by Eugene Rubin MD, PhD and Charles Zorumski MD
Most Americans are eligible for Medicare once they turn 65. But will a person on Medicare be able to find a psychiatrist who accepts it when they need one? John Havlik and associates investigated the number of active psychiatrists who accept Medicare and reported their findings in an article recently published in JAMA Network Open. Following is a summary of the salient information from this research along with our thoughts about its implications.
Individuals eligible for Medicare select either traditional Medicare or a Medicare Advantage plan. In traditional Medicare, the government pays physicians via Part B benefits. Insurance companies are involved in hiring and paying physicians in Medicare Advantage plans.
In 2021, 62.6 million individuals had health insurance through Medicare. More than half of these individuals (about 35.6 million) participated in traditional Medicare. Data regarding the number of psychiatrists participating in traditional Medicare are available through public databases. Similar data are not available for Medicare Advantage plans.
Medicare also covers certain younger individuals with disabilities; however, this group makes up less than 18% of those insured by Medicare. Thus, over 82% of Medicare enrollees are older adults who qualify based on their age.
The number of psychiatrists and the number who participate in traditional Medicare
Havlik and co-authors gathered data regarding psychiatrists’ participation in traditional Medicare from January 1, 2014, through December 31, 2022. While the total number of active psychiatrists increased from 50,416 to 56,492 during this period, the number of psychiatrists participating in traditional Medicare decreased from 22,409 to 18,637. In other words, only about a third of psychiatrists participated in traditional Medicare, the insurance plan that covers over half of elderly Americans. This may not be surprising because fewer than 60% of psychiatrists accept any type of insurance.
The number of psychiatrists accepting Medicare varies widely among states
These investigators also examined the number of psychiatrists accepting traditional Medicare in each state adjusted for the number of individuals enrolled in traditional Medicare. The state with the lowest coverage was Wyoming with 13.8 psychiatrists per 100,000 enrollees. The state with the highest coverage was Rhode Island with 174.7 psychiatrists per 100,000 enrollees. There were four states as well as the District of Columbia with greater than 100 psychiatrists per 100,000 enrollees; nine states had fewer than 40 per 100,000 enrollees. In over half of states, the number of psychiatrists per enrollee billing traditional Medicare decreased from 2014 to 2022.
Thoughts
The number of psychiatrists accepting traditional Medicare is low and has been decreasing despite a 12% increase in the number of psychiatrists. Finding a psychiatrist to provide care for a senior with traditional Medicare is likely to be a challenge and especially difficult in certain states and in rural and underserved urban areas. Although data are not available regarding Medicare Advantage plans, there is no reason to believe that the numbers would be dramatically different.
Many forms of insurance do not reimburse psychiatrists at reasonable rates, which is one reason that many elect not to participate in any insurance programs. Traditional Medicare’s reimbursement rates are lower than many commercial insurance plans, so it is not surprising that only about a third of psychiatrists accept traditional Medicare.
On the other hand, there is tremendous societal need for psychiatric care in our elderly population. The number of persons 65 and older is rising—and the number of people 85 and older is dramatically increasing. Psychiatric and neuropsychiatric conditions, including mood and anxiety disorders and dementias, are common, and many older adults have complicated medical conditions that interact with psychiatric illnesses and their treatment. The expertise of psychiatrists is needed.
There is no easy solution for the limited psychiatric coverage of older adults. Higher reimbursement rates would likely lead to some increased participation by psychiatrists. Expanded use of collaborative care models in which psychiatrists oversee care provided by primary care physicians with hands-on care provided by non-MD mental health professionals would allow psychiatric expertise to reach more individuals. Decreasing the amount of time psychiatrists spend filling out computerized paperwork and negotiating with insurance companies would allow more time for direct patient care.
The elephant in the room is the fact that medical care in the United States is among the most expensive in the world per capita, yet it is associated with poorer outcomes than care provided in many other developed countries. Controlling costs and improving quality will likely require a major reorganization of our health care system. Developing a system in which physicians, including psychiatrists, can focus on patient care and spend less time on business and insurance issues would be a helpful start toward improving health care. Such a reorganization should also take advantage of public health initiatives aimed at illness prevention and early intervention.
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