Availability of Outpatient Child Psychiatric Care During COVID-19: A Simulated-Patient Study in Three U.S. Cities

We used the Blue Cross–Blue Shield (BCBS) website to create a list of in-network BCBS child psychiatry providers in Chicago, Houston, and Los Angeles. We chose BCBS because it is the largest insurance provider in Illinois, Texas, and California.

We randomly assigned the first 120 child psychiatrists listed in Chicago and Los Angeles to three payer groups (BCBS preferred provider organization, Medicaid, or self-pay) of 40 psychiatrists each. In Houston, the BCBS database listed only 82 child psychiatrists within a 100-mile radius (the maximum search radius in the BCBS database), and these psychiatrists were assigned to the same three payer groups (27, 27, and 28 psychiatrists, respectively). We then called all 322 psychiatrists from July 6 to August 4, 2022, impersonated the parent of a 10-year-old child who had just visited the emergency department for depression, and asked for an appointment by using a standardized script that varied only by the payment type associated with that practitioner. Calls were made during normal business hours, and voicemails were left when the office did not pick up the call. If we did not receive a return call with the requested information, we called the office a second time, approximately 1 week later, and followed the same protocol as before.

Data collected included whether a call was answered, whether and when a call was returned, whether we were able to make an in-person or virtual appointment, the number of days until the appointment, and the reason why no appointment was given. Data analysis was performed with R, version 4.2.1. The Baylor College of Medicine Institutional Review Board granted our study an exemption from review.

After calling 322 psychiatrists, we were able to obtain appointments with 34 psychiatrists (11% of our sample). Of these appointments, 11 psychiatrists offered only in-person appointments, 12 offered only virtual appointments, and 11 offered both options. Many psychiatrists who offered only in-person appointments stipulated that the intake appointment had to be in person but that future appointments could be virtual. We found no significant difference in being able to obtain appointments on the basis of location. However, we did find a significant difference in being able to schedule an appointment with BCBS insurance or by paying out of pocket, compared with Medicaid (self-pay, 44% [N=15]; BCBS, 41% [N=14]; Medicaid–Children’s Health Insurance Program, 15% [N=5]; p=0.025). A total of 19% (N=60) of the telephone numbers in the database were wrong, and 25% (N=82) of psychiatrists were not accepting new patients.

Table 1 lists the reasons that offices in each city gave for not scheduling an appointment. In Chicago and Los Angeles, the most common reason appointments were unable to be scheduled was that the office was not accepting new patients (33%), and the second most common reason was that the phone number listed in the BCBS database was incorrect (20%). By contrast, in Houston, the most common reason for not being able to schedule an appointment was an incorrect phone number listed by BCBS (24%), followed by the doctor’s office requiring more information (20%). Other reasons for not being able to schedule appointments included telephone numbers that resulted in a voicemail loop, had no option to leave a voicemail, or had a completely full voicemail box that was not accepting messages.

The mean±SD time until the first available in-person appointment was 44±30 days (range 1–112 days) for all cities, and the mean time until the first available virtual appointment was 37±44 days (range 1–208 days). However, the mean number of days varied widely between cities: Chicago averaged a wait of 65 days for an in-person appointment and 59 days for a virtual appointment, whereas Houston averaged only 24 days for an in-person appointment and 12 days for a virtual appointment. The mean number of days until the first available appointment in Los Angeles was similar to that of Houston (23 days for an in-person appointment and 21 days for a virtual appointment).

Although being able to access pediatric mental health care is more important than ever, we found that obtaining a child psychiatric appointment in the three cities in our study was very difficult. Moreover, when we were able to secure an appointment, the wait time averaged more than a month for both the virtual and in-person appointment formats.

