Cutting Off the Help

[Upbeat Guitar Music]

Mike: Welcome, everybody. This is Avoiding the Addiction Affliction, brought to you by Westwords Consulting and the Kenosha County Substance Use Disorder Coalition. I'm Mike McGowan.

Mike: Given everything we read and hear about the increase in people experiencing mental health and substance use issues, you would think getting help for those issues would be increasingly easy, (chuckle) right?

Mike: No, wrong. So many of us rely on insurers when they or family members are in need of higher touch mental health treatment, such as intensive outpatient programs, round the clock care and residential. Well, what happens when the access to that help is denied? That's among the topics we're going to talk about with our guest, Kandyce Walker.

Mike: Kandyce was, and we'll get into this, the chief operating officer and director of nursing at Trauma Recovery Institute in Cedar Park, Texas. Welcome, Kandyce.

Kandyce: Hi, Mike. Thank you for having me.

Mike: Well, it's always good to talk to somebody from Texas. You sound better than I do.

Kandyce: (laugh) Well, you know, depending on the weather.

Kandyce: Every day is something different. We'll see what my mood is like today.

Mike: Hey, we're coming out of winter here. It was minus something last week at this time and now it's 40 some degrees. That's spring, right?

Kandyce: Yeah, that's spring. Exactly. It's coming.

Mike: Before we get into the substance of the conversation, I mentioned in the introduction the Trauma Recovery Institute, you all had to close your doors, right?

Kandyce: We did, actually.

Mike: In August of... and what precipitated that? Because it's germane to our conversation.

Kandyce: Yeah, it actually it goes really right in hand with this conversation that we're having. So, there were a few different things that kind of went into play. But the Trauma Recovery Institute opened in 2001.

Kandyce: Just as a small outpatient, P. H. P. I. O. P. (Partial Hospitalization and Intensive Outpatient Program) The doctor that we're working with, Dr. Colin Ross is very well known for his work with dissociative disorders. So we were actually a very specialized clinic really specifically working with dissociative disorders, but really anybody with trauma. And we realized that there really weren't a lot of P. H. P. I. O. P.'s around that were not connected to hospitals.

Kandyce: And so we decided to open up the facility. I will say that over the four years that we were open or three and a half, we struggled with insurance. It was a constant fight all the time. Every single client. It was never an easy process. As the providers, when you're trying to focus on patient care, which is where your focus should be, instead, you're putting endless man hours into just trying to get paid for your services and don't even get me started on reimbursement rates.

Kandyce: Reimbursement rates. So essentially long story short is in August of 2024, we ended up having to close our doors. We were not making enough money to essentially keep the program open and running at a high quality level.

Mike: I'm shaking my head because this is not a new story and it's frustrating.

Mike: Part of the reason I'm doing what I'm doing today is I got tired, Kandyce, of arguing with insurance companies to get an additional 24 hours with somebody that was going to end up in an ER if we discharge them.

Kandyce: Absolutely. Absolutely. That's why I'm so excited to be here today because this is absolutely a topic that I'm super passionate about because the reality is that people do not come to treatment for mental health or substance abuse because they're doing well in life, right? They are not doing very good. And so when you've got somebody who's already not doing well, they're not handling emotions.

Kandyce: They've got a lot of stuff that's happened to them over their lifetime. Dealing with insurance is an added stressor, right? So it's like, we're trying to get them to be able to learn skills and be able to manage life. And then you throw in insurance that says, Oh, Hey, just kidding. I know you pay a monthly premium, but we're not going to cover this for X Y Z. And they'll give you whatever reason they feel like because every policy is different and every insurance company is different and how they do things are different. And so then the clients have this looming over their head of either A:, how am I going to pay for this? B: you know, am I going to be able to say, am I going to get cut off, my insurance, then what do I do?

Kandyce: And, you know, and a lot of Americans right now can't afford to self pay mental health. So then it becomes this epidemic of, well, if you have money. Then you get treatment. So it's mental health and substance abuse has become a luxury and it shouldn't be a luxury.

Mike: And we'll get into your background in a, in just a little while, but I, I actually ask you to be a part of this after reading an article in ProPublica that chronicled somebody that you worked with.

