member of your family is in a crisis, ask your plan for help finding a provider. If your plan won’t
help, turn to the human resources department where you work, if there is one.
l If you’ve made a good-faith effort to find someone and can’t get help in a reasonable time from the list
provided, don’t just give up and pay out of pocket. l Ask your plan for a “single-case exception” — an option
many health-care consumers are unaware of. It allows your insurance plan to reimburse an out-of-network
provider while you pay no more than a co-pay.
l You can also request a single-case exception if the only available provider is a long distance from your
home or doesn’t practice the specialty you need.
l Also ask for an exception if you’ve been allowed to see an out-of-network therapist online or by phone
during the pandemic but now the plan has stopped covering it.
l To contest a lack of coverage either for medical services needed or already provided, you must first
appeal directly to your health plan. With a private plan, you must file within six months of care being
denied. The insurer must make a decision within 30 days if your appeal is for a service you haven’t
received, and within 60 days if it is for a service already received.
l If you don’t get a satisfactory decision on an appeal, take your case to the government agency that
regulates your insurer for an independent review. The customer service line of your health plan should tell
you which agency to call. Don’t wait 30 days if there’s a health crisis. Contact your regulator immediately.criminate against people who
cannot afford to keep pushing,
never mind pay out of pocket in a
crisis.
The origin of the San Diego
lawsuit is as unusual as the law-
suit itself. As a law student at the
University of California at Berke-
ley, Abigail Burman proposed the
legislation for an assignment in
one of her classes. Her professor,
Erin Bernstein, passed it on to a
colleague at the San Diego Attor-
ney’s office, while Burman fleshed
out the proposal in a paper pub-
lished in the winter in the Yale
Law and Policy Review. In that
paper, Burman charges that the
ghost networks are a worrying
sign of the overall failure of law-
makers and regulators to protect
consumers.
Burman said she couldn’t com-
ment because she was clerking for
an appellate-court judge and had
to abide by prohibitions against
judicial involvement in political
issues. But Simon Haeder, an as-
sistant professor of public policy
at Pennsylvania State University
and longtime expert on ghost net-
works who worked with Burman
on her paper and then with the
San Diego Attorney’s office, said
that Burman “collected the data
they’re using and wrote the law
review article that’s the founda-
tion of the case.”
Griswold said part of the prob-
lem with all those non-providing
mental health providers owes to
insurance firms’ low reimburse-
ments for such care. Insurance
firms, on average, pay her only
half of what she typically receives
from cash clients, she said. As a
result, Griswold and other thera-
pists say they may stay on the
providers’ lists as a Plan B for
when cash-paying patients may
be scarce, but hold out for higher
rates if possible.
Griswold filed a grievance with
the California Department of In-
surance against Kaiser, the insur-
er for her husband’s company in- But the case was never set-
tled. “Two weeks after I filed it, my
husband’s company decided to
switch plans,” she says. “They told
me it was because they’d gotten so
many other complaints.”
ing specialty mental health clini-
cians at a rate outpacing member-
ship growth while “optimizing cli-
nician schedules to maximize pa-
tient-facing time.” Kaiser has also
“significantly expanded” virtual
care by therapists during the pan-
demic and is investing $30 mil-
lion to help increase the number
of clinicians entering the mental
health field, he wrote.
Molina and Health Net repre-
sentatives did not respond to re-
peated emails and calls. But in
motions filed in response to the
suit, all three firms challenged the
city’s authority to hold them ac-
countable, since they were being
regulated by the state.
They all pointed out some of the
difficulties in keeping accurate
and up-to-date directories when,
according to Molina’s response,
“providers regularly (even daily)
have updated information, or en-
ter or leave Molina’s network...
without providing advance notice
to Molina, or any notice to Molina
at all.”No adequate action
Elliot described her lawsuit as
unprecedented, saying she filed it
because state regulators weren’t
adequately addressing the prob-
lem. California gives some city
attorneys authority to sue on be-
half of residents throughout the
state.
Elliott says she had filed the
lawsuit because state regulators
weren’t adequately addressing
the problem. California gives
some city attorneys authority to
sue on behalf of residents
throughout the state.
“I was astonished to see how
egregious the problem was,” says
Elliott, despite claiming that she
had encountered illusory net-
works herself several times as the
mother of two teens.
“I just hadn’t looked at it
through my city attorney lens,”
she adds. “Most of us are so busy
that we just keep making the calls
until we eventually get some kind
of response.”
