Psychiatrist Participation in Private Health Insurance Markets: Paucity in the Land of Plenty

Access to specialty mental health care in the United States is poor, and the dearth of specialty mental health providers has been a long-standing public health concern (1–3). Each year, almost 60% of people with a mental illness and one-third of individuals with severe mental illness receive no mental health care (4). Recent policy improvement efforts have focused on improving insurance coverage for mental health care but have had limited success (5–8).

Although nearly 90% of the national population is insured, the availability of specialty psychiatric care depends on how many psychiatrists accept insurance (9–12). Because few psychiatrists accept insurance, the effects of demand-side policies to improve insurance coverage could be muted. Self-reported information from psychiatrists suggests that nearly half of psychiatrists who accept new patients do not accept health insurance, and rates of insurance participation have been decreasing (13).

The sparse literature on the practices of psychiatrists is limited by reliance on physician self-reported information, which is subject to both response and selection biases. Although these studies provide some information about psychiatrists’ practice behavior, there are few details about insurance participation with respect to the types of patients served or the number of patients with insurance their psychiatrist accepts, which, if available, could inform policy solutions. In this article, we use state physician licensing data and an all-payer claims database to examine the characteristics of Massachusetts psychiatrists practicing in 2013. To better understand access to specialty mental health care, we assessed how many psychiatrists treated patients with different types of insurance, the number of insured patients they treated, and differences in the traits of psychiatrists with more versus less insurance participation.

Methods

Study Design

We focused on Massachusetts, where data on both physician supply and patient health care utilization were available. The data sources provided empirical information about the psychiatrists who legally can practice in the state as well as those who delivered care paid for by health insurance, and the data do not rely on physician or patient recall. We chose the year 2013 to examine physician participation because it occurred after the shift to evaluation and management coding for psychiatry, designed to improve billing and insurance participation for psychiatrists, and before the loss of Employee Retirement Income Security Act plan data from the All-Payer Claims Database (APCD) (14, 15).

We used a four-part process involving state medical databases to identify the number of psychiatrists available to patients with different types of private health insurance. We began by describing the sample of psychiatrists who could practice in Massachusetts, using state licensing data from the Massachusetts Board of Registration in Medicine (BORIM) to identify psychiatrists with active licenses who were available to provide care. We identified the subgroup of psychiatrists who worked in Massachusetts by using their registered addresses. We collected additional details about physician business and practice information from the Centers for Medicare and Medicaid Services (CMS) National Provider Identifier (NPI) data set (e.g., registered address) when needed. Addresses were used to restrict the psychiatrist sample to only those who were more likely to be actively practicing in Massachusetts. Next, we quantified the number of patients seen and the corresponding claims billed by psychiatrists in order to examine variation in practice patterns across the subgroup. We used the APCD, a statewide data set that aggregates medical and pharmacy claims for both commercially and publicly insured individuals throughout Massachusetts (16), to evaluate empirical information about physician behavior through paid insurance claims for care delivered. Last, we identified psychiatrists with a full caseload of insured patients, defined based on prior literature (17) as those who had claims for at least 300 unique insured patients per year, and compared them with psychiatrists with fewer patients. The institutional review board at Mass General Brigham approved the study protocol.

Study Sample

From the Massachusetts BORIM, we identified all psychiatrists who held active medical licenses in the state throughout 2013 (18) to find those eligible to practice. Using BORIM, we collected physician characteristics, including education and training, certification and licensure, hospital affiliation, address, and history of disciplinary action or malpractice claims. In sensitivity analyses (data not shown), we tested the validity of restricting our study sample to psychiatrists with Massachusetts addresses by expanding the geographic area to include psychiatrists with addresses in neighboring states.

Using the Massachusetts APCD, we identified psychiatrists who provided specialty mental health care reimbursed by private insurance by examining paid insurance claims within the state APCD in 2013. We included four types of insurance: group commercial, individual commercial, Medicare Advantage, and Medicaid managed care. We excluded Medicaid fee for service (FFS) (approximately 33% of Mass-Health in 2013) (19) from the analyses because of incomplete capture of behavioral health claims (behavioral health care was carved out to the Massachusetts Behavioral Health Partnership) in the beginning of 2013. In addition, claims data for traditional FFS Medicare beneficiaries and Veterans Affairs beneficiaries were not available to outside researchers through the APCD (20). Although we excluded FFS Medicaid and traditional Medicare from our main analyses, we conducted secondary analyses by using the CMS Physician and Other Supplier Public Use File to examine whether psychiatrists billed for patients with traditional Medicare in 2013 and by using APCD data to examine whether psychiatrists billed for patients with Medicaid FFS in the last quarter of 2013 (data not shown).

