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Long list of reasons ERs are overflowing with behavioral health patients


It’s painfully difficult to access psychiatric care

Re “ERs swamped by behavioral health patients” by Jessica Bartlett (Page A1, June 8): Long before COVID-19, psychiatric care was difficult to access for a mixture of reasons.

First, mental health needs far exceed the number of qualified clinicians. Second, insurance payments for mental health care are so low that many outpatient clinicians accept only cash and hospitals limit the number of psychiatric beds because when they provide mental health care, they generally do so at a loss.

For those people who want to use health insurance, their insurers make it as difficult as possible to access care.

One thing insurance companies do is require time-consuming prior authorizations for psychiatric admissions — a requirement that is almost entirely unique to psychiatry — in hopes that clinicians will be discouraged from trying to facilitate access to those services. In a study several years ago, my colleagues and I found that clinicians at Hasbro Children’s Hospital in Providence spent an average of 60 minutes on the phone with insurance representatives in order to hospitalize depressed and suicidal patients.

Another way insurers make it difficult to access care is by not maintaining accurate lists of providers who are in their network and accepting new patients. I’ve conducted a handful of “secret shopper” studies in which Harvard colleagues and I found numerous wrong numbers and full practices in insurance databases as well as practitioners who simply never returned phone calls.


Is it any wonder that our emergency departments are literally overflowing with patients awaiting hospital beds? Add the pain, suffering, and isolation brought on by the pandemic, and the painful fact is that an already-broken system has become all but inaccessible for many.

Dr. J. Wesley Boyd

Bellaire, Texas

The writer is a lecturer (part time) in the department of global health and social medicine at Harvard Medical School and a professor of psychiatry and medical ethics at Baylor College of Medicine.


State should recognize key role physician assistants play

The behavioral health crisis is an ongoing second pandemic in our state. Policy makers should listen to the Massachusetts Health and Hospital Association, which found that staffing issues have played a primary role in the crisis.

There are more than 4,000 physician assistants practicing in all medical settings, including psychiatric settings, across Massachusetts. They have thousands of hours of behavioral health training and are often the first provider to evaluate a patient in crisis. However, PAs currently cannot authorize behavioral health admission, restraint, and seclusion.

Governor Baker acknowledged the key role PAs play in behavioral health care when he and the state Department of Mental Health issued Bulletin #22-02 in January 2022, which grants qualified PAs the same authority as other qualified health care professionals to provide services under Massachusetts laws governing mental health evaluations and involuntary restraint. This would have previously required a second exam by another doctor or nurse practitioner, increasing provider burden.

We call on the Legislature to allow us to practice at the top of our licenses and help address the behavioral health crisis by ensuring that this emergency state order does not lapse and is enshrined into statute.

Joshua Merson

Legislative chair

Massachusetts Association of Physician Assistants


Dominant medical model of diagnosis and medication is failing many

I read Jessica Bartlett’s front-page article with a mixture of rage and frustration, and I am not even the parent of a child desperately needing care and instead being warehoused in an inappropriate setting. Rather, I am a psychoanalytically and family systems-oriented clinical psychologist. I have watched, over more than 30 years in practice, as mainstream mental health care has been increasingly dominated by a medical model of diagnosing and treating mental health distress as if it suddenly descends upon the brain of a child or adolescent, decontextualized from a history of complex experiences and relationships with the important people in their lives.


Often, the parents of youth now waiting in ERs have been seeking adequate help for their child for years. Treatment has increasingly focused on counting symptoms, with the aim of then finding the right medication for a child, even those as young as 4. At the same time, commercial insurance companies have decreased reimbursement rates to mental health providers and forced them to jump through bureaucratic hoops to get payment at all. As a result, many practitioners have decided to take only private-paying patients, resulting in the tragic inequities in mental health care access that have been growing for years in this state.

Since the start of the pandemic, commercial insurers have decreased reimbursement rates for family and couple therapy. Family- and home-based interventions are critical to treating complex emotional distress in children and their families before it reaches a crisis point. The shortage of community-based care is one of the driving forces behind the increased need for hospital-level psychiatric care. This crisis will require significant investment and, maybe more important, a major paradigm shift to pre-Prozac models of mental health care if things are going to change.


Susan H. Phillips


The writer has a private practice, and holds a doctoral degree and is program cochair of the Psychodynamic Couple and Family Institute of New England.

Lawmakers should take up the measure before them

A measure before the Legislature to address barriers to mental health care deals with some of the issues in Jessica Bartlett’s detailed article, such as emergency room boarding. This bill was also the subject of a November 2021 Boston Globe editorial.

The Senate bill would use American Rescue Plan funds for an online portal to make it easier for health care professionals to locate psychiatric beds. These same funds also would be used for recruiting and training behavioral health care professionals. The bill would require that a behavioral health professional be available during emergency room operating hours.

If there is anything that this pandemic has taught us, it is the importance of timely, quality health care, and this includes those requiring mental health care. Passage of bills such as this would represent an essential improvement in addressing the mental health care needs of those who require it.

Helen Zazulak


In face of high deductibles and onerous rules, she’s seeing a few patients pro bono

Health insurance presents barriers to care for many families and clinicians alike.

Many working families with private insurance have a high deductible requiring paying thousands of dollars out of pocket before insurance will pay for therapy. This prohibits some families who struggle with the costs of housing, food, and other basic needs to seek or consistently receive care.


MassHealth, our state Medicaid program, requires clinicians to complete the Child Adolescent Needs and Strengths certification every two years in order to submit billing, another onerous barrier for mental health providers.

As an essentially retired clinician, I have chosen to provide pro bono therapy for a few teens who probably otherwise would not get consistent care because their families cannot afford the deductibles and the current CANS recertification process is unacceptable.

Perhaps insurance providers should be required to eliminate high deductibles for mental health care and the CANS recertification should be extended to every four years. Addressing these barriers could increase access to mental health care for vulnerable young people.

Sally Cheek

Jamaica Plain

The writer is a licensed independent clinical social worker.