Having health insurance doesn't mean mental health care access. Insurance companies make certain of that.

Insurers often maintain minimal lists of in-network providers, loaded with meaningless names and numbers.
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By J. Wesley Boyd, associate professor, Harvard Medical School, and staff psychiatrist, Cambridge Health Alliance

Most well-insured individuals assume that, if they ever need psychiatric care, they will be able to get it.

They are wrong.

The reason that they are wrong is that insurance companies are in the business of making money, and they make money when the folks they “insure” don’t actually receive care. Although this is the basic business model of insurers, they can’t be too obvious about that fact. And so, insurers seemingly employ subtle ways to make it more difficult than is necessary for folks to receive care when it is needed.

I am a psychiatrist at a public hospital that treats a multiethnic, diverse patient population, and for years I have seen firsthand the way these tactics are utilized by insurers.

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One way that insurance companies make it difficult to obtain mental health care is to require clinicians to obtain prior authorizations before patients can be admitted to inpatient psychiatric facilities. Several years ago, my colleagues and I conducted a small study and found that clinicians spent an average of 38 minutes on the phone with insurers obtaining authorization to admit someone to the hospital, even after the clinicians had deemed these individuals dangerous enough to either themselves or someone else that a psychiatric hospitalization was needed. A follow-up study with a larger sample found clinicians spending an hour on the phone for each authorization.

Given that these requests are essentially all approved if the clinician spends the time, insurance companies obviously hope that the sheer time-consuming hassle of having to make the call will dissuade clinicians from seeking to admit folks to psychiatric facilities.

It is important to note that psychiatric care is singled out for this kind of profiteering and scrutiny. By comparison, if a woman is in labor, her obstetrician does not have to spend time on the phone getting permission to admit her. If a child needs an emergency appendectomy, the pediatrician or surgeon is not required to call the parent’s insurance company.

Accessing outpatient psychiatric care isn’t much easier, even if it doesn’t require preauthorization. Insurers often maintain minimal lists of in-network providers, effectively punishing patients who choose to see a provider who is not in their network by making them pay more out-of-pocket (if the insurance company covers any of the cost at all). And the lists of in-network providers that insurers do maintain are often loaded with meaningless names and numbers.

I have to date conducted three different studies looking at availability of three different kinds of outpatient psychiatric services: clinics; adult psychiatrists; and pediatric mental health care. In each of these studies my co-authors and I used the Blue Cross Blue Shield database and posed as patients — or as the parent of a child — and called either clinics or individual providers seeking appointments. Although we were using a list of supposedly in-network providers, we were scarcely able to obtain appointments.

When we called Boston-area clinics, we were able to secure appointments only 12 percent of the time, even when we told them we had BCBS insurance. When we called adult psychiatrists, we could only obtain appointments only 26 percent of the time. For pediatric appointments, our success rate was even lower. Over and over in these studies we would simply not receive calls back, even though we left two separate messages approximately a week apart asking for calls back. Additionally, many phone numbers in the databases provided by BCBS were simply wrong (and included a McDonald’s restaurant and a jewelry store) and many of the practices we called were full and not accepting new patients.

I used to think the inadequacy of the BCBS database of providers was unintentional. But given how chronic the problem is — even in the face of scrutiny by state attorneys general and others — I now feel otherwise. After all, if a person who seeks mental health care is unable to access it, the insurance company pockets money that would otherwise go pay for its customers’ treatment.

Since I first started researching these issues, publishing our results and getting the attention of regulators, insurance companies have begun to send out letters to providers on their in-network lists asking them to update their contact and practice information; I have received a number of these requests myself. One insurer asks providers to go to a website and check all of their practice locations for accuracy and says that if all of the information is accurate, no further action is required. Another insurer sends a letter with the provider’s information printed on it and says that if one doesn’t respond within 45 days the insurer “will assume that your contact and practice information listed below is correct.”

The obvious problem with either such method of supposed due diligence is that the insurance companies have no way of knowing if their letters are delivered to the intended providers and, even if they are, whether they are ever opened. Additionally, there are no penalties for providers who fail to update their information — and I do not know of any physician who has been kicked off an insurance panel because he or she did not verify the accuracy of their information.

In conclusion, given their profit motive, accessing mental health care when it is needed — whether inpatient or outpatient — will remain difficult at best as long as insurers are in the mix. Implementing a not-for-profit single payer health care system would, I wager, improve access to mental health care and allow those who need mental health care to actually receive it.