Kendra F. Dunlap (2:36)

This process has been very frustrating. You finally get the courage to reach out, just to be kicked to the side and just not feel seen.

Soojin Pak (2:46)

Why is it so hard to find a therapist? Someone who is the right fit, who takes your insurance and has room in their caseload for a new client, it can impossible to find that provider. A recent survey found that 40% of people seeking mental health care had to make four or more calls just to find a provider who would see them. Compare that to physical health care, where only 14% of people face that same runaround. So what's going on? The reality is there just aren't enough therapists that take insurance to serve everyone who needs needs care. Even though nearly all Americans have insurance, only about half of people with mental health issues can access treatment. So why aren't there more therapists in network? To understand why, we'll go straight to the source. Today we're hearing from Kendra F. Dunlap, a trauma focused therapist who chose to leave insurance networks in 2022. Based in Berkeley, California, Kendra runs a practice called Soul Harmony Therapy. Its slogan is where every part of you is welcome. And it's fitting. She's got a warm and comforting presence. For Kendra, becoming a therapist seems like it was always in the cards.

Kendra F. Dunlap (4:09)

I will say that I was always that kid that was really sensitive to people around me. Always that friend that people would come to and talk to, even adults when I was a child. I'm not sure how great that was, but that's who I was. So I would say that even before I came to this profession formally, that's kind of where I started. And then I saw a lot in my own community, in my own family, the impact of mental health challenges, especially when we think about intergenerational trauma, how that shows up, how that shows up physically. So I always knew I wanted to do something in the helping profession.

Soojin Pak (4:50)

Kendra started out in HR but eventually made the jump to get her master's in counseling. Today she specializes in trauma informed therapy and caregiver support. She works primarily with bipoc women, men and caregivers. These are people juggling heavy loads who often come to therapy for the first time, struggling with perfectionism, family pressures and people pleasing.

Kendra F. Dunlap (5:14)

I would say that my practice is rooted in trauma informed, relational and liberation focused approach that really takes into consideration systemic oppression and racism and all those things that impact how we see the world. Most of my clients, I would say, are women. We work a lot on trauma work that can be any trauma. I think of trauma as a spectrum from little T trauma they call it, or big T. Some abuse, lots of self esteem. Again, because I work with high achievers. Those are the people that are the caregivers that always take care of everybody else but find themselves kind of low on the list, if on the list at all. And so yeah, that's my practice.

Soojin Pak (6:04)

And how do you see your own identity informing the way you show up in your practice?

Kendra F. Dunlap (6:10)

I think it's kind of at the heart of it, right? It's how I show up as a black woman in the world, how I've been taught to shrink back sometimes and not speak up, or just how I expect the world to see me. So knowing what that feels like and then having to unlearn some of those messages about who I am in the world, I think informs how I come. I try to be grounded and curious and open. I can't say that I know everybody's experience, even someone that looks very similar to me. I can't promise that I'm going to know their whole experience, but I can promise that I'm going to be curious and open.

Soojin Pak (6:53)

That kind of thoughtful, client centered approach is at the heart of Kendra's work. But for all the meaningful work she does, there's another side. The administrative work of insurance. When Kendra first started her practice, she figured the insurance piece would be manageable. Her HR background had given her plenty of experience.

Kendra F. Dunlap (7:14)

So I felt like, okay, this is pretty easy. I've talked to a lot of colleagues, so I felt pretty comfortable that I would be able to navigate it. And I will say, in 2016, I think that was true. We're in a totally different time now. But back then it was pretty straightforward. Once you got kind of settled in, I thought, okay, this is, this is pretty approachable and doable.

Soojin Pak (7:38)

And then what was sort of the red flag moment for you when you started to realize, wait a minute, this is not what I thought it was going to be. And possibly, I don't know if you thought, oh, is this sustainable?

