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Patient Characteristics and Treatment Patterns Among Psychiatrists Who Do Not Accept Private Insurance

Published Online:https://doi.org/10.1176/appi.ps.201800014

Abstract

Objective:

Privately insured individuals frequently use out-of-network psychiatrists. Yet, whether treatment provided by psychiatrists who do not accept private insurance differs from treatment provided by those who do has not been studied. The investigators described provider characteristics, patient characteristics, and treatment patterns among psychiatrists who do not accept new patients with private insurance.

Methods:

Data for this study came from the National Ambulatory Medical Care Survey (2011–2014), a nationally representative annual cross-sectional survey of physicians providing ambulatory care. Responses of psychiatrists who report accepting any new patients (N=440) were examined, representing 7,634 visits.

Results:

Compared with psychiatrists accepting privately insured patients, those not accepting privately insured patients had fewer visits with patients with serious mental illness (42% versus 53%; p=0.016). These psychiatrists had a higher proportion of visits lasting longer than 30 minutes (48% versus 34%; p=0.026), and their patients were more likely to have had 10 or more visits in the past 12 months (41% versus 28%; p=0.013). There were no differences in the proportion of visits in which treatment included psychotherapy (48% versus 44%).

Conclusions:

Although psychiatrists not accepting patients with private insurance were less likely than other psychiatrists to treat patients with serious mental illness, their patients were more likely to have longer visits and a relatively high number of visits in the past year. The low rate of acceptance of insurance among psychiatrists may have the greatest effect among those most in need of services.

Among the 43.4 million people with a mental illness in the United States, only about 43% received treatment in the past year (1). One often-cited barrier to treatment is access to a mental health specialty provider, in part because psychiatrists have been less likely than other physicians to participate in private (commercial) insurer networks (2). The most recent research examining psychiatrists’ participation in plan networks examined data through 2010 and found that participation was declining significantly, with only about 55% of psychiatrists accepting new patients with private insurance by 2009–2010 (3). This compared with rates of about 90% for other physician specialties. Although privately insured patients obtain mental health care from out-of-network providers at high rates (4), little is known about the types of patients treated by psychiatrists who do not accept private insurance and whether the treatment they deliver differs from that delivered by psychiatrists in network.

Related to patient characteristics, differences in demand for specialty mental health treatment may be relevant. Privately insured patients willing to pay the higher costs associated with out-of-network care may have less serious symptoms, in part because they are more likely to have stable employment and a higher income. Conversely, those with the most serious symptoms may be eager to see a provider quickly, even if doing so comes at the significantly higher cost associated with an out-of-network psychiatrist. Psychiatrists who prefer to treat individuals with less serious diagnoses, perhaps to reduce off-hours calls and appointments (particularly for psychiatrists in solo practice), may decline to accept private insurance to allow for more discretion over the types of patients joining their panel.

Psychiatrists who do not accept private insurance may also provide different treatments. If insurers set relatively low payment rates for psychotherapy to encourage patients to seek lower cost treatments (i.e., medication) and patients are willing to pay out-of-network rates for psychotherapy, psychiatrists who have a preference for providing psychotherapy or who believe it is the most effective treatment (perhaps in combination with medication treatment) may choose not to accept private insurance. Moreover, not accepting private insurance may allow some psychiatrists to avoid strict and time-consuming medical necessity reviews that are triggered by longer treatment episodes.

Generally, mental health providers cite low reimbursement, excessive paperwork, and late or incorrect payments as reasons for not participating in a private insurance network (57). Implementation of the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) may have addressed some of these barriers to psychiatrists’ participation in networks. Under MHPAEA, many private insurance plans are required to use a similar process to determine the management rules for behavioral health and medical and surgical care, potentially reducing administrative requirements on mental health providers (8). Similarly, MHPAEA prohibits most private insurance plans from using different standards for choosing or reimbursing mental health providers and medical or surgical providers. There is some evidence that plans responded to these requirements by expanding their mental health provider networks. In 2011, a large, nationally representative plan survey reported that four out of five plans increased the number of providers in their behavioral health network after MHPAEA (9). In this article, we describe provider characteristics, patient characteristics, and treatment patterns among psychiatrists who do not accept new patients with private insurance (2011–2014).

