Acceptance of New Clients by Mental Health Clinicians in Massachusetts: Findings From a Representative Survey

According to the 2016 National Survey on Drug Use and Health, approximately 14% of adults (34.3 million) in the United States reported experiencing mental illness in the past year (1). Among these individuals, only 43% reported receipt of mental health services in the past year. Many factors may contribute to this gap between mental illness prevalence and mental health service use (2), including stigma (3) and lack of insurance that providers will accept or other capacity to pay for services (4). Even among persons with adequate insurance, inability to find mental health clinicians who accept new clients is a substantial barrier to accessing mental health services, because not all clinicians accept all insurance plans and some clinicians may not be accepting new clients (5–7).

Numerous factors affect whether people can find clinicians who accept new clients, including workforce shortages (8) and limited information on whether clinicians are accepting clients in a particular insurance network (7, 9). Finding the right clinician may be even more challenging for individuals with specialized treatment needs (e.g., children or individuals with co-occurring conditions such as a substance use disorder), having limited English proficiency, not having insurance, or living in underserved geographic regions (10–13). Although several prior studies have assessed acceptance of new clients by clinicians, they focused exclusively on acceptance by physicians (5, 14–17), and only one included findings specifically for psychiatrists (5). To our knowledge, no prior studies have assessed new client acceptance among other types of licensed mental health clinicians at the state or national level.

This study assessed factors associated with the average number of new clients that clinicians reported accepting each month. The study used data from a representative survey of licensed mental health clinicians providing outpatient mental health care in Massachusetts from 2016 to 2017. The survey was designed to identify supply-side factors affecting access to treatment. Although Massachusetts has among the highest number of mental health clinicians per capita in the United States (18), Massachusetts residents continue to face barriers to mental health service access (19, 20). Understanding overall rates of new client acceptance and how new client acceptance varies by provider and practice characteristics may help clinicians and policymakers allocate resources and align incentives to improve access to needed outpatient mental health services.

Methods

Data

We surveyed six types of licensed mental health clinicians practicing in Massachusetts to ensure representation from the variety of clinicians that provide outpatient mental health services: psychiatrists, psychologists, licensed certified social workers (LCSWs), licensed independent clinical social workers (LICSWs), licensed mental health counselors (LMHCs), and licensed marriage and family therapists (LMFTs). Clinicians were asked about their current practice, including rates of new client acceptance and average wait times for new clients. This study was approved by the Abt Associates Institutional Review Board.

Survey sample frame and survey sample.

We developed a sample frame using lists of licensed mental health clinicians in Massachusetts: the Massachusetts Office of Consumer Affairs and Business Regulation Division of Professional Licensure Databases (21) and the Massachusetts Board of Registration in Medicine’s list of licensed physicians (22). These clinician lists represented the best data to develop a survey sampling frame of Massachusetts licensed mental health clinicians because they include all clinicians regardless of insurance participation or network affiliation and are frequently updated (Massachusetts requires biennial licensure renewals). We selected a random sample of 2,250 clinicians from these lists, stratifying by clinician type or credential and geographic location.

Survey administration.

The Clinician Survey of Outpatient Mental Health Access in Massachusetts was a 20-minute, multimode survey of Massachusetts licensed mental health clinicians designed to collect information on wait times and facilitating factors and barriers for individuals seeking outpatient mental health services. We conducted cognitive interviews with six participants prior to survey administration to ensure questions were easy to answer and uniformly understood. We fielded the survey from September 2016 to March 2017 using a mail push-to-web design, followed by a mail survey and telephone follow-up with nonrespondents. The initial push-to-web mailing included a survey incentive that ranged from $5 to $10 to encourage participation, regardless of whether individuals returned the survey. The final adjusted response rate was 28.1% (N=413), which was calculated using the American Association for Public Opinion Research Response Rate 3 methodology (23). We restricted the analytic sample to 391 respondents with complete data on all measures used in this analysis.

Measures

Outcome measure: acceptance of new clients per month.

We used the clinician-reported average number of new clients accepted per month, over the prior 6 months, as the primary outcome measure to quantify each clinician’s ability to see new clients.

Clinician and client demographic characteristics.

The number of new clients that clinicians report seeing may reflect a clinician’s client mix (e.g., serving populations with high turnover, such as individuals experiencing homelessness), setting (e.g., established therapist with a private practice versus new clinician in a community health center), or organizational policies (e.g., use of open access models or double-booking). For these reasons, comparisons are adjusted for clinician and client demographic characteristics.

We measured clinician credential according to the information available in the sampling frame, which was defined by the specialty for which clinicians were licensed in Massachusetts to practice. We split clinicians into four groups for analyses: social workers (LICSWs and LCSWs), counselors and therapists (LMHCs and LMFTs), psychologists, and psychiatrists. We grouped social workers (LICSWs and LCSWs) and counselors and therapists (LMHCs and LMFTs) so that we would have sufficient power for analysis. We mapped zip codes from clinician licensure data and with the Massachusetts Executive Office of Health and Human Services (EOHHS) regions (24), which reflect variation in population density, socioeconomic factors, and geographic boundaries used in the administration of Medicaid.

