The Taproot Podcast - Why Can't Psychotherapists Form a Union (Spoiler Alert:They Can't) What is the RUC in Healthcare

Episode Date: January 17, 2026

Can Therapists Start a Union? The Antitrust Trap, the Shadow Committee, and the Economic Strangulation of American Psychotherapy Analyzing America’s Healthcare Regulations and Their Effect on Us: Why the Law Prevents Therapists from Organizing While Allowing a Private Committee to Fix Prices for the Entire Medical System The Monthly Rage Thread If you hang around therapist forums long enough, you will see it happen. It operates with the regularity of the tides. Someone posts a thread, usually after receiving a contract from an insurance company offering 1998 rates for 2025 work, and asks the obvious question: “We are the ones providing the care. The system collapses without us. Why don’t we just all go on strike? Why don’t we form a union and demand fair pay?” It is a logical question. In almost every other sector of the economy, workers who feel exploited band together to negotiate better terms. Screenwriters shut down Hollywood to get paid for streaming residuals. Auto workers walk off the line. Teachers fill the state capitol. Nurses at major hospital systems have successfully unionized and won significant concessions. So why, in the midst of a national mental health crisis, does the mental health workforce remain so politically impotent? The answer is not that we lack will. It is not that we lack organization. The answer is that for private practice therapists, forming a union is a federal crime. This is not a political manifesto. It is an analysis of the bizarre regulatory environment that governs American healthcare, a system of antitrust laws, shadow committees, and bureaucratic classifications that effectively strips clinicians of their bargaining power while empowering the corporations that pay them. If you want to understand why corporate tech monopolies are ruining therapy, or why the corporatization of healthcare feels so suffocating, you have to understand the legal straitjacket we are all wearing. And you have to understand the one group that is allowed to set prices, the one group exempt from the rules that bind the rest of us. Part I: You Are Not a Worker, You Are a Standard Oil Tycoon The primary reason therapists cannot unionize dates back to the era of oil barons and railroad tycoons. The Sherman Antitrust Act of 1890 was designed to prevent massive corporations like Standard Oil from colluding to fix prices and destroy the free market. It prohibits “every contract, combination… or conspiracy, in restraint of trade.” The law was a response to genuine abuses: companies buying up competitors, dividing territories, and coordinating prices to gouge consumers who had no alternatives. Here is the catch: In the eyes of the federal government, a private practice therapist is not a “worker.” You are a business entity. Even if you are a solo practitioner struggling to pay rent in a subleased office, seeing clients between crying in your car and eating lunch at your desk, the law views you as the CEO of a micro-corporation. You are classified as a 1099 independent contractor, not a W-2 employee, and that distinction makes all the difference in the world. If two workers at Starbucks talk about their wages and agree to ask for a raise, that is “collective bargaining,” which is protected by the National Labor Relations Act. But if two private practice therapists talk about their reimbursement rates and agree to ask Blue Cross for a raise, that is “price-fixing.” It is legally indistinguishable, in the eyes of the Federal Trade Commission, from gas stations conspiring to raise the price of unleaded. It sounds absurd, but the FTC takes it deadly seriously. When independent contractors organize to demand higher rates, when they share information about what they are being paid and coordinate their responses, they are engaging in horizontal price-fixing, one of the most serious violations of antitrust law. The Sherman Act provides for criminal penalties, including fines and imprisonment. The law that was meant to break up monopolies is now used to prevent social workers from asking for a cost-of-living adjustment. The irony is crushing. The same regulatory framework that prevents two therapists from discussing their rates allows massive insurance conglomerates to merge repeatedly, concentrating buyer power in fewer and fewer hands. UnitedHealth Group, for example, has acquired dozens of companies over the past two decades, becoming the largest healthcare company in the United States. When they offer a “take it or leave it” contract to providers, they do so with the full knowledge that fragmented, legally prohibited from organizing therapists have no counter-leverage. The antitrust laws, designed to prevent monopoly power, have created a system where sellers are atomized and buyers are consolidated. Economists call this “monopsony,” and it is precisely the market distortion the Sherman Act was supposed to prevent. Part II: The Day the “Learned Profession” Died For a long time, doctors and lawyers thought they were exempt from these laws. They argued that they were “learned professions,” not mere tradespeople, and therefore above the grubby laws of commerce. They believed that their ethical obligations to patients and clients set them apart from the rules that governed steel mills and meatpacking plants. Medicine was a calling, not a business, and surely the government would not regulate the sacred doctor-patient relationship as if it were a commercial transaction. That illusion was shattered in 1975 by the Supreme Court case Goldfarb v. Virginia State Bar. The case involved lawyers, not doctors, but its implications cascaded through every licensed profession in America. The Goldfarbs were purchasing a home and needed a title examination. The Virginia State Bar had established a minimum fee schedule for such services, and every lawyer they contacted quoted the exact same price. They sued, arguing that this fee schedule was illegal price-fixing. The Supreme Court agreed. In a unanimous decision, the Court ruled that professional services, including legal and medical advice, are “trade or commerce” subject to antitrust laws. The “learned profession” exemption, which had been assumed but never explicitly established in law, was declared a myth. “The nature of an occupation, standing alone,” the Court wrote, “does not provide sanctuary from the Sherman Act.” This ruling was intended to lower prices for consumers by preventing lawyers from setting minimum fees, and in that narrow sense it was a good thing. But in healthcare, it had a catastrophic side effect: it made it illegal for doctors and therapists to band together to resist the pricing power of insurance companies. The “learned profession” exemption is dead. We are now just businesses, and businesses are not allowed to hold hands. This creates the illusion of progress: we have “free market” competition among providers, but monopsony power among payers. It is a market where the sellers are forbidden from organizing, but the buyers are allowed to merge until they are too big to fail. The result is not a free market at all. It is a market designed to transfer wealth from one class (providers) to another (insurers and administrators), with the law itself serving as the enforcement mechanism. Part III: The Cartel in the Basement If therapists cannot collude to set prices, surely nobody else can, right? Wrong. There is one group in American healthcare that is allowed to meet in a room, decide what every doctor’s time is worth, and set prices for the entire industry. It is called the RUC, the AMA/Specialty Society Relative Value Scale Update Committee. And understanding the RUC is the key to understanding why talk therapy is dying in the medical model, why psychiatrists abandoned the couch for the prescription pad, and why your insurance company offers you a ghost network of providers who never answer the phone. The Birth of a Shadow Government To comprehend the current crisis in mental health economics, one must excavate the foundations of the physician payment system. Prior to 1992, Medicare reimbursed physicians based on a system known as “Customary, Prevailing, and Reasonable” charges. Under this system, physicians were paid based on their historical billing charges. It was inherently inflationary; it rewarded those who raised their fees most aggressively and created wide geographic disparities for identical services. In response to spiraling costs, Congress passed the Omnibus Budget Reconciliation Act of 1989, mandating a transition to a fee schedule based on the resources required to provide a service. This birthed the Resource-Based Relative Value Scale. The intellectual architecture for this system was developed by a team of economists at Harvard University, led by William Hsiao. Hsiao’s team sought to create a “unified theory” of medical value, attempting to quantify the “work” involved in disparate medical acts, comparing the cognitive intensity of a psychiatric evaluation with the technical skill of a hernia repair. The Harvard study was revolutionary. It promised to level the playing field, suggesting that cognitive services, the thinking and talking that comprises primary care and mental health, were vastly undervalued relative to surgical procedures. Had Hsiao’s original recommendations been implemented purely, the income gap between generalists and specialists might have narrowed significantly. But the administrative complexity of assigning values to over 7,000 Current Procedural Terminology codes overwhelmed the Health Care Financing Administration. Into this administrative vacuum stepped the American Medical Association. The AMA, fearing that the government would unilaterally set prices, proposed a “partnership.” They would convene a committee of experts to maintain and update the relative values, providing this labor-intensive service to the government at no cost. The government accepted. Thus, in 1991, the RUC was born, not as a government agency, but as a private advisory body with unparalleled influence over public funds. The Architecture of Control The RUC’s claim to legitimacy rests on its status as an “expert panel.” But a structural analysis of its composition reveals a profound bias that mimics the governance of a cartel designed to protect incumbent interests. The committee consists of 32 members, but power is concentrated in the 29 voting seats. Of these, 21 seats are appointed by major national medical specialty societies. The distribution is not proportional to the volume of services provided to Medicare beneficiaries, nor is it proportional to the physician workforce. Instead, it is frozen in a historical moment that favored high-technology specialties. Primary care physicians, who perform roughly 45 to 50 percent of Medicare work, hold approximately 4 to 5 seats, giving them about 17 percent of the vote. Procedural and surgical specialties, including surgery, radiology, and anesthesiology, hold 15 to 18 seats, giving them roughly 60 percent of the vote despite performing only 35 to 40 percent of Medicare work. The American Psychiatric Association holds a single seat. One seat. This lone representative must negotiate with a supermajority of specialists, neurosurgeons, cardiothoracic surgeons, radiologists, and ophthalmologists, whose financial interests are often diametrically opposed to the valuation of cognitive work. The cartel dynamic is enforced by a statutory requirement of budget neutrality. The Medicare Physician Fee Schedule is a zero-sum game. If the total relative value units projected for a given year exceed the budget, a “scaler” is applied to reduce the conversion factor, effectively cutting everyone’s pay. Therefore, any proposal to increase the value of psychotherapy, which would increase the total RVU spend, effectively asks every surgeon in the room to take a pay cut to fund the raise for psychiatrists. Given that a two-thirds majority is required to pass a recommendation, the procedural bloc holds absolute veto power over any redistribution of wealth. The Secret Chamber A hallmark of cartel behavior is the restriction of information. For nearly two decades, the RUC operated in near-total secrecy. While recent years have seen minor concessions to transparency, such as the publication of vote totals, the core deliberative process remains opaque. RUC meetings are private. The public, the press, and even non-RUC physicians are largely barred from attending the deliberations where billions of tax dollars are allocated. Participants, including the specialty advisors who present data, must sign strict non-disclosure agreements. These agreements prevent them from discussing the specific tradeoffs, deals, or arguments made within the chamber. A former RUC participant described these agreements as “draconian,” designed to insulate the committee from public accountability. The Government Accountability Office and the Center for American Progress have noted the inherent conflict of interest. The individuals setting the prices are the same individuals who receive the payments. Unlike a regulatory agency, where officials are salaried and divested of industry assets, RUC members are practicing physicians whose personal incomes are directly tied to the decisions they make. This secrecy serves a functional purpose: it allows for “logrolling.” A representative from Orthopedics might support an inflated value for a Cardiology code in exchange for Cardiology’s support on a Knee Replacement code. This “I’ll scratch your back” dynamic creates an upward pressure on procedural values that excludes those outside the dominant coalition, specifically primary care and mental health. The Antitrust Shield Why has the Department of Justice not broken up this cartel? The legal shield is the Noerr-Pennington Doctrine. This Supreme Court doctrine establishes that private entities are immune from antitrust liability when they are petitioning the government. Because the RUC technically only “recommends” values to CMS (that is petitioning), and CMS “decides” (that is government action), the RUC is protected by the First Amendment right to petition. This legal loophole allows the RUC to operate with monopolistic characteristics without fear of prosecution, provided CMS continues to go through the motions of “reviewing” the recommendations. And CMS accepts those recommendations over 90 percent of the time. Because private insurance companies generally base their rates on Medicare, this private committee effectively sets the price of healthcare for the entire country. If independent therapists did this, if they gathered in a room and agreed on what their services should cost, they would face criminal prosecution. But because the RUC operates under the fiction of “advising” the government, it is protected. The same regulatory framework that criminalizes therapist solidarity provides cover for industry-wide price