Mike: And she was getting better. And then the insurance company said, and I love this, Oh, you're getting better. Therefore, you no longer need the treatment.

Kandyce: Exactly.

Mike: What other disease do we do that with?

Kandyce: And I say this all the time where it's like, Okay, here's the trick is you've got to get better, but only get better enough.

Mike: (laugh)

Kandyce: Because if you get too better, then they don't want to approve you. So it's really like a double edged sword. It's like, if you are not getting better, Well, then your treatment's not working and we're not going to cover it. But if they're getting better, then it's, Oh, well, now they don't need your treatment.

Kandyce: And I will tell you, I have personally done many peer to peers. So that's kind of the way that it works in insurance world for those people who don't understand of like, you get the treatment, you can get an authorization, you submit a claim, they can approve or deny for whatever reason they feel like.

Kandyce: And then at that point, now you have to appeal and you have to try to fight to get your money for services you've already provided for someone and so with insurance companies, they will essentially come in when you do utilization review, which is essentially where you discuss the case with them, (air quotes) "discuss" and they will say, Okay, well, we're not approving anymore.

Kandyce: So they need today's their last day.

Mike: Yeah.

Kandyce: Well, how kind is that to just take somebody and say, Hey, you know, this treatment that's really helping you and you're feeling better? Well, it's gone as of today and we have no other options. And so with our facility, one of the reasons that it kind of took a financial hardship is because the doctor and I, we refused to discharge people on the day that insurance denied them. So we would always give them an extra free week to transition. Now is that the right thing to do? Yes. Business wise, is that the right thing to do? It's not for your pocketbook.

Kandyce: You know, so it's like quality care versus money.

Mike: Let's use specifics. We can't obviously use people's names. But this is somebody typical typical, right? She was suicidal, she was depressed, she was cutting up to three times a week And she was getting better.

Kandyce: Right.

Mike: And then the review process, as I recall, one of the doctors took all of seven minutes.

Mike: Seven minutes.

Kandyce: Seven minutes.

Mike: To review a case and say, yeah, I made my determination. Well, okay. Who are they working for?

Kandyce: I like to think that as Americans, we think that our medical doctors are the ones that are deciding what our care is. Unfortunately, it's the insurance companies. Because I've never really understood why if a doctor says, Hey, I have spent time.

Kandyce: I have evaluated this patient. I have determined that this is what the right thing is for them. That an insurance company, medical doctors, a psychiatrist, or whatever doctor he is. Can get on the phone, ask a handful of questions and then say, no. You know, like for instance, for certain clients that are suicidal and they're actively suicidal. I had a client once that was absolutely suicidal. All the documentation to prove it and still got denied. Guess what? We won that appeal. But do you know how many months later? It was eight months later that we finally got paid. So you know what I mean?

Kandyce: It's like all the documentation, they're just taking it. And sometimes it depends. So some insurance companies will use something called a locus. It's called a level of care utilization system. And so it's kind of a questionnaire, but it leaves out all the meat to why a client is there things going on?

Kandyce: So sure objectively that day they might be doing okay. But what else is going on? And so we're not looking at a big picture, they're just looking at like where they're at right in this moment.

Mike: And it also assumes a level of care, a continuum of care that may not exist.

Kandyce: Correct.

Mike: I mean, it's not like you go from floor five to floor four to three to one.

Mike: What if you go from five to there is no 4, 3, 2, and now you're just back in floor one, if that makes sense.

Kandyce: Right. Right. There's a lot of like continuation of care that just kind of falls off. When insurance denies. And the thing is, is that a lot of times, and I'm just going off my personal experience.

Kandyce: And I'm not going to say every single person that we dealt with with insurance was terrible. We had some really great ones. But I can remember very specifically arguing with a utilization rep because she initially was like, I'm not going to approve I. O. P. Level of care. And then after talking to her, she was like, well, no, I'm not going to approve I. O. P., she now needs P. H. P., which P. H. P. Is a level up when the initial part of the call, she was trying to make me go down.

Kandyce: And it was just this back and forth and the argument of well, they're getting better so they, they don't need treatment and I'm like, okay, well, or they're getting worse. A lot of times in treatment and in substance abuse and mental health they go hand in hand, right? And you see these things and it's like they're getting better It's like or they're getting worse.

