Conclusions

In this analysis of a national survey of office-based physicians, acceptance rates of all types of insurance were significantly lower for psychiatrists than for physicians of other specialties. For private fee-for-service insurance and for Medicare, acceptance rates by psychiatrists have dropped since 2005. In 2009-2010, almost half of all psychiatrists did not accept private fee-for-service insurance and over half did not accept Medicare or Medicaid. To our knowledge, no prior studies have documented such a striking difference in insurance acceptance rates by psychiatrists and physicians of other specialties. These low rates of acceptance may impact recent calls for increased access to mental health services such the President’s “Now is the Time” proposal in the wake of the recent school shooting.

Low reimbursement has been cited as a reason why physicians do not accept insurance.6,14 While reimbursement rates for office-based psychiatric treatment are similar to those for office-based medical evaluation and management, the desire to provide psychotherapy may be a reason why many psychiatrists do not accept insurance. Average Medicare reimbursement for psychotherapy ranges from $77.05 for up to 25-30 minutes to $161.84 for 75-80 minutes.15 A report in the lay press cites these rates as a reason why psychiatrists are shifting from psychotherapy to providing only medication management.16 As a result, psychiatrists who want to provide psychotherapy may opt not to accept insurance.

A shortage of psychiatrists may also be a potential reason why many do not accept insurance. Faukler et. al. recently reported a 14% decline in the number of graduates from psychiatry training programs over an eight year period from 2000 to 2008.17 These declines coupled with an aging workforce (55% of psychiatrists are age 55 or older) may mean that the supply of psychiatrists cannot meet the demand for their care.18 As a result, many psychiatrists may have so much demand for their services that they do not need to accept insurance. Our data also suggest that psychiatrists in urban settings (where most are distributed) may have greater ability to opt out of insurance plans. Future research might investigate the extent to which non-acceptance of insurance is linked to practice locations in higher income areas.

Our data show that the majority of office-based psychiatrists practice in solo practices which can likely function with much less infrastructure than larger single-specialty or multi-specialty group practices.4 As a result, they may have little incentive to hire staff to interact with insurance companies. In addition, individuals seeing psychiatrists may have concerns about stigma associated with having a mental disorder and worry about the privacy of reports to insurance companies.

Unfortunately, the NAMCS does not ask physicians why they do not accept insurance so all of these potential explanations for our findings are hypothetical. Another limitation of our analysis is that the NAMCS does not collect specialty information or insurance acceptance information on physicians practicing in hospital outpatient departments. Nevertheless, the physicians surveyed in the NAMCS represent the physicians that see approximately 90% of outpatient visits in the U.S. Finally, the NAMCS surveys specialty based on the proportion of physicians practicing in that specialty. Although the sample of physicians is weighted to reflect these proportions, the sample of psychiatrists in the NAMCS is relatively small compared with other specialties (e.g. family practice, internal medicine). As a result, the confidence intervals of each point estimate are relatively wide.

It is unknown if low acceptance rates of insurance by psychiatrists impact access to timely care for patients with mental health problems. More research is needed to understand the barriers that patients face when trying to seek psychiatric care and the barriers that physicians face when trying to refer their patients for psychiatric care. Nonetheless, our findings suggest that policies to improve access to timely psychiatric care may be limited because many psychiatrists do not accept insurance. If, in fact, future work shows that psychiatrists do not take insurance because of low reimbursement, unbalanced supply and demand, and/or administrative hurdles, policymakers, payers, and the medical community should explore ways to overcome these obstacles.

One area that may offer lessons for improving access to psychiatry is the policy, payment, and medical community’s response to the primary care shortage. Facing this looming shortage, Medicare and Medicaid have increased payment for primary care, and new models of delivery and payment-such as the patient-centered medical home-shift care to non-physician providers and staff.19-21 Similar changes in psychiatry may incentivize more psychiatrists to accept insurance, allow them to care for more patients, and encourage more students to pursue careers in psychiatry.

Top 13 psychiatrists who accept medicaid edit by Top Q&A

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