coordination by the most powerful medical specialties. Part IV: The Mechanics of Suppression To control a market, one must control its currency. In American medicine, that currency is the Relative Value Unit. Every medical service, from a 15-minute therapy session to a heart transplant, is assigned a total RVU value. This value is the sum of three components: the Work RVU, which accounts for physician time, technical skill, mental effort, and judgment; the Practice Expense RVU, which covers overhead costs like rent, staff, and equipment; and the Malpractice RVU, which reflects professional liability insurance costs. The Work RVU, which comprises roughly 50 to 55 percent of the total value, is determined by RUC surveys. When a code is flagged for review, the relevant specialty society distributes a survey to a sample of its members. These respondents are asked to estimate the time and intensity of the service compared to a “reference service.” This methodology violates several principles of statistical validity. The surveys are voluntary and distributed by the specialty societies themselves. The respondents are typically those most active in the society and most invested in maximizing reimbursement, advocates rather than neutral observers. The sample sizes are often shockingly small; RUC surveys frequently rely on fewer than 50 or 70 respondents to set the price for services performed millions of times annually. A sample of 30 orthopedic surgeons might determine the value of a procedure costing Medicare billions. The Time Arbitrage The most critical variable in the RUC equation is time. The Work RVU is conceptually derived from the formula: Work equals Time multiplied by Intensity. Therefore, inflating the time estimate is the most direct route to inflating the price. Independent studies by RAND and the Urban Institute, often using objective data like Operating Room logs, have consistently shown that the RUC overestimates the time required for surgical procedures. A procedure valued by the RUC as taking 60 minutes may, in reality, take 30 minutes. This creates an arbitrage opportunity. If a gastroenterologist can perform a “60-minute” colonoscopy in 20 minutes, they can effectively perform three procedures in the time allotted for one. They bill for three hours of work in one hour of real time. This “efficiency gain” is captured entirely by the physician as profit. Psychotherapy cannot utilize this arbitrage. CPT codes for psychotherapy are explicitly time-based in their definition. Code 90832 requires 16 to 37 minutes. Code 90834 requires 38 to 52 minutes. Code 90837 requires 53 minutes or more. A psychiatrist cannot perform a 60-minute therapy session in 20 minutes; doing so constitutes fraud. Therefore, the revenue of a psychotherapist is capped by the linear passage of time. They can sell, at maximum, roughly 8 to 10 units of labor per day. A proceduralist, aided by RUC-inflated time assumptions, can sell 20 or 30 units of “RUC time” in the same day. This structural discrepancy creates a widening income gap that no amount of “hard work” by the therapist can close. It is not a market failure. It is market design. The “Thinking” Penalty The RUC’s bias is not merely structural; it is philosophical. The committee, dominated by surgeons and proceduralists, consistently values “doing things to people,” cutting, scanning, injecting, far more highly than “talking to people,” diagnosing, counseling, managing complex chronic conditions. This creates a regulatory environment that functions as a de facto wealth transfer from cognitive care to procedural care. In 2013, a major revision of psychiatry codes exposed this bias in stark relief. Previously, psychiatrists used codes that bundled the medical evaluation with the psychotherapy. The new system required psychiatrists to bill an E/M code for the medical management plus an “add-on” code for psychotherapy. While intended to improve transparency, this change exposed psychotherapy to the raw mechanics of the RUC’s valuation bias. By isolating the “therapy” component, the committee could subject it to rigorous cross-specialty comparison. And the committee, dominated by surgeons, views “talking to a patient” as low-intensity work compared to “operating on a patient.” The economic signal was clear. This created the 15-minute med check culture not because psychiatrists stopped caring, but because the regulatory environment made relational care financial suicide. It effectively “illegalized” the practice of deep, slow psychiatry for anyone who wanted to take insurance. Part V: The “Messenger Model” and Other Legal Fictions When therapists ask about collective bargaining, lawyers will often point them to the only legal loophole available: the “Messenger Model.” In this model, a third party (the messenger) acts as an intermediary between a group of providers and an insurance company. The messenger takes the insurance company’s offer and conveys it to each therapist individually. Each therapist must then make a unilateral, independent decision to accept or reject it. The messenger is strictly forbidden from negotiating. They cannot say, “The group rejects this.” They cannot say, “We want 10% more.” They cannot advise the therapists on what to do. They can only carry messages. This is why “Independent Practice Associations” are often toothless. In the 2008 case North Texas Specialty Physicians v. FTC, the Fifth Circuit Court of Appeals made clear that if an IPA actually tries to leverage its numbers to demand better rates, it violates antitrust laws. If it follows the messenger model, it has no leverage. It is a “heads I win, tails you lose” regulatory structure designed to protect payers, not providers. The only exception is “clinical integration,” where providers genuinely merge their practices, share infrastructure, and accept joint financial risk. But this requires substantial capital investment and essentially means ceasing to be an independent practitioner. It is a legal pathway available mainly to large physician groups and hospital systems, not to solo therapists working out of rented offices. Part VI: Market Distortions and the Flight to Cash When a cartel sets a price below the market equilibrium, suppliers exit the formal market. This is precisely what has happened in psychotherapy. Mental health providers generally have lower overhead than surgeons. They do not need MRI machines or sterile surgical suites. And they face high consumer demand; the national mental health crisis ensures a steady stream of people seeking services. This gives them an “exit option” that proceduralists do not have. They can refuse to accept insurance and operate as cash-only businesses. The statistics are stark. Nearly 50 percent of psychiatrists do not accept commercial insurance, compared to less than 10 percent of other specialists. A 2023 survey indicated that 64 percent of private practice therapists planned to increase their cash-pay rates. Research published in Health Affairs Scholar found that patients are 10.6 times more likely to go out-of-network for mental health care than for medical/surgical care. This mass exodus is a rational economic response to RUC-suppressed rates. If the RUC says an hour of therapy is worth $100 via the RVU-to-dollar conversion, but the market demand is willing to pay $250, the provider will leave the RUC-controlled sector. They are not abandoning their profession; they are abandoning a pricing regime that values their work at less than half its market rate. Ghost Networks The RUC’s pricing failure creates “Ghost Networks,” directories filled with providers who are ostensibly “in-network” but are functionally inaccessible. They are either full, not accepting new patients, retired, have moved, or simply do not respond to inquiries from insurance-based patients because the administrative burden of prior authorizations and clawbacks outweighs the suppressed fee. This is not a “shortage” of providers in the absolute sense. There is no shortage of therapists in private practice. There is a shortage of therapists willing to work at the RUC-determined price point. The insurance directories are graveyards of phantom availability, creating the illusion of access where none exists. The Cost Paradox The central thesis of the RUC’s defenders is that they “control costs.” By strictly managing RVUs, they claim to save taxpayer money. In psychotherapy, this logic backfires catastrophically. By suppressing reimbursement rates to a level that drives providers out of the network, the RUC forces patients into the cash market. The theoretical in-network cost might be a $20 copay with the insurer paying $100. The actual out-of-network cost is $250 cash out-of-pocket, paid in full by the patient. Thus, the “cost of therapy” for the consumer skyrockets. Therapy becomes a luxury good, accessible only to those with disposable income. For the poor and middle class, the “cost” is effectively infinite, because the service becomes inaccessible. The RUC’s cost-control measure for the system becomes a cost-multiplier for the patient. It shifts the financial burden from the risk pool, where it belongs, to the individual, where it causes maximum harm. The Signal to Students The RUC sends powerful economic signals to medical students making career decisions. When a student observes that a dermatologist or radiologist can earn $500,000 working regular hours, while a psychiatrist earns $240,000 handling emotional trauma and on-call emergencies, while a primary care doctor earns even less, the choice is clear for those motivated by financial security. The undervaluation of cognitive codes discourages the best and brightest from entering mental health and primary care. The cartel’s pricing structure creates a perpetual labor shortage in the fields most needed for public health, while creating a surplus in high-margin procedural specialties. We then wonder why there are not enough psychiatrists, why primary care is in crisis, why mental health access is collapsing. The answer is in the price signal, and the price signal is set by a committee of proceduralists meeting behind closed doors. The Hands Are Tied The question “Why can’t therapists start a union?” is not just a labor question. It is a window into the broken soul of American healthcare. We have built a system where a secret committee of proceduralists can legally fix prices to favor surgery over therapy, but a group of social workers cannot band together to ask for a living wage. We have utilized laws meant to break up Standard Oil to break up the solidarity of caregivers. The same regulatory framework that criminalizes therapist coordination provides legal cover for industry-wide price coordination by the most powerful medical specialties. The result is a regulatory environment that drives doctors crazy, burns out therapists, and leaves patients navigating a fragmented, assembly-line system that was never designed to heal them. It was designed to process them. Until we confront the legal architecture of this system, the RUC, the Sherman Act, the 1099 trap, we will remain powerless to change it. And the reality of therapy is that quick fixes, whether in treatment or in policy, usually end up costing us more in the end. Some states are beginning to push back. New York and California have implemented strict network adequacy standards requiring mental health appointments within 10 business days. These regulations force insurers to expand their networks, which means they must attract providers, which means they must raise reimbursement rates above the RUC/Medicare floor. It is effectively a state-level override of the RUC cartel, forcing capital back into the mental health labor market. The Medicare Payment Advisory Commission has long advocated for stripping the RUC of its power, proposing the use of empirical data, tax returns, payroll records, practice invoices, to set values automatically. But these are patchwork solutions to a systemic problem. The fundamental issue remains: we have created a healthcare system that knows the price of everything and the value of nothing. We have engineered a system where the only way to survive is to stop acting like a healer and start acting like a factory. And we have wrapped this system in a legal framework that criminalizes resistance while protecting the status quo. The hands are tied. But at least now we can see the ropes. Bibliography For those interested in the primary sources and legal texts that underpin this analysis, the following external resources provide high-trust verification of the claims made above: Goldfarb v. Virginia State Bar, 421 U.S. 773 (1975): The Supreme Court decision that ended the “learned profession” exemption from antitrust laws. Read the Oyez Summary. The Sherman Antitrust Act (15 U.S.C. §§ 1–7): The foundational text of US antitrust law prohibiting restraint of trade. Read the Document at the National Archives. North Texas Specialty Physicians v. Federal Trade Commission (5th Cir. 2008): A key ruling establishing that independent physicians cannot collectively bargain on fees without financial integration. Read the Court Opinion. FTC/DOJ Statements of Antitrust Enforcement Policy in Health Care (1996): The federal guidelines explaining the “Messenger Model” and the narrow exceptions for clinical integration. Read the Guidelines (PDF). The RUC (AMA/Specialty Society RVS Update Committee): The AMA’s own description of the committee structure and its role in valuing physician work. Visit the AMA RUC Page. “Special Deal” by Haley Sweetland Edwards (Washington Monthly, 2013): An investigative deep-dive into how the RUC operates and its impact on primary care vs. specialty pay. Read the Investigation. The National Labor Relations Act (NLRA): The law governing the right to unionize, which specifically excludes independent contractors. Read the NLRA. Laugesen, Miriam J. Fixing Medical Prices: How Physicians Are Paid. Harvard University Press, 2016. The definitive scholarly analysis of the RUC’s history, structure, and influence on American healthcare pricing. Government Accountability Office. “Medicare Physician Payment Rates: Better Data and Greater Transparency Could Improve Accuracy.” 2015. GAO’s critical analysis of RUC methodology and conflicts of interest. Center for American Progress. “Rethinking the RUC.” 2015. Policy analysis of the RUC’s structural bias against primary care and cognitive services. Health Affairs Scholar. “Insurance Acceptance and Cash Pay Rates for Psychotherapy in the US.” 2023. Empirical research on out-of-network utilization in mental health care. Medicare Payment Advisory Commission (MedPAC). “Report to the Congress: Medicare and the Health Care Delivery System.” 2024. Annual policy recommendations including proposals for reforming physician fee schedule methodology. Joel Blackstock, LICSW-S, is the Clinical Director of Taproot Therapy Collective in Hoover, Alabama. He specializes in complex trauma treatment and writes at GetTherapyBirmingham.com.  

