Special Series: The Health of Our Mental Health Professionals
A veteran psychologist in Minnesota reflects on the rise of the Managed Care Black Box from 1987 to modern day | By Kimberly J. Soenen February 12, 2025
Today, in THE FINE PRINT, a second featured conversation about the Mental Health of our Mental Health professionals.
Now retired, Dr. Robert Ellison started and managed the Minnesota Valley Psychologists Cooperative Association from 1987-2010. He is currently 75 years of age and resides in Roseville, Minnesota. A 1971 graduate of Hamline University in St. Paul, Minnesota with a major in Psychology, he completed his Masters degree at New Mexico State University in Counseling Psychology in 1972, and later returned there to complete his Doctorate in 1984.
From 1980-84 he worked for the Dona Anna County Community Mental Health Center. His career in Psychology spans more than 30 years working as a counseling psychology intern at LaTuna Correctional Institute in Anthony, Texas and the Urban West Central YMCA Detached Worker Program. In addition to his private practice, his career includes juvenile prostitution work in Minnesota and work at the Whites Sands Missile Range Heath Clinic, Dona Anna Community Mental Health Center and Casa del Encanto Residential Treatment. He retired from private practice in 2018.
Dr. Ellison was diagnosed in 2004 with Stage Four Prostate Cancer and will complete his most recent round of chemotherapy soon. Several members of his family are Emergency Medicine physicians and Mental Health professionals. He is now reflecting on how healthcare has changed since Managed Care took over and what he is hopeful about despite the current state of research funding cuts, science censorship, privatization and recklessness.
He began by addressing how Mental Health professionals have no choice but to be tethered to Commercial Health Insurance industry.
Soenen: What are your thoughts on the Mental Healthcare professional community in the state of Minnesota and what clinicians are currently experiencing since the height of the Covid pandemic and the Optum / Change UnitedHealthcare cyber attack in 2024?
Ellison: It’s dangerous for someone who is practicing in the Mental Healthcare field to speak out about what Commercial Health Insurance companies do to the Mental Health professional community.
Since Managed Care came to existence, clients have been hampered with impediments to healthcare access in multiple ways, including referral denials, diagnostic assessment denials, treatment plan denials, prior-authorization denials, limiting care to six sessions (even when the client needs more care), delaying reimbursements and denial to reimburse for services rendered.
Access is also limited in other ways. Many rural areas have actual shortages of trained professionals, for example.
Soenen: What role do Commercial Health Insurance companies play in leveraging Mental Health and improving lasting healthy outcomes?
Ellison: As long as Commercial Health Insurance companies maintain the inherent conflict of interest, are obtuse and unclear in their service and reimbursement criteria, are allowed not be accountable to the contract or make timely payments to the providers, and fail to negotiate reimbursement rates in good faith or at all, then I fear for the Mental Health and medical well-being of our country.
Soenen: You are now retired but practiced for more than 30 years. Why did you become a clinical psychologist?
Ellison: I became a Clinical Psychologist because of my curiosity about the human mind, the processes of learning, and social and emotional development. I wanted to understand why people, including myself, thought and felt about what they seemed to be experiencing. My undergraduate major in Psychology limited my clinical options and a masters degree was where the clinical and psychotherapy specialization developed.
Soenen: What were your early days like?
Ellison: Upon returning to Minnesota as a young man, the YMCA offered me a job working with delinquent youth on the streets of Minneapolis. To receive third-party Commercial Health Insurance reimbursement in Minnesota, it was necessary to have a doctorate as well as licensure.
During my doctoral education, training, internships, dissertation and employment in an out-patient clinic, and residential treatment facility for adolescents, my work with children and families was fulfilling and working with a pediatric population became my niche. However, it took about three additional years accumulating supervision hours while providing outpatient psychotherapy and passing the licensure exam before I could start my own private practice.
Soenen: What does starting your own practice entail?