Kandyce: Sometimes I expect them to get worse before they get better. If you've been dissociating you've been putting down and you've been doing drugs and you're doing all the things to to keep you from dealing with the stuff that's causing these symptoms. When you start bringing it up, you can get worse before you get better because you've got to tackle it.

Kandyce: You got to address it. So having a little bit of setback is kind of really normal when you're going through the scheme of things, but when they take this little snapshot of what's going on and then make a determination without any external factors of what is personally going on in their lives and all that, and they'll cut you off.

Kandyce: No, no, no, I have questions. Just answer the questions. Okay, but you're missing it. You're missing it. And it's just you more, clients are people. They're not numbers.

Mike: And one of the things I don't understand, and I've never really understood this, is that for instance, when that person we're talking about was in discharge, it would have cost, I think the article said 10 grand to keep her in another residential facility for so long.

Mike: Well, she ended up suicidal, redoing stuff. Ended up in ER and the bill to the insurance company ended up not being 10 grand. 60 grand.

Kandyce: Oh, ridiculous.

Mike: That's what I don't understand, Kandyce. It's cost effective to listen to the people doing the treatment. And if I can be cynical, it's almost as though they think you're scamming them, rather than providing accurate information.

Kandyce: Absolutely. And it always felt that way. I think as a provider in dealing with insurance companies, it was kind of a little anxiety inducing for some of my clinicians that had to do peer to peers. Because you don't feel like you're fighting with somebody to help someone.

Kandyce: You feel like you're fighting an enemy and the insurance does kind of become an enemy. But exactly to your point, what ProPublica wrote about was one wonderful, beautiful story that actually reflects so many people with that exact same story. That happened more times than I can count so much so that during UR calls.

Kandyce: I would tell them Okay, well, i'm gonna let you know you're gonna deny this and then this client is going to end up suicidal and they're going to end up at the ER and you're going to end up with inpatient and now you're going to have to start back from inpatient down to P. H. P. to I. O. P. So this actually is going to cost you more money and it could possibly cost this client's life.

Kandyce: I have sat for hours on the phone counseling client, like I'm not a therapist, but talking with clients about their insurance and about the fact that now the one time that they find a place that they feel like they fit in, that they can find similarities in their groups and they're finding treatment that's helped.

Kandyce: It is now ripped away from them. So that hope that they had is now gone. So what is the point in living? Because I had treatment, I was gonna do it, and now I don't have anything, and I'm left by myself again. And so they become suicidal, and then they go to the ER, and the lucky ones go to the ER.

Kandyce: What happens to the ones who don't and then we're losing people over insurance denials when based on the reimbursement rates we got, give me a break. They're not hurting that bad. But I use this analogy all the time because my previous experience was I was a paramedic and then became an RN and then ended up working my way up at Trauma Recovery Institute. But I'm like, okay, if somebody got into a car accident, just think of this. Somebody gets into a car accident and they have broken so many different bones in their body and they got to go to rehab, right?

Kandyce: Cause they can't walk, they can't move. And then insurance company says, okay, well, we're only going to give you three to four days at a time. And then I need you to keep calling to let me know, but after 30 days or 40 days, yeah, you're done and no more treatment that would be cruel and unkind.

Kandyce: So until we can start looking at mental health, just because we visibly can't see what's going on inside. And so we start looking at that the same way as we look at trauma, physical body trauma that you can see, what is the difference?

Mike: None. And you come to this from being an EMT, right?

Kandyce: Correct.

Mike: You got to see the whole spectrum, and you made the choice then to work on this end of the field.

Kandyce: Yeah, and honestly, it was kind of interesting when I first started into mental health, I was like, I don't really have mental health experience. And then I realized, my time as a paramedic gave me a lot of mental health experience. (laugh)

Mike: I would think so. I would think so.

Kandyce: So you get to witness a lot of, you know, some of the most horrific things that, that you can be a part of and you see people go through and then it transitioned pretty well into mental health, but and listen, I'm always been very, very open about my own story.

Kandyce: Really my passion for mental health came from therapy saving my own life. It's something that I have said for a long time, I've done a lot of hours of my own personal therapy, but because I've been through it myself and I've been a client at some point in my life, I understand how they feel because I've been there. And where my life was at versus where it is now, I would have never guessed that this is what would happen. And that's just with treatment, it can really change your life.