Being able to keep calling is a
“privilege” for those with the time
to do so, notes Strunk, who says
the ghost networks therefore dis-‘Egregious and deceptive’
San Diego City Attorney Mara
Elliott filed lawsuits last summer
against three large insurance net-
works, accusing Kaiser Founda-
tion Health Plan, Molina Health-
care of California and Health Net,
a subsidiary of Centene, of violat-
ing state and federal law in creat-
ing “formidable, dangerous, and
unlawful barriers to patient care,
harming public health and Cali-
fornia health insurance markets.”
Kaiser, with more than 9 mil-
lion clients, “is among the worst
actors in California” in terms of
the inaccuracy of its provider net-
works, says the lawsuit against
that firm. The lawsuit contends
the plan has more than 30 percent
inaccuracy rates in its mental
health care directory and an over-
all inaccuracy rate of 19.14 per-
cent.
Molina, with nearly 1 million
enrollees, has had, according to
the lawsuit, “a truly staggering
inaccuracy rate of over 80 percent
for psychiatrists” and an overall
inaccuracy rate of more than 50
percent. Health Net, with more
than 2.3 million enrollees, had an
overall error rate of 18.13 percent,
that lawsuit said, with nearly
twice that for psychiatrists.
“It’s an egregious and deceptive
policy we’re not willing to toler-
ate, that can make difference be-
tween a person being healthy and
not healthy,” Elliott said in an
interview.
All three lawsuits charge that
the health firms persist in “pub-
lishing and advertising provider
information known to be false
and misleading.” The result is par-
ticularly harmful to people with
low incomes and with high need
for medical services, and in partic-
ular for women who “dispropor-
tionately bear the burden of ghost
networks because they are more
likely to perform unpaid care
work for others,” the lawsuits say.
Kaiser Permanente spokesman
Marc Brown says in an email that
the plan’s leaders “strongly dis-
pute” the lawsuit’s claims. Citing
the “overall national shortage of
therapists,” he says Kaiser is hir-
NETWORKS FROM E1
73 doctors and none available: Ghost networks vs. good mental health care
ERIC PETERSEN FOR THE WASHINGTON POSTAdolescent Psychiatry, most of
the nation is facing a severe short-
age of practicing child and adoles-
cent psychiatrists. Last year, a
coalition of physicians’ groups de-
clared a child mental health crisis
in the United States in response to
the strain on children and the
shortage of treatment options.
For many caretakers, the diffi-
culty of balancing those systemic
realities with work brings them to
a tipping point. Stewart’s re-
search shows that parents who
struggle to get services or must
spend significant time arranging
their children’s care are about one
and a half times as likely to leave
the workforce than their counter-
parts raising kids without mental
health needs.
Lee was one of those parents.
Today, caring for her son is her
full-time job, and the knowledge
of the flexibility she would need to
continue working discourages
her from reentering the work-
force. “Nobody would have kept
me on,” she says.
Instead, she started a home
business making custom hand-
bags. But the decision has
strained her family’s finances,
which hinge on the income of her
husband, a computer engineer.
“All of the earning potential is on
him,” Lee says. “That’s extra pres-
sure on him, too.”What employers can do
Employers can help. On Our
Sleeves’s research showed that
the vast majority of employees
would value courses about chil-
dren’s mental health in the work-
place, and the organization will
offer a free digital curriculum for
working parents that corpora-
tions and individuals can access
starting in April. Employers can
offer more flexible scheduling
and alert employees to existing
mental health benefits and sup-
ports.
“It’s the right thing to do,” Stew-
art says. “Parents are suffering,
and no one should have to feel like
a bad parent or a bad employee if
they need extra support.”
She recommends parents seek
out other parents whose children
have mental illnesses and brush
up on their legal rights; the Amer-
icans With Disabilities Act out-
laws discriminating against a
caregiver who assists with a dis-
ability, and certain employees at
organizations with 50 or more
workers are entitled to up to 12
weeks of unpaid, job-protected
leave each year under the Family
Medical and Leave Act.
“Employers are in a position to
do so much good,” Bledsoe Post
says. But for now, “the stigma is
winning.”about how the employee will
make up for the employer’s flexi-
bility. When caretakers do get the
flexibility they seek, Stewart says,
“they are dedicated, they’ll get the
work done, they’ll give you the
commitment you’re looking for.”
That’s more true in 2022, when
a tight labor market means em-
ployees can be choosy about
where they work. Replacing an
employee can cost between 16
percent and two times that em-
ployee’s salary. Employers have to
balance that cost against having
workers miss work or fall behind
because of the stress of taking
care of a child with mental illness.
