We cannot reasonably expect physicians to fill the gaps in care if insurance companies do not make the environment conducive to doing so in a time of high medical school debt (on average, $180,723) while physician salaries overall are actually declining. They must incentivize insurance participation in ways that will not produce losses for the doctors seeking to provide care while getting out of debt and reaping the rewards of their hard work. Yet with 46.8% of respondents citing the reason for unmet mental health care being cost or insurance issues, the dearth of adequate care for those of lower and middle classes must be addressed.
One potential avenue to balancing insurer and physician priorities in healthcare provision is to provide government tax credits to insurance companies willing to provide higher reimbursement rates for the less lucrative, but clearly evidence-based psychotherapy, primary care, and geriatric care. While primary care physicians are not trained as psychiatrists (beyond a psychiatry rotation in medical school), they currently provide approximately half of the mental health treatment in the country, with approximately 25% of primary care patients having a diagnosable mental health condition. Yet the national-level starting salaries in general internal medicine, geriatrics, and psychiatry are $180,000, $184,000, and $185,300 respectively, compared with, for example, $232,500 in OB/GYN, $325,000 in hematology/oncology, and $337,500 in gastroenterology. The rates of reimbursement do not incentivize entering these fields in the first place, leading to marked shortages of psychiatrists such that 59% of specialists are at least 55 years old. Moreover, once within a given specialty, the insurance system’s current schedule of reimbursements does not incentivize engaging in the well-supported but less lucrative aspects of the field (e.g., a 45-minute psychotherapy session with a psychiatrist as opposed to three 15-minute medication management appointments).
The shifts in insurance reimbursement rates should take a few forms. Given the pressures that primary care physicians face in providing mental health care, insurance companies should allow physicians to bill for longer or more involved appointments when mental health interventions are required extending beyond a simple check-in on symptoms, vitals, and medication management. Absent the ability to do so, physicians are effectively taking losses when providing that added (and needed) care for these higher need patients.
The ability to bill insurance for higher rates for primary care appointments will do much to address the shortage of primary care physicians that the United States faces, and within that to address the shortcomings in the earnings that existing PCPs face when addressing their patients’ mental health (and other complex) needs. This ability to bill more for longer appointments will be particularly essential in the domain of geriatrics, given that not only do we have a shrinking number of geriatricians despite an aging population, but the needs of such patients are often diverse and spanning both physical and mental health.
Second, having higher “customary and reasonable” rates for psychotherapy will allow for psychiatrists (and non-MD psychotherapists) to practice the well-supported psychotherapy and integrated therapy and medication, without experiencing the same financial deficits that they do currently. Insurers typically designate the “usual and customary” fee for a 45-minute psychotherapy session to be $225 in New York City even if a practitioner’s private practice rate is $300 or more (which in that region is quite common), compared with a "usual and customary fee of $125 for a brief medication appointment (meaning 3-4 of such appointments per hour). It is not difficult to see why one would be less than inclined to accept insurance for psychotherapy, especially given the added burdens of claim submissions and the like. While not being as lucrative as multiple medication management appointments per hour, raising the “usual and customary” fees to better approximate the average charges for psychotherapy in the region will help to close the gap and do more to encourage such a practice of more integrated mental health treatment. Indeed, by raising by $50 the fee recognized by insurance, psychiatrists could raise in-network earnings expectations by tens of thousands in annual income if operating a full-time practice.
Changing insurance reimbursement schedules to such a degree is far from a costless enterprise, which poses particular challenges given that private insurance companies are by definition for-profit and yet have already in many cases reported losses in recent years in the aftermath of the Affordable Care Act. In addition to ensuring these changes within the government-sponsored health plans, providing government-sponsored tax incentives for private insurers to adopt these changes for all plan participants would nevertheless be an important first step in triggering these improvements to the American healthcare system, allowing physicians the greater financial freedom to enter areas of medicine in which we have a dearth of practitioners, and once practicing, to provide the best evidence-supported medicine.
So often, we express woes as to the extent to which we spend money on the American healthcare system and yet obtain poor results. Indeed, one in every six dollars contributed to the US GDP spent on healthcare but compared with other nations, the US has a lower share of residents covered, fewer hospital and physician visits, and high rates of obesity, infant mortality, and chronic disease such as diabetes and heart disease. This can be disheartening to policymakers and advocates who understandably seek to see positive outcomes emerge from such heavy investments. It is only natural to want money to be well spent, not to mention to want a population physically and emotionally healthy enough to be productive in a diverse economy. While reducing healthcare spending is unlikely to be the solution given the immense gaps in care, reallocating healthcare spending might be.
Better facilitating integrated physical and mental health will be essential to the progress that the United States hopes to make in this domain. By ensuring mental wellbeing, individuals may be more invested in staying on top of their physical wellbeing, and may be less prone to such issues as substance abuse. When well cared-for physically, the stressors and anxieties of health may be alleviated. And while we paint in broad strokes the need to do better in this regard, we have done little to improve the means to ensure better care for those who cannot afford massive out-of-pocket expenses. Incentivizing insurers to make it more financially sound to enter the areas of medicine at the forefront of the physical and mental health integration – primary care, geriatrics, and psychiatry – and to incentivize modes of care better supported by evidence-based medicine (whether the ability to bill more for longer primary care and geriatric appointments when addressing additional mental health concerns, or the use of psychotherapy in addition to medication) – will be essential starting points en route to ultimately mandating insurers’ provision of such higher levels of coverage. It will additionally offer health researchers evidence on the effectiveness of such incentive structures in encouraging broader in-network participation, and the responsiveness of patient populations as we work to improve US health outcomes.
Public health and economics can certainly be at odds with one another, but they needn’t be when looking at the potential cost savings of avoiding hospitalization (whether physical or psychiatric) or problems associated with prescription drug non-adherence or being on disability or unemployment insurance due to the exacerbation of physical and/or mental illness. Smart investments today can yield payoffs down the line.