Methods

Data Source

We examine the 2011–2014 National Ambulatory Medical Care Survey (NAMCS), an annual survey of office-based physicians conducted by the Centers for Disease Control and Prevention’s National Center for Health Statistics. The sampling frame consists of physicians in the master files of the American Medical Association and the American Osteopathic Association who are primarily in office-based practice and principally engaged in patient care activities. Visits to community health centers are not included. In all cases, we excluded from our sample any providers who reported not accepting any new patients. Over the time period studied, 90% of psychiatrists and 96% of all other specialties were accepting new patients. Each provider reported information about several randomly chosen patient encounters.

Measures

Our main outcome measure was whether the provider self-reports accepting new patients with private insurance. Each provider in the survey was asked, “If you currently accept ‘new’ patients into your practice(s), which of the following types of payment do you accept?” If a provider was not accepting new patients, information about accepted payment types was not requested. Thus, for this study, we focused only on providers who reported accepting new patients. Following methods originally used by Bishop et al. (3), we created a measure of acceptance of new patients with noncapitated private insurance. Other psychiatrist practice characteristics we considered included region, whether the psychiatrist practices in a metropolitan statistical area, is in solo practice, or has evening or weekend availability. Starting in 2011–2013, providers were also asked about their electronic health record capabilities. We considered whether the practice submits claims electronically, meets the U.S. Department of Health and Human Services meaningful use criteria, records clinical notes, or uses secure messaging exchanges with patients.

Patient encounter or visit data considered included whether the patient was aged 19 or under, was female, was a new patient, had two or more chronic conditions, had a diagnosis indicating serious mental illness (ICD-9-CM diagnoses 295.xx–298.xx), or a substance use disorder (ICD-9-CM diagnoses 291.xx–292.xx and 303.xx–305.xx, except 305.1, tobacco use disorder). Related to treatments received, we considered whether the visit included psychotherapy (which NAMCS [10] defines as “all treatment involving the intentional use of verbal techniques to explore or alter the patient’s emotional life in order to effect symptom reduction or behavior change” and is distinguished from “all other mental health counseling”), whether medication was ordered or provided during the visit, whether the duration of visit (i.e., the amount of time the physician spent in face-to-face contact with the patient) was 30 minutes or longer, and whether the patient had 10 or more visits in the past 12 months.

Statistical Analyses

We considered whether psychiatrists accepting new, noncapitated private insurance patients and those not accepting such patients differed with respect to characteristics of provider practices and characteristics of patients treated by these providers. In all analyses, provider or visit survey weights were used to make results nationally representative. We used design variables provided by the National Center for Health Statistics and employed an ultimate cluster design for estimating variance. This study was declared exempt from institutional review board review by the Yale Human Subjects Committee. We used Stata 14.2 for all analyses.

Results

Our final NAMCS sample included 440 psychiatrists responding in 2011–2014, with data from 7,634 visits, representing 119,605,827 patient visits nationally. Among psychiatrists, 65% were accepting new privately insured patients. This number was significantly higher (89%) for other physician specialists (p<0.01).

Psychiatrists’ Practice Characteristics

We considered differences in psychiatrists’ practice characteristics, as shown in Table 1. Psychiatrists not accepting new privately insured patients were more likely to report being in solo practice (75% versus 63%; p=0.037). For both types of providers, more than 97% of practices are in a metropolitan statistical area. Psychiatrists not accepting private insurance were also less likely than other psychiatrists to accept new patients with Medicare (39% versus 75%; p<0.001) or Medicaid (31% versus 52%; p=0.001). Practices that do not accept new patients with private insurance were significantly less likely to submit claims electronically (46% versus 77%; p<0.001), use clinical note recording (44% versus 62%; p=0.046), and use secure messaging exchanges with patients (8% versus 19%; p<0.050).

TABLE 1. Characteristics of psychiatry practices, by acceptance of new patients with private insurance, in percentagesa

Accepts new patients with private insurance
CharacteristicTotal (N=440)No (N=141)Yes (N=299)p
Region.113
 Northeast273525
 Midwest171019
 South282632
 West282924
Metropolitan statistical are989997.042
Solo practice647563.037
Evening and/or weekend availability394736.113
Accepts Medicare 633975<.001
Accepts Medicaid 463152.001
Electronic health record capabilitiesb
 Submits claims electronically684677.001
  Meets HHS meaningful use criteria908890.761
 Uses clinical notes recording574462.046
 Uses secure messaging exchanges with patients17819.050

aSource: National Ambulatory Medical Care Survey (NAMCS), 2011–2014. Survey-weighted percentages are based on the sample that was surveyed, which was limited to psychiatrists who report accepting new patients. Physician characteristics are weighted with the NAMCS physician weight.