The nation’s mental health
supports were overtaxed long be-
fore the pandemic. Between 2007
and 2016 alone, pediatric emer-
gency room visits for mental
health conditions rose 60 per-
cent, and one 2021 analysis found
that children wait an average of
48 hours in the emergency room
before they are transferred to in-
patient mental health facilities.Therapist shortage
Even for less acute crises, the
crunch is real. According to the
American Academy of Child and“A literal tsunami” of eating disor-
ders, depression and anxiety as
engulfed her office, and there isn’t
an end in sight, she says. “There
are still so many patients who are
sicker than they used to be by the
time they [get] care.”
The pediatrician’s own work
life has been complicated by her
11-year-old son’s mental health
challenges.
Diagnosed with anxiety at age
7, he has undergone a variety of
therapies — and when he entered
middle school in 2021, his symp-
toms worsened and he developed
depression, too. Brigham has
been able to juggle his appoint-
ments and stay on top of medica-
tion changes that have helped
him remain in school, but by
virtue only of an understanding
workplace and a part-time sched-
ule that gives her the flexibility
she needs.
But gaining the understanding
of employers requires the risky
self-exposure Stewart studies.
The most successful interactions,
she says, involve “negotiation
with promise” — divulging a
child’s health status, but present-
ing human resources or a supervi-
sor with a proactive promiseplans. But even when parents do
have insurance, it doesn’t neces-
sarily cover the needed treat-
ments. One 2021 study found that
1 in 3 children in the United States
is underinsured. About 40 per-
cent of children with complex
health needs, including the need
for ongoing treatment or medica-
tion for an emotional or behavior-
al health condition, didn’t have
enough insurance to cover their
needs.
That’s a familiar problem for
Sam Cohen, a marketing execu-
tive from New York. His 12-year-
old daughter has dyslexia and
ADHD, and he’s had to take on
extra hours to pay for therapies
that aren’t covered by his insur-
ance. “I have missed work many
times to help her with her strug-
gles,” he says. Though he is open
with his employer, he has told
only his close co-workers about
his daughter’s condition.Pandemic has worsened crisis
The pandemic has deepened
the crisis, says Kathryn Brigham,
an adolescent medicine specialist
at Massachusetts General Hospi-
tal. Since May 2020, she has seen
her patients’ mental health tank.mental health concerns and their
employment. Fifty-four percent
of participants say they’ve sought
professional help for their chil-
dren’s mental health, and 56 per-
cent of those said their child had a
formal mental health diagnosis.
That defies common percep-
tions of child mental health, says
Marti Bledsoe Post, executive di-
rector of On Our Sleeves. “We’re
talking about a much greater pop-
ulation than the often-cited 1 in 5
children with a mental health
disorder, she says.
Those concerns have compli-
cated caretakers’ work lives. Over
half said they’d been interrupted
at work to deal with their child’s
mental health, and 53 percent
said they missed work at least
once a month because of those
concerns. About 50 percent said
they think about their child’s
mental health while working.
And for a subgroup that said their
children’s mental health was dis-
rupting their work lives, 71 per-
cent said their stresses made their
job harder to handle.
Preoccupied parents can affect
businesses’ bottom line. Yet few
caretakers were comfortable dis-
closing their child’s challenges in
the workplace. Only 23 percent
said they would be comfortable
talking to human resources about
those issues; 21 percent said they
were comfortable talking to their
co-workers while 20 percent said
the same about their bosses.
That doesn’t surprise Lisa M.
Stewart, an associate professor in
California State University at
Monterey Bay’s department of so-
cial work. In years of research as
to how and why parents talk to
their employers about their chil-
dren’s mental health, she has
learned that many choose never
to talk about that facet of their
lives at work.
“They really want to control
the flow of information,” she says.
The decision to disclose, she says,
“is fraught with challenges be-
cause of the very real threat of
getting fired and being retaliated
against.”
“The real tragedy is that as a
country, our mental health care is
tied to our employer,” Bledsoe
Post says. The stakes feel precari-
ous for exhausted parents who
say they worry that an employer’s
limited patience could endanger
the therapies, medication and
other modalities they need to
help their children.
According to recent data from
the Census Bureau, 54.4 percent
of insured people in the United
States — more than 177 million in
all — have employer-sponsored
CHILDREN FROM E1
Parents face growing battle to care for their kids’ mental health while working
ERIC PETERSEN FOR THE WASHINGTON POST“Parents aresuffering, and noone should have tofeel like a badparent or a bademployee if theyneed extrasupport.”
Lisa M. Stewart, associate
professor in California State
University at Monterey Bay’s
department of social work