In a discussion during the American Psychiatric Association 2018 Annual Meeting, held in New York, New York, a panel of psychiatrists argued that private insurance is failing patients with mental health disorders, and that a single-payer system would provide better access and better care for the most seriously ill patients.

J. Wesley Boyd, MD, PhD, a psychiatrist who focuses on adult outpatient psychiatry in the Cambridge Health Alliance, explained that mental health disorders, which affect 1 in 5 adults, are the leading cause of disability in the United States. Additionally, only 20% of children and youth with mental health disorders will get treatment, and “The effects can be lifelong and potentially devastating, both in terms of inability to retain work, possible interactions with the justice system, you name it…the stakes are very high.” In Boyd’s view, “The insurance industry is not doing anyone a favor when it comes to mental health care.”

Insurance companies create obstacles to needed mental health care, Boyd argued, starting with prior authorizations. “Anytime I have called for a prior authorization, I set aside 40 minutes to do that. I call a number, inevitably it’s a wrong number…I’m counting on being transferred at least twice before I get the person I need.” To Boyd, the difficulty in reaching the right person to authorize care is not merely a hassle, but potentially a deliberate attempt by insurers to curb access to care. “They want to make it as difficult for us as possible,” he said.

According to Boyd, payment for psychiatric services by private insurers is so low that many facilities lose money for the services that they provide, and consequently reduce access to the services that they offer.

Boyd discussed a study1 that he and his colleagues conducted in which they phoned 64 in-network Blue Cross Blue Shield (BCBS) mental health facilities in the Boston area to assess a patient’s ability to gain treatment. Researchers able to get an appointment only 12% of the time. In 23% of cases, they received no return call after trying twice to reach the clinic. In 23% of cases, facilities’ representatives explained that the patient would be required to receive primary care at the facility in order to be eligible for mental health services.

Monica Malowney, MPH, a consultant with the Public Consulting Group, added that in her own study2, in which she and colleagues called 360 adult psychiatrists in 3 major cities using a provider list from BCBS, only 119 clinicians were reachable on a first round of calls. In another such study3 that focused on 913 psychiatrists in 5 major US cities who provide care to children, the researchers were able to get an appointment only 17% of the time.

Stephen Kemble, MD, who is retired from psychiatric practice, argued that value-based payment reform is compounding the problem of accessible care for patients with serious mental illnesses. According to Kemble, value-based models incentivize clinicians to avoid risky, more complex, socially disadvantaged patients because they may cost more to treat than other patients; “If you’re paid upfront, you want to avoid sick people. [You’re] cherry-picking.”

Kemble questioned whether the fee-for-service model itself is really to blame for the problem of high-cost, unnecessary care. Other drivers, such as lack of access to appropriate outpatient care, leads to unnecessary emergency department visits and hospitalizations.

Furthermore, the administrative burdens that come with a shift to value-based care, said Kemble, are creating physician burnout. In his experience in Hawaii, he has found that few private practice psychiatrists are willing to invest in the upgrades required to comply with reporting procedures associated with new payment models, so many clinicians simply stop accepting Medicare and Medicaid instead. As a result, he said, access in Hawaii is increasingly limited to community mental health centers and hospital clinics, so a number of seriously ill patients are unable to get urgently needed care.

Leslie Gise, MD, clinical professor of psychiatry at the John A Burn School of Medicine at the University of Hawaii and a staff psychiatrist at the Maui Health System, added that the current state of the healthcare system disproportionately disadvantages women in gaining access to mental healthcare, in part by charging women more for their coverage. The Affordable Care Act did not fully do away with the problem of “gender rating” enrollees, Gise said, because there are only nominal penalties for violating the law, an higher costs to employers to provide insurance to women can result in lower wages for female workers.

Furthermore, women who divorce often lose their private health insurance, she said, and the linkage of marital status and health insurance contributes to declines in women’s health. “Everyone should have adequate healthcare for life. Divorce should have nothing to do with it.”

A well-designed single-payer system that would cover all people for life, said Gise, would provide better outcomes, greater equality, and cost-reduction for the healthcare system at large.

References

1. Boyd JW, Linsenmeyer A, Woohandler S, Himmelstein DU, Nardin R. The crisis in mental health care: a preliminary study of access to psychiatric care in Boston. Ann Emerg Med. 2011;58(2):218-219. doi: 10.1016/j.annemergmed.2011.03.053.

2. Malowney M, Keltz S, Fischer D, Boyd JW. Availability of outpatient care from psychiatrists: a simulated-patient study in three US cities. Psychiatr Serv. 2015;66(1):94-96. doi: 10.1176/appi.ps.201400051.

3. Cama S, Malowney M, Bodurtha Smith AJ, et al. Availability of outpatient mental health care by pediatricians and child psychiatrists in five US cities. Int J Health Serv. 2017;47(4):621-635. doi: 10.1177/0020731417707492.