21 November 2014, 9.24pm AEDT
Need to see a psychiatrist? Call your insurance company first
Tara F Bishop
Assistant Professor of Healthcare Policy and Research, Assistant Professor of Medicine at Cornell University
Tara F Bishop receives funding from the National Institute on Aging, the Commonwealth Fund, the Robert Wood Johnson Foundation, and the Physician’s Foundation.
The Conversation is funded by CSIRO, Melbourne, Monash, RMIT, UTS, UWA, ACU, ANU, ASB, Baker IDI, Canberra, CDU, Curtin, Deakin, Flinders, Griffith, the Harry Perkins Institute, JCU, La Trobe, Massey, Murdoch, Newcastle, UQ, QUT, SAHMRI, Swinburne, Sydney, UNDA, UNE, UniSA, USC, USQ, UTAS, UWS, VU and Wollongong.
Not everyone can pay out of pocket. Stock image of counseling session via Monkey Business Images/Shutterstock
Last week, a patient contacted me to find a psychiatrist because his anxiety was beginning to get out of control. He wanted to see someone who could do therapy and prescribe medications if he needed them. I gave him some names but warned him that none of them took insurance. If he wanted to find a psychiatrist that took his insurance, he’d need to call his insurance company to find one.
And this situation is not uncommon in my primary care practice. I can treat simple psychiatric conditions like depression and anxiety but, like many internists, I do not have the training to provide therapy or treat more severe psychiatric conditions. If a patients needs psychiatric care, the best I can do is to offer them some recommendations and tell them to contact their insurance company. As you can imagine, this poses a barrier for patients trying to access the psychiatric care they need.
Half of psychiatrists do not take insurance
This motivated me to study psychiatrists and insurance. Last year, a team of researchers and I published a study using data from a national survey of doctors examining this issue.
We found that almost half of psychiatrists take don’t take health insurance – whether it’s private health insurance, Medicare (insurance for the elderly), or Medicaid (insurance for the poor).
Specifically, we found that in 2009 to 2010, only 55% of psychiatrists took private health insurance, 55% took Medicare and 43% took Medicaid. This presents a significant barrier for patients who need to see psychiatrists.
It’s important to emphasize that this was a sharp contrast to every other type of doctor. For example, 94% of cardiologists took private health insurance during that same time period and 95% of general internists took Medicare. When pooled together, 88% of physicians all specialties other than psychiatry took private health insurance and 86% took Medicare. Acceptance rates for Medicaid were low overall because reimbursement rates are low. Nevertheless, psychiatrists had some of the lowest Medicaid acceptance rates of all specialties.
The results shocked us and when our study was published last year, we learned that the results also shocked the general public.
Doctors, patients and reporters corroborated our findings. I started to hear more and more stories of patients who struggled to find a psychiatrist who took their insurance.
Less money for more work
So why is this the case? First, low reimbursement may be a problem. Medicare pays US$130 to US$140 for a new visit to a psychiatrist. Although that rate is not much different from a visit to a primary care doctor, visits to psychiatrists may be longer because they involve counseling and therapy.
Second, a shortage of psychiatrists may also be factor. From 2000 to 2008, 14% fewer medical students chose to pursue careers in psychiatry and 55% of psychiatrists are over 55 and close to retirement age. As a result, many psychiatrists may have so much demand for their services that they do not need to accept insurance.
Finally, psychiatrists may not have or need the administrative capacity that other doctors need. A psychiatrist may be able to function without a lot of staff like nurses, medical assistants, and administrative assistants. Because of this some psychiatrists may not be motivated to hire that staff just to interact with insurance companies.
Since the time of our study, our team has been developing ways to further study the problem but also to explore solutions.
One obvious step is to increase reimbursement for mental health-care. But such changes can be difficult. Medicare relies on a review panel of physicians to change reimbursement and it is unclear whether that panel will suggest increased reimbursement for psychiatrists.
But there are other promising options that make it easier for patients to access mental health care. For example, the New York City Department of Health and Mental Hygiene runs a program called Lifenet which patients can call to find a psychiatrist or other mental health provider in New York City who takes their insurance.
Another very effective program, called Impact, was developed by faculty at the University of Washington and helps primary care physicians treat depression. A nurse, social worker or psychologist works closely with patients in the primary care doctor’s office and has a designated psychiatrist to help with patients who are not improving.
These are good starts but much more needs to be done in order to ensure access to psychiatrists across the board. For now, I have told my patient that he will probably have to pay for his psychiatric care even though he has insurance or will have to find someone who takes his insurance without my help.
Hopefully in the future, we will have more options for him.