Since the onset of the COVID-19 pandemic, many psychiatrists have shifted to offering virtual appointments. We were able to obtain approximately an equal number of in-person and virtual appointments, and wait times for in-person appointments were slightly longer than for virtual appointments (44 days vs. 37 days). Therefore, our study offers further evidence that telehealth alone is not enough to increase access to care (10). Although the shift to virtual appointments may have made it easier for patients to attend appointments, such ease is of little benefit if patients are unable to schedule any appointments.

Many of the calls that were made were not answered and were directed to voicemail, an occurrence in line with research that shows that this phenomenon is more common when patients are trying to obtain mental health care compared with other forms of medical care (14). Furthermore, many voicemail boxes were full, resulted in a voicemail loop, or had no option to leave a message, all of which compound the difficulties of seeking psychiatric services.

We encountered numerous wrong numbers and full practices in the BCBS database. This finding is somewhat surprising because, although it has been known for years that insurance databases contain many inaccuracies (11–13), many insurance companies have taken steps to correct their databases. However, our findings suggest that insurance company efforts have been inadequate. Moreover, given the ravages of the COVID-19 pandemic on the mental health care system and the growing number of children requiring mental health care since the onset of the pandemic, parents hoping to use insurance to find a psychiatrist for their child are likely to be frustrated by the large number of clinics they have to call to secure an appointment—or even a position on a provider’s waitlist.

Our study had several limitations. First, the sample was limited both in terms of the total number of psychiatrists called and the small number of cities (N=3). Second, because a BCBS database was used, many practitioners in each city would presumably not be listed in this database; thus, our findings concerning the difficulties of obtaining child psychiatric appointments might be overestimated. Finally, given that most adolescent mental health care is provided by pediatricians as well as by mental health practitioners who are not psychiatrists (e.g., social workers and psychologists), our study cannot accurately assess the difficulty of obtaining pediatric mental health care in general.

In addition to improving the accuracy of their databases, insurance companies should reimburse mental health services at higher rates to increase the number of psychiatrists willing to accept insurance. Currently, mental health services are reimbursed at rates that are so low that health care institutions often lose money when they offer mental health care. Thus, many hospitals and clinics limit access to the mental health services they offer, exacerbating the separate problem of an insufficient number of psychiatrists to cover demand. Increasing reimbursement rates for mental health care would therefore potentially reduce disparities in care, ease workforce shortages, and address other unmet needs.

In addition to increasing reimbursement rates for services, efforts are needed to increase access to mental health care for child and adolescent patients. One way might be to enforce existing parity laws and to increase the number of psychiatry graduate medical education positions. Given recent appropriations in the federal budget for accomplishing these tasks, efforts should be made to monitor the impact of these appropriations to determine whether they are effective in improving access to care. Another option is to embed mental health services in primary care settings so that providing mental health treatment to patients occurs more smoothly.

Finally, other creative programs exist that attempt to increase access to mental health care for child and adolescent patients, such as Texas Child Health Access Through Telemedicine and the Massachusetts Child Psychiatry Access Program. These programs generally utilize an interdisciplinary care, a collaborative care, or a consultative care model, expanding access through the use of existing resources. Efforts and funding to expand these programs and create similar initiatives in other states represent a promising avenue for increasing access to care.

Ultimately, our results confirm what many already know: in the midst of a mental health crisis, having insurance is not enough to guarantee access to mental health care when it is needed. In our study, many child and adolescent psychiatric practices were full; moreover, among those few psychiatrists who were accepting new patients, even fewer were willing to see patients with Medicaid. This finding is concerning, given that Medicaid has long been a primary payer of mental health services in the United States; furthermore, since the beginning of the COVID-19 pandemic, Medicaid enrollment has substantially increased. Given these two facts, our difficulty in obtaining an appointment with Medicaid is particularly concerning (15). This difficulty also highlights the stark reality that those who are poor and hope to use public insurance are frequently denied mental health care. Because COVID-19 has disproportionately harmed racial-ethnic minority groups and impoverished populations, our findings represent a double insult and a deepening inequity in access to care. Better accessibility of postpandemic child psychiatric services is urgently needed.