Medicaid Enrollees Struggle to Receive Psychiatric Care

William Schpero, PhD

Credit: Weill Cornell Medical College

A recent study revealed Medicaid enrollees struggle to receive psychiatric care.¹ The largest Medicaid-managed care plans across 4 US cities only had 17.8% of psychiatrists or mental health professionals listed as in-network for Medicaid who were reachable, accepted Medicaid, and could provide a new patient appointment.

“We’ve long known that relatively few psychiatrists participate in the Medicaid program, which compromises access to necessary care,” said senior author William Schpero, PhD, assistant professor of population health studies at Weill Cornell Medicine and co-associate director of the Cornell Center for Health Equity, in a press release.² “This is compounded by the issue identified in our study: even among psychiatrists listed as participating in Medicaid, actual access to care is apparently quite low.”

Nearly 40% of Medicaid enrollees have mental health issues.³ The prevalence is greater than that of mental disorders in the general worldwide population, where 1 in every 8 people is affected, according to the World Health Organization.⁴ Despite Medicaid enrollees having a greater prevalence of mental health problems, they also are the ones to have lower access to psychiatric care.¹

Psychiatrists are less likely than other clinicians to accept Medicaid. A claims-based study of 2018 Medicaid managed care directories found in some plans > 90% of listed mental health care providers did not actively participate in the Medicaid program. However, the studies did not assess wait times or enrollees’ experiences with accessing care.

A recent mandate from the Centers for Medicare and Medicaid Services now obligates states to perform independent secret shopper surveys to assess network adequacy in Medicaid-managed care. Investigators conducted a “secret shopper” audit study to evaluate availability and wait times for adult appointments with psychiatrists or mental health professionals across 4 of the largest US cities: New York City, Los Angeles, Chicago, and Phoenix. These states had all expanded Medicaid eligibility under the Patient Protection and Affordable Care Act.

The team selected 80 random psychiatric prescribing clinicians, such as psychiatrists, nurse practitioners, and physician assistants, listed in the provider directories for the Medicaid-managed care as accepting new patients. They used a standardized protocol and calling script during which 5 investigators called clinicians during normal business hours between May 12, 2023, and July 6, 2023, posing as Medicaid enrollees seeking the earliest appointment. If the clinician could not provide an appointment, the callers asked for a consultation with another clinician at the same practice.

Investigators kept track of appointment availability, wait times, and reasons an appointment could not be made. They then compared the 4 cities’ appointment availability using χ2 test with Bonferroni correction and wait times using a 1-way analysis of variance test.

After calling 320 clinician offices, 27.2% (n = 87) had available appointments. Among the sampled clinicians, only 17.7% had availability, and 9.4% of the alternate clinicians at the same practice had availability. Callers were most likely to get an appointment in New York (36.3%), followed by Phoenix (30%), Chicago (27.5%), and Los Angeles (15%). As seen here, New York and Los Angeles had significantly different appointment availabilities (P = .002).

The median wait times were 11 days (IQR, 6 – 20 days) in Phoenix, 23 days (IQR, 9 – 35 days) in Chicago, 28 days (IQR, 11 – 84 days) in New York, and 64 days (IQR, 24 – 126) in Los Angeles, the longest by far. Phoenix and Los Angeles had significantly different wait times (P = .001), as with Phoenix and New York City (P = .03) and Chicago and Los Angeles (P = .049).

Among the 263 clinicians who could not make an appointment, 15.2% had an incorrect or out-of-service listed number, and 35% did not answer the phone.

Investigators said the study was limited by not comparing Medicaid enrollees with people who have commercial health insurance. Also, investigators only called practices in urban areas and requested an appointment for depression. Thus, the findings may not generalize to rural areas or patients seeking treatment for other psychiatric conditions.

“Most states have outsourced the provision of the Medicaid benefit to private health plans,” said Diksha Brahmbhatt, MD, from Weill Medical College of Correll University, the first author, in a press release.² “It is up to states—with guidance and oversight from the federal government—to ensure these plans construct networks of mental health professionals who don’t just participate in Medicaid on paper, but meaningfully make appointments available to enrollees.”

References

1. ^{Brahmbhatt D, Schpero WL. Access to Psychiatric Appointments for Medicaid Enrollees in 4 Large US Cities. JAMA. Published online July 31, 2024. doi:10.1001/jama.2024.13074}
2. ^{Medicaid Enrollees Struggle to Find Psychiatric Care. EurekAlert! July 31, 2024. https://www.eurekalert.org/news-releases/1053219. Accessed August 5, 2024.}
3. ^{Guth, M, Saunders, H, Corallo, B, et al. Medicaid Coverage of Behavioral Health Services in 2022: Findings from a Survey of State Medicaid Programs. KFF. March 17, 2023. https://www.kff.org/mental-health/issue-brief/medicaid-coverage-of-behavioral-health-services-in-2022-findings-from-a-survey-of-state-medicaid-programs/#:~:text=Nearly%2040%25%20of%20the%20nonelderly,because%20of%20their%20low%20incomes.. Accessed August 5, 2024.}
4. ^{Mental Disorders. World Health Organization. June 8, 2022. https://www.who.int/news-room/fact-sheets/detail/mental-disorders. Accessed August 5, 2024.}