To determine insurance participation, we quantified the number of unique outpatients with paid insurance claims for each eligible psychiatrist during the year. We examined various thresholds for participation because different levels of engagement in the insurance market have different implications for patient access to care. Although a national sample of community psychiatrists indicated a mean caseload of approximately 300 patients for full-time providers, estimates of caseloads had ranges of up to 1,000 patients in some practices (17). We used 300 patients as our primary caseload threshold but examined other thresholds (e.g., any outpatient; at least 20 unique patients; or at least 50, 100, or 500 patients per year) (see online supplement) (17). Although we focused on all psychiatrists with active licenses, we were not able to determine the number of hours a psychiatrist practices nor whether some of the physicians in our cohort were not seeing patients. We grouped the claims by the four insurance types.

Statistical Analyses

We summarized the characteristics of psychiatrists who billed each type of insurance. We used logistic regression to assess factors associated with participation in different insurance markets. For some analyses, we grouped physician addresses by hospital referral region. Across all types of insurance, we examined factors associated with having more than 300 unique patients per year (i.e., a “full” caseload). We identified outpatient visits by procedure code and compared the average amount paid for each procedure code across insurance types.

Confidence intervals have not been corrected for multiple comparisons. We used Stata, version 14, for all analyses and visualized data by using Tableau Desktop, version 2019.3.2, or GraphPad Prism, version 8.

Results

Psychiatrists in Massachusetts

A total of 2,770 psychiatrists held active Massachusetts state medical licenses in 2013. Of these, 2,348 psychiatrists had addresses in Massachusetts. On average, psychiatrists with addresses in Massachusetts had been out of medical school for 27.6±13.0 years (median=27 years, interquartile range 18–37 years). Overall, 78% were board certified and 51% had at least one hospital affiliation (Table 1). The state population was 82% white, 8% Black, 7% Asian, 2% more than one race, and <1% Native American; 11% of the population was Hispanic (21).

Insurance Market Participation

Among the 2,348 psychiatrists with addresses in Massachusetts, 79% (N=1,843) had at least one claim for an outpatient in the APCD (Table 1), whereas 6% (N=151) had claims for more than 300 unique patients during the course of the year (Figures 1 and 2). The mean number of patients per psychiatrist in 2013 was 73.2±142.8 (Table 1), and the median was 18. The mean number of outpatients per year was slightly higher among psychiatrists with a hospital affiliation than among those without a hospital affiliation (74.5 versus 71.9, respectively) and, among psychiatrists with 300 or more patients, was higher for those with a hospital affiliation than for those without a hospital affiliation (553.0 versus 501.4, respectively). The number of claims per patient paid to the psychiatrist remained relatively stable even as the number of patients per psychiatrist increased (see online supplement).

Physician Characteristics Associated With Insurance Participation

There were no significant differences in hospital affiliation or geographic location of psychiatrists with at least one claim for an outpatient versus none. Neither board certification nor having a prior malpractice claim was associated with an increased likelihood of having an outpatient claim. Psychiatrists within 19 years of medical school graduation and those with ≥40 years since medical school graduation, some of whom may be retired or semiretired, were less likely to bill for at least one outpatient compared with those with 30–39 years since medical school graduation (7–19 years, odds ratio [OR]=0.67, 95% confidence interval [CI]=0.47–0.94; ≥40 years, OR=0.68, 95% CI=0.48–0.98).

Similarly, psychiatrists were less likely to bill for at least 300 unique outpatients if they had ≥40 years since graduation or were within the first two decades since graduation, relative to those with 30–39 years since medical school graduation (7–19 years, OR=0.49, 95% CI=0.29–0.83; ≥40 years, OR=0.45, 95% CI=0.26–0.76). Being board certified decreased the likelihood of having claims for 300 or more outpatients (OR=0.39, 95% CI=0.25–0.76). Psychiatrists in the Worcester versus Boston hospital referral region were more likely to have 300 or more insured outpatients (Table 2).