bIncludes data from 2013 to 2014 because some measures were not included in 2011 and 2012 surveys. HHS, U.S. Department of Health and Human Services

TABLE 1. Characteristics of psychiatry practices, by acceptance of new patients with private insurance, in percentagesa

Enlarge table

Visit Characteristics

Visits to psychiatrists not accepting new privately insured patients were significantly less likely to involve individuals with serious mental illness (42% versus 53%; p=0.016), although there were no significant differences in the proportion of visits by patients with at least two general medical conditions (18% versus 22%; p=0.342) or by whether the visit involved a patient with a substance use disorder diagnosis (11% versus 9%; p=0.371). Psychiatrists not accepting new privately insured patients were marginally significantly less likely to treat individuals ages 19 and under (11% versus 17%; p=0.075; see Table 2).

TABLE 2. Characteristics of visits to psychiatrists who do or do not accept new patients with private insurance, in percentages (2011–2014)a

Visit characteristicAll visits (N=7,634)Visits to psychiatrists who do not accept private insurance (N=2,243)Visits to psychiatrists who accept private insurance (N=5,391)p
Patient characteristic
 Age 19 and under161117.075
 Female565657.831
 New patient979.235
 ≥2 chronic conditions201822.342
 Serious mental illness504253.016
 Substance use disorder9119.371
Treatment characteristic
 Visit included psychotherapy434844.518
 Any prescription or nonprescription drugs ordered or provided during visit878488.244
 Visit lasted ≥30 minutes394834.026
 Patient had ≥10 visits in the past 12 months324128.013

aSurvey-weighted percentages of patient encounters are based on the sample that was surveyed, which was limited to visits with psychiatrists who reported accepting new patients. Patient characteristics are weighted with the National Ambulatory Medical Care Survey patient weight.

TABLE 2. Characteristics of visits to psychiatrists who do or do not accept new patients with private insurance, in percentages (2011–2014)a

Enlarge table

Whether the psychiatrist does or does not accept new patients with private insurance had no significant association with the proportion of visits that included treatment with psychotherapy (44% and 48%, respectively; p=0.518) or whether any prescription or nonprescription drugs were provided during the visit (88% and 84%, respectively; p=0.244). Visits among psychiatrists not accepting new privately insured patients were significantly more likely to last 30 minutes or longer (48% versus 34%; p=0.026) and to involve patients with 10 or more visits in the past 12 months (41% versus 28%; p=0.013).

Discussion

This study is the first to look at patient characteristics and treatment patterns associated with whether a psychiatrist reports accepting new privately insured patients. We found that psychiatrists who accept private insurance may be seeing patients with more complex treatment needs—psychiatrists who accept insurance had approximately 25% more visits involving a patient with a diagnosis indicating serious mental illness. This difference in the patient panel may be due to patient demand or provider behavior. If patients with more serious diagnoses anticipate needing more services, the cost of seeing out-of-network psychiatrists may be prohibitive. In addition, these patients may be more likely to benefit from ancillary services such as case management, which may be more available among psychiatrists who accept private insurance. Provider behavior may also play a role if providers who choose not to participate in private insurance networks are more willing to accept new patients with less serious diagnoses (i.e., “cream skimming” the easy-to-treat patients).

Despite seeing more patients with serious mental illness, psychiatrists who accept insurance on average spent less time with their patients and saw them fewer times than psychiatrists who do not accept insurance. We found that visits to psychiatrists who do not accept private insurance were more likely to last 30 minutes or more and more likely to involve patients with 10 or more visits in the past 12 months, suggesting more intense treatment episodes. Insurers may be managing care and be more likely to require a justification for longer visits or treatment episodes of exceptionally long duration from network providers, resulting in the less intense care provided among network providers. Psychiatrists not participating in private insurance networks may feel less pressure to end treatment with a patient, particularly if they receive fewer requests for appointments from new patients, given their higher out-of-pocket cost.

Anecdotal reports suggest that some psychiatrists do not accept new patients with private insurance because of a preference for providing psychotherapy (compared with medication management), which at longer durations may be less likely to be approved by plans. That we found no differences in the proportion of visits that included psychotherapy suggests other important reasons for not accepting patients with private insurance.