Eillison: In 1987, I opened up the Minnesota Valley Psychologists Cooperative Association. Therapists joined the cooperative and paid $2,000.00 if they wanted to work together. Five or six psychologists were working for $60.00 an hour from the Commercial Health Insurance and the patients would pay a copay of $20.00. I have tracked and modeled the inflation rate, and 50 years later, today, the rate would be $460.00 per hour.
Soenen: How has Commercial Health Insurance increased costs while diminishing care?
Ellison: Everything has increased—premiums, deductibles, upcoding, Denial of Care rates—except our rate of compensation. And the patients are struggling to afford care. Regarding Managed Care, what are Commercial Health Insurance companies managing, exactly?
Soenen: What was the most challenging aspect of your work?
Ellison: Being able to provide sufficient care with continuity and compassion when the third party in the transaction, the nameless entity that is the least familiar to the client’s needs, is making the decisions that effect the client’s life.
Soenen: What was the element of the work that kept you engaged all those years?
Ellison: I remained curious and I knew enough to know that I didn’t know it all. The work was always interesting as well as challenging. The independence of practicing privately offered flexibility of my work schedule, no imposed limits in training, and ability to expand my practice into forensics. I knew that my clients were benefiting from the services I provided.
Soenen: You speak of The Black Box metaphorically, figuratively and literally. What do you mean by The Black Box?
Ellison: The Black Box needs a self-correcting system to keep institutions ethical or moral. We are now missing that independent oversight. The Republic has been convinced by the Commercial Health Insurance industry lobby that people don’t deserve healthcare. It’s dangerous for someone who is practicing in the field to speak out against the Commercial Health Insurance industry’s tactics—the pressure to upcode, Denial of Care barriers, Fear of Reprisal for speaking to the press about harm…I’d like to see more physicians and medical care providers unionize for that reason.
“There is a whole world out there. I don’t have exclusive wisdom or tap into universal thought. But I have come believe that we could be part of the cosmic choir of compassion if we wake up. Institutions exist for a reason but we need the human link. We need to maintain human connection. We are what we pay attention to. We need to pay attention to our human connections.”
-Dr. Robert Ellison
Soenen: Did your ability to care for your clients change between 1987-2018 in any way?
Ellison: The ability to provide care for the client has become more difficult because of the multiple blocks to the continuity of care by a bureaucracy that has no independent monitoring or institutional self-corrective measures to ascertain its policies and procedures. Not unlike the frustration of the interviewees of Stephen Colbert’s Questionnaire (on The Late Show with Stephen Colbert on CBS) when he asks, “What number am I thinking of?” The Black Box is far from transparent.
Soenen: You began practicing before the rise of the Commercial Health Insurance Industry Denial of Care business model (still legal as of this writing) and retired before the Covid pandemic. What changes did you encounter during the course of your career in the context of access, affordability and the ability to care for patients?
Ellison: Fewer folks sought therapy in the early 1970’s because of public stigma and very few Commercial Health Insurance companies offered coverage of any kind. The Parity Act and Managed Care have expanded the number of people covered but has brought its own barriers to access. Prior to Managed Care consolidating wealth and power, clients were given ten sessions after a diagnostic assessment was submitted and had an 80/20 copay split.
Soenen: What about affordability?
Ellison: Overall, I believe that copayments have remained about the same. The cost of premiums for many has increased greatly. Because therapy can easily surpass six sessions, clients often quit care or have to pay out-of-pocket. This practice has increased and adds to the out-of-pocket costs for the client. Some services like forensic work, or Psych testing is not covered and must be charged to the client.
Soenen: How are you feeling about the state of healthcare, Mental Health and Public Safety today?
Ellison: I am pleased in the reduction of public stigma and increased awareness of Psychotherapy and Psychological services in general. I am glad that more folks have Mental Health insurance, but I am fearful that Mental Health and healthcare professionals are dependent on an unsustainable model of service.
Soenen: The former United States Surgeon General was on tour for two years speaking about the need for young people to get Mental Healthcare to prevent isolation, anxiety and loneliness. But how, in a country that does not offer Universal Healthcare, are citizens supposed to access and afford lifelong care without gaps or barriers?