Insurance Market Distribution

Insurance participation was greater for group commercial insurance compared with public insurance programs, which tend to have lower reimbursement levels (see online supplement). Specifically, among the 1,843 psychiatrists with at least one outpatient, most (N=1,720, 93%) participated in group commercial insurance, whereas a minority participated in Medicare Advantage (N=602, 33%), marketplace plans (individual commercial plans with high levels of public subsidies) (N=616, 33%), and/or Medicaid managed care (N=597, 32%) (see online supplement). Among those with claims for at least one outpatient, the odds of having at least one claim for public insurance programs were lower for recent medical school graduates than those with 30–39 years since graduation (0–6 years since graduation, OR=0.55, 95% CI=0.32–0.92) (see online supplement). Those with a hospital affiliation (OR=1.62, 95% CI=1.31–1.99) and those with any claim outside Boston were also more likely to have at least one claim for public insurance programs among psychiatrists with any claim (see online supplement).

By county, the ratio of psychiatrists to residents ranged from 1.0 to 5.2 per 10,000 enrollees for psychiatrists with at least one outpatient claim, from 1.8 to 11.5 per 10,000 enrollees for those with at least one group commercial insurance claim, and from 2.8 to 17.6 per 10,000 enrollees for those with at least one Medicaid managed care claim.

Discussion

Access to psychiatrists through private insurance appears to be difficult (8), and our findings suggest that the supply could be considerably lower than previously described for U.S. residents who rely on health insurance to pay for their care. Even in areas with relatively large numbers of psychiatrists, such as Massachusetts, most psychiatrists accept private health insurance for only a few patients per year, and few psychiatrists meet even conservative definitions of a full outpatient caseload of patients billed through private health insurance. We found that many psychiatrists who participate in the insurance market see very few patients with insurance reimbursement, which suggests that counting psychiatrists alone could grossly overestimate the supply available to patients who cannot afford to pay out of pocket. Furthermore, more psychiatrists participate in commercial insurance than public insurance, as previously described (13), and this disparity increases when looking at psychiatrists who carry full caseloads. Finally, we found that a high proportion of psychiatrists have been in practice for several decades and that more of these psychiatrists are active participants in the insurance market compared with those with few years of practice, which raises concerns about the potential for even greater workforce challenges in the future, as older psychiatrists retire. Without substantial increases in the inflow of new psychiatrists, and particularly those who participate in insurance markets and to a greater degree than current trends demonstrate, difficulties with access could soon worsen.

In Massachusetts, as elsewhere across the country, the small number of psychiatrists who accept insurance and are taking new patients is troubling, particularly for patients with insurance plans with lower than average reimbursement levels (13, 22). We found that three-quarters of psychiatrists with an active license and a registered address in Massachusetts had an insurance claim during 2013, suggesting that some licensed psychiatrists might practice without participating in any insurance market or might not practice at all. Although Massachusetts appears to have a higher proportion of psychiatrists with some insurance participation compared with estimates of the national average (78.5% versus 55.3%) (13), even among the population of physicians who had an insurance claim, the average number of unique patients who had a claim through private insurance was small, with 50% (N=1,181) of psychiatrists billing for 18 patients or fewer in the year. Furthermore, the subset of psychiatrists billing for a full caseload of patients came to less than 10% (N=151) of all providers, suggesting that access to outpatient psychiatry may be far more limited than previously realized. Many psychiatrists are likely compensated in some capacity outside of billing insurance for outpatient care, possibly by treating patients who self-pay or by pursuing nonclinical work (23, 24). These providers may not be accepting new patients or may not be seeing many patients through the insurance market.

Several factors could influence a psychiatrist’s decision about accepting insurance and could explain resulting practice differences between those who do and do not participate, including concerns about administrative burdens required for insurance reimbursement, higher payments outside of the insurance market than within, and the ability to customize treatment plans that may not be adequately reimbursed (e.g., psychotherapy) (24, 25). The amount of reimbursement, the required administrative steps, and the complexity of the patient population may vary by insurance type (e.g., commercial group insurance plans typically pay higher reimbursement compared with other private insurance, such as Medicaid managed care) (26). Although the option to pay privately for mental health services might work well for psychiatrists and for some patients with financial resources, this system would not work well for patients with less disposable income, who also could be at elevated risk for mental illness (27).

