Obtaining mental health care can be difficult even for people who are covered by health insurance. Patients regularly deal with hurdles such as incorrect phone numbers for providers' offices, insurers' prior authorization requirements, month-long delays in scheduling appointments and psychiatrists who refuse to accept insurance at all, according to a series of studies by J. Wesley Boyd and colleagues at the Cambridge Health Alliance.
In a study approved by the Cambridge Health Alliance's Institutional Review Board and published in Psychiatric Services in January 2015, Boyd and his co-authors posed as people with depressive symptoms and tried to schedule appointments with 360 psychiatrists listed in a major insurer's database in Boston, Houston and Chicago. The callers presented themselves as being able to pay out-of-pocket or having insurance through either Blue Cross Blue Shield or Medicare and attempted to schedule appointments with the psychiatrists listed.
"I got interested in the work because I would hear complaints all the time from people trying to use their insurance to get in, and then also in my experience as a practitioner, insurance companies do everything they can to make it as hard as possible for me to give the kind of care I want to give to my patients," says Boyd, an associate professor of psychiatry at Harvard Medical School.
The researchers made two rounds of calls. In the first round of calls, they managed to reach only 119 psychiatrists, or 33% of the 360 they attempted to call. They received return calls for 36% of the unanswered calls.
Many of the phone numbers in the database turned out to be wrong. Of the 360 phone numbers the researchers tried, 16% were incorrect — connecting callers with unsuspecting receivers including staff at McDonald's, a boutique, and a jewelry store.
"I give my spiel, 'Hi, my name is Jared Hall, I've been depressed, I was in an emergency room last night, they told me I need to see a psychiatrist within two weeks, I have Blue Cross Blue Shield PPO insurance, can I come make an appointment?'" Boyd recalls. "And the guy listened entirely to the whole spiel and he goes, 'Hey Jared, I'm really sorry to hear that, but this is a jewelry store.'"
In the second round of calls two weeks later, the researchers reached out again to the psychiatrists with whom they could not attempt to schedule an appointment during the first round. They reached out to 222 listed providers and got through to their offices for only 28% of their calls. About one-third (34%) of their unanswered calls in this round were later returned.
"After two rounds of calling, we were able to obtain appointment availability information for 219 of 360 psychiatrists," the authors write. Of these psychiatrists, only 93 (26%) agreed to accept the caller as a new patient. Appointments were denied for a number of reasons, including that the psychiatrist was not accepting new patients (15%); only saw inpatients, adolescents, or patients with specialized concerns such as substance use disorder (10%); did not accept a particular payment type (such as Medicare); only accepted referrals; needed more information; or was out of the office.
There were not significant differences in success rate by payment type, though success rates did vary by city. The researchers were most likely to schedule appointments with psychiatrists in Houston and least likely to schedule them with psychiatrists in Boston. On average, irrespective of city and payment type, patients had to wait 25 days for the first available appointment. Wait times ranged between 0 and 93 days.
"Our findings add to the growing evidence that the mental health system is difficult for consumers to access," the authors write. "The findings are in line with national data demonstrating that two-thirds of primary care physicians cannot obtain outpatient mental health services for patients who need them." Further, though Massachusetts has the highest per capita supply of active physicians, it was hardest to obtain appointments in Boston. Texas has the ninth lowest supply of active physicians, but it was easiest to get appointments there.
"The difference may therefore be related to the size of the insured population or to demand," the authors continue, citing the fact that Boston has low rates of uninsured patients compared with Houston. "Expanding health insurance coverage through the Affordable Care Act may thus do little to change the conditions that made it difficult for us to obtain outpatient appointments with psychiatrists — or worse, expansion of coverage might further overwhelm the capacity of available services from these providers."
A follow-up study published in the International Journal of Health Services in 2017 used the same methods, with a focus on children. The researchers posed as parents of a 12-year-old with depression and tried to call 601 pediatricians and 312 child psychiatrists listed as in-network by Blue Cross Blue Shield, asking to schedule an appointment as soon as possible. The providers were located in five cities across the U.S. — Boston, Houston, Minneapolis, Seattle and Chapel Hill, North Carolina.
As with the earlier study, the success rate was low. After two rounds of calls, the researchers had scheduled appointments with just 32% of the providers listed.
