A standard joke among the elites of New York City And Los Angeles is that everyone is in therapy - it's possible because they are likely more rich and, it turns out, many psychiatrists are not interested in patients who aren't wealthy enough to not need to use insurance to pay.

But Congress, motivated by public outrage at recent mass shootings and their link to psychiatric medications, want mental health care to be covered by insurance and for psychiatrists to have the same standards as government-paid doctors have.

The paper found that psychiatrists increasingly refuse to accept Medicare and Medicaid, or even private insurance, as payment. In the five years between 2005 and 2010, investigators found that the percentage of psychiatrists who accepted private insurance dropped by 17 percent, to 55 percent, and those that took Medicare declined by almost 20 percent, also to about 55 percent. Their acceptance of Medicaid is 43 percent, the lowest among all medical fields.

"More than physicians in other specialties, psychiatrists accept lower rates of insurance, and those who don't take insurance are likely charging cash for their services," says the paper's lead author, Dr. Tara F. Bishop, an assistant professor in the Department of Public Health and Medicine at Weill Cornell Medical College.

The number of psychiatrists also dropped 14 percent between 2000 to 2008, likely because psychiatrists are retiring and medical students are choosing to go into more evidence-based medicine. It isn't lack of demand. Today, the Centers for Disease Control and Prevention estimate that a quarter of adults in the United States report having a mental illness at any given time, and that about half of adults will suffer from one in their lifetime. 

"In the current climate, where the need for increased mental health services is now recognized, I suspect our study conclusions will be an eye opener for both the public and the medical community," she says. "I must say we were surprised by the findings. No prior studies have documented such striking differences in insurance acceptance rates by psychiatrists and physicians of other specialties -- primarily because no one has looked closely at the issue."

These low insurance rates may "impact recent calls for increased access to mental health services, and if the trend of declining acceptance rates continues then the impact may be even more significant," the researchers say in their study.

"For example, not only are there fewer physicians who can help people with moderate to severe symptoms of mental illness, those patients must then try to find a doctor who will take their insurance," Bishop says. "This is not a formula for success." 

Solo practitioners less likely to accept insurance

The Weill Cornell investigators, working with researchers from Columbia University and the University of California, San Francisco, used a nationally representative survey to conduct their study. That database is the National Ambulatory Medical Care Survey (NAMCS), administered by the Centers for Disease Control's National Center for Health Statistics (NCHS). It represents about 90 percent of the ambulatory care delivered in the United States -- the care provided in private physician offices or group practices, Dr. Bishop says.

The database does not include psychiatric outpatient clinics linked to hospitals or large medical centers. "Some patients with some of the most severe mental illnesses, such as schizophrenia or bipolar disease, may be cared for in those clinics, and this database does not capture that population," she says.

The average number of physicians surveyed each year by the NAMCS is about 1,250, and psychiatrists represent 5.5 percent of these doctors.

The researchers don't know why psychiatrists are increasingly rejecting insurance payment; questions about motivation were not included in the survey. "But we can speculate that insurance provides lower reimbursement rates than psychiatrists feel cover the costs of care," Bishop says.

Yet other doctors can, so does that mean that psychiatrists are less interested in the public good than other doctors? Perhaps, but there is also a time factor. General physicians and even other specialized doctors can often see a few people an hour, but the therapy prized by elites is usually about an hour in length, so psychiatrists may not be able to see as many patients in a day as physicians of other specialties can.

About 60 percent of psychiatrists work alone and accepting insurance entails administrative work, which they may not want to pay people to do. Solo practitioners are less likely to accept all types of insurance.

Bishop advocates offering incentives to medical students to pursue psychiatry and even increasing insurance payments to practicing psychiatrists, which would seem to do little except cause all doctors to stop taking insurance so they could get more money from the government also.

Published in JAMA Psychiatry