Banned in Boston: Access to psychiatric care

Imagine you have severe depression and go to a Boston emergency room for treatment. You are told to follow up with a psychiatrist within two weeks. You have good health insurance, so this shouldn’t be a problem, right?

Wrong. In a new study just published in the Annals of Emergency Medicine, we found quite the opposite. Access to outpatient psychiatric care in the greater Boston area is severely limited, even for those with excellent private insurance.

We posed as patients insured by Blue Cross Blue Shield of Massachusetts PPO, the largest insurer in the state. We called every BCBS in-network mental health facility within a 10-mile radius of downtown Boston, reporting that we had been evaluated in an emergency department for depression and discharged with instruction to obtain a psychiatric appointment within two weeks.

Only eight (13 percent) of the 64 sites listed on the BCBS website offered appointments, four (6 percent) of which were within two weeks. Fifteen clinics (23 percent) never called us back, despite our leaving two messages requesting an appointment. Another 15 clinics told us that we could only be seen in their facility if we had a primary care physician in their system.

Our Boston findings are consistent with national data showing limited availability of mental health services. For example, two-thirds of primary care physicians report that they cannot obtain outpatient mental health services for patients who need them.

The limited availability of psychiatric services has serious consequences for patients and their families. Mental health disorders are common, affecting nearly one in four adults annually. Inadequate treatment can result in individual and family suffering, lost productivity, and even death. Suicide, the third leading cause of death among youth ages 10-24, is more common among those suffering from mental illness.

Inadequate mental health care also creates problems for our health care system and society at large. A third of the homeless and more than half of all prison and jail inmates have mental illness.

The nation’s emergency departments are de facto psychiatric wards, with 79 percent of emergency doctors reporting that their hospitals board psychiatric patients for whom appropriate treatment resources could not be found, sometimes for days.

Although there are many contributors to the inadequacy of our mental health system, managed care has hit psychiatric services hard. Private insurers aggressively constrain patients’ access to services through stringent provider networks. As our study shows, this is often covert: insurers provide lists of in-network providers, but most are unavailable.

Because insurance company reimbursements for psychiatric services are far lower than for other types of care, hospitals also frequently restrict access. By contrast, hospitals compete for insured patients who need highly profitable procedures such as MRI scans or elective surgeries like knee replacements.

Insurance industry practices have also discouraged many private psychiatrists from accepting patients with health insurance.

Until such time as we have a truly universal health system providing comprehensive care, we need to ensure that insurance companies reimburse psychiatric care adequately. Until they do so, psychiatric patients will remain vulnerable, second-class citizens.

J. Wesley Boyd is an assistant clinical professor of psychiatry at Harvard Medical School and Rachel Nardin is an assistant professor of neurology at Harvard Medical School.

Submit a guest post and be heard on social media’s leading physician voice.

Comments are moderated before they are published. Please read the comment policy.

  • Regina

    This is happening all over the country. Miami is another example.

  • Anonymous

    My psychiatrist quit taking my BCBS insurance several years ago not because payments were too low but because it took her up to six months to get paid.  Luckily I’ve been in a maintenance phase for several years and have to see her only a few times yearly, but out-of-network costs are very high. I don’t know what I’d do if I went into an acute phase and had to see her as often as I did when I first started.

  • Ed Sodaro

    From a malparctice avoidance perspective, unstable severely depressed patients are high risk.  They are therefore avoided by most office based psychiatrists seeking to keep their malpractice rates and risk low.

    BCBS is also a nightmare to deal with if this unstable highly depressed patient needs hospitalization.  It is often impossible to get BCBS to cover them foro inpatient care.  Even in the event they are admitted, these patients can only stay a couple of days and are then dumped, usually still unstable, back into outpatient status.

    In addition, most psychiatrists avoid anonymous self-referrals.  It would be a very different story if a referring primary care physician known and trusted by the psychiatrist were involved in the case.

    • Anonymous

      As it happens, Ed Sodaro *is* mistaken. For the record, here in Massachusetts we do not have universal health insurance (we *do* have a reform law that requires virtually everyone to purchase policies from private insurance companies — the poorest receive subsidies of up to 100% — in what has become an unprecedented jackpot for our state’s private insurance industry. We have also created a new class of criminal, as tens of thousands of citizens risk substantial penalties for failing to purchase policies they can’t afford. And finally, due in significant part to the costs associated with private insurance company “overhead,” we are facing increasingly urgent and crippling state budget deficits). I believe that he is equally mistaken in regard to the potential benefits of a fully-funded, cooperatively managed national health insurance system.

  • Richard Koffler

    The leap from the finding that mental health care is not available to the conclusion that a single-payor system will solve the problem is delusional (pun intended). Single-payor systems shift the allocation of budgets entirely to formula-wielding, lawyer-overseen bureaucrats even more so than today, where government already controls half of the healthcare dollars and regulation distorts the economics of the other half. A total distortion by central planning will make today’s bad system even worse.

    • Ed Sodaro

      100% accurate commentary.

  • Bruce Kimzey

    Mental health parity coverage is already in place thru Obamacare. One reason psychiatrists have shield away from PPOs in past is that they have paid only 50%. The law now is that medical and psych health are to be covered equally.  The carriers do not so much as mention this on their websites. My plan Blue Cross PPO finally is begrudging paying.

  • Anonymous

    Realistically care first for those with severe mental illnesses.  By “realistically,” I mean a recognition that the sickest often know they aren’t.  i.e. – Anosognosia.  Thus, they have little/no internal motivation to maintain treatment adherence.  Construct systems that will manage the illnesses well enough that the risk of criminal incarceration is meaningfully reduced.  Sadly, national criminalization of the mentally ill is, in significant part, a reflection of policy and statutory failure on the civil side.  The criminal justice system is a safety net that can accomplish what the civil sector cannot.  Unfortunately, it often requires victims as the price of admission.

    Once the sickest are tended to, we should then attend to the other levels of human misery, remembering without arrogance, that much human of suffering is none of our business.  In that context should we pose as mock patients, making phone calls re: access to mental health services.

  • Michelle Reitman

    We are facing the same situation in Florida…soon to be made worse the recent changes in provider contracts being handed us by BCBS….

Most Popular