To the Editor: I wish to compliment Dr. Goldman on his column in the December 2001 issue, "Is There a Shortage of Psychiatrists?" (1). In answer to this important question, he found that indeed there is a shortage of psychiatrists in the United States, and a curious one at that. Psychiatrists seem unable to adequately serve patients enrolled in behavioral health carve-outs—that is, most of the privately insured public. Psychiatrists do sign up to participate in the provider networks of carve-outs, as evidenced by a 10 percent increase in the number of psychiatrists in the United Behavioral Health (UBH) network. However, they appear to favor treating privately paying patients over network patients. In his article, Dr. Goldman wondered why and mentioned fees, but then he skipped on to a discussion of the complex demand and supply issues at play in psychiatry.
That discussion, although interesting, may miss the point. Fees are a big issue, and so is micromanagement. If managed behavioral health carve-outs paid psychiatrists at reasonable rates and did not demean them by conducting utilization reviews presided over by lesser-trained clinicians, the functional problem of access might be resolved. A test of whether there is a true shortage of psychiatrists or a de facto boycott of UBH and other behavioral health carve-outs would be to determine whether Medicare and other non-carve-outs also have problems in getting psychiatrists to see their enrollees. I have never encountered such a complaint about the Medicare system, and I do not find that access to psychiatrists is a problem in our local psychiatrist-friendly health maintenance organization. Also, how is the profession to recruit into a field that is overcontrolled by managed care carve-outs?
Dr. Goldman is right to be pessimistic. However, as senior vice-president for behavioral health services at UBH he is nicely positioned to do something other than bemoan the sad state of psychiatry. How about his pushing UBH to free psychiatrists from case-by-case utilization review, something United Healthcare did for other physicians? I agree with Dr. Goldman that one of the results of the current situation may be an increase in the granting of prescribing privileges to psychologists by state legislatures, with all the dangers this carries for patients.
Dr. Pomerantz is assistant clinical professor of psychiatry at Harvard Medical School and codirector of the mental health program of Health New England, a health maintenance organization in western Massachusetts.