Half of psychiatrists reject private and federal insurance, preferring cash

Access to mental health care has become a prominent issue in Congress following mass shootings around the country. But a new study in JAMA Psychiatry, led by researchers at Weill Cornell Medical College, suggests that unless those in need of help have deep pockets, they might have a hard time finding a psychiatrist that will provide the needed services.

The study found that psychiatrists increasingly refuse to accept Medicare and Medicaid, or even private insurance, as payment. In the five years between 2005 and 2010, investigators found that the percentage of psychiatrists who accepted dropped by 17 percent, to 55 percent, and those that took Medicare declined by almost 20 percent, also to about 55 percent. Their acceptance of Medicaid is 43 percent, the lowest among all medical specialties.

"More than physicians in other specialties, psychiatrists accept lower rates of insurance, and those who don't take insurance are likely charging cash for their services," says the study's lead author, Dr. Tara F. Bishop, an assistant professor in the Department of Public Health and Medicine at Weill Cornell Medical College.

The number of psychiatrists is also quickly dwindling—a drop of 14 percent from 2000 to 2008—because psychiatrists are retiring and medical students are not choosing to go into psychiatry. These issues may lead to a perfect storm of untreated issues nationwide, Dr. Bishop says.

"In the current climate, where the need for increased mental health services is now recognized, I suspect our study conclusions will be an eye opener for both the public and the medical community," she says. "I must say we were surprised by the findings. No prior studies have documented such striking differences in insurance acceptance rates by psychiatrists and physicians of other specialties—primarily because no one has looked closely at the issue."

These low insurance rates may "impact recent calls for increased access to , and if the trend of declining acceptance rates continues then the impact may be even more significant," the researchers say in their study.

"For example, not only are there fewer physicians who can help people with moderate to severe symptoms of mental illness, those patients must then try to find a doctor who will take their insurance," Dr. Bishop says. "This is not a formula for success."

Additionally, with the growth of the population, need for services will increase, she says. The Centers for Disease Control and Prevention estimates that a quarter of adults in the United States report having a mental illness at any given time, and that about half of adults will suffer from one in their lifetime.

While the term "" is broad, and includes depression and anxiety that general care doctors can help with, those doctors are overwhelmed, says Dr. Bishop, who is herself a primary care physician. "We don't have a work force that can keep up with all the issues—mental health aside—in our growing and aging population."

Solo practitioners less likely to accept insurance

The Weill Cornell investigators, working with researchers from Columbia University and the University of California, San Francisco, used a nationally representative survey to conduct their study. That database is the National Ambulatory Medical Care Survey (NAMCS), administered by the Centers for Disease Control's National Center for Health Statistics (NCHS). It represents about 90 percent of the ambulatory care delivered in the United States—the care provided in private physician offices or group practices, Dr. Bishop says.

The database does not include psychiatric outpatient clinics linked to hospitals or large medical centers. "Some patients with some of the most severe mental illnesses, such as schizophrenia or bipolar disease, may be cared for in those clinics, and this database does not capture that population," she says.

The average number of physicians surveyed each year by the NAMCS is about 1,250, and psychiatrists represent 5.5 percent of these doctors.

The researchers don't know why psychiatrists are increasingly rejecting insurance payment; questions about motivation were not included in the survey. "But we can speculate that insurance provides lower reimbursement rates than psychiatrists feel cover the costs of care," Dr. Bishop says.

Part of the reason for this reluctance may be that it takes considerable time—typically, an hour or so—to provide counseling and therapy, and therefore, psychiatrists may not be able to see as many patients in a day as physicians of other specialties can, Dr. Bishop says.

Additionally, more psychiatrists than physicians of other specialties practice alone—60 percent—and accepting insurance entails considerable administrative work, she says. The study found that these solo practitioners are less likely to accept all types of insurance.

These issues could be resolved if incentives are offered to medical students to pursue psychiatry, and if insurance payments to practicing psychiatrists are increased, the researchers say.

Dr. Bishop is delving deeper into the issues her study raises. She plans to interview to understand why they are not accepting , and what can be done to change their minds.

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