The most common barrier to scheduling appointments was incorrect phone numbers. "Other reasons, in order of highest frequency, included: the provider was not accepting new patients, the provider was not accepting general outpatients (i.e., provider was a specialist), the provider did not accept the insurance type offered, no reason given or no answer, and more information was needed," the paper states.
It was easier to schedule appointments with pediatricians than with child psychiatrists — 40% of pediatricians were able to accommodate the patient, while only 17% of child psychiatrists were. Pediatricians also were able to accommodate the patient sooner; on average, patients had to wait 12.7 days for an appointment with a pediatrician, compared with 42.9 days for a child psychiatrist — a difference of about one month.
Availability also varied by city and insurance type. Medicaid-insured children were less likely to get appointments than those with private insurance and those who were self-paying.
"The high prevalence of pediatric mental health problems in the United States creates a dire need for services that both pediatricians and child and adolescent psychiatrists can meet," the authors conclude. "Our results illustrate that, in the five U.S. cities we surveyed, appointment availability is low and wait times long for a family seeking care for a child with depression, regardless of provider or payment type."
Another barrier to mental health care access is prior authorization, meaning that before the patient can receive care, they must have it approved by their health insurer. Whether or not care is covered is at the discretion of the insurer.
Patients arriving at an emergency room in need of inpatient psychiatric care often require prior authorization before they are admitted.
Boyd has published two letters documenting the administrative hurdles of psychiatric patients in the emergency room. In the first, a small study of 53 patients arriving at the Cambridge Health Alliance psychiatric emergency room, Boyd and his co-authors found that insurers approved all but one of the physician requests for authorization — but it took a while. Obtaining authorization took, on average, 38 minutes, though 10% of requests took over an hour to approve. The longest request took 5 hours to receive approval.
The authors write, "If the preauthorization process does help contain costs, it does so largely through a deterrent effect — we call it 'rationing by hassle factor' — given that in all but 1 case physician requests for authorization were granted."
A follow-up study, published in the American Journal of Emergency Medicine, looks at data on 203 children admitted to the psychiatric consultation service at the emergency room at Hasbro Children's Hospital in Rhode Island.
Insurers approved all attempts to obtain authorization for an inpatient psychiatric stay. On average, the process took about an hour, though the range spanned from 3 minutes to over 3 hours.
"Given that 100% of our attempts to obtain authorization were granted, the need to obtain prior authorizations appears to function more as an administrative hurdle rather than an effective triage mechanism, because if professionals know they or their colleagues are going to have to spend lengthy amounts of time on the phone with the insurance company, they may think twice prior to trying to admit a given patient," the authors write. "Adding prior authorization to an already difficult process, especially for psychiatric patients who are deemed to be of 'imminent risk' to themselves or others, seems both dangerous and predatory."
The authors continue, "Onerous prior authorization requirements that single out the most severely ill psychiatric patients should be halted. It burdens our psychiatric clinicians and functions to limit care by placing time consuming bureaucratic burdens on clinicians rather than meaningfully evaluating patient’s needs."
Clinicians also face challenges to providing psychiatric care in the form of insurance reimbursements.
"Psychiatry is reimbursed so poorly by insurance companies that offer mental health care, for hospitals and clinics, is generally a money-losing proposition, meaning they spend more to provide the mental health care than they ever get reimbursed," Boyd says.
In fact, one study finds that psychiatrists receive lower insurance reimbursements even as compared with non-psychiatrist medical doctors providing the same services. The median reimbursement for in-network psychiatrists providing services to patients with low-to-moderately severe concerns was 13% less than that received by non-psychiatrist medical doctors ($66 per visit compared to $76). For moderate-to-highly severe conditions, psychiatrists received 20% less in reimbursements than non-psychiatrist medical doctors — $91 versus $114.
And because insurance reimbursement is low and the demand for psychiatrists outstrips supply, access is restricted to patients who can afford it out of pocket. "A lot of psychiatrists in private practice simply won't take insurance, they'll just say, 'I take cash only,' and they can often make 50% more or double and sometimes triple what insurance companies are willing to pay them," he says.
Boyd suggests that increasing insurance reimbursement rates for psychiatry might help address the country's shortage of mental health care providers.
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