Massachusetts contains some of the highest concentrations of academic medical centers and psychiatrists in the country (1). Massachusetts may represent a positive outlier in the country with respect to the overall supply of psychiatrists, given that there are more than 27 psychiatrists per 100,000 residents—many more than in most states and particularly states with lower population density—and more than double the national average of 12.9 psychiatrists per 100,000 residents (1, 2). It should be noted that, in 2006, Massachusetts implemented health care reform requiring all residents to have a minimum level of insurance coverage. However, Massachusetts physicians in other specialties have also been found to have low levels of insurance acceptance (28). Thus, despite the ample physician supply, disparities in access to care resulting from low participation of psychiatrists in insurance markets has led to lack of parity in access to mental health care for patients with private insurance.

Massachusetts and other states are working to set state network adequacy requirements such that there are enough providers across medical specialties to serve the population enrolled. Understanding the psychiatric workforce and how to incentivize provider participation is essential to meet these requirements (29). Network adequacy rules already vary across states and insurance types; however, it may be worth taking into account the practice patterns of psychiatrists and whether psychiatrists participating in insurance networks are accepting new patients. When considering network adequacy rules, the mere presence of psychiatrists in the state or in a network does not guarantee that patients will have adequate access to specialty mental health care, particularly if these psychiatrists are not seeing significant numbers of patients through insurance.

A further barrier to care may be limitations imposed by insurance networks where the supply of psychiatrists may be further constrained for patients enrolled in a particular plan. For psychiatrists who had insurance claims in 2013, a majority had claims through group commercial insurance, an insurance with more generous reimbursement (30–33). In geographic regions outside Boston, the likelihood of a claim through noncommercial insurance was higher than in Boston. This may be the case because the availability of self-pay patients is lower in these regions or because providers have chosen to work in underserved areas where patients are covered by noncommercial plans.

Our study confirms prior findings that the population of psychiatrists in Massachusetts is approaching retirement age (24, 34–37). In this state, the number of younger psychiatrists could be insufficient to replace older psychiatrists as they retire. It is striking to note that almost half of psychiatrists have been out of medical school for at least 30 years, even though some psychiatrists have retired during this period and the following decades (23). Furthermore, we found that this cohort of psychiatrists was most likely to see patients and to bill for a high number of patients through insurance, highlighting concern for the future, as these physicians leave the workforce.

There were several limitations to our study. First, the study focused on a single state and used claims data, which, as we suggested earlier, could represent a positive outlier. Second, we could collect information only about insurance claims for each psychiatrist but did not have data about clinical encounters outside of the insurance market involving these physicians (e.g., self-pay visits). As a result, we could not determine the entire caseload for a given psychiatrist but only the caseload billed through insurance for the coverage types included in our study. The population of Massachusetts has, on average, a high level of income compared with that of other states; thus, it is possible that a greater proportion of residents in Massachusetts, compared with elsewhere, are able and willing to pay out of pocket for psychiatric services. Third, this study may overestimate care provided by preceptors working with trainees, because trainees may be billing under their preceptor’s NPI, rather than their own, when they are the service provider. We also excluded public health insurance (e.g., Medicare and Medicaid FFS) from our study because of concerns about the availability of Medicare data and the completeness of Medicaid data in the version of the APCD we used. However, we did include publicly financed insurance administered by private insurance companies (e.g., Medicaid managed care plans). Although we excluded these groups from our main analyses, we were able to examine patterns in traditional Medicare by using the CMS public use file and in Medicaid FFS from the last quarter of 2013 and found patterns similar to those of included groups (e.g., traditional Medicare appeared similar to Medicare Advantage, and Medicare FFS appeared similar to Medicaid managed care). Furthermore, the racial-ethnic composition of licensed psychiatrists was not available through our data sources. Last, our study comprised data from 2013, but policies and state mandates change over time. However, Massachusetts was an early adopter of mental health parity policies and insurance coverage expansion, so the results in 2013 could more closely approximate the current landscape compared with other states. Nevertheless, they may not be fully representative of the current landscape. Despite these limitations, our data give a snapshot of what is likely a representative description of psychiatrist participation in insurance markets across the country.

Conclusions

Most psychiatrists with active Massachusetts licenses and addresses in the state have limited participation in health insurance markets, and many may be seeing patients outside of the insurance market or may not be practicing at all. Access to psychiatrists is unevenly distributed, with very limited supply in some areas and within some types of insurance plans. These challenges are likely to worsen substantially in the next decade or two because half of licensed psychiatrists have 30 or more years of practice and may be approaching retirement.