Down in the basement It's cheap Hey guys, it's Joel And thank you for listening To the Taproot Therapy Collective podcast This will be the last part, Part four of our kind of talking about Some of the technical parts of health care

That may not be interesting to everybody, but this is the last one, which covers some of the economic stuff. You know, the first two were on the DSM, you know, looking at one disorder in the DSM and then a deeper dive into some of the history of the kind of, the kind of contradictory assumptions, I think, are in the document and why they won't be leaving

anytime soon unless the system changes quite a bit. So this one is on some of the regulatory aspects that limit innovation and drive up the cost of health care, especially psychotherapy, which is my area of practice. So, you know, if you hang around therapy, watercoolers, online forums like the, you know, clinical directors, Facebook group or the, um, private practice, you know, subreddit or something, you see all over again, you know, people start asking, you know, like, why are we the ones providing care while the system collapses and we have all of this, uh, our rates get driven down, you know, like I get, uh, network with a, uh, insurer and then, uh, I'm already, you know, taking a, uh, hit to be a network

and take an insurance remit and then I get contacted by multi-plan and they say, hey, if you want that Blue Cross Blue Shield remit like in the next four weeks instead of longer, why don't you just go ahead and take half and then you'll just get half as much? And then that way we'll process the paperwork more timely. Or you get contacted by a patient who thinks that they have Blue Cross and they type the information in, but it really is an insurance company where one of these little scam companies went to their, you know, uh,

group and said, hey, we'll just manage the mental health portion. And it'll be exactly like Blue Shield. It's just that you get a little bit of money back and like it's weird more efficient. And then it turns out that what they're going to do, what's just like Blue Cross Blue Shield is that when you go to a Blue Cross Blue

Shield therapist, they call them and say, hey, the patient doesn't really have Blue Cross Blue Shield. But instead of 250 or, you know, the insurance remit rate, why don't we give you, uh, 60 bucks.

Um, does that work? And if not, we're going to tell the patient that you wouldn't play ball. And then they're going to have to go to another provider. And you're already three sets. and with the person who thought that they had Blue Cross because the plan was fraudulently advertised as being just like Blue Cross.

I wish Blue Cross would go after those guys while we're talking about it. I don't know why they don't because they market illegally all the time. And I tell their clinical director every time I hear from her and they have not changed their practices. I won't mention the name of the company, but you could probably figure it out if you live in Birmingham. And you Google Birmingham in two other words. But it's a logical question, right?

Like why don't therapists, if they're so important, make more? and then if a therapist is a EMDR specialist and they make $300 an hour, that looks pretty good. I don't make $300 an hour. You don't really see all the costs that are built into that, which I'm not even really going to go through professional liability insurance and just like all the ways that that $300 is cut up. An hour of therapy is not really an hour of therapy.

It takes another hour to chart and usually about 30 minutes to plan and review. But, yeah, it's a question that makes sense. So, you know, auto workers form unions, teachers, fill unions, nurses, have unions. So why are they not like a therapist union that all of the therapists in the state can go to and or the country and say, hey, this is what we're working for and you need to find it in your coffers to pay for it. So it's not coming out of the patient's pocket. And it's not coming out of my lifestyle. You know, most of us are smart enough to do something else that would make us more money. Most good therapists are. And the answer is that, you know, those structures feel the same.

but therapists are mostly paid by one or two organizations, but for some reason, the way we regulate, they're not able to form a union. This is just kind of examining health care. I'm not actually advocating for a therapy union and for reasons in the article, it'll be clear that that's not possible. But it is something that you think about.

So this is not a political thing about pro-con unions. It's just looking at the way that we call the same thing by different names and illegal by one name, legal by another, So it's a weird regulatory environment. And the real reason that therapists can't unionize, you know, it goes back to the era of oil barons and railroad tycoons. So you have like the Sherman Antitrust Act, which I think is before 1900 even, probably just before, but around then. And it's designed so that giant companies like standard oil can't collude to price fix and destroy the free market.

