Psychiatrists taking new Medicare patients: Unicorns of Medicine?
If you accept a form of health insurance but never take new patients, can you still claim to take their insurance?
In a past life as a medical social worker employed by a large health system, I worked in a hospital-based primary care practice serving a large share of geriatric, Medicare-entitled patients. As any social worker in the healthcare milieu will attest, I spent much of my time dealing with access-to-care issues, the examples of which are frustratingly endless and chiefly determined by one’s insurance coverage and ability to pay.
Perhaps the most persistent, baffling, and static problem I encountered was an utter lack of outpatient psychiatric care for Medicare patients. I can’t count how many times the physicians I worked with, who had referred their patients to me for help connecting to a community-based psychiatrist, stared at me aghast as I explained that, yet again, there were no referral options. This was not due to lack of psychiatrists or psychiatric nurse practitioners (PNPs) generally, or even lack of psychiatrists/PNPs contracted with Medicare — both existed, albeit in less-than-ideal numbers. It was because, mysteriously, those who accepted Medicare did so in a purely academic sense. They stopped short of actually accepting new patients — ever.
If one checks Medicare’s “Physician Compare” website for contracted psychiatrists in any urban-ish area, one will likely find a reasonable quantity who theoretically accept Medicare coverage. The illusion crumbles, however, when one begins contacting these providers one by one, only to discover that precisely zero are accepting new patients now or anytime in the foreseeable future.
There are a variety of reasons why older adults, like all others, may need mental healthcare under normal circumstances, and recent data shows this need has understandably increased amid the current threat of coronavirus infection which poses particular risk for their age group. One in four older adults now report depression or anxiety, a share which has more than doubled compared to pre-pandemic levels. Current public health guidelines recommend that older adults continue to limit social interactions, which increases risk of social isolation and loneliness and therefore poor mental health.
Not all mental health issues require treatment from a psychiatrist. Often, psychotherapy is effective on its own in alleviating depression or anxiety, but in cases where medication is needed, primary care providers are often able to prescribe for straightforward issues with lower severity levels. For older adults however, cognitive issues — whether it’s early decline, full-blown dementia, or the simple fact of an “aging brain” — can complicate the clinical picture and tip the scales in favor of specialist (psychiatric) intervention. Most primary care providers are not comfortable prescribing in cases of greater psychiatric complexity, such as when cognitive and mental health issues must be disentangled to determine the extent to which each may be contributing to a patient’s mental state. In these cases, psychiatry is overwhelmingly needed, and sometimes on an urgent basis.
Adults under sixty-five who receive Disability benefits also qualify for Medicare, and around twenty-five percent of them are eligible for Disability based on a mental health disorder. This is a population for whom engagement with psychiatry is critical in order to maintain stability and avoid crisis, and access is no easier for them.
When outpatient access to psychiatry isn’t possible, deterioration is not only inevitable, it becomes cruelly necessary in order to get help. I remember an elderly female patient with lifelong bipolar disorder that had been stable long-term, until some cognitive changes led to a flare-up. She was able to obtain a one-time psychiatric consult at an academic medical center, but symptoms continued to worsen and she was unable to find a Medicare-contracted provider who was open to new patients for ongoing follow-up. The patient’s condition continued to deteriorate until delirium set in and she began wandering at night. She presented to the ER on numerous occasions but, because she was not suicidal or homicidal, did not meet criteria for hospital admission. The cycle continued for some time, at great emotional cost to the patient and her family, until she was finally hospitalized.
Although this patient was more fortunate than most in that she was ultimately able to connect with an ongoing source of psychiatric care post-hospitalization, this was achieved only at a high cost of extended and preventable psychiatric unraveling. In that respect, her story is typical.
These days my work involves more Medicare data than patients. We know that since more psychiatrists opt out of Medicare than any other specialty, patients already have a reduced provider pool to choose from. Of those who remain contracted with Medicare, it’s unclear from a data perspective how many accept new patients. Past physician surveys conducted by the CDC’s National Center for Health Statistics indicate that psychiatrists accept new Medicare patients at a lower rate than any other specialty, and much less frequently than office-based physicians overall. Even this low figure may be inflated, however, as the survey question was, in the past, plagued by non-specificity as to whether Medicare patients were ever, sometimes, or never accepted.
So, out of the sixty-two percent of psychiatrists who have not formally opted out of Medicare, why do so few accept new patients? If they choose to effectively close their practice to Medicare, why not just cease accepting it altogether? The American Psychiatric Association (APA) provider guidance on “Troubleshooting Medicare” ponders this same question: “one might wonder why psychiatrists who do not want to treat Medicare patients don’t just take the step of opting out of Medicare”. Since the opt-out period must last a minimum of two years, it is often more sensible “for physicians who think their practice or employment situation might change” to hedge their bets and preserve the option of accepting Medicare in case they need to do so in future. The Medicare patient thus becomes totally optional, relegated to either a whim or a last resort.
While the increasing scarcity of Medicare-accepting psychiatrists coupled with the unwillingness of those who are left to take on new patients may be simply annoying for those able to pay out-of-pocket, for others it’s a deal breaker that precludes access altogether, and leads to greater costs incurred through the use of crisis care. The volume of providers who accept Medicare on a theoretical basis creates a false sense that there are options available for older or disabled adults in need of psychiatry when in fact the opposite is true. Psychiatrists and PNPs who choose not to accept new Medicare patients should be forced to opt out, so that the true scope of this crisis in access can be seen and addressed.
Sarah True is a freelance writer and independent healthcare policy analyst and researcher based in Washington, DC. She spent seven years providing direct care as a medical social worker.
