Privileges quest fizzles

At a time when mental health care and health insurance have taken center stage in the American dialogue, it can be shocking to find that patients may find basic access to mental health care increasingly difficult.

In a recent study published in the Journal of the American Medical Association, researchers found that the number of psychiatrists who accept insurance payments has dropped, which could leave greater numbers of less-affluent clients without services. In the five years from 2005 to 2010, private insurance acceptance dropped 17 percent, to 55 percent of total psychiatrists. The acceptance of Medicare is now at 55 percent and Medicaid at 43 percent.

What this might mean for psychology, and specifically for those who would like to see prescription privileges extended to that field, remains to be seen.

The data set was part of the National Ambulatory Medical Care Survey, administered by the Center for Disease Control’s National Center for Health Statistics, a continuously sampled survey that provides information on medical care provided in physician’s offices. The survey contains information on demographics of patients as well as physician characteristics including geographic location, type of practice, and specialization.

This database study pulled information out about the psychiatrists included in the overall study and the researchers were somewhat surprised to find the reduction in insurance acceptance.

“Yes, we were surprised,” says Tara Bishop, M.D., an assistant professor in the Department of Public Health and Medicine at Weill Cornell Medical College and lead author of the study. “We have been looking at this data for some time but only recently looked at specialty differences. One of my co-authors and I have had difficulty finding psychiatrists for our patients because of insurance issues but we did not realize it was a larger national issue.”

Adding to the issue is a reported shortage of psychiatrists around the country. According to the National Institute of Mental Health, psychiatrists are, on average, older than other physicians (except for preventive medicine practitioners), the number of training programs has decreased and fewer medical students are choosing to specialize in psychiatry.

A reduction in the number of general practitioners, who often treat minor mental health issues, may also affect the availability of mental health care.

“We currently have a shortage of general practitioners in the country and expect a larger shortage as the population ages,” says Bishop. “GPs certainly take care of patients with mental health conditions such as depression and anxiety but we don’t know much else about how GP shortages affect these patients in particular.”

At a time when national tragedies have brought the need for mental health care to the forefront and the discussion about insurance laws dominates the media, this report on the lack of access to psychiatric care has set off alarms across the mental health world.

As the number of insurance-covered Americans grows, the need for services will also grow and, without a corresponding expansion in availability by psychiatrists, more will inevitably turn to other forms of mental health care. One area that will undoubtedly undergo further scrutiny will be the issue of prescription privileges for psychologists.

The drive for prescription privileges across the country has largely died down over the past five to 10 years. Back in 2002, 31 states had created task forces to lobby their legislatures for prescription rights. Most failed and at this point, only New Mexico and Louisiana have made provisions for psychologists to obtain prescription privileges.

According to Sandra Rose, Ph.D., former committee chair for the Prescriptive Authority Committee of New Hampshire and past president of the New Hampshire Psychological Association, the push in New Hampshire has not been active in a number of years, although not because proponents do not see a need.

“The access issue has not gotten any better over the years,” she says. “I work in a community health center and we work with the underserved patients. There is hardly any option for psychiatrists who take Medicaid. Even though psychiatric nurse practitioners can prescribe, we can’t even recruit anyone. There is just no one to recruit.”

The American Psychological Association, which originally backed the drive starting with a task force created in 1989, has not seen much renewed interest yet, says spokesperson Luana Bossolo.

“It’s been known for a number of years that there is a shortage of psychiatrists particularly in rural areas where access to mental health services is an issue,” she says. “That said, historically, prescription privileges for appropriately trained psychologists has been a state level initiative. The APA Practice Organization is not aware of any New England states with prescription privileges legislation.”

Of course, even if the torch were re-ignited, there is no guarantee that it would get any further with another attempt. The arguments against it, including concerns of proper training, were strong enough to defeat most attempts in the past.

“Access to mental health care is a concern across the board,” says National Alliance for Mental Health spokesperson Bob Carolla. “Prescription privileges aren’t a solution to the shortage of psychiatrists that exists (independent of the insurance issue). For prescribing, the threshold concern is still medical training, knowledge and safety.

Bishop, who is also a primary care physician, hopes that further analysis of the data will bring us closer to an understanding of why psychiatrists are rejecting insurance payments.

“We are hoping to analyze more national data to further clarify the extent of access problems for patients with mental health needs and we plan on surveying or interviewing psychiatrists to better understand their reasons for not accepting insurance,” she says. “As we define the problem better and understand the reasons for the problem, we hope to implement and research solutions and policies.”