Editor’s note: Part of a series of occasional articles on how money affects patients and their care. To read more, click here.
Massachusetts has more mental health care providers per capita than any other state, more psychiatrists than anywhere but Washington, D.C., more child psychiatrists than all but D.C. and Rhode Island.
Yet poor and middle-class patients describe an often-frustrating and painful struggle to find a provider who will see them, at a price they can afford. They sometimes suffer longer than necessary, or settle for care by an inexperienced or less-credentialed practitioner.
How can this be? Only about half of all licensed mental health care providers — psychiatrists, psychologists, social workers, mental health counselors, and marriage and family therapists — accept payment from Massachusetts Medicaid. Only about half of all psychiatrists in the Northeast accept employer-based private insurance — and that number is falling, according to a 2014 study in the journal JAMA Psychiatry.
Mental health care has become, in large measure, a private-pay business that operates outside the insurance system.
It is another schism in the already fractured behavioral health care system, one that makes services readily available to those with the means to spend $200 an hour for therapy, but can frustrate those without enough money, regardless of how hard they try to find a therapist and how desperate they are for treatment.
“Only people with financial means can receive serious mental health help from clinicians,’’ said Philip Johnston, a former state health and human services secretary and chair of the Blue Cross Blue Shield of Massachusetts Foundation, a nonprofit that studies access.
Providers say the problem is rooted in numbers: Medicaid, and some commercial insurance companies, don’t pay enough to practitioners, who are already in constant demand. The government program pays psychiatrists and psychologists $92 for a 45-minute session.
Commercial plans generally do not disclose their rates. But one psychologist said she gets about $70 from Harvard Pilgrim Health Care for 45 minutes, and about $100 from Blue Cross Blue Shield of Massachusetts. And taking insurance means spending lots of unpaid time on paperwork and appealing rejections.
The result is that many mental health professionals refuse anything but direct payments from patients — although some offer lower fees based on a patient’s income. And some patients may be able to get a portion of their payments reimbursed by their insurance company.
“There’s a lot of red tape and [therapists] don’t want to bother anymore,’’ said Paul Goldberg of Arlington, who searched more than six months for a provider for a family member. “The good therapists say, ‘It’s not worth it. We don’t need this. We can charge whatever we want.’ And they do.’’
Johnston argues that it’s unethical for providers to opt out of providing care to Medicaid patients, and favors a stern approach: Require clinicians to accept Medicaid as a condition of their license. Massachusetts Health and Human Services Secretary Marylou Sudders appeared to endorse that controversial idea during remarks she made at a conference last fall.
In a recent interview with the Globe, Sudders said that if strategies such as raising Medicaid fees don’t attract more psychiatrists in the next year, she will consider pushing for a change in licensing rules. She has heard the most complaints about lack of access to psychiatrists for patients who need medication.
Dr. Gary Chinman, president of the Massachusetts Psychiatric Society, declined to comment.
Jennifer Warkentin, director of professional affairs for the Massachusetts Psychological Association, said the group has not taken a position on the issue. “ ‘How much time am I investing in getting this money versus how much am I getting paid?’ That is the question providers ask about whether to take insurance,’’ she said.
A solution cannot come soon enough for those seeking mental health treatment.
Many complain providers willing to see Medicaid patients are inexperienced. Patients’ conditions can worsen while they languish on waiting lists. And when they do get an appointment, they can face a revolving door of therapists, as the more experienced ones leave to open their own practices — where they no longer take Medicaid.
This was the frustrating scenario for Georgia Kirk, 13.
It’s not that her mother didn’t try to find a doctor to treat Kirk’s bipolar disorder, depression, and anxiety. More than 20 phone calls to psychiatrists and psychologists several years ago led only to dead ends.
Jessica Kirk finally got an appointment for her daughter with a New Hampshire practice at what seemed like a bargain — $150 an hour, out of pocket. When that became too costly, she cut back on Georgia’s therapy. In July 2017, Georgia Kirk fell apart, ending up in a psychiatric hospital for two weeks — a crisis her mother believes may have been averted with more consistent treatment.
Before Kirk was discharged, the staff at Franciscan Children’s hospital recommended she seek help from South Bay Community Services in Lawrence. That ultimately did not work out, and in June, she began seeing a psychologist at Lahey Clinic in Burlington who is new to the profession and takes Medicaid.
“It’s been a huge struggle for us for years,’’ said Jessica Kirk, who lives in North Andover.
It is an all too common story.
