What's the Point if Psychiatrists Don't Accept Insurance, Medicare?For all of the hailing of mental health parity rules and the affordable care act over the past year, few advocates in these discussions actually talk about the reality on the ground.

And that reality is that most psychiatrists — about 57 percent — don’t accept Medicaid, the government’s insurance for the poor. Which probably doesn’t matter to you if you’re not poor.

But what might matter to you more is how few psychiatrists accept private insurance or Medicare. According to a recent study, that number is at a surprising 55 percent — and dropping.

What’s the point of these laws if so few psychiatrists even accept this form of payment?

The study was conducted by Bishop et al. (2013) in JAMA Psychiatry and paints a grim picture for anyone searching for a psychiatrist in the United States. Nearly half of all psychiatrists surveyed simply don’t take any kind of insurance — meaning if you want to see them, you’ll have to pay full cash price, out of your own pocket.

The researchers used data from the The National Ambulatory Medical Care Survey (NAMCS), a nationally representative survey administered by the Centers for Disease Control and Prevention’s National Center for Health Statistics. The study looked at office-based physicians in the United States to calculate rates of acceptance of private insurance, Medicare, and Medicaid by psychiatrists vs physicians in other specialties. They also wanted to compare characteristics of psychiatrists who accepted insurance and those who did not.

The mean number of physicians surveyed from each year between 2005 and 2010 was 1250 and 5.5 percent of these physicians were psychiatrists.

Here’s what they found:

The percentage of psychiatrists who accepted private noncapitated insurance in 2009-2010 was significantly lower than the percentage of physicians in other specialties (55.3% [95% CI, 46.7%-63.8%] vs 88.7% [86.4%-90.7%]; P < .001) and had declined by 17.0% since 2005-2006.Similarly, the percentage of psychiatrists who accepted Medicare in 2009-2010 was significantly lower than that for other physicians (54.8% [95% CI, 46.6%-62.7%] vs 86.1% [84.4%-87.7%]; P < .001) and had declined by 19.5% since 2005-2006.Psychiatrists’ Medicaid acceptance rates in 2009-2010 were also lower than those for other physicians (43.1% [95% CI, 34.9%-51.7%] vs 73.0% [70.3%-75.5%]; P < .001) but had not declined significantly from 2005-2006.

They also found that there were significant regional differences. Psychiatrists in the Midwest were more likely to accept private insurance (85.1%) than those in the Northeast (48.5%), South (43.0%), or West (57.8%).

So Are Psychiatrists Just Greedy?

Probably not. The researchers note that “low reimbursement has been cited as a reason why physicians do not accept insurance. However, reimbursement rates for office-based psychiatric treatment are similar to those for office-based medical evaluation and management, such as primary care services.”

But psychiatrists usually spend more time with each patient than a primary care physician does, meaning they can see less patients per hour as the average family doc.

There’s also less of them — more than a 14 percent decline since 2000. Meanwhile, the population continues to grow, meaning that demand goes up for psychiatrists’ services. As demand goes up and supply goes down, the price a psychiatrist can command for the same service also will tend to go up.

So while insurance companies don’t recognize this market imbalance, psychiatrists do. This isn’t greed, this is market economics at work on an industry-wide scale.

There are a couple of solutions, none of which are easy. Insurance, Medicare and Medicaid could all up their reimbursement rates, to bring them in line with the economic reality of the profession. That’s unlikely to happen, because private insurance companies tend to follow Medicare’s lead, and there’s no money there to increase Medicare rates.

Another solution is to get more psychiatrists into the practice of psychiatry during med school. That’s not happening, because savvy med students see that psychiatry is one of the lowest paying specialties in medicine. Medical school is expensive, so young doctors choose a career path partially based upon what makes economic sense.

All I know is that all of this work to bring mental health parity to the masses hasn’t done a thing to make it more easy for most people to gain access to a psychiatrist. And while psychiatrists are not the end-all, be-all of mental health, they are an important component of holistic, comprehensive mental health care.


Bishop et al. (2013) Acceptance of Insurance by Psychiatrists and the Implications for Access to Mental Health Care. JAMA Psychiatry. Published online December 11, 2013. doi:10.1001/jamapsychiatry.2013.2862