Need to see a psychiatrist? Call your insurance company first

21 November 2014, 9.24pm AEDT

Need to see a psychiatrist? Call your insurance company first

Author

1. 

   Tara F Bishop

   Assistant Professor of Healthcare Policy and Research, Assistant Professor of Medicine at Cornell University

Disclosure Statement

Tara F Bishop receives funding from the National Institute on Aging, the Commonwealth Fund, the Robert Wood Johnson Foundation, and the Physician's Foundation.

The Conversation is funded by CSIRO, Melbourne, Monash, RMIT, UTS, UWA, ACU, ANU, ASB, Baker IDI, Canberra, CDU, Curtin, Deakin, Flinders, Griffith, the Harry Perkins Institute, JCU, La Trobe, Massey, Murdoch, Newcastle, UQ, QUT, SAHMRI, Swinburne, Sydney, UNDA, UNE, UniSA, USC, USQ, UTAS, UWS, VU and Wollongong.

 

Not everyone can pay out of pocket. Stock image of counseling session via Monkey Business Images/Shutterstock

Last week, a patient contacted me to find a psychiatrist because his anxiety was beginning to get out of control. He wanted to see someone who could do therapy and prescribe medications if he needed them. I gave him some names but warned him that none of them took insurance. If he wanted to find a psychiatrist that took his insurance, he’d need to call his insurance company to find one.

And this situation is not uncommon in my primary care practice. I can treat simple psychiatric conditions like depression and anxiety but, like many internists, I do not have the training to provide therapy or treat more severe psychiatric conditions. If a patients needs psychiatric care, the best I can do is to offer them some recommendations and tell them to contact their insurance company. As you can imagine, this poses a barrier for patients trying to access the psychiatric care they need.

Half of psychiatrists do not take insurance

This motivated me to study psychiatrists and insurance. Last year, a team of researchers and I published a study using data from a national survey of doctors examining this issue.

We found that almost half of psychiatrists take don’t take health insurance – whether it’s private health insurance, Medicare (insurance for the elderly), or Medicaid (insurance for the poor).

Specifically, we found that in 2009 to 2010, only 55% of psychiatrists took private health insurance, 55% took Medicare and 43% took Medicaid. This presents a significant barrier for patients who need to see psychiatrists.

It’s important to emphasize that this was a sharp contrast to every other type of doctor. For example, 94% of cardiologists took private health insurance during that same time period and 95% of general internists took Medicare. When pooled together, 88% of physicians all specialties other than psychiatry took private health insurance and 86% took Medicare. Acceptance rates for Medicaid were low overall because reimbursement rates are low. Nevertheless, psychiatrists had some of the lowest Medicaid acceptance rates of all specialties.

The results shocked us and when our study was published last year, we learned that the results also shocked the general public.

Doctors, patients and reporters corroborated our findings. I started to hear more and more stories of patients who struggled to find a psychiatrist who took their insurance.

Less money for more work

So why is this the case? First, low reimbursement may be a problem. Medicare pays US$130 to US$140 for a new visit to a psychiatrist. Although that rate is not much different from a visit to a primary care doctor, visits to psychiatrists may be longer because they involve counseling and therapy.

Second, a shortage of psychiatrists may also be factor. From 2000 to 2008, 14% fewer medical students chose to pursue careers in psychiatry and 55% of psychiatrists are over 55 and close to retirement age. As a result, many psychiatrists may have so much demand for their services that they do not need to accept insurance.

Finally, psychiatrists may not have or need the administrative capacity that other doctors need. A psychiatrist may be able to function without a lot of staff like nurses, medical assistants, and administrative assistants. Because of this some psychiatrists may not be motivated to hire that staff just to interact with insurance companies.

Possible solutions

Since the time of our study, our team has been developing ways to further study the problem but also to explore solutions.

One obvious step is to increase reimbursement for mental health-care. But such changes can be difficult. Medicare relies on a review panel of physicians to change reimbursement and it is unclear whether that panel will suggest increased reimbursement for psychiatrists.

But there are other promising options that make it easier for patients to access mental health care. For example, the New York City Department of Health and Mental Hygiene runs a program called Lifenet which patients can call to find a psychiatrist or other mental health provider in New York City who takes their insurance.

Another very effective program, called Impact, was developed by faculty at the University of Washington and helps primary care physicians treat depression. A nurse, social worker or psychologist works closely with patients in the primary care doctor’s office and has a designated psychiatrist to help with patients who are not improving.

These are good starts but much more needs to be done in order to ensure access to psychiatrists across the board. For now, I have told my patient that he will probably have to pay for his psychiatric care even though he has insurance or will have to find someone who takes his insurance without my help.