Kendra F. Dunlap (7:54)

For me it was. I always thought it would be sustainable. Maybe I was a little bit naive, probably so, because it wasn't that difficult. And then 2020 hit, the pandemic hit. And even then I thought, okay, not, you know, it's a little bit more bureaucracy because I think you had a lot more people with a high need. And so there were more people utilizing insurance. We were all kind of tucked in a time. We're working from home and, and so trying to make calls to the insurance company. So I would say it was probably in 2021 in the middle where I thought, I'm spending a lot of my time and energy navigating this system in a way I had never had before.

Soojin Pak (8:42)

What Kendra was experiencing wasn't happening in a vacuum. The pandemic had completely transformed mental health care and frankly, overwhelmed the system. The numbers really tell the story. Adults seeking psychotherapy jumped from about 16.5 million people in 2018 to nearly 20 million by 2021. At the same time, virtual therapy went from practically nothing, just 1% of appointments pre pandemic to over a third of all sessions by 2021. That increased demand has had big effects, consequences we're still dealing with today. Mental health providers often find themselves drowning. Longer wait lists, heavier caseloads, and by 2021, nearly half reported burnout. Kendra was navigating all of these changes within a strained system, while also battling more and more insurance issues. I wanted to understand what that actually looked like day to day. Give me a snapshot of, like, the nitty gritty of what that process was like. And then what changed for you? Like, just process wise.

Kendra F. Dunlap (9:58)

So in 2016, when I started you, you saw a client, you wrote the note, you used the. Whatever portal they had to get the claims paid. The claims were paid within a reasonable amount of time. I would say anywhere from two weeks to 30 days. Reasonable. That's as easy as it was mostly online. I didn't do the paper because I thought, oh, no, I've done that before. I'll do it online. Easy come 20. I would say 2021, 2022. When they had to pivot and go telehealth, they had these antiquated ways that you had to bill and submit claims. And that's fine. At the beginning, we're working out hiccups, right? There's codes you have to use. If you don't use the right codes to get denied, fine. I gave them a couple of months, a year to get it worked out. We're two years in. It is not worked out. And that meant that every week, for every client that I had credentialed with them, I had to call to correct the claim. So I would do the claim. The claim would be denied, not because of anything that I did, but because the system hadn't been updated to take this code. And I'm thinking, we're two years in. I think telehealth is here to stay. When do you think it might get fixed? I kept getting the message that it wasn't a priority and it probably wasn't going to get fixed. That's when I thought, if I have to do this every week for every client that I have, and I'm spending two hours a week being rerouted, having calls hung up, getting different kinds of messages about what I needed to do, I started to really think, was this sustainable? And Especially given the reimbursement rate wasn't great. I thought, I don't know that this is sustainable.

Soojin Pak (11:56)

Talk to me about that reimbursement rate.

Kendra F. Dunlap (11:58)

It was 50 to 60% lower than the market rate for a licensed marriage family therapist in the San Francisco Bay area. So I knew going in, taking insurance, you kind of already know you're not going to get your highest rate or what you can get in the market. And that was fine because I wanted it to be accessible. And if I was not having much problems with the administrative part, I thought, ah, it wasn't so bad. But when I started to really take a look at how much time I was spending a month calling, trying to get paid, really what I realized is I was losing money because I could have taken more clients on, but then that would have meant spending even more time trying to get paid. And it was having to, to call to fix the mistake that wasn't mine.

Soojin Pak (12:52)

Yeah, yeah. On top of the fact that it's already, for lack of a better word, a discounted rate, if you will, so.

Kendra F. Dunlap (12:59)

Exactly.

Soojin Pak (12:59)

You know, to make it accessible, you, you sort of understand that there are trade offs. And then you realize, wait, that trade off now is affecting the way whether I can be a business and whether I can offer this. So at what point did you realize, okay, if I keep doing this, then I don't know that this business can sustain itself.

Kendra F. Dunlap (13:25)

Really what it was about was I wanted to be able to be the most present with my clients and offer the best care that I could, ethically and just morally, that was really important to me. And spending so much time having to do this during the pandemic, when all of us are going through this, myself included, it really started to take a toll on my physical and mental health. And thinking about also how I wanted to show up for my clients, that was really the decision I had to finally come to the conclusion that there might be other ways to bring access to clients without this model, because this wasn't going to be sustainable for me.

