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

Abstract

Objective:

Access to specialty mental health care may be poor because many psychiatrists do not accept health insurance reimbursement, whereas many patients rely on insurance to help pay for care. The objective of this study was to examine the extent of participation in private insurance by licensed psychiatrists.

Methods:

Using 2013 Massachusetts licensing data and the All-Payer Claims Database, a cross-sectional analysis of licensed psychiatrists in Massachusetts was undertaken. The fraction who filed insurance claims, number of unique patients with insurance claims per psychiatrist, and physician characteristics associated with insurance participation were evaluated.

Results:

In 2013, 2,348 psychiatrists were licensed in Massachusetts. Overall, 78.5% had at least one paid claim for an outpatient visit in the APCD but only 6.4% had claims for at least 300 patients/year (a full caseload). Psychiatrists had a median number of 18 patients with claims (mean = 73). Compared to those 30-39 years from medical school graduation, psychiatrists within 19 years of graduation were less likely to bill for an outpatient (Odds Ratio [OR]=0.67 for 7-19 years, 95% Confidence Interval [CI]=0.47-0.94) and less likely to have claims for 300+ patients/year (OR=0.49 for 7-19 years, CI=0.29-0.83). Participation varied across insurance types (93.3% for group commercial plans vs 32.7% for Medicaid Managed Care plans).

Conclusions:

Among Massachusetts psychiatrists, participation in the private insurance market appears to be limited. Currently, older psychiatrists are more likely to participate, and access to psychiatrists for patients seeking care using insurance could worsen as these psychiatrists retire.

Introduction

Access to specialty mental health care in the United States is poor, and the dearth of specialty mental health providers has been a longstanding 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 the generosity of insurance coverage for mental health care, but have had limited success.^5-8

Although nearly 90 percent of the national population is insured, the actual availability of specialty psychiatric care depends on how many psychiatrists accept insurance.^9-12 To the extent that 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 are decreasing over time.¹³

The sparse literature on the practice of psychiatrists is limited by reliance on physician self-reported information, which is subject to both response and selection biases. Though these studies provide some information about psychiatrist practice behavior, there are few details about insurance participation with respect to types of patients served or the number of patients with insurance they accept to help inform policy solutions. In this manuscript, we use state physician licensing data and an all-payer claims database to examine the characteristics of Massachusetts psychiatrists practicing in 2013. 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 and less insurance participation to better understand access to specialty mental health care.

Methods

Study Design

We focused on Massachusetts where we had available data on both physician supply and patient healthcare utilization. These data sources provide 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 do not rely on physician or patient recall. We chose the year 2013 to examine physician participation 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 (ERISA) plan data from the All-Payer Claims Database (APCD).^14,15

We sought to identify the actual supply of psychiatrists available to patients with different types of private health insurance and employed a four-part process involving state medical databases. We began by describing the sample of psychiatrists that could practice in the state of Massachusetts, using state licensing data from the Massachusetts Board of Registration in Medicine (BORIM) to identify psychiatrists with active licenses available to provide care. We identified the subgroup that works in the state of Massachusetts by their registered address. We collected additional details about physician business and practice information from the Centers for Medicare and Medicaid Services National Provider Identifier (NPI) dataset (e.g., registered address) when needed. Addresses were used to restrict the psychiatrist supply to only those who were more likely to be actively practicing in Massachusetts. Next, we quantified the number of patients seen and corresponding claims billed by psychiatrists to examine variation in practice patterns across the subgroup. We used the APCD, a statewide dataset that aggregates medical and pharmacy claims for both commercially and publicly insured individuals throughout Massachusetts¹⁶ to evaluate empirical information about physician behavior through paid insurance claims for care delivered. Lastly, we identified psychiatrists with a full caseload of insured patients, defined as those who had claims for at least 300 unique insured patients per year based on prior literature,¹⁷ and compared them to those with fewer patients.

Study Sample

From the Massachusetts BORIM, we identified all psychiatrists who held active medical licenses in the state throughout 2013¹⁸ to find those eligible to practice. Using BORIM, we collected physician characteristics including education and training, certification and licensure, hospital affiliation, current address, and history of disciplinary action or malpractice claims. We tested the validity of restricting our study psychiatrists to those with Massachusetts addresses by expanding the geographic area to include psychiatrists with addresses in neighboring states in sensitivity analyses (data not shown).

