Patient Characteristics and Treatment Patterns Among Psychiatrists Who Do Not Accept Private Insurance

Our final NAMCS sample included 440 psychiatrists responding in 2011–2014, with data from 7,634 visits, representing 119,605,827 patient visits nationally. Among psychiatrists, 65% were accepting new privately insured patients. This number was significantly higher (89%) for other physician specialists (p<0.01).

This study is the first to look at patient characteristics and treatment patterns associated with whether a psychiatrist reports accepting new privately insured patients. We found that psychiatrists who accept private insurance may be seeing patients with more complex treatment needs—psychiatrists who accept insurance had approximately 25% more visits involving a patient with a diagnosis indicating serious mental illness. This difference in the patient panel may be due to patient demand or provider behavior. If patients with more serious diagnoses anticipate needing more services, the cost of seeing out-of-network psychiatrists may be prohibitive. In addition, these patients may be more likely to benefit from ancillary services such as case management, which may be more available among psychiatrists who accept private insurance. Provider behavior may also play a role if providers who choose not to participate in private insurance networks are more willing to accept new patients with less serious diagnoses (i.e., “cream skimming” the easy-to-treat patients).

Despite seeing more patients with serious mental illness, psychiatrists who accept insurance on average spent less time with their patients and saw them fewer times than psychiatrists who do not accept insurance. We found that visits to psychiatrists who do not accept private insurance were more likely to last 30 minutes or more and more likely to involve patients with 10 or more visits in the past 12 months, suggesting more intense treatment episodes. Insurers may be managing care and be more likely to require a justification for longer visits or treatment episodes of exceptionally long duration from network providers, resulting in the less intense care provided among network providers. Psychiatrists not participating in private insurance networks may feel less pressure to end treatment with a patient, particularly if they receive fewer requests for appointments from new patients, given their higher out-of-pocket cost.

Anecdotal reports suggest that some psychiatrists do not accept new patients with private insurance because of a preference for providing psychotherapy (compared with medication management), which at longer durations may be less likely to be approved by plans. That we found no differences in the proportion of visits that included psychotherapy suggests other important reasons for not accepting patients with private insurance.

Practice characteristics also differ. We found that psychiatrists who accept new patients with private insurance are more likely to have electronic medical record systems with greater capability, which may reduce billing costs or errors. Psychiatrists who do not accept insurance are more likely to be in solo practice and may not be able to afford the overhead or complex implementation of an electronic medical record. These systems may lead to care of higher quality if access to information about general medical conditions is more readily available. Overall, psychiatrists have fewer electronic medical record capabilities than other specialists. In our sample, 62% of psychiatrists could submit claims electronically in 2014; one NAMCS report indicated that when considering all specialties, 89% could submit claims electronically (11).

Policy observers have suggested that psychiatrists may not accept new privately insured patients for two important reasons—low overall reimbursement rates and administrative hassles associated with reimbursement by private insurers. Information on whether these psychiatrists accept new patients with Medicare coverage may shed light on the relative importance of these two concerns. Historically, Medicare has fewer administrative hurdles to payment once care is delivered. Even though administrative hurdles under private insurance may have been reduced somewhat by MHPAEA, they are still likely higher than under Medicare. We find that about 39% of psychiatrists not accepting new privately insured patients do accept new Medicare patients, suggesting that the administrative burden may be an important reason for not accepting private insurance for these psychiatrists.

Rates of psychiatrists accepting new privately insured patients remain quite low compared with other specialties, justifying ongoing concerns about access to mental health care for the privately insured. Lack of acceptance by psychiatrists may impede or delay receipt of care, particularly if provider directories are not accurate (12). It may also lead to an additional financial burden on patients due to higher cost sharing for out-of-network care as well as balance billing (4). Although not generalizable, a patient and family survey conducted by the National Alliance on Mental Illness found that 30% to 32% of respondents reported having difficulty finding a mental health specialist who would take their insurance (13). Unlike many prior state parity laws, the MHPAEA requires that plans offering an out-of-network benefit for mental health have equivalent benefit design to out-of-network medical care (including copayment, coinsurance, out-of-pocket maximums, and deductibles). Critics have noted the difficulty in enforcing requirements of MHPAEA, and there have been numerous complaints by patients about policies that are not in compliance with MHPAEA (14, 15). There has also been significant criticism of the lack of transparency of some of the provisions. Perhaps with greater enforcement and disclosure requirements, plan policies may change in such a way as to encourage more psychiatrists to accept private insurance.

Delivery system reforms have led to an increased emphasis on providing mental health treatment in primary care, perhaps by a team of providers that includes a mental health specialty provider (16). This change may alleviate provider shortages and increase access to mental health care, even in the face of limited participation by psychiatrists in private insurance networks. In addition, other mental health specialty providers, including psychologists and social workers, may provide needed mental health services, particularly psychotherapy. Yet, for individuals with more serious mental illness, access to a psychiatrist may still be critical. Thus, when there is a shortage of psychiatrists, it may be optimal at a population level for some patients, particularly those with less severe anxiety disorders or depression symptoms, to be treated in a primary care setting.

Limitations of the data are important to consider when determining implications of these findings. We only considered psychiatrists because data on other mental health professionals were not available. These data do not include all outpatient visits; hospital-based outpatient care and care delivered in community health centers are not included. Although nationally representative, the sample of psychiatrists in each year is relatively small, and some meaningful differences may not be detected. There are well-known limitations to survey data such as difficulties in accurately determining diagnoses and other patient characteristics or treatments patterns. This may be particularly true in the case of psychotherapy, because what constitutes psychotherapy may be interpreted differently by different psychiatrists. We used recorded diagnoses to identify serious mental illness, which, in the absence of information on functional limitations, may not accurately categorize some patients. Finally, this study was descriptive in nature and we are unable to determine what policies—such as higher reimbursement, changes to health plan precertification, or treatment review—may ameliorate the problem of low psychiatrist acceptance of new privately insured patients. Likewise, we cannot determine the consequences of this problem for patient outcomes.

Although psychiatrists who do not accept patients with private insurance are less likely to treat patients with serious mental illness, their patients were more likely to have longer visits and a relatively high number of visits in the past year. The low acceptance rate of insurance among psychiatrists may have the greatest effect among individuals who are most in need of services.

This study was supported by a grant from the National Institute of Mental Health (R01MH106635).