Access to Coverage May Not Mean Access to Care in Mental Health, Psychiatrists Say

The Affordable Care Act's (ACA) promise of broader availability of healthcare coverage, coupled with a federal law aimed at ensuring that mental health coverage is on par with that of other items in a plan, should mean that those with mental health disorders will finally get better care, right?

The Affordable Care Act’s (ACA) promise of broader availability of healthcare coverage, coupled with a federal law aimed at ensuring that mental health coverage is on par with that of other items in a plan, should mean that those with mental health disorders will finally get better care, right?

Not necessarily, say 2 psychiatrists with experience in Massachusetts, where healthcare reform similar to the ACA has been in place since 2006. The psychiatrists, J. Wesley Boyd, MD, PhD, of the Cambridge Health Alliance and the Department of Psychiatry at Children’s Hospital Boston, and Amy Funkenstein, MD, who completed her general psychiatry residency at Cambridge Health Alliance and is now a chief resident at Brown Medical School, presented studies revealing the real-world hurdles that those with mental health disorders face when trying to receive care—even when they have insurance.

“The point of these studies is that simply expanding coverage is not enough to ensure that those with mental health disorders obtain care,” Dr Boyd said.

He and Dr Funkenstein were part of the panel, “How Obamacare Fails the People With Mental Illness,” which took place Saturday during the 167th Annual Meeting of the American Psychiatric Association, being held at the Jacob K. Javits Convention Center in New York City. Along with moderator Leslie H. Gise, MD, and Steven Sharfstein, MD, MPA, the panelists asserted that expansion of coverage under the ACA does not resolve the complexity of the US healthcare system, and Dr Sharfstein said that, in fact, the complexity is worse.

US healthcare reform’s failure to move single-payer reimbursement means that the system will retain many of the same incentives to withhold care from persons with mental health disorders, the panelists agreed. Dr Gise said a single-payer system “is not perfect,” but it would resolve many problems for mentally ill patients and their providers.

Dr Boyd was lead author of the study, “The Crisis in Mental Health Care: A Preliminary Study of Access to Psychiatric Care in Boston,”1 in which callers followed the script of a person with depression seeking follow-up care after an emergency department (ED) examination discharge. Callers made attempts with every in-network mental health facility within a 10-mile radius of downtown Boston, and they told potential providers (or left messages) that they had insurance coverage through Blue Cross Blue Shield of Massachusetts.

Of the 64 attempts, only 8 callers were able to schedule an appointment. Another 15 were told they could only schedule an appointment if they were a patient of a primary care physician within the system. Fifteen calls were never returned after 2 attempts, 8 had no availability, and 6 specialized in youth or addiction services only.

Dr Boyd said that because reimbursement for mental health services is so poor, hospitals do not encourage care because treatment of those with mental health disorders results in financial losses for the facility. And, he said, such deterrents work. “Imagine if you are a depressed person,” Dr Boyd said. How likely is that patient to persist in calling to get a follow-up appointment, he asked?

Dr Funkenstein’s presentation, “Insurance Preauthorization: Rationing by Hassle Factor,” was based on her 2013 study2 of the challenge that goes on in EDs every day: getting approval from insurance carriers for a patient to be admitted for psychiatric care. Working with fellow residents, Dr Funkenstein asked them to keep logs of how many minutes it took to gain admission, along with the result. Although the residents noted that in extraordinary cases they did not fill out the survey form, Dr Funkenstein collected 53 data sheets with an average time of 38 minutes to obtain admission, with a few “outliers” of 80 to 85 minutes. Dr Funkenstein said she is in the midst of a much larger study involving more precise data-gathering, and so far the average approval time is 54.3 minutes.

“They are approving every admission,” she said of the payers. “This is just a hoop to go through. I’m not entirely sure what this is saving them; I know it’s not saving us anything.”

When asked by The American Journal of Managed Care if this process is a reason hospitals lose money on mental health, as Dr Boyd referenced, Dr Funkenstein said that it was, and that she would welcome a cost analysis of how much both hospitals and insurers spend for personnel on a process that almost always results in admission.

A psychiatrist in the audience said he agreed that prior authorization was a problem, but he cautioned that for-profit substance abuse facilities would overbill if there were no restrictions. In an exchange, he and Dr Funkenstein agreed that there were ways for payers to absolve high-performing facilities of administrative burdens, if they chose to do so.

Both studies were published in the Annals of Emergency Medicine, in part because the psychiatrists said that ED physicians would immediately appreciate the importance of their results. Funkenstein’s study triggered a response from Massachusetts’ attorney general, whom she said is examining a possible ban on routine prior authorizations.

Dr Sharfstein, who operates a mental health facility in Maryland, said the healthcare bureaucracy, both among government regulators and within payers, is a significant contributor to cost in the United States. “We deal with 60,000 patients and 1200 different payers. We have 30 full-time people who just try to sort out (the) insurance, not even prior authorization, just to get the bills paid. A similar hospital in Canada would have 1 or 2.”

Dr Boyd said the unless the system changes, payers will continue to set up structures to shave days off hospital stays or trim services in other ways, because many are publicly traded and obligated to make money. “If profit is your main motive, you’re going to do what you can to limit access to your service,” he said.


  1. Boyd JW, Linsenmeyer A, Woolhandler S, Himmelstein DU, Nardin R. The crisis in mental health care: a preliminary study of access to psychiatric care in Boston. Ann Emerg Med. 2011;58(2):218-219.
  2. Funkenstein A, Malowney M, Boyd JW. Insurance prior authorization approval does not substantially lengthen the emergency department length of stay for patients with psychiatric conditions. Ann Emerg Med. 2013;61(5):596-597.