Using the Massachusetts APCD, we identified psychiatrists that 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 insurance; Medicare Advantage; and Medicaid Managed Care. We excluded Medicaid fee-for-service (FFS; approximately 33% of MassHealth in 2013¹⁹) from the analyses because of incomplete capture of behavioral health claims (behavioral health care was carved-out to Massachusetts Behavioral Health Plan) in the beginning of 2013. In addition, claims data for traditional FFS Medicare beneficiaries and Veterans Affairs were not available to outside researchers through the APCD.²⁰ Though we excluded FFS Medicaid and Traditional Medicare from our main analyses, we conducted secondary analyses to examine whether psychiatrists billed for patients with Traditional Medicare using the CMS Physician and Other Supplier Public Use File in 2013 and Medicaid FFS using APCD data for 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 different thresholds for participation because different levels of engagement in the insurance market have different implications for patient access to care. While a national sample of community psychiatrists indicates a mean caseload for full-time providers to be approximately 300 patients, estimates of caseloads have ranged up to 1,000 patients in some practices.¹⁷ We used 300 patients as our primary caseload threshold, but also 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 at all. We grouped the claims by the four insurance types.

Statistical Analyses

For each type of insurance, we summarized the characteristics of psychiatrists who billed that 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 (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 using Tableau Desktop 2019.3.2 or GraphPad Prism 8. The Institutional Review Board at our institution approved the study protocol.

Results

Psychiatrists in Massachusetts

There were 2,770 psychiatrists with active Massachusetts state medical licenses in 2013. Of these, 2,348 psychiatrists had addresses in Massachusetts. On average, psychiatrists working in Massachusetts had been out of medical school for 27.6 years (median 27 years, interquartile range 18-37 years). Overall, 78.5% were board certified and 51.0% had at least one hospital affiliation (Table 1). The state population was 82% white, 8% black, 7% Asian, and less than 1% Native American. Eleven percent were Hispanic.²¹

Table 1.

Characteristics of psychiatrists with an active Massachusetts medical license in 2013.

	Psychiatrists with Massachusetts addresses (N=2,348)		Psychiatrists with Massachusetts addresses and claims for at least one unique outpatient (N=1,843)		Psychiatrists with Massachusetts addresses and claims for at least 300 unique outpatients (N=151)
Characteristics	N	%	N	%	N	%
Average years since medical school graduation (years)	27.6		27.8		29.6
Years since medical school graduation
0-6 years	102	4.9	71	4.2	1	0.71
7-19 years	498	24.0	392	23.3	25	17.9
20-29 years	563	27.1	470	28.0	40	28.6
30-39 years	488	23.5	416	24.8	49	35.0
40+ years	428	20.6	331	19.7	25	17.9
Any hospital affiliation	1,198	51.0	980	53.2	72	47.7
Board certification in psychiatry	1,842	78.4	1,498	81.3	108	71.5
History of malpractice claims	87	3.7	79	4.3	16	10.6
History of disciplinary action	45	1.9	37	2.0	6	4.0
Average number of insured outpatients per provider in 2013	73.2		93.3		526.0

Notes: Addresses according to the Board of Registration of Medicine and Center for Medicare and Medicaid Services. Data are presented as column percentages except when specified. Characteristics presented represent totals for which data were available.

Insurance Market Participation

Among the 2,348 psychiatrists working in Massachusetts, 78.5% (n=1,843) had at least one claim for an outpatient in the APCD (Table 1) while 6.4% (n=151) had claims for more than 300 unique patients during the course of the year (Figure 1). The mean and median number of patients per psychiatrist in 2013 were 73 and 18 (Table 1, Figure 2). The mean number of outpatients/year was slightly higher among those with a hospital affiliation for all psychiatrists and those with 300 or more patients (72 vs 75 for all psychiatrists in Massachusetts and 501 vs 553 for those with at least 300 outpatients). The number of claims per patient paid to the psychiatrist remained relatively stable even as the number of patients per psychiatrist increased (Online Supplement).

Figure 1.

(A) Locations of individual psychiatrists by zip code with active Massachusetts medical licenses who have addresses in Massachusetts and (B) The subset of psychiatrists who billed insurance plans for a full caseload of patients (300 or more patients). Each point on the map represents the number of psychiatrists in that zip code. The larger the circle, the more psychiatrists.

Figure 2.

