Blue Cross Blue Shield of Massachusetts is trying to entice more child psychiatrists to join its network, offering a 50 percent boost in pay in the hope of toppling a key barrier to mental health care in the state.
The majority of child psychiatrists in Massachusetts do not accept health insurance because of low reimbursement rates, forcing parents to pay out of pocket or wait weeks to months for an appointment.
Announced Thursday, the pay raise for child psychiatrists is among several changes by Massachusetts’ largest health insurer that are intended to address a longstanding defect in the state’s health care system: Despite near-universal insurance coverage and, compared to other states, an ample supply of psychiatrists, people in Massachusetts often cannot get mental health care when they need it.
“We recognize the health care system too often places a low priority on mental health care and care for people with addiction issues,” said Andrew Dreyfus, Blue Cross president and CEO. “This is a strong statement about our commitment to mental health care in Massachusetts.
Among an estimated 400 child psychiatrists in the state, only 140 have enrolled in Blue Cross’s provider network, Dreyfus said. With the 50 percent reimbursement increase, Blue Cross’s payments are “very close” to the roughly $350 hourly rates that psychiatrists charge private pay patients, he said.
Blue Cross, which has 2.8 million members, started working on the plan before COVID-19 struck, but the insurer has seen an increase in demand for mental health services amid evidence that more people are suffering from anxiety and depression as the pandemic drags on.
The Blue Cross initiatives include a pledge to continue paying for mental health visits by video chat or telephone at the same rate as in-person visits; this extends indefinitely an emergency telehealth policy adopted in response to the pandemic. Other measures will expand access to two other forms of online care and provide financial incentives for primary care physicians to integrate mental health care into their practices.
“I don’t want to pretend that these five new initiatives will cure all the problems facing our mental health system,” Dreyfus said. “But it’s a very exciting start.” The insurer currently spends about $800 million a year on mental health services, and estimates that the new programs might cost an additional $20 million in the next year.
Advocates for mentally ill people greeted the changes with a mixture of enthusiasm and skepticism.
“While I applaud BCBSMA for taking these steps, only time will tell if it will actually make a difference in the number of child psychiatrists who will take private insurance,” Karen Gromis, deputy director of the National Alliance on Mental Illness Massachusetts, said in an email to the Globe.
“We are going to take a wait and see attitude toward these worthy initiatives,” Gromis added. “Will they be enough? Why did it take a pandemic for BCBSMA to realize the value of telehealth where there is a dearth of clinicians? There remain a lot of questions.”
Lisa Lambert, executive director of the Parent/Professional Advocacy League, a Massachusetts nonprofit advocating for children with mental illness, reacted enthusiastically to the plans.
“This is fabulous. This is overdue. A lot of times children with mental health issues are not the first priority even though they’re growing and growing in numbers,” she said. “This is responsive to all of that.”
Lambert said that families often wait six to eight weeks for an appointment with a child psychiatrist, and then may have to drive an hour to get there.
Other health insurers “are doing many of the same things,” said Lora Pellegrini, president and CEO of the Massachusetts Association of Health Plans, which represents 17 health insurers but not Blue Cross. “It’s important as an industry that we continue to focus on mental health.”
Sarah Chiaramida, the association’s senior vice president of health policy, said that many plans are increasing rates for child psychiatrists, although apparently not as steeply as Blue Cross.
A 2018 survey found that half of Massachusetts residents who sought treatment for mental illness or addiction could not get an appointment with a clinician, because providers either didn’t have slots available or didn’t accept their insurance.
The problem is especially acute for children — even though Massachusetts has a higher concentration of practicing child psychiatrists than anywhere in the country except for Rhode Island and Washington, D.C.
Dr. Ken Duckworth, Blue Cross’s senior medical director for behavioral health, said he discussed the new rates with a focus group of child psychiatrists, and their reaction gives him hope that Blue Cross can draw an additional 25 or 30 into its network. He said Blue Cross already has eliminated the paperwork that providers find burdensome; in mental health care, Blue Cross requires no prior authorizations or reviews of the need to continue care.
In exchange for the higher pay, the psychiatrists must agree to maintain some appointment availability for Blue Cross members and attest that they are measuring their patients’ progress.
“A 50 percent bump — that’s a pretty generous increase,” said Dr. Don Condie, past president of the New England Council of Child and Adolescent Psychiatry, who was part of the focus group even though he already accepts Blue Cross coverage. “Whether or not it will be enough to attract enough people is an open question.”
