Insurance card with "not accepted" symbol ovrelayed
Psychiatrists are increasingly opting out of insurance network.

This post consists of personal anecdotes mixed with hard statistics.  Ezra and I recently had two very different experiences with psychiatrists.  And when I say psychiatrists, I am referring to medical doctors who went to medical school and therefore can prescribe medications.  I specifically am not referring to clinical psychologists, who often have Ph.D’s or Psy.D’s and have therefore also earned the title of “Doctor.”  Clinical psychological and psychiatrists perform similar roles, but only the psychiatrists can prescribe medication.  [For an explanation of the difference between a Ph.D and a Psy.D, click here, here, and here.] [Editor’s note: After an informal poll of a few clinical psychologists, “happily accept insurance” may overstate their level of joy.  Reimbursement rates are becoming unsustainably low for talk therapy as well.]


Fun fact: Advanced Practice Psychiatric Nurse Practitioners obtain masters degrees or Ph.D’s and can also see patients and prescribe most psychiatric medications just like psychiatrists.


However, talking things through isn’t always enough, especially for Yours Truly who was recently diagnosed with Bipolar Disorder. Until now, both Ezra and I relied on our primary care physician, in concert with our clinical psychologists, for the medication aspect of our mental health treatment.  [There is actually a bit of controversy over whether mental health treatment should be part of a primary care physician’s job.]

Bipolar Disorder is a serious disorder that Psychiatrists can treat

For me, however, a psychiatrist has become a necessity because Bipolar Disorder is a serious illness that requires some seriously specialized medical expertise to manage.  For example, the lifetime risk of death by suicide in those who suffer from Bipolar Disorder is somewhere between 6-15%, and separate studies have observed an annual suicide rate 10-20 times greater than that of the general population [source: page 4 of this presentation by Dr. Julie Anderson of Oregon Health & Science University].  The average reduction in life expectancy among people with Bipolar Disorder is between nine and 20 years.  To put things in perspective, the life expectancy today of persons infected with HIV, a death sentence just a couple decades ago, is nearly identical to that of the general population. My Bipolar Disorder quite literally puts me at a much greater risk of premature death than my HIV+ status ever will. [Don’t worry.  Remember, I’m Optimistic Despite It All].  Specialists such as psychiatrists really can help achieve a better outcome with such a serious illness.


Less fun fact: the average delay from onset of symptoms to a correct diagnosis of Bipolar Disorder is around ten years, due to the difficulty psychiatrists and psychologists have in diagnosing the illness.


Ezra’s and my experiences with our psychiatrists

Ezra decided to see a psychiatrist at the suggestion of his clinical psychologist. Because why not?  This psychiatrist accepts insurance and is supposed to be more expert in the treatment of mental illness than a primary care physician.  I, on the other hand, have a pre-existing relationship with a psychiatrist from a year back when everyone thought I was just depressed. [For an excellent discussion of the difference between “regular,” or “unipolar” depression and Bipolar Disorder, click here.]  My psychologist advised me to get back into her office right away so we could start working on medications.  Thankfully, because this was not a first-time appointment, I had to wait only days, not weeks or months.  In contrast, one recent study found that, in Boston, the average wait time for a first appointment is 25 days.

Ezra accompanied me to my psychiatrist appointment, which was scheduled for 30 minutes but lasted 45.  My psychiatrist was warm, made eye contact, asked both of us questions about my moods and behaviors, and discussed numerous medication options.  Prior to the appointment, she had even given me a genetic screening to help determine which medications might work best.  Check out the Sample Report to see what I mean.  My psychiatrist and I decided that she would take over all mental health prescriptions from my primary care physician, and I left with several new prescriptions and instructions on how to discontinue my old regimen and start my new one.

Sample report of genetic analysis describing gene-drug interactions unique to a specific patient.

Ezra’s experience with his psychiatrist was quite different.  Because this was an initial psychiatric assessment, he spent about 45 minutes in the waiting room filling out reams of paperwork (which is normal).  When he finally met his psychiatrist, Ezra was seen in a sparsely decorated, impersonal, corporate-feeling office.  The psychiatrist asked a few questions, but his eyes rarely strayed from his computer as he punched in the answers.  Ezra mentioned that he struggles with depression and anxiety.  A few questions later, the psychiatrist wrote a prescription for Zoloft and hydroxyzine and sent Ezra on his way.  The whole ordeal lasted 20 minutes–less than half the time it took to fill out the paperwork for the initial assessment.  For a description of what an initial assessment should look like, from Drs. Waldinger and Jacobson, click here.

Why psychiatrists are not accepting insurance: some personal exlanations

Bedside manner aside, there is a plausible explanation our different experience with our psychiatrists.  According to a 2014 study published in the Journal of the American Medical Association, only 55.3% of psychiatrists accepted insurance, down 17% from the 72.3% who accepted insurance in 2005-2006.  The downward trend is obvious, and Ezra’s psychiatrist should probably be commended as one of the increasingly few who continue to accept insurance.

A number of psychiatrists have published statements on why they no longer accept insurance.

Dr. Dinah Miller, a contributor to KevinMD.com, explains that in addition to the obvious benefit of being able to set one’s own fee to whatever the market will bear, there simply is too much hassle involved with participating in network with an insurance company.  According to Dr. Miller, the complexities of the billing process generally necessitate secretarial support, an overhead expense made all the more burdensome by the lower reimbursement rates paid by insurers.

Her essay can be found here.