Distribution of unique outpatients seen by all psychiatrists who had active state licenses in 2013 with addresses in Massachusetts, depicting the percentage of psychiatrists with each range of patients. Please note the change in range of y-axis at the 1% mark.

Physician Characteristics Associated with Insurance Participation

There were no significant differences in hospital affiliation or geographic location of psychiatrist with at least one claim for an outpatient vs. none. Neither board certification nor prior malpractice claim was associated with an increased likelihood of having an outpatient claim. Psychiatrists within 19 years of medical school graduation and those 40+ years from medical school graduation, some of whom may be retired or semi-retired, were less likely to bill for at least one outpatient when compared to those 30-39 years from medical school graduation (Odds Ratio [OR]=0.67 for 7-19 years, 95% Confidence Interval [CI]=0.47-0.94; OR=0.68 for 40+ years, CI=0.48-0.98).

Similarly, psychiatrists were less likely to bill for at least 300 unique outpatients if they were 40+ years or within the first two decades from graduation relative to those 30-39 years from medical school graduation (OR=0.49 for 7-19 years, CI=0.29-0.83; OR=0.45 for 40+ years, CI=0.26-0.76). Being board certified decreased the likelihood of having claims for 300 or more outpatients (OR=0.39, CI=0.25-0.76). Psychiatrists in the Worcester vs. Boston Hospital Referral Region were more likely to have 300 or more insured outpatients (Table 2).

Table 2.

Factors associated with billing for any outpatient and billing for a full outpatient caseload (300 or more patients) through any insurance for all licensed psychiatrists with a Massachusetts practice address.

Characteristics Associated with Any Outpatient (N=1,946)	OR	95% CI		p-value
Years since medical school graduation (vs. 30-39 group)
0-6	0.43	0.26	0.73	0.002
7-19	0.67	0.47	0.94	0.022
20-29	0.92	0.65	1.30	0.624
30-39	-	-	-
40+	0.68	0.48	0.98	0.037
Any hospital affiliation	1.14	0.90	1.45	0.264
Board certification in psychiatry	1.33	0.94	1.87	0.110
Has malpractice claim	2.06	0.97	4.36	0.060
Has disciplinary action	0.88	0.40	1.96	0.759
Hospital Referral Region: (vs Boston, Massachusetts)
Springfield, Massachusetts	1.38	0.79	2.42	0.263
Worcester, Massachusetts	1.06	0.64	1.75	0.823
Characteristics Associated with Full Caseload (300 Patients, N=1,946)	OR	95% CI
Years since medical school graduation (vs. 30-39 years)
0-6	0.11	0.02	0.83	0.033
7-19	0.49	0.29	0.83	0.008
20-29	0.64	0.40	1.02	0.059
30-39	-	-	-
40+	0.45	0.26	0.76	0.003
Any hospital affiliation	0.90	0.62	1.30	0.558
Board certification in psychiatry	0.39	0.25	0.61	<0.001
Has malpractice claim	2.86	1.53	5.32	0.001
Has disciplinary action	1.68	0.67	4.23	0.272
Hospital Referral Region: (vs Boston, Massachusetts)
Springfield, Massachusetts	1.82	0.97	3.43	0.062
Worcester, Massachusetts	2.55	1.38	4.70	0.003

Notes: OR=odds ratio, CI=confidence interval

Insurance Market Distribution

Insurance participation was greater for group commercial insurance compared with public insurance programs, which tend to have lower reimbursement levels (Table S4). Specifically, among the 1,843 psychiatrists with at least one outpatient, most (93.3%) participated in group commercial insurance whereas a minority participated in the Medicare Advantage (32.4%), Marketplace Plans (33.4% for these individual commercial plans with high levels of public subsidies), and/or Medicaid Managed Care (32.7%) markets (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 30-39 years from graduation (OR=0.55 for those 0-4 years from graduation, CI=0.32-0.92; Online Supplement). Those with a hospital affiliation (OR=1.62, 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 those with any claims (Online Supplement).

By county, the ratio of psychiatrists to residents ranged from 1.0 to 5.2 per 10,000 for psychiatrists with at least one outpatient claim and ranged from 1.8 to 11.5 per 10,000 enrollees for those with at least one group commercial insurance claim and ranged 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 difficult⁸ and our findings suggest that the actual supply could be considerably lower than previously described for Americans 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 meet even conservative definitions of a full outpatient panel of patients. We found that i) 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 those who cannot afford to pay out of pocket; ii) more psychiatrists participate in commercial over public insurance as previously described,¹³ in addition, this disparity increases when looking at psychiatrists who carry full caseloads; and iii) a high proportion of psychiatrists have been in practice for several decades and 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, difficulties with access could worsen in the near future.

