Rates of psychiatrists' participation in health insurance networks

Characteristics of Veterans With Depression Who Use the Veterans Choice Program of the Veterans Health Administration

OBJECTIVE

The Veterans Choice Program (VCP) of the Veterans Health Administration (VHA) allowed eligible veterans to use their benefits with participating providers outside the VHA. The authors aimed to identify characteristics of veterans with depression who used or did not use mental health care through the VCP.

METHODS

In this cross-sectional study, the authors analyzed secondary data from the national VHA Corporate Data Warehouse. VHA administrative data were linked with VCP claims to examine characteristics of VCP-eligible veterans with depression. The study sample included 595,943 unique veterans who were enrolled in the VHA before 2013, were eligible for the VCP in 2016, were alive in 2018, and had an assessed Patient Health Questionnaire-9 (PHQ-9) score or depressive disorder diagnosis documented in the VHA between 2016 and 2018.

RESULTS

Veterans who used the VCP had lower medical comorbidity scores and lived in less socioeconomically disadvantaged counties, compared with veterans who received only VHA care. VCP veterans were also more likely to have a PHQ-9 score assessment and to have higher mean depression scores. Mean counts of annual mental health visits per 1,000 veterans were markedly higher for direct VHA care than for care provided via the VCP. As a percentage of the total counts of visits per 1,000 veterans across the VCP and VHA, residential programs and outpatient procedures were the services that were most frequently delivered through the VCP.

CONCLUSIONS

Between 2016 and 2018, the VCP was used primarily to augment mental health care provided by the VHA, rather than to fill a gap in care.

Policy Complexities in Financing First Episode Psychosis Services: Implementation Realities from a Home Rule State

Over the past decade, significant investments have been made in coordinated specialty care (CSC) models for first episode psychosis (FEP), with the goal of promoting recovery and preventing disability. CSC programs have proliferated as a result, but financing challenges imperil their growth and sustainability. In this commentary, the authors discuss (1) entrenched and emergent challenges in behavioral health policy of consequence for CSC financing; (2) implementation realities in the home rule context of Ohio, where significant variability exists across counties; and (3) recommendations to improve both care quality and access for individuals with FEP. The authors aim to provoke careful thought about policy interventions to bridge science-to-service gaps, and in this way, advance behavioral health equity.

Acceptance of Insurance by Psychiatrists and Other Physicians, 2007-2016

OBJECTIVE

The authors aimed to analyze psychiatrists' and other physicians' acceptance of insurance and the associations between insurance acceptance and specific physician- and practice-level characteristics.

METHODS

Using the restricted version of the National Ambulatory Medical Care Survey, January 2007-December 2016, the authors analyzed acceptance of private insurance, public insurance, and any insurance among psychiatrists compared with nonpsychiatrist physicians. Because data were considered restricted, all analyses were conducted at federal Research Data Center facilities.

RESULTS

The unweighted sample included an average of 4,725 physicians per 2-year time grouping between 2007 and 2016, with an average of 7% being psychiatrists. Nonpsychiatrists participated in all insurance networks at higher rates than did psychiatrists, and the acceptance gap was wider for public (Medicare and Medicaid) than private (noncapitated and capitated) insurance. Among psychiatrists, those practicing in metropolitan statistical areas and those in solo practices were significantly less likely than their peers in other locations and treatment settings to accept private, public, or any insurance. These findings were also observed among nonpsychiatrists, although to a lesser extent.

CONCLUSIONS

In addition to general policy interventions to improve insurance network adequacy for psychiatric care, additional measures or incentives to promote insurance network participation should be considered for psychiatrists in solo practices and those in metropolitan areas.