Mike: Yeah, I think that story is so typical of a lot of, not all, but a lot of practitioners got into the line of work because they were helped.

Kandyce: Yeah, it will. And especially when you think about like in your lowest times, you're like, I'm never getting out of this. There's no help for me. There really is.

Kandyce: It's the right help, but you got to be able to get to it if you need to use insurance and how many people need to use insurance, a lot. (laugh)

Mike: Is that how you access the help for yourself? How did you end up accessing the help system?

Kandyce: So I actually was able to just save up enough money to where I was able to do therapy enough.

Kandyce: And luckily I just got lucky and I lucked out with the most rockstar therapist ever. And so she was able to get a lot done with what I could do, but I mean, we're running into this pretty much everywhere where individual clinicians and therapists are not getting paneled with insurances because A: it's not worth it, B: the reimbursement rates are trash, C: they're going to have to fight to get their money. And so they're going to a cash pay option, which I understand. They got to make a living. They've got to earn it. But then you've got somebody who's struggling to, they, they're having a hard time even keeping a job.

Kandyce: And now I got to look for $100 to $200 a week for self pay. I mean, it gets pricey. So a lot of people have to use their insurance, but if nobody's taking insurance anymore, then what?

Mike: Well, okay. Let me break that down. Cause this is a conversation, Kandyce, I have a lot with my friends who are therapists.

Mike: If you go to a cash pay system. Well, what's your clientele look like and what do the underserved do? And now we see the Medicaid system. We don't know, but as we sit here, the Medicaid system is being threatened. So what do people do who don't have access to cash? We can't just serve people who can pay.

Kandyce: Yeah. And you know, and I think that that to me is what the sad thing about this is. Which is kind of reverts back to the whole if you have money, you get care, right? So you it's a privilege. You know what people who don't have funds are doing is they're going to you know local community centers and we try to you know stay in contact with all like any kind of programs that offer discounted therapy services and things like that. Now you're going to get what comes with that, which is going to be probably early level clinicians, and there's nothing wrong with it.

Kandyce: Hey, I used to hire early level clinicians all the time and I love them. So no shame on that. But, you know, you're going to have higher turnover because if they're not hardly charging anything, then people are not hardly making anything. And so when you're a new therapist, and you're trying to build yourself up, that works.

Kandyce: But once you get out on your own, you're like, I can make more money. Everybody needs to be able to afford to live. And with cost of living going up as it is, it's making it hard for clinicians and clients, both.

Mike: Well, the case that we're talking about that was in the article, you managed to guide that person back into the appropriate level of care.

Mike: And then how long does it take to acquire the support system and the skills necessary to be in a safe zone?

Kandyce: That's a really great question. And I really think it kind of depends on the client, right. And it kind of depends on where they come in at. How much treatment have they already had?

Kandyce: Where are they at? What are they trying to focus on? I had clients that sometimes they'd come and they would say, I have two weeks and I'm like, all right, get on in here and we're going to do the best we can with the two weeks we got. I had one client with an insurance policy that there was no authorization needed.

Kandyce: And so she was able to stay with us for almost a year. And based on trauma history, she needed it, she needed all of that because we're not talking, I mean, like, of course, we've got anxiety, depression, some of the basic stuff. I always say that, like all of us Americans live with every single day now.

Kandyce: But no, as a joke, but no, a lot of our clients are coming because they have horrific, horrific pasts. Things that we read about with the Jeffrey Epstein stuff and the physical and the sexual and the psychological abuse and these kind of things, they don't get better after 30 days of treatment.

Kandyce: This is a lifetime of abuse and of hurt and of harm. And that doesn't just magically go away because you attend 30 group sessions and a couple individuals, you know what I mean?

Mike: Yeah, and we've had so many people on this podcast and I've worked with so many people over the years who in recovery will drop on you.

Mike: Oh, yeah, and did I talk to you about the sexual abuse that I suffered which is... If they're using substances or they're disassociated, we'll never deal with it. It's only from a safe place that they can deal with some of that really hard stuff to turn that corner and not carry the shame with them.

