"My colleagues and I were hearing a lot of stories from patients who wanted mental health care but were unable to find a psychiatrist willing to take their insurance, so we decided to look into the problem," explains Tara Bishop, MD, an assistant professor of public health and an assistant attending physician at New York-Presbyterian Hospital/Weill Cornell Medical Center.

Mental Health Care and Health Insurance

Bishop and fellow researchers at Weill Cornell Medical College in New York surveyed a large group of psychiatrists from 2005-2010 and found—to their surprise—that the complaints were true: a majority of psychiatrists refused to accept Medicare, Medicaid and even private insurance. They also found:

  • The percentage of psychiatrists who take private insurance dropped by 17 percent—just 55 percent were willing to accept private insurance. Most simply prefer cash.
  • Medicare acceptance rates declined by almost 20 percent and those taking Medicaid was just 43 percent—the lowest among all medical specialties.

The findings were hard to believe at first. "We figured there was a problem but I practice in New York and it shocked me that this seems to be a national problem—not just a New York City problem," Bishops says.

Weill Cornell investigators worked with researchers from Columbia University and the University of California, San Francisco and used a nationally representative sample of psychiatrists (MDs and DOs—doctors of osteopathic medicine). The data collected did not include MSWs or psychologists. It also did not cover the population of patients seen in psychiatric outpatient clinics linked to hospitals or large medical centers where—according to the Centers for Disease Control and Prevention (CDC)—many acute psychiatric emergencies are handled.

Why Isn't Insurance Accepted?

Although Bishop says the researchers were not able to go into the details of why these doctors aren't accepting insurance she speculates that psychiatry is a more burdensome field than other specialties. Here, she discusses a few possibilities:

Longer office visits. "Psychiatric care takes considerable time—typically an hour or so—to provide counseling and therapy," Bishop says explaining that many psychiatrists are also sole practitioners. "Psychiatrists may not be able to see as many patients in a day as physicians of other specialties."

Longer treatment periods. Mental health care can also be long and hard to define due to so many individual factors. "Often there is no clear cut beginning and end of treatment compared to say treating an ear infection or pneumonia, for example. That may also be a factor for doctors and insurance companies," she says.

Lower rates of insurance. "More than physicians in other specialties, psychiatrists accept lower rates of insurance and those who don't take insurance are likely charging cash for their services," says Bishop. "If you can sustain a practice without the paperwork and time spent on the phone with insurance companies than why would you be motivated to start taking insurance?"

A Shortage of Doctors

Complicating the problem further is that the number of psychiatrists is also dwindling. Researchers saw a drop of 14 percent from 2000 to 2008 because many are retiring and medical students are not opting to pursue psychiatry.  

Although general care doctors can help with issues of depression and anxiety, the growth of the population and need for services will increase. The CDC estimates that a quarter of adults in the U.S. report having a mental illness at any given time and about half of adults will suffer from one in their lifetime.

"We don't have a work force that can keep up and I worry these factors may lead us to a perfect storm of untreated mental health issues nationwide," Bishop adds.

The Future of Mental Health Care

Researchers believe incentives may need to be offered to medical students to pursue psychiatry and pressure may need to be put on insurance companies so that payments to practicing psychiatrists are increased.

"The argument I've heard is that reimbursement is the problem," Bishop says. "We need to think carefully about the administrative hassle of dealing with insurance companies and address why the burden is so much more overwhelming in psychiatry compared to other specialties."

In addition, it may be time to think about treating mentally ill people from many different angles. "There may be a team-based approach incorporating RNs, social workers and other medical personnel that could be put in place to provide better care so that those who need help get it," says the researcher.

No prior studies have documented such striking differences in insurance acceptance rates by psychiatrists and physicians of other specialties—primarily because no one has looked closely at the issue, says Bishop. She plans to delve deeper into the issues her study raises. "I intend to interview psychiatrists to understand why they are not accepting insurance and what can be done to change their minds."

Tara Bishop, MD, reviewed this article.

Tara Bishop, MD. Phone interview 9 January, 2014. http://www.weillcornell.org/physician/tfbishop/

The Centers for Disease Control and Prevention. "Emergency room visits by patients with mental health disorders-North Carolina, 2008-2010," Web. Accessed 28 January 2014. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6223a4.htm

60 Minutes. "Nowhere To Go: Mentally Ill Youth In Crisis," Television. Aired 26 January 2014. http://www.cbsnews.com/news/mentally-ill-youth-in-crisis/