Acceptance of New Clients by Mental Health Clinicians in Massachusetts: Findings From a Representative Survey

Survey respondents included licensed mental health clinicians with several different credentials (Table 1). Social workers represented 49% of licensed mental health clinicians in Massachusetts; counselors and therapists, 22%; psychologists, 20%; and psychiatrists, 10%. Clinicians most commonly worked in solo private practices (33%) or group private practices (30%). Forty-two percent of clinicians worked ≥30 hours per week, and 10% were in their first year at their current position.

Clinicians reported that, on average, 53% of their clients were aged 26 to 64 years old, and nearly all respondents (90%) served clients in this age group (Table 2). Relatively few clinicians served any clients that were age 5 or younger (11%) or ages 6 to 12 (31%). Clinicians identified the majority of their clients as white/Caucasian (77%), and many served at least some African American/black and Asian American/Asian clients (9% and 5%, respectively).

On average, clinicians accepted seven new clients per month, a median of four new clients per month, and an interquartile range of two to eight new clients per month (Table 3). Overall, 95% of clinicians reported accepting any new clients. In bivariate analysis, the mean number of new clients accepted per month varied significantly by practice setting (bivariate F test, p <0.001). Clinicians in practices owned by a hospital or health system accepted 15 new clients per month, whereas clinicians in group private practices accepted only four new clients per month. When stratifying by clinician type, the mean number of new clients accepted per month did not significantly vary, and the distributions were also relatively similar, with a median of three or four for each clinician type.

After adjusting for other factors, clinicians in practices owned by hospitals or health systems reported accepting 5.9 more new clients per month, on average, than clinicians in solo private practices (95% confidence interval [CI]=1.0 to 10.8; Table 4). Clinicians in private group practices reported accepting fewer new clients per month, on average, than clinicians in solo private practices (−2.0 clients per month; 95% CI=–3.7 to –0.4). Clinicians in community health centers or community mental health centers reported accepting slightly more new clients than those in solo private practices, but the difference was not statistically significant. Working part-time was negatively associated with acceptance of new clients (−4.8 clients/month for clinicians working <20 hours per week, relative to those working ≥30 hours per week; 95% CI=–7.2 to –2.3), and first year in position was positively associated with acceptance of new clients (2.8 clients per month; 95% CI=0.3 to 5.3).

This study reports findings from a representative survey of mental health clinicians practicing in Massachusetts in 2016 and 2017 and is the first study, to our knowledge, to report rates of new client acceptance by licensed psychologists, social workers, and mental health counselors, in addition to rates for psychiatrists alone. In this survey, almost all mental health clinicians—19 out of 20—reported accepting at least one new client per month during the prior 6 months. The distribution of new clients accepted per month was relatively wide, with a mean of seven clients per month, a median of four, and an interquartile range of two to eight. Responses at the higher end of the distribution, with reports as high as 80 new clients per month, could reflect newly hired clinicians or those specializing in brief treatment or assessments. Prior studies of new client acceptance among primary care physicians have reported estimates of similar magnitudes (15, 16), although these studies did not include estimates for mental health clinicians other than psychiatrists. One recent study using the 2015 National Electronic Health Records Survey found that that 89% of primary care physicians were currently accepting new patients (16), similar to reported acceptance rates of any new clients in this study (95%). Our study expands this access measure to the context of mental health, assessing average new clients accepted per month and adjusting for key client and practice characteristics.

On average, clinicians in practices owned by hospitals or health systems reported accepting more new clients than clinicians in private solo and group practices. Prior research has found that practices owned by hospitals or health systems also had longer wait times than other settings (26). Greater acceptance of new clients in hospital or health system-owned settings, along with longer wait times, may reflect a mental health care system that channels individuals in need of outpatient mental health services to specific types of practice settings and clinicians, based on their insurance type or ability to self-pay for services. Practices owned by hospitals or health systems may have greater administrative support for collecting insurance payments and maintaining wait lists of clients (26). In contrast, clinicians in private practice may have more autonomy to choose the clients they serve and how many but fewer resources designated for insurance administration and client scheduling. This insight, although not universally generalizable, may still be valuable for individuals seeking outpatient mental health services.