Because what standard oil would do if you remember the T. pot dome scandal and you know that part of your history book which most people don't was they would go in and they would sell oil cheaper than it actually cost to make it so they would lose money and people would buy the oil from standard and it would put everybody who couldn't eat you know what was the equivalent of millions of dollars of losses at the time out of business and then they would jack it up and double the price and no one was competing with them which you know people saw that looked bad um we like monopolies now i mean what's a competitor to amazon i can't really think of one. So this isn't used a whole lot, but believe you me, if therapists unionized,

it would be used. So this law was a response to the genuine abuses, the companies that were basically trying to have a monopoly and become, you know, separate from the state, but the sole provider of something that everyone in the country needed or a large portion. And so it's a good law. I mean, I support the Sherman Antitrust Act. But here's the catch, you know, in the eyes of federal government, a private practice therapist is not a worker because we're not employed by the same person, even though we're usually paid by the same, you know, insurance entity. We're just a business. I'm an LLC. I contract with Taproot. You know, a percentage of my income goes back to make my collective run, just like every other therapist that runs there. We all have the same rate. And,

you know, if you are a solo practitioner struggling to pay rent in a sub-lease office, seeing clients between crying in your car and eating lunch at your desk and, you know, rocking back and forth, biting a washcloth and your tub crying, you know, the law views you as the CEO of a micro corporation. And so you're classified as a 1099 independent contractor, you know, or a W-2 employee, but usually those are at smaller places, you know, where the union might be three or four people. So it doesn't really work. And then also the provider isn't the one really paying you because somebody else is paying them, the insurance company.

So, you know, if you said, hey, pay us more than the insurance company pays you, Mr. owner at a five-person company or will leave, then the then. business would fail because they're just not going to be able to pay you more money than they get paid. It doesn't make sense. So if two workers at a Starbucks talk about their wages and they agree to ask for a raise, that's collective bargaining because they both work for Starbucks. The National Labor Relations Act protects them. But if two private practice therapists talk about their reimbursement rates and then they agree to ask Blue Cross for a raise

and then maybe I call 50 of my friends in the state and ask them to call 50 of their friends, that's price fixing. That's illegal. I can't do that. If I get on a subreddit and I say, hey, I think that we should all hold tight and leave the Union, you leave the Blue Cross Network until they make us get paid this or something, which again,

an example, I'm not advocating for that. I'm not saying that I want Blue Cross three minutes to go up. I'm just saying that that would be, how much noise I made may or may not make somebody pay attention to me, but as soon as I start doing it, it's illegal. So it sounds absurd, but the FTC takes that seriously. And it's not absurd in a lot of things. Those laws should be there.

They're not bad. We've strung them together in a weird way that I'll get to, but independent contractors organized to demand higher rates, and when they share information about what they're being paid and coordinate their responses, they're engaging in horizontal price fixing, which is one of the most serious violations of the antitrust law. So the Sherman Act provides criminal penalties, fines imprisonment, you know, all that,

that laws let you break up monopolies, and it now is used to prevent social workers from asking for a cost of living adjustment, which I'm not the only profession that's been hit by that. If you look at the cost of living over time, everything costs way more. Inflation takes a chunk, and we don't really make more than we used to. Just average workers, millionaires make more. But until you start getting up into the hundreds of thousands,

you know, average incomes are not really going up unless you're super wealthy. So for a long time, doctors and lawyers thought that they were exempt from these laws. And they, you know, argued and they were learned professions, not mere tradespeople. And so they were above the grubby laws of commerce. But then they believed that their ethical obligation, to patients and clients set them apart from the rules that governs steel mills and meatpacking plans. And so medicine was a calling, not a business. It was, doctors were seen as sort of like secular priests in a sense, and lawyers as kind of like rogue agents and under the just culture.

And so surely the government's not going to regulate this sacred patient doctor relationship if it was just like it was a commercial transaction, you know, that is a long time ago. But in 1975, the Supreme Court case, I think it was goldfarb versus. I don't know, someone in Virginia. They, the case took lawyers, not doctors, but its implications cascaded through every licensed profession in America. So the Goldfarbs were purchasing a home. A lot of, just as an aside legally,

a lot of things that affect doctors also affect lawyers and vice versa. It's like a profession that is, they're the top of the food chain professions kind of for what they do. And so anyway, the Virginia state bar probably, you know, had these minimum fees for services. And every lawyer that they contacted quoted the exact same price. And so they sued arguing that this fee scheduling was illegal because obviously they're talking. They're all saying like none of us are going to work for less than this. And so the Supreme Court agreed in a unanimous decision, the court rules that professional services,

including legal and medical advice or trade or commerce. and so they're subject to antitrust. So learn professional exemption, which had been assumed but never really established, was declared a myth. This is not real. The nature of an occupation standing alone, the court says, doesn't mean that it is not the Sherman Act.

So just because you're working in a single office doesn't mean that you can call your friends because you don't work for the same company. You don't all work for the auto GM. And so this ruling was intended to lower prices for consumers by preventing lawyers from setting minimum fees. And in the narrow sense, it was good, but in health care, it had a catastrophic side effect. It may do the legal for doctors and therapists to band together to resist the pricing power of insurance companies.

And so the learned profession, because, you know, it's we all work for the insurance company, basically. It's very hard, at least a lot of people's goal is to get to a point where they don't have to take insurance. But it's very hard to start a practice with one. And it's definitely very hard to run a big practice, which the, you know, geographically, you need some of each for different reasons. but we're now just businesses, and businesses are not allowed to hold hands, even though we're all technically, quote, unquote, working, getting an insurance remit from the same person. So there's this illusion of progress that we have this free market to compete among providers,

but there's still somebody who's really setting the rate. And so this power among payers, you know, it's this market where sellers are forbidden from organizing, but the buyers are allowed to merge until they are too big to fail. So the thing that is your boss as a therapist is essentially a monopoly. By the way, man, there's like some states, I know Kansas is one of them. Some of them reversed it. But like where Blue Cross is like an actual like private company, like, you know, in most places. But in like Kansas, they somehow became a nonprofit.

Ooh, let me, if you know how that one happened, write me an email, maybe that's another article. But yeah, so they got the benefits of being non-profit, but also like the monopoly, you know, insurance for the state. But the law itself serving as this enforcement mechanism was what, you know, kept this market from transferring too much wealth to one class. And so the balances kind of went away because of the structure of how we did health care in America. So if therapists can't collude or set prices, if you're wondering if a therapist can start a union, go ahead, spoiler alert, they can't. So there's been some, you know, kind of ways that people have tried to get a problem. around this, but there's one group in American health care that's not that is allowed to meet in this room. And they decide what every doctor is worth. And they set prices for the entire

industry. And it's called the RUC or the special society relative value scale update committee. But they consider the first part one word. So it's the RUC. We talked about it in the last episode about the DSM. But I thought it was important to go into that to a little bit more detail. because when my mention of that resulted in doctors, sending me emails saying that I was a conspiracy theorist saying that because of the, I was pointing out the economic engine of their profession existed and they've never heard of this thing. Evidently, it's not very well known. But if the people that are, you know, I'm not going to call anybody out, but if the people

that are very high up in their industry and think they know a lot about it don't seem to know that like, you know, CPT codes are patented by the AMA. And then the AMA turns around in lobbies for insurance companies to require that you bill with a CPP code. So everyone who's using a CPT code like me, every time I make a, every time I do a service of psychotherapy, you know, I get probably through my EMR, I don't pay it directly, pays a royalty to the AMA. You know, how is that okay? You're saying everyone in the whole country has to use these codes that we just happen to get a royalty on. And then you're netting $200 million. That's not a conspiracy theory.

That's actually how your profession works. If you're a member of the AMA, maybe read about how it functions. But anyway, not a conspiracy theory. And it occurred to me when I got some of those emails that this may not be terribly well known. So to comprehend this current mental health situation, you've got to go back to the foundations of the physician payment system. So in 1992, a lot of things changed. But before that, Medicaid reimbursed physicians based on a system known as customary, prevailing, and reasonable charges. So under that system, physicians were paid based on their historical billing charges.