Racial Differences in Self-Report of Mental Illness and Mental Illness Treatment in the Community: An Analysis of Jail Intake Data

Jails and prisons in the United States house people with elevated rates of mental health and substance use disorders. The goal of this cross-sectional study was to evaluate the frequency of racial/ethnic differences in the self-report of mental illness and psychiatric medication use at jail entry. Our sample included individuals who had been incarcerated between 2016 and 2020 at the Middlesex Jail & House of Correction, located in Billerica, MA. We used data from the "Offender Management System," the administrative database used by the jail containing data on people who are incarcerated, and COREMR, the electronic medical record (EMR) used in the Middlesex Jail & House of Correction. We evaluated two primary outcomes (1) self-reported mental illness history and (2) self-reported use of psychiatric medication, with the primary indicator of interest as race/ethnicity. At intake, over half (57%) of the sample self-reported history of mental illness and 20% reported the use of psychiatric medications. Among people who self-reported a history of mental illness, Hispanic (AOR: 0.73, 95% CI: 0.60-0.90), Black (AOR: 0.52, 95% CI: 0.43-0.64), Asian/Pacific Islander (Non-Hispanic) people (AOR: 0.31, 95% CI: 0.13-0.74), and people from other racial/ethnic groups (AOR: 0.33, 95% CI: 0.11-0.93) all had decreased odds of reporting psychiatric medications. Mental illness was reported in about one-half of people who entered jail, but only 20% reported receiving medications in the community prior to incarceration. Our findings build on the existing literature on jail-based mental illness and show racial disparities in self-report of psychiatric medications in people who self-reported mental illness. The timing, frequency, and equity of mental health services in both the community and the jail setting deserves further research, investment, and improvement.

Toward Greater Accountability in Mental Health Care

Lack of accountability contributes to the gap between best practices and potential outcomes. Few mental health providers routinely practice evidence-based care. In fact, within the mental health field, there is significant controversy over the use of evidence-based practices. Lack of accountability affects individuals receiving care at the patient level, provider level, and systems level. The authors identify several impediments to accountability in behavioral health care. These include failure to develop a diverse, well-trained workforce; challenges in measurement; misalignment of payment incentives; and misguided regulations. Accountability arrangements typically consist of several elements: a clear articulation of goals, objectives, or standards; metrics so that progress toward achieving goals can be tracked; and consequences for insurers, providers, and professionals for achieving or failing to achieve objectives. To advance system goals, the full complement of accountability tools should be consistently applied to all sources of behavioral health care and supports. The authors focus on three sets of accountability tools-performance metrics, payment incentives, and regulatory standards-that when implemented thoughtfully can help move the field toward more positive outcomes in behavioral health.

Ongoing Disparities in Digital and In-Person Access to Child Psychiatric Services in the United States

OBJECTIVE

To estimate the number and geographic distribution of children and adolescents in the United States who reside in counties with neither child and adolescent psychiatrists nor sufficient Internet broadband to support telepsychiatry services.

METHOD

This analysis combined data from the Health Resources and Services Administration's Area Health Resource Files on child psychiatrist workforce with Federal Communications Commission information on broadband coverage to generate a composite of in-person and digital access to child psychiatric services throughout the United States. Using multivariable fixed-effects Poisson regression analysis, we estimated the number of children and adolescents (aged 5-19 years) without access to psychiatric services and examined disparities across counties in the United States.

RESULTS

We estimate that 6,035,402 children and adolescents in the United States (approximately 10%) have inadequate in-person and digital availability of child psychiatric services within their counties. Although this was true for only 3% of children and adolescents in urban counties, this applied to more than half (51%) in rural counties (adjusted odds ratio [AOR] = 2.71; 95% CI = 1.94, 3.78; p < .001). Likewise, only 3% of children and adolescents in high-income counties had insufficient digital and physical access, compared to more than 4 in 10 children and adolescents (41%) in low-income counties (AOR = 0.43; 95% CI = 0.30-0.61; p < .001). Counties with a higher density of Black and Hispanic residents had greater likelihood of service availability (p < 0.001), potentially a function of living in metropolitan communities.

CONCLUSION

Although telehealth holds promise for promoting access to child and adolescent psychiatric services, large disparities in overall access to services persists in rural and low-income communities.

Comparison of Performance of Psychiatrists vs Other Outpatient Physicians in the 2020 US Medicare Merit-Based Incentive Payment System

Question

How did psychiatrists perform in the 2020 Medicare Merit-Based Incentive Payment System (MIPS) compared with other outpatient physicians?