Practice characteristics also differ. We found that psychiatrists who accept new patients with private insurance are more likely to have electronic medical record systems with greater capability, which may reduce billing costs or errors. Psychiatrists who do not accept insurance are more likely to be in solo practice and may not be able to afford the overhead or complex implementation of an electronic medical record. These systems may lead to care of higher quality if access to information about general medical conditions is more readily available. Overall, psychiatrists have fewer electronic medical record capabilities than other specialists. In our sample, 62% of psychiatrists could submit claims electronically in 2014; one NAMCS report indicated that when considering all specialties, 89% could submit claims electronically (11).

Policy observers have suggested that psychiatrists may not accept new privately insured patients for two important reasons—low overall reimbursement rates and administrative hassles associated with reimbursement by private insurers. Information on whether these psychiatrists accept new patients with Medicare coverage may shed light on the relative importance of these two concerns. Historically, Medicare has fewer administrative hurdles to payment once care is delivered. Even though administrative hurdles under private insurance may have been reduced somewhat by MHPAEA, they are still likely higher than under Medicare. We find that about 39% of psychiatrists not accepting new privately insured patients do accept new Medicare patients, suggesting that the administrative burden may be an important reason for not accepting private insurance for these psychiatrists.

Rates of psychiatrists accepting new privately insured patients remain quite low compared with other specialties, justifying ongoing concerns about access to mental health care for the privately insured. Lack of acceptance by psychiatrists may impede or delay receipt of care, particularly if provider directories are not accurate (12). It may also lead to an additional financial burden on patients due to higher cost sharing for out-of-network care as well as balance billing (4). Although not generalizable, a patient and family survey conducted by the National Alliance on Mental Illness found that 30% to 32% of respondents reported having difficulty finding a mental health specialist who would take their insurance (13). Unlike many prior state parity laws, the MHPAEA requires that plans offering an out-of-network benefit for mental health have equivalent benefit design to out-of-network medical care (including copayment, coinsurance, out-of-pocket maximums, and deductibles). Critics have noted the difficulty in enforcing requirements of MHPAEA, and there have been numerous complaints by patients about policies that are not in compliance with MHPAEA (14, 15). There has also been significant criticism of the lack of transparency of some of the provisions. Perhaps with greater enforcement and disclosure requirements, plan policies may change in such a way as to encourage more psychiatrists to accept private insurance.

Delivery system reforms have led to an increased emphasis on providing mental health treatment in primary care, perhaps by a team of providers that includes a mental health specialty provider (16). This change may alleviate provider shortages and increase access to mental health care, even in the face of limited participation by psychiatrists in private insurance networks. In addition, other mental health specialty providers, including psychologists and social workers, may provide needed mental health services, particularly psychotherapy. Yet, for individuals with more serious mental illness, access to a psychiatrist may still be critical. Thus, when there is a shortage of psychiatrists, it may be optimal at a population level for some patients, particularly those with less severe anxiety disorders or depression symptoms, to be treated in a primary care setting.

Limitations of the data are important to consider when determining implications of these findings. We only considered psychiatrists because data on other mental health professionals were not available. These data do not include all outpatient visits; hospital-based outpatient care and care delivered in community health centers are not included. Although nationally representative, the sample of psychiatrists in each year is relatively small, and some meaningful differences may not be detected. There are well-known limitations to survey data such as difficulties in accurately determining diagnoses and other patient characteristics or treatments patterns. This may be particularly true in the case of psychotherapy, because what constitutes psychotherapy may be interpreted differently by different psychiatrists. We used recorded diagnoses to identify serious mental illness, which, in the absence of information on functional limitations, may not accurately categorize some patients. Finally, this study was descriptive in nature and we are unable to determine what policies—such as higher reimbursement, changes to health plan precertification, or treatment review—may ameliorate the problem of low psychiatrist acceptance of new privately insured patients. Likewise, we cannot determine the consequences of this problem for patient outcomes.

Conclusions

Although psychiatrists who do not accept patients with private insurance are less likely to treat patients with serious mental illness, their patients were more likely to have longer visits and a relatively high number of visits in the past year. The low acceptance rate of insurance among psychiatrists may have the greatest effect among individuals who are most in need of services.

Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut (Busch, Ndumele, Loveridge); Department of Population Health, New York University School of Medicine, New York (Kyanko).
Send correspondence to Dr. Busch ().

The funders played no role in the design or conduct of the study; in the collection, management, analysis, or interpretation of the data; or in the preparation, review, or approval of the manuscript.

The authors report no financial relationships with commercial interests.

This study was supported by a grant from the National Institute of Mental Health (R01MH106635).

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