Half of Psychiatrists Reject Health Insurance

Deborah Brauser

December 17, 2013

US psychiatrists have the lowest acceptance rate for all types of health insurance compared with physicians in other specialties, new research suggests.

Results from a national survey show that psychiatrists increasingly refuse to accept Medicare and Medicaid, or even private insurance. The survey revealed that in the 5 years between 2005 and 2010, the percentage of psychiatrists who accepted private insurance dropped by 17% to 55%, and those who accepted Medicare declined by almost 20% to 55%. At 43%, psychiatrists' acceptance of Medicaid is the lowest among all medical specialties.

Instead, psychiatrists were likely to charge cash for their services, said lead author Tara F. Bishop, MD, MPH, assistant professor in the Department of Public Health and Medicine at Weill Cornell Medical College in New York City.

"We were very surprised by our findings, but it validated some of the experiences I have had as a primary care doctor, as well as experiences by some of my coauthors," Dr. Bishop told Medscape Medical News.

She added that the study did not examine the reasons behind the insurance rejections. "But we can speculate that insurance provides lower reimbursement rates than psychiatrists feel cover the costs of care."

Commenting on the findings for Medscape Medical News, Jeffrey Lieberman, MD, president of the American Psychiatric Association (APA), agreed with Dr. Bishop's assertion.

"It's generally understood in healthcare currently that the so-called 'cognitive specialties' are reimbursed at a much lower, less financially desirable rate than the procedural and surgical specialties," said Dr. Lieberman to Medscape Medical News.

However, he noted that the recent issuance of the final rule on the Mental Health Parity and Addiction Equity Act may lead to future improvements, "if it's enforced adequately."

The study was published online in JAMA Psychiatry.

Shedding New Light

The investigators note that when it comes to insurance acceptance, little is known about the potential differences among medical specialties.

Dr. Tara Bishop

The researchers examined data from the National Ambulatory Medical Care Survey (NAMCS), which is administered by the Centers for Disease Control and Prevention's National Center for Health Statistics and represents approximately 90% of all ambulatory care delivered in the United States.

Dr. Bishop noted that the NAMCS does not include data on psychiatric outpatient clinics linked to hospitals or large medical centers.

"Some patients with some of the most severe mental illnesses, such as schizophrenia or bipolar disease, may be cared for in those clinics, and this database does not capture that population," she said in a release.

The NAMCS surveys roughly 1250 physicians per year. It does not include data on the fields of pathology, radiology, or anesthesiology.

Results showed that between 2009 and 2010, 55.3% of psychiatrists vs 88.7% (P < .001) of other specialists accepted private noncapitated insurance. Similarly, 54.8% of psychiatrists vs 86.1% of other specialists (P < .001) accepted Medicare, and 43.1% vs 73% (P < .001) accepted Medicaid.

Cardiologists had the highest acceptance rate of private insurance (93.6%) and Medicare (99.4%).

An Eye-opener

In addition, solo practitioners were less likely than group practitioners to accept all types of insurance. More psychiatrists (60.1%) practiced alone compared with other specialties (33.1%), and Dr. Bishop pointed out that accepting insurance is associated with a greater administrative workload.

The study also revealed that psychiatrists in the Midwest were significantly more likely to accept private insurance (85.1%) compared with those in the West, Northeast, or South (57.8%, 48.5%, and 43%, respectively; P = .02). There was no significant difference between the regions for Medicare or Medicaid acceptance.

"In the current climate, where the need for increased mental health services is now recognized, I suspect our study conclusions will be an eye-opener for both the public and the medical community," said Dr. Bishop.

She added that the overall findings were surprising.

"No prior studies have documented such striking difference in insurance acceptance rates by psychiatrists and physicians of other specialties ― primarily because no one has looked closely at the issue."

Dr. Bishop reported that the investigators will continue looking at more survey data as they become available. She also plans to interview psychiatrists about the reasons why they do not accept insurance.

"I think that is the only way we'll be able to figure out solutions. If we understand the mechanisms and the drivers of their unacceptance, I think we'll be able to have a better conversation about how to get more psychiatrists into network," she said.

Worthy of More Attention

"Overall, this is a good study carried out by capable investigators in an area that requires greater attention," commented Dr. Lieberman, who is also professor and chair of the Department of Psychiatry at Columbia University College of Physicians and Surgeons in New York City.

Dr. Jeffrey Lieberman

"At the same time, it also needs to be recognized that it has a major limitation. It was really confined to office-based practitioners, which represents just a subpopulation of psychiatrists providing mental health care," he added.

He noted that the study also did not shed any light on the reason for psychiatrists' reluctance to accept private insurance, which he believes is due to a historic inequity in reimbursement for psychiatric services. Still, he said, the recent passing of the final rule of the Mental Health Parity Act is cause for optimism.

"Now that the final rule has been issued, and it does have good provisions that address scope of service and prohibition of nonquantitative limits, that'll be some real teeth in the legislation. But there will need to be transparency and enforcement," he said.

Dr. Lieberman added that the APA has taken legal action against insurance companies the organization felt were shortchanging mental health services and has several lawsuits pending.

"The APA is definitely looking out for the interests of its members and psychiatric practitioners. But the hope is that this won't require having to sue every [insurance] company. The advent of the final rule being issued, which makes it a force of law, should help in that regard."

The study authors and Dr. Lieberman report no relevant financial relationships.

JAMA Psychiatry. Published online December 11, 2013. Abstract

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