To the Editor:
Mental health disorders are common, affecting nearly 1 in 4 adults annually.
1
Unfortunately, less than a third will receive services within a year.2
Inadequate treatment results in individual and family suffering, lost productivity, and death: suicide, the third leading cause of death among individuals aged 10 to 24 years, is associated with inadequate care.As Massachusetts clinicians caring for patients with mental illness, we experience frequent difficulties obtaining psychiatric care for our patients. But how bad are things, really? To find out, we conducted a “simulated patient” study, with the approval of the Cambridge Health Alliance institutional review board.
Study personnel posed as patients insured by Blue Cross Blue Shield of Massachusetts Preferred Provider Organization, the largest insurer in Massachusetts. We called every in-network mental health facility within a 10-mile radius of downtown Boston, claiming that we had been evaluated in an emergency department (ED) for depression and discharged with instructions to obtain a psychiatric appointment within 2 weeks. If necessary, we left a message and made a second call attempt.
Eight (12.5%) of the 64 sites offered appointments, 4 (6.2%) within 2 weeks (Table). The 2 principal reasons we could not schedule an appointment were that our calls were not returned or that the facility required patients to have an in-system primary care provider. Six sites stated that they needed more information before scheduling an appointment. Assuming these 6 sites would have offered timely appointments, our highest estimate of available appointments within the 2-week period is 10 of 64 facilities (15.6%).
TableProvider response to a request for an outpatient psychiatric appointment for depression.
| Response | Number of BCBS-PPO Providers (%), N=64 |
|---|---|
| Appointment granted within 2 weeks | 4 (6.3) |
| Appointment granted after 2 weeks | 4 (6.3) |
| No appointment granted without a PCP within their system | 15 (23.4) |
| No return call despite leaving 2 messages | 15 (23.4) |
| No psychiatrist available/cutbacks | 8 (12.5) |
| Youth/specialty services only | 6 (9.4) |
| Required more or specific information | 6 (9.4) |
| Didn't accept insurance | 1 (1.6) |
| Only group treatment offered | 1 (1.6) |
| No reason given | 4 (7.1) |
BCBS-PPO, Blue Cross Blue Shield-Preferred Provider Organization; PCP, primary care provider.
This result confirms our suspicion that even for patients with private insurance, mental health services in the Boston area are severely limited, which is in line with national data showing limited availability; for example, two thirds of primary care physicians report that they cannot obtain outpatient mental health services for patients who need them.
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Our inadequate mental health system has widespread social effects. A third of the homeless and more than half of all prison and jail inmates have mental illness.
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The nation's EDs are de facto psychiatric wards, with 79% of emergency physicians reporting that their hospitals board psychiatric patients for whom appropriate treatment resources could not be found, sometimes for days.4
Although there are many contributors to the inadequacy of our mental health system, managed care has hit psychiatric services hard. Private insurers aggressively constrain patients' access to services by stringently limiting provider networks. As our study shows, this is often covert; insurers provide lists of in-network providers, but most are unavailable. Reimbursements for psychiatric services are far lower than for other types of care, so institutions frequently restrict access as stringently as possible, often, as in our study, by requiring that a patient have an in-system primary care provider (even though the insurer requires no referral). Many private practitioners refuse to accept insurance payments altogether. Improved reimbursements for psychiatric care will be an important step in reducing the barriers to care experienced by patients with severe depression.
References
- The numbers count: mental disorders in America.(Accessed October 8, 2010)
- Prevalence and treatment of mental disorders, 1990 to 2003.N Engl J Med. 2005; 352: 2515-2523
- Beyond parity: primary care physicians' perspectives on access to mental health care.Health Aff (Millwood). 2009; 28: w490-w501
- ACEP Psychiatric and Substance Abuse Survey 2008. American College of Emergency Physicians, Irving, TX2008 (Accessed September 26, 2010)
Article info
Footnotes
Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The authors have stated that no such relationships exist.
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© 2011 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.
