Getting psychiatric care in the United States is a lot harder than it should be. Patients around the country are having a hard time booking appointments for outpatient care, and face significant hurdles when it comes to receiving inpatient psychiatric care. Why is this the case?
This largely because there just aren’t enough psychiatrists to meet demand. This is even more true for child and adolescent psychiatrists.
First, few medical students choose to enter psychiatry. This is partly because many medical students implicitly or explicitly get the message from classmates, teachers and the general public that psychiatry is not “real” medicine.
In medical school students are usually exposed to inpatient psychiatry instead of outpatient psychiatry, despite the fact that practicing psychiatrists overwhelmingly work in outpatient settings. And many students simply don’t find inpatient psychiatry appealing. Not surprisingly, exposure to outpatient psychiatry in medical school is correlated with far greater numbers of medical students choosing to go into the field.
Wrestling With Insurance Companies
To compound matters, psychiatrists are paid less than other doctors. This is partly because mental health is often carved out of general medical coverage and then managed under a different set of rules, often by an aggressive for-profit company. Profits increase when patients can’t actually use mental health services promised to them by their insurance plan.
Health insurance companies also make it as hard as possible for patients to access needed care. Even if these services are covered under their insurance plans, patients and doctors still face hurdles in arranging for mental health services.
One way of doing this is to require something called prior authorization. For instance, before a patient can be admitted to an inpatient facility for treatment, even when the case is urgent, the clinician must receive prior authorization from an insurer.
Last year colleagues and I published a study and found that clinicians spent an average of 38 minutes on the phone with insurers obtaining authorization for payment. And this is after clinicians deem a patient to be in need of admission to an inpatient facility, usually because of suicidal thoughts or plans. In our study, only one request out of 53 was actually denied, which clearly illustrates that these calls are an unnecessary hurdle for patients who need urgent access to inpatient care.
Thus, the prior authorization requirement was likely put in place to discourage clinicians from admitting patients. As such, it amounts to rationing health care by making it a hassle to access needed services.
And only psychiatric patients are singled out for this scrutiny — not women in labor, not children with asthma attacks, not anyone who needs an emergency appendectomy. But, a patient with suicidal thoughts who needs inpatient care urgently, must have it approved before they can even be admitted. Until prior authorization is obtained, there is no guarantee that any inpatient hospitalization is going to be covered any the insurance company. This fact is not lost on medical students considering their futures. Medical students are avoiding psychiatry in part because of the amount of wrangling they may need to do in order to get their patients the care they need.