Soojin Pak (14:11)

Well, I mean, it's beyond a frustrating experience just hearing this. It's heartbreaking. This is the experience of so many people accessing any kind of healthcare, especially in communities of color and poor communities. That must have been such an emotional toll, sort of struggling with that and you know, on one hand figuring out a way to be there for your clients, but to sort of sit with this dilemma that the reason why you even got into therapy or a lot of it was because you wanted to serve this community, that now you're just like, I don't know that I can in the way that I had wanted to or intended to.

Kendra F. Dunlap (14:55)

Absolutely. And also what was heartbreaking for me is that during this time when there was such a high need and they're still at such a high need. Right. There's a mental health crisis. I was getting about six to 10 inquiries a week from people looking for therapists. And they would say, I can't find someone that represents who I want to work with and how I want to work with somebody. And nobody's taking insurance. And before I decided to not take insurance or get off the panel, I was trying to recruit my colleagues. I have a big group of referral list that I work with and they were like, kendra, we can't. This is not sustainable for us either. And I thought, oh, yeah. And it was hard because people were looking for months or years for a therapist.

Soojin Pak (15:40)

When we come back, what pushed Kendra to a breaking point and how transitioning out of network impacted her clients? That's after the break. Let's be real. Without the black press, who's covering how black Americans are really treated in the healthcare system? Mainstream media barely scratches the surface, but word in black goes deep because lives depend on it. They're reporting the truth about medical racism, black maternal mortality, breast cancer in black women, mental health stigma, all of it. Want to stay informed and empowered? Subscribe to their weekly health newsletter and get the stories that actually put black health first. Go to wordinblack.com that's wordinblack.com and sign up because being informed is how we protect each other. Want to listen to your favorite Lemonada shows without the ads? Subscribe to Lemonada Premium on Apple Podcasts. You'll get ad free episodes and exclusive bonus content from shows like Wiser Than Me with Julia Louis Dreyfus, Fail Better with David Duchovny, the Sarah Silverman podcast, and so many more. It's a great way to support the work we do and treat yourself to a smoother, uninterrupted listening experience. Just head to any Lemonada show, feed on Apple podcasts and hit subscribe. Make life suck less with fewer ads with Lemonada Premium. What do you want people, listeners to understand about what therapists are really up against in the current system and the way that it is set up now?

Kendra F. Dunlap (17:27)

I want folks to understand that it's not just about money. Some of it is about the money because we have to have practices that are sustainable. We have operating costs, cost of living. So I want them to kind of know that I want them to know what we're up against about clawbacks and what clawbacks are for. Folks that don't know is when insurance companies ask for money back that they've already paid the provider. And they'll do that because again, they'll say, oh, you didn't put this in the note, or you didn't put in that. And that is a big fear of clinicians because more and more it is happening and that can be so detrimental to a sole practitioner or even a group. And they can ask for money back almost. It depends on the state, depends on the jurisdiction. But they could go back two or three years. That's a big fear. And you're trying to hold space for your clients while worried if you're going to be able to pay your bills, if you're going to be able to keep your practice open. So I want people to understand that.

Soojin Pak (18:37)

Let's pause on clawbacks. It's a term most people outside the industry have never heard of. But like Kendra said, it's a huge, huge source of stress for in network providers. Basically, an insurance company can demand back money they've already paid a provider, sometimes years after the fact. Maybe they decide the therapy notes weren't detailed enough to justify the treatment or it was the wrong billing code for a small practice. Suddenly owing thousands of dollars you thought you'd already earned can be financially devastating. Like Kendra says, these money issues are just part of a bigger picture. It's all about losing control over how you practice. That's what she wants people to understand.

Kendra F. Dunlap (19:23)

I want them to understand the lack of autonomy, that when we panel with insurances or venture capital companies, they tell you again how you can charge, how you can see clients, also your data. Some of these big companies have had some pretty significant data breaches where they've either sold your personal confidential data, were recording clients sessions without the knowledge of either the client or the clinician because they were going through these VC company platforms. As a clinician, we want to be able to manage how your information is being dealt with your sensitive personal health information. So I want people to understand those are concerns and considerations we're thinking about when we're deciding who we're going to panel with. And just the level of burnout, never. And I have been doing this for 20 years. I'd have to say in the last five years, the level of burnout has never been higher.