Kandyce: You literally just hit the exact thing that I learned.

Kandyce: The one thing that I learned in running Trauma Recovery Institute was the number one thing for clients is safety. Safety. They need to feel safe in the environment that they're in. They need to feel safe with the people that they're in the group with, and they need to feel safe with those clinicians that are leading groups, or the clinician that's with them.

Kandyce: So, that's in a facility setting, but in an individual therapy setting. Like that safety and that trust have to be there before they'll open up. And so, that was another thing we would go into with insurance companies, is, you know what, it might take two to three weeks for us to build safety. For us to even build that core, like we are here for you.

Kandyce: We are here to help you. These people have been abused, abandoned, taken advantage of. They come to us with other treatment center trauma, other clinician trauma. They don't trust people. And what I would say. Every time you don't trust me and guess what? If you did, I'd be a little more concerned, right?

Kandyce: Because your entire life has taught you don't trust anybody. So that trust building needs to be built into treatment center times of how much time they're giving but these insurance companies are not looking at our clients as people.

Kandyce: It's all about money.

Mike: Yeah. So what are you doing now?

Kandyce: So I'm actually in the process of moving into actually working for a billing company.

Kandyce: It's a, just a small business billing company. Believe it or not, it's actually the one that I hired and they worked with me. And so we essentially went through the ringer together. And so now my goal is to advocate for clients, facilities, doing appeals like I will fight these insurance companies because I'm now seeing it with other facilities.

Kandyce: So that tells me we weren't the only one dealing with this.

Mike: Oh, no, I think it's endemic. Don't you?

Kandyce: Absolutely.

Kandyce: And until we really start openly talking about it... I do love this new age and era where now we're starting to talk about mental health and substance abuse and how really, truly important this stuff is, but until we can get the word out there of like, hey, these insurance companies got to quit deciding and well, insurance companies deciding what our client care is going to be, our doctors need to do that.

Mike: Yeah. Did you ever, this is going to sound like a weird question.

Kandyce: Go ahead.

Mike: Do you ever see the Incredibles?

Kandyce: Yes.

Mike: Okay. All right. The, the scene we're talking about, if those of you who've seen it know what I'm going to say is where he sits there and he whispers to the woman, I can't tell you what to do, but if I were you, I'd go to this floor and fill out this form and do this as a way to just get more care.

Mike: People need advocates, Kandyce.

Kandyce: Absolutely and that has been my goal since Trauma Recovery Institute closing. I mean, it broke my heart. It broke my heart that we were providing really good care and like top of the level, the clients kept coming back. Our referrals were based on clients telling other clients, like they were our babies.

Kandyce: We loved them. We had an amazing facility. So to see it shut down because of something like this. Now I just use that anger and I fuel it towards advocating for other people because you'll learn a lot and a lot of people really just don't know. And so you go off of like, I don't know, my insurance sent me a bill and then it says I owe this much and I pay it and I just, or they said I can't, you know, they're not going to cover it and now I owe $20,000 like, okay, let's fight this. And I think insurance companies almost kind of they, I don't know, I'm looking for the words.

Kandyce: So it's almost like they are hoping that you don't fight them.

Mike: Right.

Kandyce: Because guess what, then you don't have to pay and sometimes fighting them is exhausting.

Mike: It is. Maybe I should call you Mrs. Incredible.

Kandyce: Yeah, hey, there you go. I'll take it!

Mike: Yeah, it has to, I'll let you go with this. It has to feel good.

Mike: It has to feel good when you help somebody navigate that system.

Kandyce: Absolutely.

Mike: Because who would know how? You and I know the system and we struggle navigating it.

Kandyce: Mm hmm. Even knowing the system, you struggle with it. So people who don't know anything about the system, those are my people.

Kandyce: That's who I want to help because it's unfair.

Mike: I hope you're continue to do it. We can hear the passion in your voice. I'm going to attach. Kandyce's LinkedIn information in case you want to get a hold of her and just continue this dialogue somewhere else.

Mike: Thanks for your passion, your hope, your expertise, Kandyce, this is great.

Mike: For those of you listening, we hope you join us anytime you're able. And until then, we hope that you stay safe. Speak up when you can. And if you're able to, speak up for people who can't speak up for themselves.