So if you've charged $200 and then cost of living goes up, you raise it to $220, then you raise it to $250, they kind of look at the curve there and pay you, you know, their rate commiserate with what you have been charging historically. So the free market can bear it. Medicaid will try and meet it. They're not going to meet it as high, but they're going to take it into consideration and shoot for it. So it rewarded those who raise their fees the most aggressively because if you wanted to start out your practice, you didn't want to charge $200. You wanted to charge $500 because you wanted

that to look like what your rate was. So this created this wide geographic disparity for identical services. And the people who were kind of doing the bad thing that we shouldn't reward were getting rewarded. And so they decided to change it. So this cost are spiraling in the 90s. And Congress passed the Omnibus Budget Reconciliation Act. And that said that we had to transition to a fee schedule based on resources required to a provider. And that birthed this relative, or resource-based relative value scale. And so the, which is what the RUC sets. So the intellectual architecture for the system was developed by this team of

economists at Harvard University. And the Harvard team decided that there was this unified theory of medical value. So they're attempting to quantify, again, you know, the thing that I complain about a lot in psychotherapy. I don't have a problem with it in this context, but I think we need to know the limits of quality versus quantity, especially in research. Anyway, they wanted to quantify all the work, quote unquote, involved, how many units of work involved in a disseparate medical acts, and then compare them to cognitive intensity, how long do it take you to get smart enough to do it. And they also wanted to look at how much expensive equipment does it involve. How much

training, how much time, how much expensive education, how much expensive equipment. It's one of the reasons why, like, every time there's like some new, huge thing invented, like UAB bought like a, I know this isn't what it actually was, but like a proton accelerated or cure cancer, and then they thought they were going to get these insurance agreements, and then they ended up not getting the money they wanted, so they just closed the whole thing down after saying, but it's why they chase so much like high-tech stuff, especially around like surgery and intervention-driven medicine and hospitals in America, that's all, we'll get a little number telling you, you know, you bought this big machine and we're

going to reimburse you for it. So the Harvard study is revolutionary. Also, by the way, that's why there is so much testing in American health care that you don't find in European health care. We do a whole lot of really expensive tests that the evidence says we don't really need. And we're kind of a testing culture. They tend to look when there's a problem in Europe, and then they tend to look if there's a very obvious kind of preventable thing. Like in America, we just test for everything because it's super expensive and you can bilk insurance for it a whole lot. So, you know, promise to level

this act promised to level the playing field suggesting that, you know, services that were like talking were going to be less expensive than, you know, primary mental health and surgery is going to be the most expensive, you know, just trying to make it fair. So if the recommendations of the original committee had been implemented purely,

the income back gap between generalists and specialist would have narrowed. So you wouldn't have people trying to do like 600 foot surgeries, you know, a month in order to get the most money. Like a lot of, for some reason, I don't really understand it. You do notice, like, part of my job was to have medical students in my car and, like, teach them about mental health when I was doing my, like, field work when I worked at UAB because I was outpatient looking for people with chronic homelessness and schizophrenia.

And so the doctors generally, like, if they encounter psych at all in their rotation, it's like Psyche R. They liked that, and then you get to see these people, these different disciplines. Some of those foot people, man, they're ambitious. I don't know why that is. But anyway, you make a lot. So, you know, the people who, some people strive to make a lot and, you know, go into that, not say anything bad about them.

But the administrative complexity of assigning, you know, these values to over 7,000, you know, current procedural terminology codes. It over what, which is what CPT code stands for, by the way. it overwhelms the health care financing administration. And in that administrative vacuum comes the AMA, and they're like, hey, this is like really confusing. You aren't medical people. You don't track the industry.

You don't really know what's up. You want some help, bro. And so like the AMA, fearing that the federal government would unilaterally just set prices, they proposed, because they didn't want those prices to be universally set. They wanted to be able to negotiate independently and say, hey, I'm worth a little bit more. And I think that general and family practice medicine, the system would probably be served by incentivizing more people to do that instead of these crazy specialties that net a whole lot. And I'm not saying that if you are the only person who knows how to replace an aorta backwards or whatever with a blue laser in the world that you shouldn't make a little bit more and be reimbursed for what you have to invest in it.

I just think the gap is huge. When you've got millions of dollars in between the highest and lowest earning doctor, big gap. So anyway, the government, so the AMA says, let's just convene this committee of experts to maintain and update the relative values and we'll provide this labor intensive service to the government for free, which because we're nice and we want to help. And the government's like, thanks, man, that's cool. And so 91, the RUC is born. And everything changes in 92. And if you're old like me, you can kind of remember that happening. Like I do remember not really knowing the words for like corporatization, not really know.

knowing that it wrote the names for like data collection, but realizing that I was like in a different world as I was growing up and kind of asking my parents. And they didn't, they weren't seeing those things. They were a frog, you know, boiling in a pot. So the RUC claims legitimacy as this expert panel who, of the AMA's finest doctors who know the most about their specialty. But a structural analysis of its composition reveals that there's a profound bias. that mimics the governance of a cartel designed to protect their interests. They're not just doing a nice thing for the federal government for free, believe it or not. So this committee consists of 32 members, but power is concentrated mainly among 29 voting seats. The other ones can just talk, not vote.

And then of those 21 are appointed by major national medical specialty societies. And so the distribution is not proportional with the volume of services provided to Medicaid beneficiaries. you're not looking at the market and then appointing this. You're looking at the specialty, which may not be that important in broader national medicine because it may not be very common. There may be, you know, in some extreme cases, there may be like less than 100 people that do a certain procedure almost in the world, especially if it's new or super complicated in a certain way.

Specialties are going to be broader than that. But they have a whole lot of representation just because of what they do, not because of really what the need of the country is. So primary care physicians who perform roughly 45 to 50% of Medicaid work, they hold approximately 4 to 5 seats. And that gives them 17% of the vote, 17, if I wasn't clear, 17, not 70. And procedural and surgical specialies, including surgery, radiology, anesthesiology, they hold 15 to 18 seats, giving them roughly 60% of the vote, despite performing only 35 to 40% of the Medicare work. And so the American Psychiatric Association holds a single seat and one seat. And this lone representative must negotiate with a super majority of specialists, neuroscience, cardio, what do you call?

I don't know what it is, you know, basically heart surgeons. I know that it's cardiovascular, whatever, I forget the name of that specialty, but it's more than just the heart. Radiology, ophthalmology, all that. And those doctors have a lot more in common because they're experts that are doing. like the psychiatrists probably have the most in common with like general practice doctors because they're talking and assessing and getting information and making guesses, whereas these other guys are like getting a robot's arm to like suture in a order of a heart or a knee or whatever. And it's very technical. And that whole thing that we talked about in that DSM article

about how all the doctors kind of think that psychiatry is fake or not real or not as hard, that's still a thing. Like as someone who had doctors in their car, you know, every other day for four years. You know, a lot of people still are kind of like, hey, you know, like a lot of people don't think psychiatry is real in my field. Or they think it's less than, but for a reason that let me try and make it sound nice.

I won't go through the list of reasons. Sometimes it's like, you know, it's just the one that you do. It's like, you just care a lot. It's like, well, that's a nice thing. Why are you saying it like a bad thing? You know, like, you kind of know what they're thinking. Anyway, whatever. So the Medicare physician fee schedules is zero-sum game.

So it's kind of this cartel dynamic that is enforced by this statutory requirement of budget neutrality. So if the total relative value units projected for a given year exceed the budget, you know, at scale, then it's just reduced. And they say, oh, if we all think that we should make this much money, but there's only this much money in the pot, then everybody's just going to take a 60% hit. So if everybody thinks that one person says I should make, you know, $1,000 and another person says, 15, you get 60% of 1,000 for your service and I get 60% of 15,000 for mine. So even like the kind of scaled reduction makes a little bit unfair. And so the any proposal to increase the value of psychotherapy, which would need to increase, you know, that that total relative value spend effectively asks every other surgeon in the room to

take a pay cut because they're all competing with each other and psychiatry is the tiniest vote. Remember one psychiatry rep out of everything, one doctor representing mental health. The other professions don't bump up against mental health at all, and they're pretty different technical things. So given that a two-thirds majority is required to pass a recommendation, then that procedural block holds veto power, and we went through those disreductions. Psychiatry is not going to get past that in the ruck. So a hallmark of a cartel, you know, if you want it because cartels are illegal in America,

is a restriction of information. Did you say, hey, I called on my friends and I said we're not working for less than this to the whole country? That still probably would be considered a violation of the Sherman Act, but it wouldn't meet the definition of a cartel because I'm telling you that, that I am doing that. So for nearly two decades, the RUC operated in near total secrecy. So while recent years, you know, unions have to be really public. The vote has to be public. You see signs on the highway.

Like, it's not a secret. If they meet in a dark room, they get in trouble. While recent years have seen some minor concessions, like about transparency where they're like, oh, maybe we should like publish who voted for what or just the vote totals or the real deliberation process, you know, the meeting minutes, what is said, is not public at all, no part of it. And so the RUC meetings are private and the public, the press, and every non-RUC physician, so even MDs are largely barred from attending the deliberations where billions of tax dollars are allocated. So 32 people decide the direction, well, and 29 that can even open their mouth.

I mean, not open their mouth, vote. The other ones can talk. And one of these people is a psychiatrist, and they're deciding where are the billions of dollars that the government's going to spend on health care that's like, your money anyway, by the way, is going to go that year. And it's completely not transparent. So participants include the specialty advisors who present the data, and they have to sign these non-disclosure agreements,

and these agreements prevent them from discussing the specific trade-offs, deals, or arguments made within the chamber ever for the rest of their life, or they get sued. And then a former RUC participant, one of them described these agreements off the record as draconian and designed to insulate the committee from public accountability. So the government accountability office and the Center for American Progress have noted several times,

like when you search for it, when you're researching an article like this, they notice the inherent conflict of interest there, that you're just kind of saying, yeah, you get to vote on your representatives, but it doesn't really matter who they are because the doctors are just going to decide this panel, and then they'll decide where the billions of dollars the representatives spend goes and who it goes too.

And so the individuals setting the prices are generally the same individual who receives the payment. And unlike a regulatory agency, which is a cartel feature, so unlike a regulatory agency where officials are salaried and divested of industry assets. Like they're not working.