This study found substantial variation in the distribution of acceptance of new clients across mental health clinicians, even within each clinician type and licensing credential. This suggests that some clinicians take a relatively limited number of new clients, especially as over half of the respondents to this study reported working fewer than 30 hours per week. Changes in policy and practice—such as alignment of payment incentives, reduced administrative burden and use of brief evidence-based treatments—may help some mental health clinicians increase the number of clients that they accept. In particular, payment policies and systems, for both private and public payers, could be more effectively designed to support clinicians in serving clients with the greatest needs. Reducing administrative burden could help reduce provider burnout (27–29), increasing reimbursement rates may encourage more health care trainees to specialize in mental health and work in settings that accept public insurance, and risk-adjusted rates might encourage clinicians to treat individuals with the highest need (30, 31). Further study is also needed to assess the average time that clients remain on clinician caseloads, along with therapies used and supportive services engaged. A larger issue, beyond the scope of this study, is how to attract and retain a skilled mental health treatment workforce (32, 33).

This study has relevance for patients, practice, and policy. People seeking treatment might more quickly find an appointment with a clinician working within a health system, given their greater volume of new clients accepted. Additionally, payers and policy makers may also be able to establish policies that encourage providers to accept new clients, especially those in smaller and independently owned practices. Policies could include reducing paperwork, increasing reimbursement rates for initial visits (6), encouraging adoption of telepsychiatry (34), and incentivizing providers to practice in areas with high unmet need for access to mental health care (e.g., through student loan payment assistance; 6).

This study had limitations. First, survey nonresponse may have biased estimates of new clients accepted in this study, to the extent that nonrespondents would have reported different outcomes than clinicians who responded to the survey. The adjusted response rate for the survey was 28%. Although Massachusetts requires practicing clinicians to update their licenses every other year, clinicians do not always update their addresses if they move, which may have contributed to clinician nonresponse, given that the sampling frame primarily used contact information from the state licensing data. We assessed nonresponse bias by exploring differences between survey respondents and nonrespondents based on information that was known for both groups (see Appendix A in the online supplement; 35, 36). Across all types of clinicians, psychiatrists were least likely to respond to the survey (unadjusted response rate=13%), whereas counselors and therapists were most likely to respond to the survey (unadjusted response rate=37%). The propensity of survey response varied significantly by clinician type (p<0.001). We did not find a statistically significant difference in propensity of survey response by EOHHS region or by year of licensure. These findings indicate that comparisons of the number of new clients by type of clinician may be limited by nonresponse bias; however, we found no differences in the characteristics of respondents and nonrespondents by region or clinician experience. The relatively lower response propensity for psychiatrists is consistent with many other studies finding that physicians can be challenging to survey (37, 38). Applying survey weights by clinician type and EOHHS region also adjusted for differential response by clinician type and region (i.e., if more clinicians responded in one region versus another).

Second, this study used findings from a survey of mental health clinicians to assess factors associated with new client acceptance, and self-reported clinician survey responses could not be independently verified. Survey respondents may be subject to social desirability bias, or a tendency to respond in a manner that the respondent believes others may prefer (39). Acceptance of new clients cannot be measured through administrative data and must instead be measured by asking the clinician, either by using secret caller studies (16) or explicitly through surveys (5, 16). Secret caller studies, which use simulated clients (e.g., with varied insurance coverage and diagnoses) to assess availability, allow information to be collected without bias from self-reports but are limited in that they include only clinicians that are willing and able to book appointments without specific insurance information. Surveys do not face this limitation, but estimates of availability from surveys may be biased, because the information collected relies on self-reports. To minimize potential concerns, we informed invited participants that their responses would be confidential and reported in aggregate only. In addition, the survey was self-administered, a method that has been shown to decrease social desirability bias relative to interviewer-based modes (40, 41). There is also no reason to believe social desirability bias should vary across respondent groups (e.g., clinician type, region), and consequently, there is no reason to believe that social desirability would have influenced differences in observed number of new clients across those groups.

This study reported representative estimates of new client acceptance among licensed mental health clinicians in Massachusetts. Half of the clinicians reported accepting four or fewer new clients, on average, per month. Acceptance of new clients was lower among clinicians in private practice than those in settings owned by hospitals or health systems. These findings may help provide guidance to clients looking for outpatient mental health care and to policymakers conducting mental health system planning and workforce development, given that provider acceptance of new clients has a direct impact on access to services for outpatient appointments. These findings also highlight the importance of payers maintaining updated lists of clinicians accepting new clients.

The authors thank Daniel Loew, John Sokolowski, Ken Gaalswyk, and Raphael Nishimura from Abt Associates’ Data Science, Surveys, and Enabling Technologies Division for their support in designing and administering the survey.