There’s a psychiatrist crisis in America and virtually nobody is having a serious conversation about how to fix it. It’s not clear how we, as a nation, can brag about our amazing healthcare system when finding a psychiatrist who takes your insurance and is open to new patients is virtually impossible in most places in the U.S.
Even worse is that the crisis continues to worsen and little is being done to address it.
Over at Popula, Jameson Rich details his ordeal in trying to find a new psychiatrist who takes his insurance:
My therapist would make a dosage recommendation in consultation with some other doctors, she said, but still another doctor would have to write the prescription. Luckily, I have a doctor who’d written me the drug in the past. He was comfortable with this only because the dose had been prescribed by an actual psychiatrist, years earlier. But his office refused in an email: “Restrictions are getting tighter and tighter.”
Then I tried my cardiologist, sending emails to my therapist and messages through the hospital’s patient e-system to my cardiologist, and each telling me to have the other one call them.
With this finally resolved, I turned next to the hospital’s outpatient clinic.
“We don’t take your insurance.”
“…Excuse me? ”
Disbelief. More calls. I called the first number back just to be sure.
“So, you’re telling me that no psychiatrist in the entire hospital takes my insurance?”
“Yes. That’s exactly what I’m telling you.”
I went back to my therapist’s office and showed her two PDFs on my laptop, over 100 pages of names provided by my insurance company’s website. Criteria: psychiatry, zip code radius, depression, adult, in-network.
She scrolled through on my hour.
I started calling her recommendations and was denied with lines each more ridiculous than the last.
“Okay, so… she’s actually a neurologist. Do you have seizure disorder?”
“He’s not seeing patients anymore.”
“Hello, you have reached the Department of Gastrointestinal Disorders.”
By this point, weeks had gone by. With each fruitless phone call, the problem that had caused me to begin the search in the first place seemed to metastasize.
I tried Columbia.
“We only take Aetna.”
“No one takes your insurance. And no one is taking new patients, anyway.”
“This is the main line…” after calling the number specifically labeled Outpatient Psychiatry,“… But if you hold, I can transfer you to outpatient psychiatry.”
A click. Ringing. Another click. Chaos.
“Hello, Emergency Room.”
All the while, as he notes, he’s a person dealing with depression. Depression sucks away a person’s energy and motivation. Expecting people in need to make a dozen or more calls to find a single psychiatrist is cruel. Imagine if we asked stage 4 cancer patients to go through this same process to find a specialist — there’d be an immediate outcry and the practice would end immediately.
Instead, this is par for the course for mental health care and treatment in the U.S. Increasingly, if you’re not willing to pay cash out of pocket and avoid your health insurance altogether, you’ll find it challenging to get an appointment. Be prepared to wait weeks, and in some cases, months for the first available appointment.
Psychiatry is suffering from a severe shortage of doctors willing to specialize in this area. A Kaiser Family Foundation analysis last year found that the U.S. has fewer psychiatrists per 100,000 people than virtually every other industrialized nation (except Sweden). As noted by Clinical Psychiatry News, “Today, 40% of psychiatrists choose cash-only private practices, the second-highest among medical specialties after dermatologists, and 75% of provider organizations employing psychiatrists report that they lose money on their psychiatric services.”
According to Medscape, the situation is pretty dire:
The number of psychiatrists is plummeting — down by 10% from 2003 to 2013. The average age of practicing psychiatrists is the mid-50s, compared to the mid-40s for other specialties, said Dr Parks.
Furthermore, approximately 55% of counties across the United States currently have no psychiatrist, and 77% report a severe shortage — a situation that is partially due to an increase in demand.
Meanwhile, psychiatric inpatient hospitals continue to close at an alarming rate.
And the crisis isn’t just striking psychiatry. I called my doctor’s office to reschedule my annual exam and found that my usual GP (general practitioner) didn’t have a new appointment until three months out! Three months to see my GP for a routine exam? This doesn’t sound like the world’s best healthcare system whatsoever.
Worse yet, the crisis is starting to impact psychotherapists, too. More and more therapists are choosing not to deal with health insurers altogether, as their paperwork and bureaucratic requirements continue to increase year after year. At the same time, they find reimbursement rates stagnate, or even decrease. Paying cash out of pocket by clients is nearly always more expensive for the patient.
There is no easy fix for this problem, because it’s been decades in the making. Psychiatry is one of the worst-paid specialties in medicine, so it naturally attracts fewer and fewer medical students every year. ((It’s not because doctors are greedy, but they do have to balance their medical school debt with the ability to make payments on those loans — and make a living. Most medical students look at the costs of medical school and the salaries of psychiatrists and make a rational decision to find a better-paying specialty.)) In addition, the training model of psychiatry is arduous, antiquated, and predicated upon other medical specialties — which may not be the best model.
Training programs should be updated and streamlined to reflect our current understanding of the brain and targeted medication interventions.
Unfortunately, this is not unusual. It seems that everything that touches behavioral health suffers from a lack of financial resources. You don’t see hospitals dedicating new treatment wings for behavioral health, and you don’t hear much about federal money for mental health treatment (with the sole exception of combating the far-more-recent opioid crisis). Most politicians and policymakers pay only lip service to mental health and it’s usually the first budget item they axe when cutting social services.
The issue can benefit from targeted interventions, starting with increased reimbursement rates for psychiatric services. In fact, the federal government should increase reimbursement rates across the board for all behavioral healthcare services. Private health insurance companies follow the government’s lead regarding these rates, so until the federal government takes action, it’s unlikely others will do so unilaterally. Clearly the inadequate rates of insurance reimbursement for psychiatrists is one of the driving factors of the current crisis.
Kicking this ball down the road to another generation will result in fewer and fewer people being able to afford or take advantage of treatment. As rates of mental illness continue to rise, this means that a greater number of people will go untreated for a mental disorder.
I believe additional use of technology (such as telepsychiatry) and innovative interventions (such as apps) can help with the crisis. But we need to be careful not to use them as a substitute for the current standard of care in psychiatry — face-to-face intervention. Physician assistants can be better trained in psychiatry to also help with the increasing demand for psychiatric services.
The most heartbreaking concern about this situation, however, is that most mental disorders and mental health concerns can be effectively treated. But since providers aren’t available that are open to new patients and will take the patients’ insurance, it’s likely that tens of thousands of Americans forgo treatment every year.
For Further Information
Experts Move to Halt Crisis in US Psychiatry – Medscape
What’s the Answer to the Shortage of Mental Health Care Providers? – US News & World Report