They're not going to say, hey, I think I should make $800 an hour, and now I'm going to go make $800 an hour. You know, like the same reason why, like, Congress can't, like, invest in war and then go vote for a war. They can't trade stocks. They're not supposed to, like, that has to all be disclosed to look for insider training. These doctors can do that, not really the same as the stock market,

but they're voting on what they make, not what somebody else with them, not as a stakeholder, makes, what they are going to make. and they're all, you know, usually high-powered people in the prime of their career. So unlike a regulatory agency where officials are salaried and they don't have good, because that's the thing. It's like you could pay these people a salary like Congress people or the Senate to chair this thing. You could pay them a really good salary and then say you have expertise, come use it. And it would remove the, you know, kind of like ethics, not the biggest problem with the RUC, but kind of legal grade.

area of I'm voting on what I'm going to make. So the secrecy serves a functional purpose. It allows for log rolling. You know, a representative from orthopedics might support an inflated value for cardiology. And then in exchange, cardiology might support a knee replacement code. And now it's like the board of a company, you know, some people trying to get controlling interest. So you're saying who, which discipline has the most votes. So that isn't good. Again, NDAs. We don't know if that's happening. But there's this, I'll scratch your back if you scratch mine that always kicks down on psychiatry. And so the Department of Justice, why don't they break this up if it meets these definitions of a cartel? But the legal shield is that there was a Supreme Court doctrine that established that private entities are immune from antitrust liability when they are petitioning the government.

So because the RUC technically, it only recommends the values. doesn't set them. I mean, Medicaid just accepts their recommendation more than 90% of the time, but like they're just a private thing that's working for free for the government doing all this hard work. They don't even get a salary. They just decide what they make that year, which is more than the salary is, by the way. You know, the RUC is protected by the First Amendment. They have the ability as a private entity to lobby the government for things that they want. And that legally, that's all they're doing. So this legal loophole allows the RUCs. to operate with a monopoly.

But they don't have, even though they have the characteristics of a monopoly and a cartel, they don't have any of the legal characteristics. So no fear of prosecution. So the CMS, the Center for Medicaid Services, continues to go through this motion of reviewing their recommendations, and the CMS accepts those recommendations for the prices over 90% of the time. So because private insurance generally relies. is, you know, they base their rates on Medicare, this committee effectively sets the price of

health care for the entire country. So when you cheer because Medicaid gets cut, realize that your fancy Blue Cross benefits are going to get cut, too. It's just going to be five years later. Because one of the things that I've done, like one of the reasons why Taproot went in directions that other firms didn't, and then they overcorrected quicker, is that what I do is research the hell out of Medicaid and then research the hell out of what Blue Cross Federal. is doing. And then look at what Blue Cross Alabama is saying. Because Blue Cross Alabama says that they're going to do a lot of stuff that they'd like to do,

but they get stopped. So if I prepare for just what Blue Cross is telling me they're going to do in two years, in my experience, about 60% of it that affects me happens because it changes before rollout. So I'm just, I've wasted all my time preparing for something that didn't happen. But what I can do is I can look at Medicaid, even as a therapist that does not take Medicaid,

because we are a collective and a percentage of our income goes back into the collective to operate it and the cost of running it is cheaper than if we were all in private practice by ourselves. But that is technically, you know, fee splitting if we paid part of the Medicaid thing to this group. So we legally can't take Medicaid. But the reason that I study Medicaid is because I know that Blue Cross Federal, Blue Cross is going to follow Medicaid by about two years. Not exactly, but if Medicaid moves in a direction, they're going to move in that same direction by proximity, maybe not exact distance, maybe not exact location, but they're going to go in that direction. And that about two and a half years after that, all the Blue Cross plans in the country, which will still all be a little bit different, will start to move in the direction of Blue Cross federal.

So if you celebrate national Medicaid getting cut, just be aware that you're celebrating your own benefits going to get cut five years from the time that you're celebrating. So have fun. Enjoy the champagne. But if independent therapists did this thing where they gathered in a room and they set the rates, they would just face criminal prosecution. Because the bruck operates under the friction of advising the government, I mean, not friction, I'm sorry, fiction of advising the government. It's protected.

The same regulatory framework that criminalizes therapist solidarity provides cover for this industry-wide price coordination by the most powerful specialties. And I'm not accusing anybody of a crime. I'm just reading the law of you. This is how it works. This is a, most of this is from a legal brief. I want to add, too,

that I'm not, I'm not criticizing Blue Cross or any insurance company here, other than the little small one I was talking about in the beginning, and I'm only criticizing them for where I perceive or from my understanding

that what things they're doing is, are not legal, and I'm not mentioning that my name. But I would love to keep seeing my Blue Cross patients. I'm not criticizing an insurance that I take. I'm not saying that they didn't anything wrong. Please don't take me out a network. I would love to keep seeing people. All I'm doing is just explaining how these things work. You could ask a lawyer. I have asked

lawyers and it's how I know some of this information. Like they review these things with you. This is just a legal review of how it works. So if it sounds like that's crazy, I'm not really saying it's crazy. I'm just telling you the law and you can decide what you think. Um, I, this is pretty much just directly, you know, I'm not, you know, using a lot of hyperbole other than that therapists. rock backward in the bathtub and bite on a washcloth and cry at the end of the day. That isn't true. I actually bite on a bar of soap. But this methodology violates several principles of statistical validity.

The surveys are voluntary and distributed by the specialty societies themselves, and the respondents are typically those most active in the society that they're in. So they're like the hobnobbers and professional or whatever. They got a lot of. So the most critical variable in the RUC equation is, time. So the work that the RVU is conceptually derived from that RVU is like the value scale that the RUC uses, sorry a lot of acronyms. You know, work equals time multiplied by intensity. Is it hard and how long does it take? That's basically the biggest variables in the

formula that decide how much you make for a service. And so therefore, inflating the time is the most direct route to inflating the prices. A lot of these things don't actually take as long in practice as they claim that they do on the, uh, in the RUC. And so independent studies by like, I ran an urban institute were two that I pulled that looked like the biggest and most comprehensive. They use, you know, objective data like operating room logs, um, to see like how long was the patient actually being operated on.

medical records tend to not be fraudulent most of the time, and if they are not for very long. When they look at, you know, what they say it takes to do it versus how much time they do it in, like one procedure valued by Ruck that takes 60 minutes in reality just took 30 for everybody. You know, some 20, some 40, average it together 30. And this creates an arbitrage opportunity. So if a gastroenterologist can perform a 60-minute colonoscopy in 20 minutes, They can effectively perform three procedures in the time allotted for one. And they bill for three hours of work in one hour of real time.

So they're able to say, hey, an hour of my time is worth $800. But then they do three one hour procedures in an hour. And now an hour of your time is worth 800 times three. So that is an efficiency gain that the free market people say is making the system be efficient by incentivizing what exactly. But anyway, psychotherapy, it can't utilize. that because the CBT code for psychotherapy is based on time. Like if you come to see me for the first time, um, it's a 907.9.1. It's an intake. And then there'll be a 90834 if you're, if I'm going to see you for, um, you know, 45 minutes. And if you want to see me for 50 minutes,

it's going to be not, or 53 minutes, it's going to be 908.37. So there's no way for me to do, uh, because it's a time based procedure. I can't do 53 minutes. of therapy four times in an hour. So a psychiatrist can't perform 60 minute therapy session in 20 minutes. Doing so would be fraudulent. And like, I don't know, one of my friends, you got to make this anonymous, but like one of my friends knew a doctor who was not very nice to him. And the guy was like world famous for his specialty.

And he would do, he made like an insane amount of money because he would do the procedure like more so than any other. doctor on earth. Like he had more like in, you know, procedure hours. And the reason was that he would do like six things in an hour that normally took people like an hour and a half. And so he was just like frantic all the time and like had all this energy and was like this workaholic. But it was like to cram as many people as he could see like the smallest amount of time. And he was like, we're old known because he had like the most hours doing it. So he could like lecture and he was seen as this expert. But I was just kind of like, man, if I ever need that process, that really important

procedure done, I think that I'm going to go to somebody who's going to take a full hour to do it, not be like, you know, flicking the blood off the scalpelter, run in the next room. So again, I don't know that guy. I'm not using his name, not accusing him of any wrongdoing, but that's kind of how it works. So the RUC's bias is not just structural. It's also a philosophy. The committee is dominated by surgeons and proceduralists, and they consistently value, value procedure, doing things to people, cutting, scanning, injecting, any kind of test, more so than talking to people. That's a thing that they bill for a consultation, but that's not why they make their money.

So in 2013, this major revision of psychiatry codes exposes this bias and really broadly because previously psychiatrists used codes that bundled the medical evaluation with psychotherapy. So, you know, when you watch a TV show, I remember watching the TV show, evil. I know I mentioned that before, but the doctor just like stops therapy in the middle and is like, oh, wait a minute, how much lithium you're on? I'm going to adjust that right now. And it's like, oh, they don't do that anymore. And then like a case, and then she says something else. And then he's like, oh, anxiety too. I'm going to actually scratch that one. The joke is that he changes the meds three times or something. But psychopharm is now separate. So the new system

requires psychiatrists to bill this EM code for the medical management plus this add-on code for psychotherapy. So it's not even its own code for psychiatrists. It's just this add-on code to changing the medicine of the patient, which is the real moneymaker code that they all do. And some psychiatrists that I've talked to, actually most psychiatrists that I talk to, which I think says more about the psychiatrist that I talk to than the nature of like what most psychiatrists think because I talk to a specific type. But they don't like this. They wish that they could spend more time with patients.

