Payment headaches hinder progress on mental health access

Dr. David Reiss has seen a lot of changes in his field during 32 years as a psychiatrist. He has a private practice in Southern California but recently began commuting to work as a locum tenens physician in New York City to offset declines in reimbursement.

“Everything these days is driven by compensation,” Reiss said. “Whether it be Medicaid, Medicare or private insurance, everything is cut to the bone.”

Seven years ago, Reiss stopped accepting new patients with private insurance at his private practice. He'd had enough of filling out paperwork and fighting with health plans to convince them that the treatment he prescribed was appropriate.

“You prescribe something but it takes someone three weeks for it to go through pre-authorization to get the prescription,” Reiss said. “It's just unworkable.”

Reiss acknowledges his decision to limit the types of patients he sees may contribute to the shortage of mental health providers in this country. About 55% of U.S. counties, all rural, have no practicing psychiatrists, psychologists or social workers, according to a 2013 report to Congress from the Substance Abuse and Mental Health Services Administration.

Just 55% of psychiatrists accepted private insurance as payment in 2010 (compared with 89% of doctors in other medical specialties) and the percentage had declined 17% since 2005, according to a 2014 study published in JAMA Psychiatry. Medicare and Medicaid acceptance rates among psychiatrists were also lower compared with the rates of other physicians. The same study found 55% of psychiatrists accepted Medicare reimbursement, compared with 86% of physicians in other specialties, while 43% accepted Medicaid, compared with 73% of other doctors.

The declining willingness to accept third-party reimbursement comes down to dollars and sense. Rates for some of the most common behavioral health services, such as outpatient therapy, diagnostic evaluations and medication management, have not changed significantly in more than a decade.

Many mental health providers and patient advocates hoped the Affordable Care Act and the 2008 Mental Health Parity and Addiction Equity Act would improve access to mental health and substance abuse treatment for millions of Americans. Indeed, the expansion of health coverage along with the protections provided in both the ACA and mental health parity legislation have increased access.

But the barriers that remain could lead to a mental health system that limits many services to people with the means to pay out of pocket.

“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.

High deductibles and cost-sharing in the most affordable ACA plans often discourage the newly insured with mental health needs from seeking care. Though mental health services are considered one of the ACA's 10 essential benefits, the law only ensures first-dollar coverage for depression screening. Mental health counseling and psychotherapy are granted parity with medical services but remain subject deductibles and cost-sharing. The average annual deductible for an individual bronze-level plan (the most affordable tier) in the ACA exchanges was about $5,700 in 2013.

“I think what we've gained in the last couple of years is greater understanding of what some of the gaps are and what we need to do to moving forward to get these things implemented properly,” said Paul Gionfriddo, CEO of the patient advocacy organization Mental Health America. “But in terms of getting a lot more providers into the mix, getting a lot more providers into the networks, and getting a lot more access for individuals, I think we still have a long way to go.”

One of the larger roadblocks has been the historically low rates psychiatrists receive compared with rates paid in other specialties, according to Gionfriddo. “Paying mental health providers less than a skilled tradesperson is not parity,” Gionfriddo said, regarding the average salary of mental health counselors and social workers. In Modern Healthcare's 2016 physician compensation survey, psychiatrists were among the five lowest paid specialties at $250,000 a year, less than half the average salary of the highest paid specialists, orthopedic surgeons.

“Behavioral health providers appear to be disproportionately low in terms of their reimbursement rates that they receive from insurers, and even from Medicaid and Medicare,” said Angela Kimball, national director for advocacy and public policy for the National Alliance on Mental Illness.

One of the most common mental health services provided is a 45-minute outpatient psychotherapy session. According to a list of Medicaid rates for mental health services for the state of Maryland, physicians get paid $83 for such a session.

Medicare, meanwhile, paid an average rate of $102 for 45 minutes of psychotherapy in 2001, according to the advocacy arm of the American Psychological Association, a rate that has since dropped by 35% to $86 a session. The organization estimates Medicare payments are about 17% lower than private market insurance rates.

Some blame the rise of managed-care organizations for the decline in reimbursement because they cut costs by reducing utilization of services. The strategies have resulted in utilization review programs that judge the medical necessity of care that providers propose.

Another challenge is earning inclusion on insurance panels.

“There is a high burden of paperwork on mental health providers compared to other forms of care, and increasingly there are challenges with credentialing and getting into the provider networks of health insurance plans or Medicaid programs,” Kimball said. “So given all of the variables that can make one's profession more challenging, I would say the odds are not stacked in favor of mental health providers.”