In the survey, we asked clinicians to provide information about their practice setting, tenure in position, part-time versus full-time status, and demographic characteristics of their clients. We characterized practice setting according to five categories: solo private practice, group private practice, practice owned by a hospital or health system, community health center or community mental health center, or other setting (e.g., schools, social service agencies). We measured workplace tenure by whether respondents were in their first year in their position, given that new clinicians may accept more new clients as they build their practice. We measured part-time versus full-time status using three categories of hours worked per week: <20, 20–29, and ≥30. Measures of client characteristics included the proportion of clients in clinicians’ panels by age group, gender, and race.

Analysis

We used cross-sectional negative binomial regression to assess the association between the number of new clients accepted per month and clinician characteristics (clinician type, hours worked per week, first year in position, practice setting, serving children or adolescents, and region). Negative binomial regression is appropriate for analyzing count data (e.g., number of new clients accepted per month) in the presence of overdispersion (25). The magnitude and statistical significance of findings from Poisson regression models were similar.

All analyses presented here incorporate sampling and nonresponse weights, defined by clinician type and geographic location. Weighted results are representative of the universe of licensed mental health clinicians in Massachusetts, as defined in the licensing board data used for the sampling frame.

Results

Survey respondents included licensed mental health clinicians with several different credentials (Table 1). Social workers represented 49% of licensed mental health clinicians in Massachusetts; counselors and therapists, 22%; psychologists, 20%; and psychiatrists, 10%. Clinicians most commonly worked in solo private practices (33%) or group private practices (30%). Forty-two percent of clinicians worked ≥30 hours per week, and 10% were in their first year at their current position.

Clinicians reported that, on average, 53% of their clients were aged 26 to 64 years old, and nearly all respondents (90%) served clients in this age group (Table 2). Relatively few clinicians served any clients that were age 5 or younger (11%) or ages 6 to 12 (31%). Clinicians identified the majority of their clients as white/Caucasian (77%), and many served at least some African American/black and Asian American/Asian clients (9% and 5%, respectively).

On average, clinicians accepted seven new clients per month, a median of four new clients per month, and an interquartile range of two to eight new clients per month (Table 3). Overall, 95% of clinicians reported accepting any new clients. In bivariate analysis, the mean number of new clients accepted per month varied significantly by practice setting (bivariate F test, p <0.001). Clinicians in practices owned by a hospital or health system accepted 15 new clients per month, whereas clinicians in group private practices accepted only four new clients per month. When stratifying by clinician type, the mean number of new clients accepted per month did not significantly vary, and the distributions were also relatively similar, with a median of three or four for each clinician type.

After adjusting for other factors, clinicians in practices owned by hospitals or health systems reported accepting 5.9 more new clients per month, on average, than clinicians in solo private practices (95% confidence interval [CI]=1.0 to 10.8; Table 4). Clinicians in private group practices reported accepting fewer new clients per month, on average, than clinicians in solo private practices (−2.0 clients per month; 95% CI=–3.7 to –0.4). Clinicians in community health centers or community mental health centers reported accepting slightly more new clients than those in solo private practices, but the difference was not statistically significant. Working part-time was negatively associated with acceptance of new clients (−4.8 clients/month for clinicians working <20 hours per week, relative to those working ≥30 hours per week; 95% CI=–7.2 to –2.3), and first year in position was positively associated with acceptance of new clients (2.8 clients per month; 95% CI=0.3 to 5.3).

Discussion

This study reports findings from a representative survey of mental health clinicians practicing in Massachusetts in 2016 and 2017 and is the first study, to our knowledge, to report rates of new client acceptance by licensed psychologists, social workers, and mental health counselors, in addition to rates for psychiatrists alone. In this survey, almost all mental health clinicians—19 out of 20—reported accepting at least one new client per month during the prior 6 months. The distribution of new clients accepted per month was relatively wide, with a mean of seven clients per month, a median of four, and an interquartile range of two to eight. Responses at the higher end of the distribution, with reports as high as 80 new clients per month, could reflect newly hired clinicians or those specializing in brief treatment or assessments. Prior studies of new client acceptance among primary care physicians have reported estimates of similar magnitudes (15, 16), although these studies did not include estimates for mental health clinicians other than psychiatrists. One recent study using the 2015 National Electronic Health Records Survey found that that 89% of primary care physicians were currently accepting new patients (16), similar to reported acceptance rates of any new clients in this study (95%). Our study expands this access measure to the context of mental health, assessing average new clients accepted per month and adjusting for key client and practice characteristics.