Ellison: Yes. When I started working in the field in 1972, Psychologists with a doctorate were receiving roughly $60-65/per 50-minute hour. Now, in 2025, a doctorate level might receive $90-110/per 50-minute hour in reimbursement payments. Given practitioners inability to negotiate a fair rate with the Commercial Health Insurance companies, people feel disempowered.
If a practitioner is unable to secure providership status and secure a contract, their only options to continue seeing clients are either taking private payment from clients, giving their services away, or working for an agency receiving a salary that typically is half what a private practitioner can make seeing a comparable number of clients.
The professionals that I am the most concerned about are those folks. They are often pushed to bill 30-40 client hours/week and driven to “out-perform” their previous attainment.
Soenen: Has the United States of America model of healthcare disincentivized Best Practice and Quality of Care?
Ellison: In the mid 1990’s, before vertical integration and Private Equity accelerated, one Commercial Health Insurance company hired salaried professionals and opened a clinic that closed a few years later because the therapists quit often and staffing was an ongoing problem; and their own rates of reimbursements to their own clinic were unable to sustain the clinics’s operation. Subsequently, as their waiting lists grew, they were forced to offer providerships to outside practitioners on a capitated basis. What that meant was therapists were obligated to provide services until completion beyond the first six sessions that would be reimbursed. Few practitioners jumped at that opportunity. The poor rates of reimbursement, and the massive disincentive this presents to practicing therapists (and therefore a client’s access to effective treatment) has only worsened.
Soenen: Who is working on changing the way in which Mental Health professionals are treated?
Ellison: Bandy X. Lee, M.D., M.Div., is a faculty member in the Law and Psychiatry Division of Yale School of Medicine. She and others experts gathered in Washington, D.C. to express concerns similar to my own being the fear that our Mental Health as a community struggles with fear, hate, suspicion, and violence. When our leaders— political or otherwise—promulgate these traits or values, an epidemic can occur. Our former Attorney General has stated as such recently. I concur.
Soenen: What advice would you give to your young medical student self?
Ellison: Immerse yourself in multiple clinical theories and practice. Take as many internships and jobs as an opportunity, not a job. Be certain that your intentions are altruistic and seasoned in reality. It is best to focus on bettering your client’s social and emotional life, and not to become wealthy.
Soenen: Are you optimistic for the Mental Health field?
Ellison: I retain some optimism because there continues to be new innovations, tools and methods being developed. I am hopeful that many more of obstacles that impede access affordability, and the profession will be afforded the respect it and its dedicated practitioners deserve.
Soenen: Is there one instance or case where you thought a young person was not going to make it and then thrived after receiving high quality care?
Ellison: I believe the assessment of numerous children with attentional and behavioral problems associated with ADD and ADHD were typically the most gratifying outcomes because of the agency and self control they gained and the emotional impact that had.
“Medical care professionals need the social and political skills to foment the positive and ethical change – Do No Harm. They need to remove the obstacles to care. It looks terrible out there and we have leaders who are removing all of the guardrails. People should let their concerns be known. People need to organize and professionals need to organize to stick guard rails in the Black Box as a way to make it all not be so helpless. Don’t give up. They need to not give up. They need to speak out and up. These conversations need to be where everyone can see them.”
-Dr. Robert Ellison
Soenen: How did you prevent burn out as Managed Care augmented Denial of Care as a business model making it more difficult over the decades for patients to access care?
Ellison: Almost immediately after going into private practice, I switched to four tens (a four-day work week.) Between 1971 to 1972 driving between the prison and home would be decompression time for me. That time was very helpful. I was driven to the pediatric practice. I also took on a job working as a Clinical Director and worked with autistic kids. All of that expanded my professional skills and awareness about autism and new therapeutic techniques.
Soenen: If you had the chance to tour the United States as the former Surgeon General did recently to address Mental Health needs, what would he prescribe now?
