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The Long Wait: Shortage of Psychiatrists Affecting Patients

By Debra Wood, contributor

Whether “boarding” in the emergency department or waiting weeks or months for an appointment with a psychiatrist, numerous behavioral health patients experience delays in care, which can lead to poor outcomes.

Why is this happening—and what can be done to address this mental health crisis?

“In 10 years, they will consider this the good old days,” said Joe Parks, MD, medical director of the National Council for Behavioral Health in Washington, D.C. “This is as good as it gets.”

Parks expects access will become even more challenging, as a wave of psychiatrists retire and patients recognize mental health treatments work and have insurance coverage for those treatments.

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The prevalence of mental health disorders

About 44.7 million people in the United States, or 18.3 percent of the population, suffer from a mental illness, according to the National Institute of Mental Health. Yet, less than half of these people have received mental health treatment.

Top diagnoses include anxiety, depression and substance abuse, including among people in their 20s and 30s, according to Parks. Additionally, people need treatment for more serious conditions, such as schizophrenia and bipolar disease.

“Demand for psychiatry is going through the roof, because stigma is down and coverage is up,” Parks said.

The federal Mental Health Parity and Addiction Equity Act of 2008 required large group commercial insurers, but not self-insured companies, to provide coverage for mental health disorders on a par with medical/surgical conditions. That expanded coverage, as did the Affordable Care Act.

“Demand is up at the same time supply is down,” Parks said.

The causes and effects of the psychiatrist shortage

The country is experiencing a psychiatrist shortage, which is challenging for patients and providers, but bodes well for those seeking new psychiatrist opportunities.

“The number of psychiatrists per capita is down about 10 percent over the last 13 years,” Parks said. “Whereas, the number of physicians overall is even.”

In 2025, demand may outstrip supply by 6,090 to 15,600 psychiatrists , according to a 2017 National Council for Behavioral Health report.

With demand up and psychiatrists in short supply, the price of a psychiatry visit has gone up, and more than 40 percent of psychiatrists operate cash-only practices. In a metropolitan area, a psychiatrist can charge and get $300 for a 45-minute therapy visit, yet on average insurers will only reimburse about $150, Parks explained. Actuarial firms have not reset the rates for behavioral health treatments.

Some psychiatrists will still accept commercial insurance and be listed on the health plan’s panel of providers, but will limit the percentage of patients. “The panels are inadequate,” Parks noted.

A 2017 study by Milliman, involving nearly 42 million Americans, found patients went out of network for outpatient behavioral health services 3.0 to 5.8 times more often than for medical-surgical services.

Six out of 10 (60 percent) of the 37,725 practicing psychiatrists in 2015 were age 55 or older, according to the Association of American Medical Colleges, which indicates many will be retiring over the next few years.

About one-third of new psychiatrists are graduates of foreign medical schools, so changes to immigration laws could adversely affect that supply, Parks said.

“And the inside the U.S. production pipeline is fixed, because there is no extra funding for graduate medical education,” Parks said. “We produce more medical students than we have first-year training slots available. There are people who have finished medical school and cannot practice.” During the last three or four years, all psychiatry residency slots have been filling, he said.

A multifaceted fix is needed

To solve the psychiatrist shortage and patient access problem, Parks said better regulation of access for treatment of mental health disorders is needed, along with better enforcement of the Mental Health Parity and Addiction Equity Act, including reimbursement rate parity.

“Secret shopper” surveys could help determine areas with insufficient access. A study led by Harvard researchers in 2014 used a secret shopper approach in Boston, Houston and Chicago, calling psychiatrists’ offices seeking an appointment. After two rounds of calling, only 26 percent of the callers were able to secure an appointment, regardless of whether they had commercial insurance or Medicare or would self-pay.

“Self-insured companies need to take a look and see they are not getting the health coverage they want for their employees,” Parks said. Then these companies need to advocate for change. After all, good mental health coverage benefits employers, because untreated anxiety and depression increases absenteeism and reduces productivity.

More psychiatry residency slots are needed, which means more federal or state funding for graduate medical education.

Another solution could involve integrated care. Patients often seek care for anxiety and depression from primary care physicians, who may be reluctant to treat these conditions if they do not have back up from a psychiatrist. But these primary care physicians could bring a psychiatrist into their practice.

“I practice in a primary care clinic, and I love it,” Parks said.

Untreated mental illness is a problem for everyone in health care. While there is not one single solution, the experts agree: more needs to be done to get patients the help they need.

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