“It's just part of the job in an outpatient practice, knowing that you'll have to fight with insurance companies,” said Dr. Bobbi Wegner, a Boston-based clinical psychologist.
Wegner said she never thought about insurance coverage or reimbursement during her first few years as a clinical psychologist intern at Mount Sinai School of Medicine in New York City. It was only after she joined the clinical staff at Boston Behavioral Medicine eight years ago that she became aware of the relationship between having the right coverage and access to care.
“We constantly have a waiting list,” Wegner said. “But oftentimes it's hard to find a match in terms of people who have insurance that I can take and a match in terms of time and availability.”
In her first three years at Boston Behavioral Medicine, Wegner handled her own billing—the clinicians at the practice are independent providers rather than employees. The hours she spent talking with insurers cut into her time to see patients, tempting her to forgo accepting insurance at all.
“Insurance is just notoriously difficult to work with,” Wegner said. “They will try to deny a claim without any real reason, just hoping that you're not going to fight it.”
Wegner ultimately opted to continue to accept insurance, she said, for the sake of making mental healthcare accessible to a wide range of patients.
Although Reiss reached the opposite conclusion, he says it wasn't easy. Still, he contends that health plans and government programs implicitly encourage mental health professionals to focus on volume to come out ahead, detracting from the quality of care. “Yes there are going to be people who can't get access, but there are more people being hurt by the access they're given where they receive lousy treatment.”
Mental health providers have struggled for years to gain more equitable compensation and recognition that they provide valuable services. And they say the recent progress hasn't been fast enough to meet increases in demand.
The mental health workforce, meanwhile, could shrink as providers retire from the field. The median age for psychiatrists is over 55, with 46% age 65 and older, according to SAMHSA.
Those numbers are particularly stark when one considers that more than half of Americans with a mental illness do not receive care. And as fewer providers are willing see all patients, other providers are asked to take on more visits while patients experience longer delays for care.
Such limits on provider access are more likely to affect low-income patients. While more low-income individuals have gained access to mental health services through the ACA's Medicaid expansion and by gaining coverage through the insurance exchanges, a shortage of mental health professionals willing to see patients with public or private insurance makes access to care increasingly difficult for low-income patients, who are often unable to afford their out-of-pocket obligations.