Kim Palchikoff: Mental health cash culture isn't helping

Las Vegas is known around the world for a lot of things — blackjack,  booze, bikini-clad pool parties. And cash. Lots and lots of cash. 

And there are doctors in town — psychiatrists, to be specific — who will take only cash. To listen to your woes for 50 minutes or so, they want 300 bucks on the barrelhead.

Like many other major American cities, including Los Angeles, San Francisco, Washington, D.C. and New York, using health insurance to pay for psychiatric visits is slowly disappearing in Las Vegas. Why? For one, it’s simpler. Doctors avoid mountains of paperwork.  Secondly, despite the passage of the Mental Health Parity and Addiction Equity Act of 2008, many psychiatrists' insurance reimbursements are still lower than those of other physicians. 

Nationally, accepting cash-only patients has been a growing trend for more than a decade. Las Vegas is just catching up. According to JAMA Psychiatry, a national psychiatric research journal, in 2009-10, barely half — 55 percent — of psychiatrists nationwide accepted any form of insurance while nearly 90 percent of physicians in other specialties did. 

Stanford professor Keith Humphreys, who spends much of his time teaching psychiatry students, is not impressed with what he calls the syndrome of the “Worried Well.” On NPR in 2016, he described how $400-an-hour therapy in the Bay Area had become a hobby of the wealthy. He worried about the well-being of the seriously mentally ill who didn’t have that sort of cash kicking around. 

The worried well syndrome reminds me of the famous “garbage scene” in the 1989 movie “Sex, Lies and Videotape” in which the affluent and bored heroine tells her psychiatrist about her biggest concern: the world having too much trash and nowhere to put it. And then there’s a 2008 New York Times story about a $600-an-hour psychiatrist with clients who want therapy in their private helicopters. 

I’ve spent almost 15 years going to free clinics to treat my bipolar disorder.  

I had a psychiatric resident see me for two years once. His services at the University of Washington State were free because his training clinic serviced low income clients. He was a big fan of research. He was the only doctor I’ve had who would print answers to my questions from a computer in his office and go over the research with me.  

I went to a free government psychiatric clinic in Reno for seven years that also treated low-income patients, mainly those with pre-existing conditions like myself who were unable to obtain healthcare in the private sector.  They were constantly short on psychiatrists there, so I mainly interacted with my assigned nurse who was just as informed as any of the doctors. 

I was thrilled when I landed a job in Washington, D.C. in 2012, down the street from the White House, working for an international broadcast media organization. It came with great health insurance. But I quickly learned that psychiatrists in D.C. take cash only. No exceptions. I called more than a dozen.

I found the best psychiatrist I could find – a Harvard graduate who was a senior researcher at the National Institutes of Mental Health. I took the plunge, paid my money,  hoping he’d be some wizard who could wave a wand, perform a miracle and make my bouts with mania and depression go away. I was naïve. I thought a pricey doctor would somehow do something different. I think the only difference is the access. I could get a hold of him at any moment. He was very attentive, answering my endless emails and phone calls. That still didn’t help. 

I became increasingly miserable in D.C.  I learned that our nation’s capital is crammed daily with more than a million career driven professionals – lots of wealthy lawyers, lobbyists, bankers and foreign policy experts from all over the world who didn’t want to talk to me.  Maybe they wanted to talk to my psychiatrist. D.C. was very fast-paced, lonely and stressful.  In my entire two-and-a-half years I lived there, I failed to make even one friend. I was a disaster. There was nothing any psychiatrist could do to change that, no matter how many times we met.  I returned to Nevada. 

Most of Nevada’s psychiatrists work in Reno and Las Vegas. Most Reno doctors take insurance. These days, I pay a mere $10 copay per visit. I am treated well. My doctor returns my phone calls quickly and someone from her group practice is on call each night. 

But Southern Nevada is going in a different direction, and there’s just something not right about it. Our state’s suicide rate is too high, and too many people need mental health help who can’t pay $300 a visit.  

It’s capitalism, pure and simple. Las Vegas’ psychiatrists and those working in America’s big cities have merely responded to the market’s demand. Wealthy cancer patients go to places like the Mayo Clinic or to the MD Anderson Cancer Center. Well-to-do clients with mental health concerns go to their own pricey physicians.

For people in cities with enough affluent customers, this mental health cash culture is creating a divide between the haves and have-nots, making it more difficult for lower-income clients with insurance to find help. 

There's got to be another way.

Kim Palchikoff can be contacted at


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