Soojin Pak (20:29)

The decision for Kendra to leave networks didn't happen overnight. It was gradual but low reimbursements. Colleagues who were just as Overwhelmed and couldn't take referrals. And underneath it all, attention. She got into this work to help people. But dealing with insurance was like having a second job she never applied for. She told me it was really a series of breaking points that finally pushed her over the edge.

Kendra F. Dunlap (20:55)

One moment in particular is, so sometimes insurance companies, there are different codes that you use to get paid. And there is a code that's a 60 minute code and it's one of the higher reimbursable rates of all the codes. And I do trauma work. So trying to see a client that doing trauma processing for less than an hour, it doesn't work. So I would get letters from the insurance company, they were counseling letters about my use of this code was more than the average clinician, which was not true. And so really what that letter was was it was trying to discourage me from using that code because it's the higher reimbursable rate. And so then I thought, well, now I'm getting a threatening sounding letter. Yeah, that's telling me how long I can provide services to my client, whom I know needs that, that longer processing time. And I think that was one of the kind of moments where I thought, now I'm being told that I can't see my client in the way that I want to do. And I know I wasn't not going to do that because I knew what my client needed. I had the experience and the expertise. I was using a specialized kind of therapy where you need a little bit longer time. I was always also losing a little money on that because I was seeing them longer because I was doing what I knew it was in the best clinical practice. So when I started to get those letters and I thought, okay, I'm not sure I want to deal with this on an ongoing basis. And then I think again, just not being able to be present because I was so focused on the administrative piece. I think those two things where finally the thing that, you know, I had to come to terms with this was the decision.

Soojin Pak (22:57)

Beyond fighting with insurance over billing and coverage issues, Kendra felt pressured to practice therapy in a way that went against her training and experience as a licensed therapist, pushing her to do less trauma informed work. She finally left insurance Networks in the summer of 2022 after being in network for six years.

Kendra F. Dunlap (23:18)

It was hard because then the next part was, how am I going to tell my clients who some of them had been searching for a therapist for months or years. And so that's probably what kept me in it a little bit longer than probably was feasible. Both mentally and physically.

Soojin Pak (23:37)

Yeah. So how did you break the news to your clients? What was that process like, and what was their reaction? Oh, I can already. I can still see it in your face, by the way, as I'm sitting here.

Kendra F. Dunlap (23:48)

Yeah, it's still painful. I have to say, though, at the heart of my work is a relationship. Right. So I'm always transparent with my clients about why I make certain decisions. So I really did share with them some of the reasons why. And I have to say, all of them were lovely about it. They were disappointed, for sure, frustrated, but they were lovely because they understood the impact. But it still didn't make me feel 100% better because I didn't have people to refer them to. Again, most of my colleagues, I belong to a group of clinicians of color. Most of them weren't taking insurance, so I didn't have them as a referral source.

Soojin Pak (24:30)

Instead, Kendra told me she pointed these clients toward insurance panels, networks of therapists created by insurance companies. But she acknowledged that those lists can be difficult to navigate. You call someone and never hear back or find out that they don't take your insurance. After all, these have been called ghost networks, lists that offer providers, but after calling and calling, you still can't find one. It's a widespread issue. After calling nearly 400 mental health providers listed by health plans in New York, the state attorneys are general Office found that 86% were ghosts. For the clients that did stay with Kendra after she stopped taking insurance, she made adjustments to help with the new costs.

Kendra F. Dunlap (25:21)

One way I tried to mitigate that was offering a sliding scale for those clients that stayed, trying to find other options where I could still continue to work with them. That felt sustainable for myself and my practice. For some of them, we were able to do that for maybe 20 to 30%. They had to go back and look for individuals.