Findings

In this cross-sectional study of 9356 psychiatrists and 196 306 other outpatient physicians participating in the 2020 MIPS, psychiatrists had significantly lower performance scores, were significantly more likely to be assessed a performance penalty, and were less likely to be assessed a bonus than other physicians.

Meaning

Psychiatrists performed worse than other physicians in Medicare’s new mandatory outpatient value-based payment system; therefore, more research is needed to evaluate the appropriateness of MIPS measures for psychiatrists.

Importance

Medicare’s Merit-Based Incentive Payment System (MIPS) is a new, mandatory, outpatient value-based payment program that ties reimbursement to performance on cost and quality measures for many US clinicians. However, it is currently unknown how the program measures the performance of psychiatrists, who often treat a different patient case mix with different clinical considerations than do other outpatient clinicians.

Objective

To compare performance scores and value-based reimbursement for psychiatrists vs other outpatient physicians in the 2020 MIPS.

Design, Setting, and Participants

In this cross-sectional study, the Centers for Medicare & Medicaid Services Provider Data Catalog was used to identify outpatient Medicare physicians listed in the National Downloadable File between January 1, 2018, and December 31, 2020, who participated in the 2020 MIPS and received a publicly reported final performance score. Data from the 593 863 clinicians participating in the 2020 MIPS were used to compare differences in the 2020 MIPS performance scores and value-based reimbursement (based on performance in 2018) for psychiatrists vs other physicians, adjusting for physician, patient, and practice area characteristics.

Exposures

Participation in MIPS.

Main Outcomes and Measures

Primary outcomes were final MIPS performance score and negative (penalty), positive, and exceptional performance bonus payment adjustments. Secondary outcomes were scores in the MIPS performance domains: quality, promoting interoperability, improvement activities, and cost.

Results

This study included 9356 psychiatrists (3407 [36.4%] female and 5 949 [63.6%] male) and 196 306 other outpatient physicians (69 221 [35.3%] female and 127 085 [64.7%] male) (data on age and race are not available). Compared with other physicians, psychiatrists were less likely to be affiliated with a safety-net hospital (2119 [22.6%] vs 64 997 [33.1%]) or a major teaching hospital (2148 [23.0%] vs 53 321 [27.2%]) and had lower annual Medicare patient volume (181 vs 437 patients) and mean patient risk scores (1.65 vs 1.78) (P < .001 for all). The mean final MIPS performance score for psychiatrists was 84.0 vs 89.7 for other physicians (absolute difference, −5.7; 95% CI, −6.2 to −5.2). A total of 573 psychiatrists (6.1%) received a penalty vs 5739 (2.9%) of other physicians (absolute difference, 3.2%; 95% CI, 2.8%-3.6%); 8664 psychiatrists (92.6%) vs 189 037 other physicians (96.3%) received a positive payment adjustment (absolute difference, −3.7%; 95% CI, −3.3% to −4.1%), and 7672 psychiatrists (82.0%) vs 174 040 other physicians (88.7%) received a bonus payment adjustment (absolute difference, −6.7%; 95% CI, −6.0% to −7.3%). These differences remained significant after adjustment.

Conclusions and Relevance

In this cross-sectional study that compared US psychiatrists with other outpatient physicians, psychiatrists had significantly lower 2020 MIPS performance scores, were penalized more frequently, and received fewer bonuses. Policy makers should evaluate whether current MIPS performance measures appropriately assess the performance of psychiatrists.

A Path Forward: Mental Health and the U.S. Pandemic Response

The COVID-19 pandemic presents a crisis of mental health in the United States (U.S.) alongside a crisis of infectious disease. Racial inequities in COVID-19 morbidity and mortality have brought health equity to the forefront of public health policy, exacerbating prior inequities in mental health care access and outcomes. This Commentary asserts that policymakers and advocates must prioritize mental health when responding to the pandemic. While the pandemic is an emergency of unprecedented scale, the authors argue that it also is an opportunity to implement broad-based mental health policy reforms in the U.S. that build on the successes of the Affordable Care Act and the Mental Health Parity and Addiction Equity Act. Guided by innovative state and local policies to promote population-level mental health, we outline a series of empirically grounded strategies for federal and state policymakers to promote mental health equity in the wake of COVID-19.

