Getting psychiatric care in the United States is a lot harder than it should be. Patients around the country are having a hard time booking appointments for outpatient care and face significant hurdles when it comes to receiving inpatient psychiatric care. Why is this the case?

This is largely because there just aren’t enough psychiatrists to meet demand.  This is even more true for child and adolescent psychiatrists.

First, few medical students choose to enter psychiatry. This is partly because many medical students implicitly or explicitly get the message from classmates, teachers and the general public that psychiatry is not “real” medicine.

In medical school students are usually exposed to inpatient psychiatry instead of outpatient psychiatry, despite the fact that practicing psychiatrists overwhelmingly work in outpatient settings. And many students simply don’t find inpatient psychiatry appealing. Not surprisingly, exposure to outpatient psychiatry in medical school is correlated with far greater numbers of medical students choosing to go into the field.

To compound matters, psychiatrists are paid less than other doctors. This is partly because mental health is often carved out of general medical coverage and then managed under a different set of rules, often by an aggressive for-profit company. Profits increase when patients can’t actually use mental health services promised to them by their insurance plan.

Health insurance companies also make it as hard as possible for patients to access needed care. Even if these services are covered under their insurance plans, patients and doctors still face hurdles in arranging for mental health services.

One way of doing this is to require prior authorization. For instance, before a patient can be admitted to an inpatient facility for treatment, even when the care is urgent, the clinician must receive prior authorization from an insurer.

One study found that clinicians spend an average of 38 minutes on the phone with insurers obtaining authorization for payment. And this is after clinicians deem a patient to be in need of admission to an inpatient facility, usually because of suicidal thoughts or plans.

The prior authorization requirement was likely put in place to discourage clinicians from admitting patients. As such, it amounts to rationing health care by making it a hassle to access needed services.

Getting outpatient care isn’t much easier. Insurers maintain narrow lists of in-network providers, effectively punishing patients who see a provider who is not in their network. And the list of in-patient providers that they do maintain is often loaded with meaningless names and numbers.

The requirement of having a primary care provider is, in fact, a stealth way that facilities limit the amount of psychiatric care they provide. Given that insurers pay so little for psychiatric care, anything these facilities offer is generally done at a financial loss. Because it is a money loser, health care facilities often place stringent limits on access to mental health services

These findings are in line with national data demonstrating that two-thirds of primary care physicians in the U.S. cannot obtain outpatient mental health services for patients who need them. These and other findings add to the growing evidence that the mental health system is difficult for consumers to access.

No doubt, more psychiatrists would increase access. Making psychiatry a more appealing field for medical students to enter, including through measures such as integrating psychiatric care with primary care to reduce stigma and offering much greater exposure to outpatient psychiatry would help. So would increased reimbursements for psychiatric care.

If we had a health care system that was not profit-driven — an improved Medicare for all system would be ideal — then one could wager that many of the impediments to accessing needed psychiatric care could be eliminated and patients could receive the care they need without unnecessary obstacles that seem set up only to generate greater profit for insurers.


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