Some Insurers Working to Encourage Psychiatrists to Join Their Networks

A priority within the field of psychiatry is ensuring that patients have access to high-quality mental health care. Yet according to a 2014 study published in JAMA Psychiatry, from 2009 to 2010, 55.3% of psychiatrists nationwide accepted private insurance, compared with 88.7% of physicians in other specialties.

More recently, a study in Psychiatric Services reported that, in Massachusetts, only 6% of the state’s licensed psychiatrists had filed insurance claims for at least 300 patients (considered to be a full caseload for a full-time psychiatrist). Older psychiatrists were more likely to participate in private insurance networks, raising concerns about what will happen to patients’ access once those psychiatrists retire.

A key reason for the lack of participation among psychiatrists is poor reimbursement. Last year a report by Milliman Inc. found that in 2017 reimbursements for primary care were about 24% higher than reimbursements for behavioral health care, a disparity that widened between 2015 and 2017 (see Psychiatric News).

But some insurers have been working to incentivize more psychiatrists to participate in their networks, improving reimbursement and emphasizing a partnership between the insurer and the physician that supports both the patient and the physician.

“There’s this idea that insurance is all about restricting people and paying little and that it’s an antagonistic relationship between the insurer and the provider,” said Greg Harris, M.D., M.P.H., associate medical director for behavioral health at Blue Cross Blue Shield of Massachusetts and a private-practice psychiatrist who accepts insurance. “So when we have a conversation with a provider and it’s clear that we have a caring view of the patient and the relationship is collaborative, they’re often surprised. We want our members to get care, and that’s our job: To get them into the optimal setting so they can get the highest quality care possible.”

Harris is chair of APA’s Committee on RBRVS, Codes, and Reimbursements and APA’s representative on the AMA Relative Value Scale Update Committee (RUC), which provides recommendations to the Centers for Medicare and Medicaid Services (CMS) related to reimbursement.

Psychiatrists should always remember they can—and should—put on their advocacy hats and fight for fair reimbursement when necessary, Harris said. “If companies are not paying well, per the Milliman report, they should be rightfully criticized,” he said. “But if they are collaborating with providers and paying fairly, then it’s on us as psychiatrists to join those networks and make sure patients have access.”

Taking Concrete Steps to Increase Psychiatrists’ Participation

In July, Blue Cross Blue Shield of Massachusetts announced a series of initiatives to increase their members’ access to mental health services and in particular encourage child and adolescent psychiatrists to join their network.

The initiatives include reimbursing telehealth visits performed by mental health specialists at the same rate as in-person visits and allowing telephonic visits even beyond the end of the COVID-19 public health emergency, increasing reimbursement rates by 50% for child and adolescent psychiatrists, offering financial incentives to primary care physicians to integrate mental health care into their practices by implementing a psychiatric collaborative care model, and expanding access to an online program to help members better manage their stress and anxiety.

Harris said that while the COVID-19 pandemic enhances the urgent need for these new initiatives and the expanded access to mental health care, they’ve been in the works since before the pandemic began. The insurer is offering increased reimbursement both to child and adolescent psychiatrists who are not in their networks and to those who already are part of the network if they are willing to accept new patients. “We’re trying to increase access,” he said. “We want people who are in our networks to see new patients.”

Ultimately, Harris said, the insurer tries to be a partner with the physician. “More partnerships between psychiatrists and health plans would benefit the public,” he said. When new psychiatrists join its network through the child psychiatry incentive plan, the insurer identifies their subspecialty and then connects them with the patients who need that care. It saves patients time, Harris said, and it allows psychiatrists to receive more referrals within their subspecialty.

Blue Cross Blue Shield of Massachusetts has emphasized to its members that, especially during the pandemic, the insurer is a resource for them to use to identify the psychiatrist with the expertise to meet their needs. It can often be very hard to use insurance directories to find a physician with a certain specialty, he explained. “We don’t want you to call 50 people to find the right clinician,” he said.

“In general, as an industry we are moving away from this fee-for-service model and into a value-based and strategic partnership model,” said Varun Choudhary, M.D. “Because of the emphasis and importance now placed on mental illness and the need for mental wellness, things have changed quite a bit.”

Choudhary is Magellan Health’s national behavioral health chief medical officer and one of the the Psychiatric Society of Virginia’s Assembly representatives. He said Magellan is investing in the technology and digital tools to make using private insurance easier for both physicians and patients.

Insurers are increasingly exploring innovative care delivery models that take into account social determinants of health, for example, or a team-based approach to care, Choudhary said. It ultimately comes down to the fact that collaboration and a team-based approach are going to be best for patients, he explained.

Psychiatrists’ Expertise Makes a Difference

There are several reasons that psychiatrists interviewed for this article cited for not joining insurance networks, such as inadequate payment, prior authorization requirements, excessive paperwork, and delays in payment.

Michael Upton, M.D., a psychiatrist practicing in Vermont, said in an email that being part of a network means he can see the patients he otherwise wouldn’t be able to see. Some patients do not want to go out of network because they cannot afford a plan’s high deductibles or copays or because they have no out-of-network benefits in the first place.

David Fassler, M.D., a child psychiatrist in Vermont and a former APA treasurer and secretary, said in an email that, over time, most insurance companies in Vermont have eliminated preauthorization and utilization review for most outpatient treatment. But he noted that insurers could increase participation among psychiatrists by reimbursing for time spent communicating with other health care professionals and with third parties such as family members or teachers. This is especially important for the care of children and adolescents, he said. Fassler is a clinical professor of psychiatry at the Robert Larner, M.D.,College of Medicine at the University of Vermont.

“The expertise a psychiatrist has is second to none among mental health professionals,” Choudhary said. “No one is going to be able to replace a psychiatrist, and psychiatrists really should understand how important they are in the larger health care system.” ■