Provider-Level Caseload of Psychosocial Services for Medicaid-Insured Children

OBJECTIVE

We estimated the caseload of providers, practices, and clinics for psychosocial services (including psychotherapy) to Medicaid-insured children to improve the understanding of the current supply of such services and to inform opportunities to increase their accessibility.

METHODS

We used 2012-2013 Medicaid claims data and data from the 2013 National Plan and Provider Enumeration System to identify and locate therapists, psychiatrists, and mental health centers along with primary, rehabilitative, and developmental care providers in the United States who provided psychosocial services to Medicaid-insured children. We estimated the per-provider, per-location, and state-level caseloads of providers offering these services to Medicaid-insured children in 34 states with sufficiently complete data to perform this analysis, by using the most recent year of Medicaid claims data available for each state. We measured caseload by calculating the number of psychosocial visits delivered by each provider in the selected year. We compared caseloads across states, urbanicity, provider specialty (eg, psychiatry, psychology, primary care), and practice setting (eg, mental health center, single practitioner).

RESULTS

We identified 63 314 providers, practices, or centers in the Medicaid claims data that provided psychosocial services to Medicaid-insured children in either 2012 or 2013. The median provider-level per-year caseload was <25 children and <250 visits across all provider types. Providers with a mental health center-related taxonomy accounted for >40% of visits for >30% of patients. Fewer than 10% of providers and locations accounted for >50% of patients and visits.

CONCLUSIONS

Psychosocial services are concentrated in a few locations, thereby reducing geographic accessibility of providers. Providers should be incentivized to offer care in more locations and to accept more Medicaid-insured patients.

Prices And Cost Sharing For Psychotherapy In Network Versus Out Of Network In The United States

Patients in the US are more likely to receive out-of-network behavioral health care, including treatment for mental health or substance use disorders, than they are to receive other medical and surgical services out of network. To date, out-of-network and in-network trends in the prices and use of ambulatory behavioral health care have been seldom described. Here we compare levels and growth of insurer-negotiated prices (allowed amounts), patient cost sharing, and use of psychotherapy services in network and out of network in a large, commercially insured US population during 2007-17. For both adult and child psychotherapy, prices and cost sharing were substantially higher out of network than they were in network. These gaps widened during the eleven-year period. Prices and cost sharing for in-network psychotherapy decreased during this period, whereas prices and cost sharing for out-of-network psychotherapy increased. Use of adult and child psychotherapy increased during this period, driven by growth of in-network rather than out-of-network use. The increasing gap in prices and cost sharing between out-of-network and in-network psychotherapy, viewed in the context of a shortage of behavioral health providers who accept insurance, may limit access to ambulatory behavioral health care.

Medicaid Acceptance by Psychiatrists Before and After Medicaid Expansion

This study uses National Ambulatory Medical Care Survey data to assess the percentage of psychiatrists who have accepted Medicaid-insured patients before and after Medicaid expansion.

Building The Mental Health Workforce Capacity Needed To Treat Adults With Serious Mental Illnesses

There are widespread shortages of mental health professionals in the United States, especially for the care of adults with serious mental illnesses. Such shortages are aggravated by maldistribution of mental health professionals and attractive practice opportunities treating adults with less severe conditions. The Affordable Care Act (ACA) and legislation extending mental health parity coverage are contributing to an increasing demand for mental health services. I consider four policy recommendations to reinvigorate the mental health workforce to meet the rising mental health care demand by adults with serious mental illnesses: expanding loan repayment programs for mental health professionals to practice in underserved areas; raising Medicaid reimbursement for treating serious mental illness; increasing training opportunities for social workers in relevant evidence-based psychosocial services; and disseminating service models that integrate mental health specialists as consultants in general medical care. Achieving progress in attracting mental health professionals to care for adults with serious mental illnesses will require vigorous policy interventions.