Dr. Robin Stone of Insight Psychiatry explains:

Managed care organizations and insurance companies can require detailed information about a patient’s psychiatric history as a condition of payment.  This may extend to requesting information regarding progress of medication treatment and/or psychotherapy. Such requirements are a serious breach of the traditional private and confidential relationship between patient and psychiatrist.”  [Editor’s Note: HIPAA specifically authorizes the disclosure of protected health information to coordinate payment for services, and I am completely unfamiliar with this legal or ‘traditional’ rule to which she cites. And this is an area of law in which I know a thing or two.]  She further writes that she “does not think it is appropriate for healthcare decisions to be determined by insurance screeners.  Therefore, she does not participate in provider contracts that result in production pressures which limit the time needed for physicians to truly understand and properly treat their patients.  As a psychiatrist-therapist, Dr. Stone knows that safety and confidentiality are crucial for successful treatment, principles that should never be compromised.” 

Her justification can be found here.

In an interview with Gardiner Harris of the New York Times, Dr. Donald Levin explains that in the 1950s, a psychiatrist would see patients for 50 minutes and offer talk therapy as part of his service.  He would typically treat 50-60 patients in once or twice weekly sessions.  However, as Mr. Harris writes:

“Now, like many of his peers, he treats 1,200 people in mostly 15-minute visits for prescription adjustments that are sometimes months apart. Then, he knew his patients’ inner lives better than he knew his wife’s; now, he often cannot remember their names. Then, his goal was to help his patients become happy and fulfilled; now, it is just to keep them functional.”

The entire interview, entitled Talk Doesn’t Pay: So Psychiatry Turns Instead to Drug Therapy, can be found here.

Psychiatrists make far less than other specialties

After having researched this article, my conclusion is that the hassles of in-network billing, combined with unsustainably low reimbursement rates, present significant challenges to psychiatrists an mental health professionals. Psychiatrists are not simply mean-spirited, lazy, or focused on the bottom line. In fact, psychiatrists are among the lowest paid physicians, and they are not alone.  Dr. Paul Sax of Harvard Medical School explains in his excellent blog HIV and ID Observations, that the specialty of Infectious Disease, which requires years of residency and then a years-long additional fellowship, ranks last in compensation even though infectious disease physicians treat some of our most serious and complex illnesses.  As he notes:

“Productivity of doctors is still measured in volume. In a fee-for-service, count-the-RVUs system, the more patients you see the more you get paid. And I suspect there are few cases less amenable to high volume service than those referred to ID/HIV doctors.”  He also explains that “Doctors in the USA are paid the most for doing procedures . . . We ID doctors barely do any procedures, and the few we can do are comparatively low ticket items such as PAP smears, CSF exams, minor wound care, I and D, etc.”

For the entire article, which includes data showing that psychiatrists fare little better, click here.

While this chart shows Infectious Disease as the least-well compensated specialty, Psychiatry fares little better.

 

Tweet with Paul Sax confirming psychiatrists do not make much money.
No one ever chose either ID/HIV or psych for the $$$.

Update: After publishing this article, I reached out to Dr. Sax via twitter to thank him for his insightful post on physician compensation.  He replied that “No one ever chose either ID/HIV or psych for the $$$.”

The problem is an insurance reimbursement system that prioritizes procedures, labs, surgeries, and other services that are quantifiable, can be assigned a billing code, and then submitted for payment.  Psychiatry simply is not that type of specialty; neither are several additional specialties that rely on brainpower rather than procedural power to deliver care.


Personal anecdote: A physician couple with whom I am closely acquainted have widely disparate incomes.  One is a pediatric endocrinologist who received an MD from Johns Hopkins University, completed a pediatrics residency at Vanderbilt, and finally stopped being a glutton for educational punishment after completing an endocrinology fellowship at Washington University. Nobody needs that much education… The much more sensible spouse decided enough is enough after also completing a pediatrics residency at Vanderbilt (where they met), and now makes significantly more money in private practice.


Ok… so what do we do, then?

So what is a patient in need of mental health services to do?  Here are my recommended steps:

  1. Make sure you are linked with a primary care physician.  You have no excuse for not having one, and in addition to keeping you physically healthy, most are competent and knowledgeable when it comes to treating “simple” depression with typical antidepressant medications.
  2. Find a therapist before you seek a psychiatrist.  A therapist, even a clinical psychologist with a Ph.D or Psy.D, is much more likely to accept insurance.  Because they do not prescribe medicine, their entire focus is on talking with you about your problem(s).  You may find that you feel better before even proceeding to step three.
  3. Consider consulting a psychiatrist.  This is not to say that the psychiatrist should be the last resort, just that it should be the last step in assembling your treatment team, a step you may even find unnecessary after having had a chance to talk to a therapist.  If you and your team agree that medication would help, and your primary care physician does not feel qualified to treat your condition, then it is time to add a psychiatrist to your team.  Critically, do not ditch your therapist after finding a psychiatrist.  As one recent literature review published in World Psychiatry concluded, “we found clear evidence that combined treatment with psychotherapy and antidepressant medication is more effective than treatment with antidepressant medication alone. This difference was significant for major depression, panic disorder, and OCD.”  For the entire article, click here.

And that’s about it.  The trend of psychiatrists (and possibly other specialists) opting out of the insurance network may continue to increase, but it does not have to break your bank.  By assembling a mental health team, the majority of whom will accept your insurance, you can access the treatment you need.


ADDITIONAL DISCLAIMER: My disclaimer on all my posts makes clear that, although I am a lawyer, nothing I write may be construed as legal advice.  This one’s even easier.  I am not a doctor.  Neither am I a Ph.D, a Psy.D, an Advanced Practice Psychiatric Nurse Practitioner, or qualified to practice medicine in any way.  Do not construe any of my writings as medical advice, and always consult with a qualified practitioner when plotting a course of treatment for your mental health needs.


 

Clinical Psychiatrists: As They Opt Out of Insurance, You Must Assemble a Treatment Team
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