Child psychiatrists face especially tough financial challenges because of the unique demands of their work, Condie said. Insurers reimburse only for face-to-face sessions with clients, but to truly understand the child’s needs, psychiatrists must also talk with school counselors, teachers, principals, parents, grandparents, babysitters and more. “Those services have never been paid for by insurance,” Condie said.
Newly minted child psychiatrists, typically facing high medical school debts, often find it easier and more lucrative to simply hang out a shingle and collect payments from patients, rather than tangle with insurance companies, he said.
Dr. Mary Ahn, who directs child and adolescent psychiatry residency training at the University of Massachusetts Medical School, said the Blue Cross pay bump will likely be enough to persuade some people opening new practices to join the Blue Cross network.
The average annual income for Massachusetts psychiatrists in group practice was $211,126 in 2019, according to a survey by the Medical Group Management Association. A separate survey the same year by another organization — Doximity, a network of medical professionals — found that psychiatrists in Massachusetts made an average of $279,165 annually. (In comparison, Doximity found that ophthalmologists made $646,249 and endocrinologists $220,832.) Neither organization had data specific to child psychiatrists.
Another key aspect of Blue Cross’s plans is paying for telehealth, which abruptly became a mainstay of mental health care when the pandemic hit. Before the pandemic, Blue Cross received 200 telemedicine claims a day. By May, the insurer was getting 40,000 a day — half for mental health care.
All insurers switched to paying the same rates for telehealth as for in-person care, including for phone calls, for the duration of the emergency. The Legislature is considering a bill that would require such payments indefinitely for mental health services. Insurers are not opposing the bill, but Blue Cross is the first to announce its payments for telehealth in mental health care will continue regardless of what the Legislature does.
Duckworth, the medical director, said that clinicians were surprised by how well telehealth worked out, for both patients and therapists.
In a survey by the Massachusetts Psychiatric Society conducted March through early June, two-thirds of psychiatrists said that telehealth had reduced no-show rates. Eighty-seven percent reported being satisfied with telehealth and 84 percent said their patients liked it too.
“There are a lot of people working out of their basements who never thought six months ago that would be something they would do,” Duckworth said. “It’s not perfect, but I think it’s a transformation in the delivery of care.”
While some patients still would prefer to see their therapist in person, that’s not going to happen until the risk of coronavirus transmission is eliminated, Duckworth said. Meanwhile, patients appreciate the convenience and studies show that remote care is effective, he said.
But Gormis, of NAMI, had a few words of caution. “Telehealth isn’t the be all and end all in therapy,” she said in her email. " It is important in rural areas, but it sometimes leaves the clinician unsure of how their client is really doing as you don’t get all the body language clues you would in face to face therapy and not at all if you are on the phone only.”
Additionally, the pay for licensed clinical social workers is already too low, Gormis said, “so reimbursing telehealth services at the same rate as in person visits probably isn’t enough.”
In another aspect of its plan, Blue Cross plans to provide financial incentives for primary care doctors to make mental health part of their practices. Doctors will be encouraged to embed a mental health clinician, such as a social worker, in their offices, and to develop relationships with consulting psychiatrists who will advise them on prescribing psychiatric medications.
And finally, two different online programs are expanding. WellConnection, a telehealth program that connects patients with doctors around the country who hold licenses in multiple states, will now also offer psychiatric care to Blue Cross members.
And an online program for people who don’t want to see a therapist but need help with mild to moderate depression and anxiety will now be made available free of charge to all Blue Cross members. Previously, the employer had to pay extra to include this benefit. The program, called Learn to Live, employs the methods of cognitive behavioral therapy to lead a person to better ways of coping with stress and sadness, through videos, exercises, and occasional support from a live, unlicensed “coach.”
The Blue Cross provider network includes 15,000 mental health clinicians, an increase of 2,000 over the past three years.
In February, Blue Cross was among five insurers that reached a settlement with Attorney General Maura Healey over allegations that they violated state laws requiring the same coverage for mental and physical health care. In Blue Cross’s case, the only issue was its provider directory, which Healey said was not kept up to date. Since then, Blue Cross has added staff to monitor the directory’s accuracy and made it easier for clinicians to update their profiles, among other measures, according to spokeswoman Amy McHugh.