Population Of US Practicing Psychiatrists Declined, 2003-13, Which May Help Explain Poor Access To Mental Health Care

A large proportion of the US population suffers from mental illness. Limited access to psychiatrists may be a contributor to the underuse of mental health services. We studied changes in the supply of psychiatrists from 2003 to 2013, compared to changes in the supply of primary care physicians and neurologists. During this period the number of practicing psychiatrists declined from 37,968 to 37,889, which represented a 10.2 percent reduction in the median number of psychiatrists per 100,000 residents in hospital referral regions. In contrast, the numbers of primary care physicians and neurologists grew during the study period. These findings may help explain why patients report poor access to mental health care. Future research should explore the impact of the declining psychiatrist supply on patients and investigate new models of care that seek to integrate mental health and primary care or use team-based care that combines the services of psychiatrists and nonphysician providers for individuals with severe mental illnesses.

Geographic Access to Specialty Mental Health Care Across High- and Low-Income US Communities

Importance

With the future of the Affordable Care Act and Medicaid program unclear, it is critical to examine the geographic availability of specialty mental health treatment resources that serve low-income populations across local communities.

Objectives

To examine the geographic availability of community-based specialty mental health treatment resources and how these resources are distributed by community socioeconomic status.

Design, Setting, and Participants

Measures of the availability of specialty mental health treatment resources were derived using national data for 31 836 zip code tabulation areas from 2013 to 2015. Analyses examined the association between community socioeconomic status (assessed by median household income quartiles) and resource availability using logistic regressions. Models controlled for zip code tabulation area-level demographic characteristics and state indicators.

Main Outcomes and Measures

Dichotomous indicators for whether a zip code tabulation area had any (1) outpatient mental health treatment facility (more than nine-tenths of which offer payment arrangements for low-income populations), (2) office-based practice of mental health specialist physician(s), (3) office-based practice of nonphysician mental health professionals (eg, therapists), and (4) mental health facility or office-based practice (ie, any community-based resource).

Results

Of the 31 836 zip code tabulation areas in the study, more than four-tenths (3382 of 7959 [42.5%]) of communities in the highest income quartile (mean income, $81 207) had any community-based mental health treatment resource vs 23.1% of communities (1841 of 7959) in the lowest income quartile (mean income, $30 534) (adjusted odds ratio, 1.74; 95% CI, 1.50-2.03). When examining the distribution of mental health professionals, 25.3% of the communities (2014 of 7959) in the highest income quartile had a mental health specialist physician practice vs 8.0% (637 of 7959) of those in the lowest income quartile (adjusted odds ratio, 3.04; 95% CI, 2.53-3.66). Similarly, 35.1% of the communities (2792 of 7959) in the highest income quartile had a nonphysician mental health professional practice vs 12.9% (1029 of 7959) of those in the lowest income quartile (adjusted odds ratio, 2.77; 95%, 2.35-3.26). In contrast, outpatient mental health treatment facilities were less likely to be located in the communities in the highest vs lowest income quartiles (12.9% [1025 of 7959] vs 16.5% [1317 of 7959]; adjusted odds ratio, 0.43; 95% CI, 0.37-0.51). More than seven-tenths of the lowest income communities with any resource (71.5% [1317 of 1841]) had an outpatient mental health treatment facility.

Conclusions and Relevance

Mental health treatment facilities are more likely to be located in poorer communities, whereas office-based practices of mental health professionals are more likely to be located in higher-income communities. These findings indicate that mental health treatment facilities constitute the backbone of the specialty mental health treatment infrastructure in low-income communities. Policies are needed to support and expand available resources for this critical infrastructure.

Black and Blue: Depression and African American Men

Depression is a common mental disorder affecting individuals. Although many strides have been made in the area of depression, little is known about depression in special populations, especially African American men. African American men often differ in their presentation of depression and are often misdiagnosed. African American men are at greater risk for depression, but they are less likely to participate in mental health care. This article explores depression in African American by looking at environmental factors, sigma, role, and other unique to this populations, such as John Henryism. Interventions to encourage early screening and participation in care are also discussed.

