A friend of mine, James, is a psychiatrist who started his career at a clinic that mainly served a Medicaid population, but recently left for private practice. He related to me that after years of frustration with limits on the amount of time he could see a patient, administrative hassles and low reimbursement, he decided to branch out on his own. He debated taking insurance in his new practice, but had heard that psychiatrists who relied on insurance could only make a living by seeing patients for 15 minutes at a time. He felt this was a disservice to his patients and undermined his ability to provide good care and ultimately, he decided not to accept insurance.
The shortage of psychiatrists who accept insurance in the United States is a serious problem. Suicide rates are climbing in the U.S. and nearly one in five Americans lives with mental illness. Yet among the 43.4 million people with a mental illness in the U.S., only about 43 percent received treatment in the past year. Psychiatrists not accepting insurance is a major barrier to receiving treatment.
In addition to preventing or delaying receipt of care, lack of acceptance of insurance by psychiatrists may also cause additional financial burden on patients who choose to go out-of-network. For many patients, using an out-of-network psychiatrist can mean higher out-of-pocket costs, higher copays and higher coinsurance.
Not every patient who presents with a mental health issue needs to see a psychiatrist. Evidence shows that primary care providers, in conjunction with trained care managers and consultation with specialty providers, can be effective in treating patients with anxiety and depression. In addition, many types of highly qualified non-psychiatrist mental health providers such as psychologists, nurse practitioners, or social workers can effectively treat individuals with mental health diagnoses.
Ideally, given their shortage, psychiatrists should treat patients with the most complex problems and who require medication management from a physician. However, in a new study, we found that visits to office-based psychiatrists not taking new patients with private insurance were significantly less likely to involve individuals with serious mental illness such as schizophrenia or bipolar disorder compared to psychiatrists that do take insurance (42 percent versus 53 percent).
This may indicate that patients who anticipate needing more services prefer to use a psychiatrist who accepts their insurance because going out-of-network may just be too expensive. It may also indicate that psychiatrists who choose not to accept insurance are opting to see less complex patients. Either way, the shortage of psychiatrists that accept insurance may impact those that need it the most.
Our study offers some clues on how to address this problem. Medicare traditionally has fewer administrative hassles for psychiatrists compared to private insurance. We found that among psychiatrists that do not accept private insurance, about a third do accept Medicare — suggesting that eliminating administrative hassle may encourage more psychiatrists to take private insurance.
Many psychiatrists, like my friend James, have also said that when they take insurance they are unable to spend as much time with patients and provide psychotherapy. Our study found that psychiatrists who don’t take private insurance more often do have longer visits with patients, but somewhat surprisingly provide psychotherapy at about the same rates as those who do.
In an ideal world, psychiatrists would serve the most psychiatrically and medically complex patients, be easily accessible across the country and take insurance. We need policies that will encourage psychiatrists like my friend James to take insurance — policies that improve reimbursement and reduce the headache of taking insurance.
These same policies will also encourage more medical students to enter the field of psychiatry. Other creative solutions to improve access, such as telemedicine and team-based care that puts the psychiatrist in the role of a consultant, are needed to ensure that those with the most severe mental illness receive the care they need.
Kelly A. Kyanko, MD, MHS is an assistant professor at NYU School of Medicine and Susan H. Busch, PhD, is a professor at Yale School of Public Health.