When Niamh, whose last name the Globe is not using to protect her anonymity, saw her longtime psychiatrist on Cape Cod relocated two years ago, her mother called 15 psychiatric practices and several community health centers. But Oonagh Brault could not find any who accepted new patients and Niamh’s insurance; she has Medicaid and a plan managed by the health care company Optum.
The state mental health department eventually referred them to a New Bedford psychiatrist, but he did not read the 19-year-old’s medical file before her appointment, and seemed unfamiliar with her history, they said. Mother and daughter left without making another appointment.
Niamh, who has long suffered from major depression, anxiety, and psychosis, went on the wait list at the Community Health Center of Cape Cod.
“There was no other option. I had to wait it out,’’ Niamh said. “I felt really lonely because I didn’t have anyone I could really confide in. I ended up going to a hospital in February.’’
In July, after waiting more than six months, she said, the health center provided her with a primary care doctor, a psychologist for talk therapy, and a psychiatrist to prescribe medication.
Finding a child or adolescent psychiatrist is especially challenging. Even though Massachusetts has 35 such professionals for every 100,000 residents under 18 — the third highest ratio in the country — the number is still considered far too low, according to the American Academy of Child and Adolescent Psychiatry.
Adults are struggling with access to mental health care, too, despite Massachusetts having one psychiatrist for every 2,089 residents, second only to Washington, D.C., according to the American Medical Association.
Another recent analysis by the University of Southern California found that for all licensed mental health providers, Massachusetts has the highest ratio in the United States: 54 for every 10,000 residents.
The Blue Cross Blue Shield Foundation, which found that just 55 percent of mental health providers in the state take Medicaid, also uncovered delays in getting care. Of all providers, 84 percent accept private insurance, the report said.
According to focus groups the foundation convened of people seeking services, adults with Medicaid said they waited two to six months for a routine appointment with a mental health provider; those with private insurance waited two weeks to three months. It’s the opposite for children: those with Medicaid waited two to six months, compared to four to nine months for the privately insured.
In a separate survey, providers reported seeing 81 percent of new patients within two weeks. Organizations that see mostly Medicaid patients, such as community health centers, said they see 59 percent of new patients within two weeks.
Those results may make access to expert care seem less of an issue than it is. Under court oversight to improve mental health care for children, Medicaid relies on unlicensed providers in some locations. These are usually new graduates who are supposed to be supervised by licensed mental health professionals.
“I am not able to see clients who have, quote unquote, good insurance,’’ said one unlicensed therapist who works in an Arbour Counseling Services clinic and did not want to be identified because she is afraid of losing her job.
There are other hidden obstacles.
At Massachusetts General Hospital, for example, many well-known psychiatrists have gained national followings through books they have written. But because they are highly sought after, they typically take only patients who have a Mass. General primary care doctor. In those cases, they accept all insurance plans the hospital takes.
But many also have outside private practices where they don’t take insurance at all; they charge as much as $200 to $300 a session.
“Insurance does not adequately provide a salary, and demand is so great,’’ said Joy Rosen, vice president of behavioral health at the hospital. “There are residents who graduate in July and can take just private pay and be full by October.’’
Medicaid and the state’s three largest private insurers said they have significantly increased the number of clinicians in their networks in response to patient demand, and reduced the paperwork burden. And Sharon Torgerson, a spokeswoman for Health and Human Services, said Medicaid is increasing fees to mental health providers by $100 million between 2016 and 2020.
Some clinicians said they don’t like to but feel forced to turn their backs on insurance — or at least limit their participation.
When psychologist Jennifer Leslie left a small group practice to open a solo office in North Andover, she decided to accept the plans most of her patients had — Blue Cross Blue Shield of Massachusetts and Harvard Pilgrim Health Care.
She said Harvard Pilgrim pays her $71.25 for a 45-minute visit, including the patient’s copayment. (Company spokesman Philip Tracey said rates are “on par with the average reimbursement rate in Massachusetts.’’)
When a patient hits 20 visits in a six-month period, Leslie gets a call from a company counselor and then a psychologist asking her to justify further treatment. Her requests are almost always denied and at that point she winds up spending many hours appealing that she doesn’t get paid for.
“Why is my treatment plan not the one that is respected?’’ she said. “Then I talk to another psychologist for five minutes, and he is the one to figure out whether it’s medically necessary for this patient?”
She has decided to close her practice to new Harvard Pilgrim patients.
“I don’t have the time,’’ Leslie said.