A recent study by Bishop et al. in JAMA Psychiatry prompted a New York Times article (“Fewer Psychiatrists Seen Taking Health Insurance,” December 11, 2013) and dialogue (“Invitation to a Dialogue: Hurdles to Mental Care,” January 4, 2014). This relatively limited study in a psychiatry specialty journal obviously touched a nerve and sparked a public debate in the media in which psychiatrists were not portrayed very favorably. From the article, one could conclude that psychiatrists do not accept insurance because it does not pay enough; they accepted patients only with “deep pockets,” and they were not willing to participate in provider networks.
Although there were elements of truth in the media coverage, the truth is more complicated, as is frequently the case. The truth of the matter begins with the fact that our country’s health care system is challenged by a shortage of mental health care providers, especially psychiatrists. Half the counties in the United States lack practicing psychiatrists. The inability to access care is further exacerbated by discriminatory, and often illegal, barriers to mental health and addiction services for patients imposed by insurance companies. Psychiatrists are routinely paid less for their services, even when they are using the same Evaluation/Management (E/M) codes, than other physicians and even though they typically spend significantly more time with patients. Patients with depression can see their primary care doctor or they can see a psychiatrist. However, primary care physicians, who are not as well trained in mental health care as psychiatrists, are paid more. In response to improvements to the CPT coding structure for psychiatry, some insurance companies reduced the rates they would agree to pay psychiatrists for E/M and psychotherapy. The Mental Health Parity and Addiction Equity Act (MHPAEA) prohibits this disparity, and APA has sued Anthem and WellPoint in Connecticut to end discriminatory reimbursement practices that lead to inadequate networks of psychiatrists.
Wholly apart from rates is the fact that insurance company gamesmanship designed to discourage psychiatrists from providing services like psychotherapy is intimidating, time consuming, and dangerous for patient care. For example, many of our members have reported that auditors from United Health Care’s “special investigations unit” tried to intimidate psychiatrists who provide psychotherapy to patients by conducting intrusive and time-consuming audits and then demanding refunds of thousands and sometimes tens of thousands of dollars in previously audited and paid claims for psychotherapy—thereby sending the clear message that psychiatrists in United’s network should not be providing psychotherapy to patients whom psychiatrists determine require that treatment. Psychiatrists want to help patients, not spend hours defending why patients from five years ago needed the care that United previously approved and paid for. These practices discourage psychiatrist participation in networks, cause inadequate networks, and increase the burden and expense for patients with mental illness. APA is challenging United’s practices and others of CareFirst Blue Cross Blue Shield, Vermont Blue Cross and Blue Shield, Value Options, and many others that APA believes to be in violation of MHPAEA.
Stigma also acts as a deterrent to patients’ using their insurance to obtain psychiatric treatment or challenging an insurance company’s discriminatory denials of coverage when they try to access care. For many reasons, some related to personal sensitivity and others justified by fear of possible discriminatory use of the information by insurers, employers, and law enforcement agencies, many people do not want to use their health insurance and prefer to pay out of pocket. Those who do try to use it and are denied access will not pursue a court challenge because they do not want to be identified as having a mental illness, they do not want their employers to know of their illness, and they do not have the financial or personal resources to fight insurers and health care plans.
No other medical specialty or its patients face such discrimination or harassment.
We worked long and hard for the passage of MHPAEA and hoped that it would rectify this situation and bring equality in treatment coverage. MHPAEA requires that the methodologies used to determine pay for psychiatrists and standards of care for patients be comparable to those used to determine pay for nonpsychiatric physicians and standards of care for medical and surgical patients. Now is the time to ensure that enforcement of MHPAEA becomes a reality. If the law is enforced, psychiatrists will be attracted into insurance networks, access to care will improve, and integrated care involving psychiatrists will become a real possibility.
APA is aggressively pursuing the full implementation and enforcement of MHPAEA. We convened a meeting of mental health care stakeholders last month to discuss how to better ensure enforcement of and education about the final rule implementing MHPAEA and improvement of coverage for patients. APA has brought litigation to enforce MHPAEA and engages in education at state legislative levels and with employers, providers, and consumers of mental health services. While the legislation and the final rule were victories for our patients, APA cannot sit idly by while industry manipulates the results. We are in this for the long haul and will not stop until discrimination against mental illness ends and mental health care is accessible to all people in need and supported by fair and reasonable insurance coverage.