Survey Reveals Stark Difficulty in Obtaining Appointments for Child Psychiatric Care

Calls to hundreds of child psychiatrists listed as in-network with Blue Cross–Blue Shield (BCBS) in three major U.S. cities led to appointments for children only 11% of the time, according to the results of a survey published in Psychiatric Services.

Telephone numbers were frequently wrong, many psychiatrists were no longer accepting new patients, and other calls went unanswered. Moreover, the average wait time for an appointment was more than a month, and few of the psychiatrists contacted were willing to accept patients who were covered by Medicaid.

“[O]ur results confirm what many already know: In the midst of a mental health crisis, having insurance is not enough to guarantee access to mental health care when it is needed,” wrote senior author J. Wesley Boyd, M.D., Ph.D., a professor of medical ethics and psychiatry at Baylor College of Medicine, and colleagues.

The researchers called 322 psychiatrists listed as in-network by BCBS in Chicago, Houston, and Los Angeles and impersonated the parent of a 10-year-old child who had just visited the emergency department for depression. They asked for an appointment using a standardized script that varied only according to how they intended to pay for the services: BCBS, Medicaid, or out of pocket.

Calls were made during normal business hours between July 6 and August 4, 2022, and voicemails were left when the office did not pick up the call. If the researchers did not receive a return call with the requested information, they called the office a second time, approximately one week later, and followed the same protocol.

The callers were able to schedule initial appointments with 34 psychiatrists (11% of the sample). A total of 60 (19%) of the telephone numbers in the database were wrong, and 82 psychiatrists (25%) were not accepting new patients. The average time until the first available in-person appointment was 44 days for all cities, and the average time until the first available virtual appointment was 37 days.

The callers who said they would pay out of pocket or had BCBS insurance were roughly three times more likely to get an appointment with a child psychiatrist than those who said they were covered by Medicaid, a finding that was statistically significant.

“[O]ur difficulty in obtaining an appointment with Medicaid is particularly concerning,” Boyd and colleagues wrote. “This difficulty also highlights the stark reality that those who are poor and hope to use public insurance are frequently denied mental health care. Because COVID-19 has disproportionately harmed racial-ethnic minority groups and impoverished populations, our findings represent a double insult and a deepening inequity in access to care.”

In an interview with Psychiatric News, Boyd said the findings are hardly surprising to anyone familiar with the dramatic shortage of child psychiatrist services in the United States. “But there is a value in making the obvious explicit, in documenting just exactly how bad the situation is,” he said.

In the Psychiatric Services paper, Boyd and colleagues discussed several remedies including advocacy for increasing reimbursement rates and increasing the workforce by expanding the number of residency slots in child psychiatry. They also pointed to several state programs such as the Texas Child Health Access Through Telemedicine Program and the Massachusetts Child Psychiatry Access Program that build bridges between child psychiatry and primary care to widen access.

But the study also underscores a longstanding problem of “ghost networks” maintained by insurance companies in which their provider list databases include wrong numbers, psychiatrists who no longer reside in the state, are no longer in the networks, and those who are no longer taking new patients. “It is a massive problem,” said Boyd. “Having a provider list of 500 psychiatrists makes the insurance company appealing to employers when they are selling their product, but if only one-tenth of those psychiatrists are able to accept new patients or can even be contacted, those databases are largely useless.”

The issue of “network adequacy” has long been a priority for APA advocacy. In May, Robert Trestman, Ph.D., M.D., chair of the APA Council on Healthcare Services and Financing, told the Senate Committee on Finance that when patients try to make appointments with psychiatrists inaccurately listed on insurers’ panels, it can lead to delays that cause their illness to worsen.

For patients who are fairly healthy and well educated, encountering inaccurate directories on insurance websites can be frustrating, Trestman told the committee. “But for people experiencing significant mental illness or substance use disorders, the process, at best, is demoralizing. At worst, it is a setup for clinical deterioration and a preventable crisis. … Patients have shared with me that they felt themselves repeatedly rejected and that, somehow, the fact that they couldn’t find a provider was their fault. Some stop looking for care.”

Boyd told Psychiatric News that insurance company efforts to respond to complaints about ghost networks have been “woefully inadequate.”

He added, “I believe insurance companies have singled out patients with mental illness and substance use disorders for extra scrutiny, and maintaining a database of supposedly in-network providers that is largely inaccurate is another way that insurance companies are profiting off the backs of those with mental health disorders.” ■