Soojin Pak (25:45)

But here's the thing that really gets me. We're all paying monthly premiums for health insurance, right? Yet these same insurance companies are doing everything they can to push therapists out of network. So what exactly are we paying for? We're left with insurance policies that don't really give us access to to quality mental health care at all. Coming up after the break, we'll dig into how all of this hits communities of color especially hard. Plus what you can actually do to find good care when the system feels stacked against you. We'll be right back.

Kendra F. Dunlap (26:34)

Hello, I'm Joelle Brevel, medical mythbuster and.

Soojin Pak (26:38)

Host of the Dose, a health policy podcast from the Commonwealth fund.

Kendra F. Dunlap (26:43)

Each season I sit down with a.

Soojin Pak (26:44)

Leading health policy expert and medical professionals to have real conversations about the issues.

Kendra F. Dunlap (26:49)

That keep them up at night.

Soojin Pak (26:51)

We talk about breakthroughs in their research and their new ideas to make our healthcare system work better for all Americans.

Kendra F. Dunlap (26:58)

This idea of equity needs to be taken up by everyone and wherever you are in your work, whatever sector that you're in, we need to have conversations about what tomorrow looks like.

Soojin Pak (27:14)

I hope you'll check out the Dose and enjoy listening to our interviews. You can find us at TheDOSE show or by searching UPodcast app for the Dose from the Commonwealth Fund.

Kendra F. Dunlap (27:30)

Hi everyone, I'm David Duchovny. Join me on my podcast Fail Better, where we use failure as a lens to reflect on the past and analyze the current moment. I speak with makers and performers like Rob Lowe, Rosie o' Donnell, and Kenya Barris, as well as thinkers like Kara Swisher and Nate Silver to understand how both personal setbacks and larger forces impact our world. Listen to Fail Better wherever you get your podcasts.

Soojin Pak (28:02)

Ghost Networks Therapists Leaving Insurance these aren't the only roadblocks to accessing mental health care. In our conversation, Kendra brought up another big one I had never thought of.

Kendra F. Dunlap (28:14)

If you use insurance, you have to have a diagnostic mental health disorder. You have to be diagnosed. So what they call it is medical or service necessity is the is the term and for a lot of individuals the stigma of a diagnosis, but also the worry about how that's being used again, especially for marginalized and bipoc communities who have historically had these kinds of stigmas attached to them and what it can mean there's a heavier weight for those communities. That was also not something that sat well for my clients. So that's also a deterrent for a lot of clinicians to take insurance.

Soojin Pak (29:02)

That requirement can be a barrier to getting care, especially for people of color. Like Kendra said, that's because of the stigma attached to a diagnosis and the way communities of color have faced discrimination and harmful stereotyping around mental health. This is on top of the other obstacles that people of color face, from finding providers who understand their cultural background to dealing with structural inequities that often leads people of color under, diagnosed and undertreated, even though they're often dealing with more stress from discrimination and financial pressures. And it's a massive equity issue. And what struck me talking to Kendra is how she thinks about the ripple effects when people can't access mental health care, especially for communities of color. I was talking to a doctor, an ob gyn and she was talking about the loss of sort of her department and these hospital closures. And she had said something to the effect of like when you lose a mother, a female, a caregiver, which is generally female in our communities, you lose the entire family. And that kind of popped into my head as you're talking about the types of clients that you have and the stories that you must hear. And when those people don't get to access care, that person's mental health, the ripple effect of that goes so beyond the individual.

Kendra F. Dunlap (30:36)

Absolutely. It's the whole community, it's the whole family. And then we're looking at the generational aspects. Right. If a mom is not getting the help that she needs and she can't be present for her child in the way that she would want to or in the way that that child needs, again, how does that child internalize what that means and then how they choose to see the world and the impacts that it has to their own mental health? And I think if we look at also, I don't know if you've heard of ACEs, Adverse Childhood Experience experiences. So what they do is the more adverse childhood experiences that you have throughout life, especially early on, it correlates a lot to later physical manifestations of that. So coronary disease, diabetes, all these systemic endocrine issues that people can have. And when we look at our communities of color, a lot of our communities of color are dealing with these types of chronic long term medical issues that were impacted by lack of resources, mental health impact. So all of those things are very much connected. So again, if that's not being addressed, the ripple it effects it has on generations and communities is pretty detrimental.