Patient cost-sharing for ambulatory neuropsychiatric services in Abu Dhabi, UAE

BACKGROUND AND OBJECTIVES

Neuropsychiatric disorders are of high concern and burden of disease in the United Arab Emirates (UAE). The aim of this study is to describe patient cost-sharing patterns, insurance coverage of ambulatory neuropsychiatric disorders, and utilization of neuropsychiatric services in Abu Dhabi.

METHODS

The study utilized the data published by Health Authority-Abu Dhabi (HAAD) and the American Center for Psychiatry and Neurology (ACPN) records in Abu Dhabi. The data were collected from the ACPN to describe patterns of insurance coverage and patient cost-sharing. The data included information on patient visits to the ACPN from January 1, 2010 till May 16, 2013. The data also included insurance coverage, total cost of treatment for each patient and the amount of coinsurances and deductibles paid by each patient. Additionally, the study utilized data published by HAAD on health services utilization, and health insurance plans in 2014. The percentage of total costs paid by patients and insurance were calculated by insurance groups and health service. Insurance plans with different patient cost-sharing arrangements for mental health treatment benefits were divided into three groups. ANOVA and MANOVA analyses were performed to test for differences among three categories of neuropsychiatric services (neurology, psychiatry and psychotherapy) in terms of the total costs and patient cost-sharing. The data were analysed using STATA version 12.

RESULTS

About 36 % of the total costs on ambulatory neuropsychiatric services was paid directly by patients; 1 % of total costs was covered by patients as co-insurances and deductibles, and 63 % of total costs was covered by insurance providers. The average cost per visit was about 485 AED ($132), including 304 AED ($83) paid by insurance and 181 AED ($49) paid by patient. About 44 % of total costs was related to psychiatry services, 28 % of total costs was related to neurology services, and 28 % of total costs was related to psychotherapy services. Using ANOVA analyses, statistical differences were found among three categories of neuropsychiatric services in terms of the total costs and patient cost-sharing. These findings provide hint on some degree of association between patient cost-sharing and neuropsychiatry services utilization.

CONCLUSIONS

The determination of parities in the coverage and finance between neuropsychiatric and physical health services will help policymakers make informed decisions on regulations of health insurance plans. Given the level of unmet need for neuropsychiatric services in Abu Dhabi, there is a need to fully include neuropsychiatric services in all basic and enhanced insurance plans. The study provided a description of patient cost-sharing and coverage of neuropsychiatric services in order for policymakers to recognize the disparities of the coverage and the degree of economic burden on households.

The Relevance of the Affordable Care Act for Improving Mental Health Care

Provisions of the Affordable Care Act provide unprecedented opportunities for expanded access to behavioral health care and for redesigning the provision of services. Key to these reforms is establishing mental and substance abuse care as essential coverage, extending Medicaid eligibility and insurance parity, and protecting insurance coverage for persons with preexisting conditions and disabilities. Many provisions, including Accountable Care Organizations, health homes, and other structures, provide incentives for integrating primary care and behavioral health services and coordinating the range of services often required by persons with severe and persistent mental health conditions. Careful research and experience are required to establish the services most appropriate for primary care and effective linkage to specialty mental health services. Research providing guidance on present evidence and uncertainties is reviewed. Success in redesign will follow progress building on collaborative care and other evidence-based practices, reshaping professional incentives and practices, and reinvigorating the behavioral health workforce.

Psychiatric Mental Health Nursing Workforce Agenda: Optimizing Capabilities and Capacity to Address Workforce Demands

BACKGROUND

The mental health service delivery transformation has created models of care that generate demand for a workforce with particular competencies.

OBJECTIVE

This article develops a psychiatric mental health (PMH) nursing workforce agenda in light of demand generated by new models of care and the capacity/capabilities of the PMH RN and advanced practice nurse (APN) workforce.

DESIGN

Examine the current capacity of the PMH nursing workforce and how health care reform and related service delivery models create demand for a particular set of behavioral health workforce competencies.

RESULTS

PMH RNs and APNs have an educational background that facilitates development of competencies in screening, care coordination, leveling care, and wellness education. PMH RNs are a large workforce but the size of the PMH APN group is inadequate to meet demand.

CONCLUSION

The specialty must strategize on how to build requisite PMH RN and APN competencies for the evolving service landscape.