On average, clinicians in practices owned by hospitals or health systems reported accepting more new clients than clinicians in private solo and group practices. Prior research has found that practices owned by hospitals or health systems also had longer wait times than other settings (26). Greater acceptance of new clients in hospital or health system-owned settings, along with longer wait times, may reflect a mental health care system that channels individuals in need of outpatient mental health services to specific types of practice settings and clinicians, based on their insurance type or ability to self-pay for services. Practices owned by hospitals or health systems may have greater administrative support for collecting insurance payments and maintaining wait lists of clients (26). In contrast, clinicians in private practice may have more autonomy to choose the clients they serve and how many but fewer resources designated for insurance administration and client scheduling. This insight, although not universally generalizable, may still be valuable for individuals seeking outpatient mental health services.

This study found substantial variation in the distribution of acceptance of new clients across mental health clinicians, even within each clinician type and licensing credential. This suggests that some clinicians take a relatively limited number of new clients, especially as over half of the respondents to this study reported working fewer than 30 hours per week. Changes in policy and practice—such as alignment of payment incentives, reduced administrative burden and use of brief evidence-based treatments—may help some mental health clinicians increase the number of clients that they accept. In particular, payment policies and systems, for both private and public payers, could be more effectively designed to support clinicians in serving clients with the greatest needs. Reducing administrative burden could help reduce provider burnout (27–29), increasing reimbursement rates may encourage more health care trainees to specialize in mental health and work in settings that accept public insurance, and risk-adjusted rates might encourage clinicians to treat individuals with the highest need (30, 31). Further study is also needed to assess the average time that clients remain on clinician caseloads, along with therapies used and supportive services engaged. A larger issue, beyond the scope of this study, is how to attract and retain a skilled mental health treatment workforce (32, 33).

This study has relevance for patients, practice, and policy. People seeking treatment might more quickly find an appointment with a clinician working within a health system, given their greater volume of new clients accepted. Additionally, payers and policy makers may also be able to establish policies that encourage providers to accept new clients, especially those in smaller and independently owned practices. Policies could include reducing paperwork, increasing reimbursement rates for initial visits (6), encouraging adoption of telepsychiatry (34), and incentivizing providers to practice in areas with high unmet need for access to mental health care (e.g., through student loan payment assistance; 6).

This study had limitations. First, survey nonresponse may have biased estimates of new clients accepted in this study, to the extent that nonrespondents would have reported different outcomes than clinicians who responded to the survey. The adjusted response rate for the survey was 28%. Although Massachusetts requires practicing clinicians to update their licenses every other year, clinicians do not always update their addresses if they move, which may have contributed to clinician nonresponse, given that the sampling frame primarily used contact information from the state licensing data. We assessed nonresponse bias by exploring differences between survey respondents and nonrespondents based on information that was known for both groups (see Appendix A in the online supplement; 35, 36). Across all types of clinicians, psychiatrists were least likely to respond to the survey (unadjusted response rate=13%), whereas counselors and therapists were most likely to respond to the survey (unadjusted response rate=37%). The propensity of survey response varied significantly by clinician type (p<0.001). We did not find a statistically significant difference in propensity of survey response by EOHHS region or by year of licensure. These findings indicate that comparisons of the number of new clients by type of clinician may be limited by nonresponse bias; however, we found no differences in the characteristics of respondents and nonrespondents by region or clinician experience. The relatively lower response propensity for psychiatrists is consistent with many other studies finding that physicians can be challenging to survey (37, 38). Applying survey weights by clinician type and EOHHS region also adjusted for differential response by clinician type and region (i.e., if more clinicians responded in one region versus another).

Second, this study used findings from a survey of mental health clinicians to assess factors associated with new client acceptance, and self-reported clinician survey responses could not be independently verified. Survey respondents may be subject to social desirability bias, or a tendency to respond in a manner that the respondent believes others may prefer (39). Acceptance of new clients cannot be measured through administrative data and must instead be measured by asking the clinician, either by using secret caller studies (16) or explicitly through surveys (5, 16). Secret caller studies, which use simulated clients (e.g., with varied insurance coverage and diagnoses) to assess availability, allow information to be collected without bias from self-reports but are limited in that they include only clinicians that are willing and able to book appointments without specific insurance information. Surveys do not face this limitation, but estimates of availability from surveys may be biased, because the information collected relies on self-reports. To minimize potential concerns, we informed invited participants that their responses would be confidential and reported in aggregate only. In addition, the survey was self-administered, a method that has been shown to decrease social desirability bias relative to interviewer-based modes (40, 41). There is also no reason to believe social desirability bias should vary across respondent groups (e.g., clinician type, region), and consequently, there is no reason to believe that social desirability would have influenced differences in observed number of new clients across those groups.

Conclusions

This study reported representative estimates of new client acceptance among licensed mental health clinicians in Massachusetts. Half of the clinicians reported accepting four or fewer new clients, on average, per month. Acceptance of new clients was lower among clinicians in private practice than those in settings owned by hospitals or health systems. These findings may help provide guidance to clients looking for outpatient mental health care and to policymakers conducting mental health system planning and workforce development, given that provider acceptance of new clients has a direct impact on access to services for outpatient appointments. These findings also highlight the importance of payers maintaining updated lists of clinicians accepting new clients.