Soojin Pak (32:06)

Therapists like Kendra are trying to break that generational cycle, but they're fighting an uphill battle. So where does that leave people seeking mental health care in an age where a whopping 90% of US adults think we're in a mental health crisis? We need some concrete solutions. I asked Kendra what resources she'd recommend for someone trying to access therapy.

Kendra F. Dunlap (32:30)

There are some directories that are specific for sliding skills. So there are, it's. There's one not for profit organization that you can go online and look for sliding skill, and that's called Open Path Collective. There are other subsidy programs. Open Path is open for everyone. The Love Lounge foundation is specifically for black women and girls. But there are other subsidy programs out there that I think groups are trying to make it accessible for different populations to be able to access therapy.

Soojin Pak (33:05)

Your workplace might also be an option. Many employers Offer something called an eap, an employee assistance program which provides free short term counseling. And don't overlook community resources like county mental health departments or organizations like Mental Health America. They can provide referrals for affordable community mental health services, crisis resources and support groups in your area. These aren't perfect solutions though. And given everything we've talked about, from insurance battles to provider burnout, I had to know what keeps Kendra going. Despite all the issues that both therapists and we as patients, our clients face, despite the world that we live in, despite the climate, despite the incredible burnout. For all of these reasons, is there anything that gives you some hope about the future of mental health care?

Kendra F. Dunlap (34:08)

Absolutely. I think what gives me hope is my clients, the resilient that my clients have, the work that I'm able to do with them, seeing them when they thrive after going through periods of really, you know, difficult situations and points. That's what keeps me in the work and keeps me engaged. It keeps me hopeful when things around us are kind of feel like they are burning down. It's those relationships and seeing that transformation that keeps me helpful and keeps me engaged in this particular field and keeps me wanting to continue to do the work.

Soojin Pak (34:49)

That's not nothing. You know what I mean? We just went.

Kendra F. Dunlap (34:51)

That's not nothing.

Soojin Pak (34:52)

We just went through an hour of a lot of. A lot of not good things. So let's just end it there. Amid a mental health crisis in this country, we need providers who can focus on therapy, not on fighting with insurance companies over coding errors. We need up to date lists of in network therapists so people aren't stuck calling number after number leading nowhere. And we need a system that truly serves everyone, especially communities of color who've been underserved for far too long. When we get this right, when therapists and clients alike have their needs met, the effects ripple outward. Our communities get stronger, our loved ones get better, and we all benefit. There's more Uncared for with Lemonada Premium if you haven't subscribed to Lemonada Premium yet, now's the perfect time. Because guess what? You can listen completely ad free. Plus you'll unlock exclusive bonus content like tips from health experts and caregivers that you won't hear anywhere else. Subscribe now on Apple Podcasts or head to lemonadapremium.com to subscribe on any other app. Or listen ad free on Amazon Music with your prime membership. That's lemonadapremium.com Uncared for is a production of Lemonada Media. I'm your host Soojin Pak Muna Danish is our senior producer. Lisa Fu and Hannah Boomershine are our producers. Our mix is by Ivan Kuraev. Music is by Andrea Christin's daughter. Jackie Danziger is our VP of Partnerships and production executive. Producers are Jessica Cordova Kramer and Stephanie Whittles. Wax this season of Uncared for is presented by the Commonwealth Fund, a nonprofit foundation working toward a health care system where everyone, no matter who they are, where they live or how much money they make, can get the health care they need. Help others find our show by leaving us a rating and writing a review. You can follow me on Instagram at sujumpak and lemonadaemenadamedia across all social platforms. Thanks so much for listening. See you next week. This show is presented by the Commonwealth Fund, a nonprofit foundation whose mission is to promote a high performing, equitable health care system. The Commonwealth Fund supports research to improve healthcare policy and practice and has a long history of exploring what the US can learn from the best healthcare around the world to do better here at home, especially for people of color, people with low income and those who are uninsured. To learn more, visit commonwealthfund. Org.