They wish that they could, but they also have to pay for med school and like all of these things. And so while it's intended to improve transparency, the change exposed that psychotherapies, therapy, it exposed it to the Rucks evaluation. And so by isolating the therapy component, the committee could subject it to rigorous cross specialty comparison. And the committee is dominated by surgeons again. And they view talking to a patient as low intensity work to operating on a patient.

Like, I'm fixing a heart. You're just talking about his mom. I'm better than you is generally the vibe most doctors that I've talked to kind of feel. And so this created this 15 minute med check culture. because that's a psychoform that can count as psychoform for a hospital to bill, a psychopharmacology session. But again, man, like, have you ever been to a psychiatrist and your visit was five minutes? Right?

Like, how many people are even getting the 15 minutes, which is not enough to implement the complexity of these diagnoses that we talked about over the last three episodes? So it's not really because psychiatrists stopped caring. It's because their profession, you know, that got being an MD, made this, structural decision that really devalued them. And because of the regulatory environment, it made relational care, just financial suicide. You couldn't do it at the same time that the cost of medicine, med school is just going through the roof and it effectively illegalized the practice of deep, slow psychiatry for anyone who wanted to take insurance. You know, I have a really great one

who talks to me for an hour, but it's a CR&P. So when therapists ask about collective bargaining, lawyers will often point out the only loophole available is called the messenger model. This would be one of the ways that psychotherapy could do something. I don't think it's a great option, but it is one that people pointed out. So, you know, in that model, this third party is a messenger that acts as an intermediary between a group of providers and an insurance company. And so the messenger takes the insurance company's offer and conveys it to each therapist individually. So you could have a messenger that just talk to all the therapists in the state that signed up for this med list

that kind of lobbied on their behalf. you'd have to come up with some way to pay the guy, but each therapist must then make a unilateral independent decision to accept or reject it. They couldn't get together and say, come on guys, we've got to agree on a number. That's a cartel. They could all just say, I would work for about $150 an hour to one guy, and then that guy would get what the others say, but they couldn't all talk about it. And so the messenger is strictly forbidden from negotiating. All they can say is most therapists say that they want to be around this number. And they can't say the group rejects that.

You have to bring it up or they're going to leave. So there's no bargaining that is possible. You're basically, you're just getting a bunch of people to hire a lobbyist that probably wouldn't do much. Therapists and social workers probably don't have as much money as these other things either. A lot of the AMA's lobbying is paid by the fact that they own CPT codes and receive royalties from that. And then there's a lot of other money in health care for different reasons,

especially around Psychoform. but that also gets pointed out to me a lot. Like I just need to be yelling about how drug companies run the world. And I don't like drug companies being able to operate regularly deregulated. Or that isn't something that I approve of. It's just that I think a lot of those critiques are very surface level. And they assume that people get in the back room and they like rub their hands and smoke cigars and scheme. If you want to find a group doing that, that isn't really how cycle like cycle far.

that isn't how like farmological companies like actually lobby like what they do is is probably worse than that but if you want to find like one group that's a small group that has a lot of power that meets regularly it looks like this entity that nobody talks about the ruck so if it follows the messenger model if we you know therapists did that it would just kind of be you'd be telling people that you kind of wanted to make more and they probably wouldn't care um so the other option that some people have talked about is that you could like murder all the therapists in the state into one business somehow, but I don't really see a viable path to doing that. I don't see a solution other than, you know, kind of a structural change here.

I don't think there's a whole lot like the individual could do. But so like if a cartel sets a price that's below market equilibrium, suppliers just exit the market. So this is precisely what happened in psychotherapy. Mental health providers generally have lowered, they have lower overhead than surgeons. They don't need MRI machines or sterile utensil, you know, sterolizing pans for surgical stuff or diamond-tipped knives. And they face these high consumer demands. The national mental health crisis ensured the steady stream of people seeking the service. And so this gives them an exit option that the proceduralists don't have. So they can refuse to accept insurance and just be a cash-only business, which one of the reasons that I wanted to start taproot was because

what I noticed was that there were these places that were full of people and they were revolving door. Therapist came out and then they left. They didn't last long. So you got a lot of kind of lower quality people who weren't going to be great. And then you got people who were just okay with somebody taking 60, 70 percent of their paycheck forever who, you know, generally there's a reason for that. They couldn't do something on their own.

Some of them were fine. And then you had great therapists who all left, you know, as soon as their contract was up, they either bought out of it or they worked it off and then they left and then they went to private practice and they didn't. take insurance and they had this money. And, you know, I could have had a cool office and then you'd be alone and you'd be the king of your little room or whatever. And that's fine. But I really liked collaboration and an institute model. And you don't see things like at the colleges anymore. You know, like Berkeley of the 1970s or Eastland, you know, like these places where so much of the

stuff that we still use was invented and came out of them. Like I didn't see those things existing. And I really wanted to get the smartest people in one place. And the way you do that is you say, I'm going to make sure that you make more money here than you would make by yourself. And that has been this really hard project of doing something that is on paper at a 99 contract, but they all have a say and it operates a little bit more like a socialist collective because, you know, I technically could do whatever I wanted, but I don't. And they trust me. And so far, this is what I've done.

So there is this mass exodus. So part of this is why there's this crisis of qualified psychiatrists who actually actually actually don't just put you on their favorite cocktail for your diagnosis, but like really listen to you is that not a lot of people end up in psychiatry because it's not the top earner. Hospitals want to deliver babies and treat but not cure cancer. That's what's in their advertisements and billboards because that's where they make money. They don't want psychords, you know, they kind of have to have them.

And then free on the psychiatry is hard. So, you know, the last stuff. that I found or survey was like 2023. And 64% of private practice therapists plan to increase their cash pay rates, like they were going to raise the cost. But, and usually you'll see that. The cash pay rate goes up. The insurance rate stays the same.

So more people leave the network. And then it also created this exit of psychiatrists where 60% of psychiatrists don't take insurance. And it's incredibly expensive. And then even if you get it in insurance, like we had a plan one year. and so many of my family needed to go. And they were like, well, we'll pay money after you've done this. And we, like, added it up.

And it was like, I would we have to be going to the psychiatrist like 19 times a year before insurance would cover anything. Like, and that was a relatively good, you know, healthcare plan for, you know, normal, I'm a social worker married to a teacher. I mean, we're not rolling in it, but the insurance was pretty good. And like, if I went to the psychiatrist like two times a week, I don't know, then I guess eventually I could make insurance pay for it, but like nobody needs to change meds that much usually. So that mass exodus is this, you know, economic pressure to the RUC's suppressed rates for psych.

So if the RUC says an hour of therapy is worth $100 via the RVU, then the market demand is 250. the provider is going to leave the RUC controlled space. They're not going to deal with insurance at all because they can make this money over here. And there are going to be a lot of rich people that have mental health problems and see the psychiatrist. Generally, those people are full.

And so they're not abandoning their profession. They're abandoning this pricing regime that they don't like and I don't like, generally, where how much power psychiatry has. So it's not really your psychiatrist's fault any more than it's your therapist's fault. And so that RCEU, pricing failure creates these ghost networks. So a lot of these like mid-tier insurance plans,

they have 2,000 people in network and you call all of them and they're like dead or out of state or like, oh, I don't really see that insurance anymore. They just leave me on their list because they don't ever have to take anyone off legally. They can just list anybody who used to be in the network and I don't want to be in that network anymore. You know, this is not a shortage of providers in the absolute. It's a shortage of therapists. There's not a shortage of therapists in private practice. Like there's historically more than ever. It's a shortage of therapists that are willing to work at an RCU determined price point. And the insurance directories are just these graveyards. Like when you go through, if you call all of those people, you maybe get a call back in

some studies from like 30% of the people that the insurance company claims are taking new patients. And so the central thesis of the RUC's defenders is that they control costs, but strictly managing, you know, the value they're supposed to be saving the taxpayer money. Like, that's the point of their organization. You know, my question looking at this information is, is that really happening? That's how they justify themselves as are they really doing what they say they are. So in psychotherapy, this logic kind of backfires because by suppressing reimbursement rates to a level that drives providers out of the network, then the RUC forces, patients into the cash market. And so the theoretical in-network costs might be a $20 copay and the insurer is actually paying,

you know, $80 of the $100. But the actual out-of-network cost is $250, cash out-of-pocket paid in full by the patient. And so thus the cost of therapy for the consumer is going up, even though it looks like, well, why aren't people going to therapy because insurance companies are paying for it more than they used to? And so therapy becomes this luxury good, this accessible only, to those people with disposable income, which, like we talked about in the last one, a lot of these variables are systemic and they affect people who are not rich more,

and they should have access to treatment, I think. And so for the poor in the middle class, the cost is effectively infinite because the service becomes inaccessible. And so the RUC's cost control measure for the system becomes a cost multiplier for the patient. And then it shifts the financial burden from the risk pool where it belongs to the individual, where it causes the maximum harm. The point of insurance is that you're pooling risk so that when you have something, you have a probability of risk, and when that risk happens, you're covered. But when you have the risk of a mental health thing, a lot of times you can't find somebody who actually treats what you got who's in your insurance network.