Ellison: I would focus on directing folks to find ways to not be powerless. Things might change as fast as you want, but we have to make sure the professionals are not feeling powerless. I guess down to brass tacks about training for psychologists—especially this is true of most practitioners in my training—most of the folks want to practice as a small group and do not want to be an institutional cog.
Soenen: You and I discussed the Fear of Reprisal physicians are feeling now especially. Today, in his Stack, Dr. Jeremy Faust questions physicians and medical society leadership who are staying silent about disinformation, censorship, grant cuts and the instability and chaos the current administration is intentionally creating. What’s your take on walking the high wire of speaking out against Harm-for-Profit vs. holding onto your career in silence in fear of retribution?
Ellison: Medical care professionals need the social and political skills to foment the positive and ethical change in the name of Do No Harm. They need to remove the obstacles to care. It looks terrible out there and we have leaders who are removing all of the guardrails. People should let their concerns be known. People need to organize and professionals need to organize to stick guard rails into The Black Box as a way to make it all not be so helpless. Don’t give up. They need to not give up. They need to speak out and up. These conversations need to be where everyone can see them.
Soenen: You mentioned that you recently read Nexus: A Brief History of Information Networks from the Stone Age to AI by Yuval Noah Harari. Are you reading anything now and are their books you would recommend to younger Mental Health professionals?
Ellison: Harari says there needs to be human beings in this process. Sirens’ Call: How Attention became the World’s Most Endangered Resource by Chris Hayes and The Secret Chief Revealed by Leo Zeff about the development of early protocols in psychedelic assisted therapy are both good, as well.
Soenen: How did you manage burn out?
Ellison: My wife and I travel whenever we could. We took the time to do that and that helps with preventing burn out. Experiencing life is different and the world can be so wonderful. We both have hobbies and it allows us to stay balanced and working. That was part of the survival. On the best way for me to center, painting, carving, photography and, since retirement, creating hand-sewn leather backpacks and messenger bags have been sources of meditation.
Soenen: What wisdom would you impart to your younger self?
Ellison: Have realistic expectations and do not feel powerless. You might see clients in November and not get paid until February or March by the Commercial Health Insurance company.
Soenen: Who were your most respected Mental Health teachers or mentors who put patients first?
Ellison: The most influential mentors that have shaped me are Dr. Elaine LeVine, Dr. Richard Fowler and Dr. Boris Hergenhan. Also, Dr. Douglas Muller. They are all dedicated scientists, professors and social advocates because of their selflessness and ethical standards.
Soenen: Newsflash — Mental Health professionals are human. Do you have a favorite band or music?
Ellison: Dylan and Neil Young. Lately, Gregorian Chants.
Soenen: Where do you go now to center yourself of maintain your Mental Health?
Ellison: Meditation wherever quiet space can be found.
Soenen: Ocean or Boundary Waters?
Ellison: That’s tough cause I am a scuba diver, but if forced I would choose the Boundary Waters.
Soenen: What is your favorite place in Minnesota and why?
Ellison: My favorite place is Camp Menogyn on the edge of the Boundary Waters Canoe Area Wilderness on West Bearskin Lake…but really is Lake Kabetogama on the peninsula between Daley Brook and Mud Bay in Voyageurs National Park.
Soenen: Healthcare for All or status quo?
Ellison: Health Care for All with the caveat that self corrective measures administered by independent bodies.
Soenen: What makes you feel hopeful now?
Ellison: It is day to day. I’m optimistic about my profession and looking at existential angst, depression, psychedelics and other tools. My field has not stopped innovating.
My motivation does not change as far as life, but what I am physically about to do. There is a whole world out there. I don’t have exclusive wisdom or tap into universal thought. But I have come believe that we could be part of the cosmic choir of compassion if we wake up.
Institutions exist for a reason but we need the human link. We need to maintain human connection. We are what we pay attention to. We need to pay attention to our human connections.
Soenen: Truly a pleasure speaking with you, Dr. Ellison. All the best with your ongoing care. Hope to see you up in the Boundary Waters this summer.
Ellison: Thank you.