Hopefully in the future, we will have more options for him.

http://theconversation.com/need-to-see-a-psychiatrist-call-your-insurance-company-first-33874

Challenges For People With Disabilities Within The Health Care Safety Net

Challenges For People With Disabilities Within The Health Care Safety Net

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November 18th, 2014

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  by Michael Ulrich

  Michael Ulrich

  View Biographical Info

   

Editor’s note: This post is part of a series of several posts stemming from presentations given at “The Law of Medicare and Medicaid at Fifty,” a conference held at Yale Law School on November 6 and 7

Medicare and Medicaid were passed to serve as safety nets for the country’s most vulnerable populations, a point that has been reemphasized by the expansion of the populations they serve, especially with regards to Medicaid.  Yet, even after 50 years, the disabled population continues to be one whose health care needs are not being met.  This community is all too frequently left to suffer health disparities due to cultural incompetency, stigma and misunderstanding, and an inability to create policy changes that cover the population as a whole and their acute and long-term needs.

Nearly 57 million Americans had disabilities in 2010, and this number is likely to grow due to an aging population, advances in technology, and negative health trends such as obesity.  While the diversity of the group’s demographics and health issues can make it difficult to define “disabled,” how it is defined in policy can have significant implications for benefits, as well as stigma.  For example, the Social Security Administration narrowly defines disability as “the inability to engage in substantial gainful activity due to a medically determinable physical or mental impairment,” which disregards those who work in spite of their disabilities.  Meanwhile, the Americans with Disabilities Act (ADA) defines disability as “a physical or mental impairment that substantially limits one or more major life activities,” focusing on the condition rather than what a person can and cannot do.

The disparities for the disabled community are abundant: In comparison to nondisabled Americans, those with disabilities are more likely to be unemployed, impoverished, have less than a high school education, and have higher levels of risk factors such as obesity, smoking, and being physically inactive.  Moreover, disability prevalence is higher in minority groups such as blacks, American Indians, and Alaska Natives. However, the vulnerability of the disabled population does not stem simply from having a disability; more importantly, like other vulnerable populations, they are not well integrated into the health care system because of certain characteristics.  It is this inability to integrate the disabled into the health care system, and in turn society at large, that must be a focus of policymaking, including the Medicare and Medicaid programs, moving forward.

The Affordable Care Act (ACA) has taken steps that should help, such as expanding coverage, but disparities arise from health status and access to care as well.  To illustrate, one study looked at disparities between the disabled and nondisabled within Medicare to minimize the effect of coverage.  Nearly 50 percent of the disabled population reported putting off or not seeking care due to cost concerns, and they were more likely to have negative consequences as compared to nondisabled Medicare beneficiaries who delayed care due to costs.  Furthermore, disabled beneficiaries were three times as likely to have difficulties finding a doctor who accepted Medicare than nondisabled, and for the lucky that did 15 percent had difficulties finding doctors who actually understood their disability or how to treat it — not to mention obstacles arising from inadequate equipment and facilities, and insufficient communication, which is critical to patients’ rights of informed consent and bodily integrity.

The ACA contains provisions aimed at tackling some of these barriers to care, including standards for accessible medical diagnostic equipment, and developing trainings to provide culturally competent care to the disabled.  Proper training is critical as many of the health disparities that the disabled suffer are due to the fact that the health care system is not designed to care for this population effectively. The disabled suffer from others’ belief that they lack the ability to achieve high-functioning lifestyles, which is illustrated by the fact that health care staff rarely, if ever, emphasize health promotion.

This is not to insinuate that the issue of coverage, or coverage of the needs of the disabled, has been rectified.  A combination of states’ right to implement eligibility criteria, Medicaid being a target for budget cuts, and the disabled costing more than any other group has left many in the disabled community without much needed coverage.  The ACA originally expanded Medicaid to anyone at 133 percent of the federal poverty line (FPL), but the Supreme Court made this optional.  With 23 states still not moving forward on expansion, there is a need for advocacy and persuasion to try to limit the force of partisan politics.  While other safety net features are available, Medicaid can offer assistance to the disabled through long-term care as well as standard necessities.  Medicare on the other hand requires nonelderly disabled individuals receive SSDI benefits for at least 24 months — they must be unable to engage in gainful activity for at least 12 months to qualify for SSDI — and long-term institutional or community-based services are uncovered.

This perverse incentive to avoid work, or punish those that do work, is an issue the disabled community faces all too often.  Expanding employment options for the disabled is important not only monetarily, but also to enhance their ability to live independently and interact with their social environment.  Too often they are cut off from large parts of society, which undoubtedly lead to their higher rates of depression and mental illnesses.  The Community Living Assistance Services and Supports (CLASS) Act aimed to help alleviate some of the concerns over long-term care, but it was ultimately deemed unsustainable.  Nevertheless, with the disabled population growing, leaving their long-term medical needs to linger until they become more costly is not an economically efficient solution.

The safety net that Medicare and Medicaid aimed to create 50 years ago is still filled with far too many gaps when it comes to the disabled.  The ACA has taken some important steps, but more needs to be done to ensure the health care system, including Medicare and Medicaid, reduces its barriers to health.  Coupling policy changes with better information and training should also contribute to a much needed normative change, so that we no longer perceive those with disabilities as having something wrong with them or being unable to function “normally.”  It is essential that as a country we recognize that health disparities for the disabled are associated less with their disability and more with our inability to structure the societal and health care framework to allow them to function optimally.

http://healthaffairs.org/blog/2014/11/18/challenges-for-people-with-disabilities-within-the-health-care-safety-net/