And so the RUC sends these powerful economic signals to medical students making their career decision. When a student observes that a dermatologist or a radiologist can earn $500,000 working regular hours or less, then a psychiatrist is earning $240,000, handling emotional trauma and on-call emergencies. And that's if they're doing something that's not really fun, which is just every 15 minutes, they're prescribing another med and they're totally full, and they just do that all day. I mean, it's not what I want to do.

That doesn't sound particularly fulfilling. The social workers of the hospital used to always complain when I worked there, and they were like, don't you wish you'd just become a nurse? You'd have a master's degree. We have master's degrees, and we make $30,000 a year. And like, they just have an associate's degree and they make $70,000. It's like, yeah, but then you have to do nursing stuff. If I wanted to do nursing stuff, I would become a nurse.

I don't. The cartels pricing structure, I'm sorry, the cartel-like pricing structure creates a perpetual labor shortage in the fields with the most needed for public health, which are, you know, general practice medicine, which is devalued, and psychiatry, which is devalued. The two things that will probably affect the most people. Like most people are not going to have some specialty, you know, knee disc, readjustment surgery in their lifetime. Some might, and they should have access to it. But that is not the majority of Americans encountering health care. You know, cardiology is like relatively common, but not as common as mental health and not as common as general practice medicine. Yet they kind of have all of the power on the RUC.

So the question is why can't therapists start a union that I opened with? Well, it's not just a labor question. It's a window into this kind of broken American health care system because we've built this system where a secret committee of proceduralists who most of us will never need or encounter can legally fix. the price to favor surgery over therapy, usually incredibly highly specific surgery that most people won't need, but a group of social workers can't band together and ask for a living wage. You know, we've utilized laws that are meant to break up standard oil and to break up the solidarity of the people that are trying to keep our kids healthy. And the same regulatory framework that criminalizes a therapist coordinating, you know, legal cover, the same framework that stops

me from coordinating with somebody else, which I'm not saying I want to do, just as a hypothetical, also lets the cost of health care creep up every single year for every person. And the result is this regulatory environment that drives doctors crazy, but it burns out therapists. And it leaves patients navigating this fragment assembly line system that was never designed to heal them. You know, like half the time I need to do a consult with a psychiatrist. I don't hear back from them for three months. And I'm not blaming them. They're busy. they've added so much paperwork to the system that becomes like a huge amount of what they have to do

and they don't have time to even talk to the therapist you probably knows the patient better and it's not because they don't want to a lot of the time sometimes they don't want to talk to me but until we confront the legal architecture of that system the RUC that Sherman Act is just this trap that says hey you all get paid by one guy but you don't work for him so you have zero power

and the reality of therapy is that quick fixes which insurance generally prefers you know, are the ones that end up costing more in the end. You know, the biggest reason that people go to the ER in this country or for chronically is like for conditions that could have been prevented, you know, and the people that are just like, well, no one's going to stop you from going to the ER, go to the R. You can't go to the ER and get chemotherapy for cancer. You can't go to the ER and get diabetes shots, you know, like that isn't the sustainable thing.

We need kind of a preventative mechanism. So those patchwork solutions are this systemic problem, but the fundamental issue remains. We've created a health care system that knows the price of everything, and it doesn't value anything that most people have to actually encounter when they get health care. So we've engineered this system where the only way to survive is to stop acting like a healer and start acting like this factory, which psychiatrists have done. And a lot of them don't like that. But when you make an economic incentive, most people will follow an incentive structure.

And the people always email and they're like, well, I know a guy who didn't. Great. I'm talking about probability. I'm talking what do you want 90% of the industry to be doing, even if one percent of it is this awesome dude that you know, that you emailed me about. You know, the hands are kind of tied here. And I don't really have a solution than going back to the drawing board about how it's structured. Because I don't think there's any, this is studying our powerlessness against that system. But here's the reason why this relates to that whole thing that I'm talking.

about with the DSM loosely is that these power structures are very interrelated, right? And remember that psychiatry wasn't saved by changing the DSM. They kept thinking that eventually this new direction of checklist will pay dividends and make us taken seriously and make diagnoses relatively consistent among doctors. Since they're using a checklist, all the patients will go in. They're getting the same checklist from different doctors, so different doctors will result in the same diagnosis. That hasn't happened.

The three, the four, and the five versions of the DSM, or attempts to go in this direction where it would have validity, and it doesn't. It's still just like these hunches of like whatever they think about you. And part of that isn't because it may not even be because checklists don't work. I don't really like the checklist of the DSM3, but they might work if you gave people an hour. It's pretty hard when you're trying to cram five-minute visits into your 15-minute billing code, but you don't get penalized for not taking that amount of time. I mean, the other thing that I don't understand is if you say that you did an hour of foot surgery,

I mean, I guess maybe you finish early and you don't want to just sit there and look at the patient. You want to get them up. So I kind of get it that, you know, what they're doing is different. So if it's over, why make them just like wait before they do the next one or something? But like if I can just be like, wow, you had a breakthrough. 20 minutes. You're good. I'm not able to do that.

Maybe all of these codes should relate to time, you know, and then the cost of the education. But you should sort of be capped on your time. Like you shouldn't be able to cram five people into an hour. If you didn't do it for 15 minutes, you can't use the code. If I don't do therapy for 53 minutes, I can't say 90837. You know, why can you use your CPT code if you're not spending that amount of time there? But this is a gilded cage that psychiatry has trapped itself in. Because remember in that DSM article, it was the schizophrenia epidemic, not the changes of the DSM

that brought back some validity to psychiatry. In the 90s, you know, the one psychiatrist who's on this rock is sitting there going, what can we do that nobody else can? We can prescribe psychiatric medication. A cardiologist isn't really trained at doing that. An LPC and a social worker can't. They were like, what makes us as psychiatrists with an MD better than social workers and LPCs?

And a lot of the through line in this argument is that when you make the industry split, like we're now splitting between clinical research and academic practice, it's a bad thing. And when you pit people against each other doing the same job, that's all so bad, right? Like that's the point of a union. So you're not competing with Bob. You're working with Bob in order to get something.

And this RUC put psychiatry in competition with me in 1980. And then by the 90s, when the Ruck is happening, they say, you know, in 92, we can prescribe medication. They can't. We're worth more. And I mean, I get it. You got loans. But generally, you want competition to be in markets, not amongst specialists. because when it's amongst the communication of an academic sector that's supposed to be working together and speaking the same language, you don't want those people fighting. It's bad for everybody. So the result was just kind of catastrophic when they said, hey, you know, schizophrenia saves it and these early antipsychotics save it. You know, we don't really have the Prozac revolution and stuff until a little bit later in the 90s where that stuff becomes, you know, something that everybody knows about. We don't really have ADHD yet. So there's this change.

chilling effect that freezes the profession, and even the psychiatrist who wanted to do therapy, who believed in it, who were trained in it, had maybe been in therapy themselves once or twice, couldn't afford to do it. And this invisible hand of the ruck pushed them towards a 15-minute med check that might actually take five minutes. And this is why the checklist model of the DSM became not just an intellectual preference, but an economic survival strategy. If you have 15 minutes with a patient, you can't do a dynamic formulation. So thank God that you got this checklist from the DSM-3, because you can just run down a list of symptoms and say that they check those boxes, and nobody can say that you're incompetent.

Nobody can say that you did anything wrong. And then you write a prescription. So the RUC and the DSM coming together did have this, and it wasn't intentional. There wasn't like one guy that did this. I don't have, you know, the Godfather complex where I think every bad thing is controlled by one thing. Sometimes bad things just sort of happen on accident or independently. And what happened here is that psychiatry built a gilded cage for themselves.

where yeah, on average they get $240,000, but they can't get out of it and they can't do what they want and they can't talk to the people who maybe know a little bit more about the way that these forces work or how therapy works or the patient and that's bad. So I usually try and offer some kind of solution. I don't have one here. I think that we need to know the history. We need to know the forces. We need to know these things.

We don't just need to say, well, that's capitalism for you. or like, yo, psychofarmacudoc companies do that, yuck, yuck. Or even the people that say that the DSM is just this system of systematic control that's designed to put people in boxes and control society and keep, you know, beautiful artists like me away from the normies that whatever. Maybe that was the result of it. It was not the initial intention. And it definitely isn't making anyone wealthy.

If you want to analyze these systems, look where money goes. And then look at why they're there and then decide if it's a good thing. and when somebody says something about it, you're able to explain to them how these things work. And a lot of therapists don't. I mean, the fact that doctors are emailing me saying that a publicly traded, a public, you know, entity disclosing its relationship to this private one that has a website and tells you exactly what it does and sort of runs our industry,

they think that is a conspiracy theory that I made up because I'm a social worker and they're a doctor? That's weird. That's pretty lowest common denominator. reductive argumentation. If you really want to make a case for why these things are bad, you need to know how they work. And if you know how they work, you're probably going to decide that they're bad.