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.

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