In Massachusetts, like across the country, the numbers of psychiatrists who accept insurance and are taking new patients is troubling, particularly for 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 not practice at all. Though Massachusetts appears to have a higher proportion of psychiatrists with some insurance participation compared to estimates of the national average (78.5% vs 55.3%),¹³ even among the population of physicians who did have an insurance claim, the average number of unique patients was small, with 50% 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 fewer than 10% of all providers, suggesting that access to outpatient psychiatry may be far more limited than previously realized. Many psychiatrists are likely working in some other capacity outside of billing insurance for outpatient care, possibly by treating patients who self-pay or pursuing non-clinical work.^23,24 It may be that these providers are not accepting new patients or that they are not 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 to other private insurance (e.g., Medicaid Managed Care).²⁶ Though the option to pay privately for mental health services might work well for psychiatrists and for some patients with 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 In some ways, 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 most states, particularly when compared to those states with lower population density, and more than double the national average of 12.9 psychiatrists per 100,000 state population.^1,2 It should be noted that, in 2006, Massachusetts implemented healthcare 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 adequate providers across medical specialties to serve the population enrolled. Understanding the psychiatric workforce and how to incentivize provider participation is essential to meet these adequacy 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 or not psychiatrists participating in insurance networks are actually 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 by insurance networks where the supply of psychiatrists may be further constrained for patients enrolled in a particular plan. For those psychiatrists who had insurance claims in 2013, the majority had claims through group commercial insurance, an insurance with more generous reimbursement.^30-32 In geographic regions outside Boston, the likelihood of a claim through a non-commercial insurance was higher than in Boston. This may be because the availability of self-pay patients is lower in these regions or providers have chosen to work in underserved areas where patients are covered by non-commercial plans.

Our study confirms prior studies that the population of psychiatrists in Massachusetts is approaching retirement age.^24,33-36 In this state, the replacement rate 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 thirty years despite the fact that some psychiatrists retire during this and the following decades of life.²³ Furthermore, we found that this cohort of psychiatrists were most likely to see patients, and bill for a high number of patients through insurance, highlighting concern for the future as these physicians leave the workforce.

There are several limitations to our study. First, this is a study from a single state using claims data, which as we suggest earlier could represent a positive outlier. Second, we could only collect information about insurance claims for each psychiatrist, but did not have data about other clinical encounters being performed by these physicians outside of the insurance market (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 in 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 as compared to elsewhere are able and willing to pay out of pocket for psychiatry services. Third, preceptors working with trainees may be overrepresented in this sample as providing more care than they actually did, because trainees may not be billing under their own NPI when they are the service provider, but rather that of their preceptor. We also excluded public health insurance (e.g., Medicare and Medicaid fee-for-service) from our study because of Medicare data availability and Medicaid data completeness concerns with the version of the APCD, though we did include publicly financed insurance administered by private insurance companies (e.g., Medicaid Managed Care plans). Though we excluded these groups from our main analyses, we were able to examine patterns in Traditional Medicare (TM) using the CMS public use file and Medicaid fee-for-service (FFS) from the last quarter of 2013 and found similar patterns to included groups (e.g., TM appeared similar to Medicare Advantage and Medicare FFS to Medicaid Managed Care). Further, the race/ethnic composition of licensed psychiatrists was not available through our data sources. Lastly, our study comprises 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 to other states. Nevertheless, they may not be fully representative of the current landscape. Despite all 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 not practicing at all. Access to psychiatrists is unevenly distributed across areas and insurance types with very limited supply in some areas and within some types of insurance plans. Finally, these challenges are likely to worsen substantially in the next decade or two because half of licensed psychiatrists have thirty or more years of practice and may be approaching retirement.

Highlights:

• Most psychiatrists have limited participation in the Massachusetts private insurance market, billing for only a few insured patients per year.

• Fewer than 10 percent of psychiatrists provide care reimbursed through insurance for 300+ patients per year, a conservative annual caseload estimate for a full-time psychiatrist.

• Even in states where the number of licensed psychiatrists who accept insurance is relatively high, access to psychiatrists for individuals relying on insurance coverage could be constrained as many psychiatrists have limited participation in the insurance market.