“I’m sorry, but I’m unable to take on new patients at this time.”
I’ve said that line hundreds of times in the 15 years since I started my solo private practice in psychiatry. I feel terrible each time I say it. Someone on the other end of the phone is suffering and has taken the difficult step to call for help — probably multiple calls, given the longstanding shortage of psychiatrists — and yet I added to their hopelessness.
For most of my years in practice, I was in-network for some insurance; I’ve always felt strongly about helping a diverse group of patients, not just those who can afford to pay private practice rates. Like most doctors coming out of residency, I was taught that (a) working for a hospital yielded both the safest career path and the most diverse group of patients, and (b) taking insurance facilitated that diversity. Departmental administration conveyed that doing otherwise essentially meant selling your soul — you’d be consigning yourself to caring for “the worried well,” affluent suburbanites with the purported psychiatric equivalent of paper cuts. Implicitly, they were asking, “What about your societal commitment? Isn’t that why you got into medicine? Isn’t that what we’ve been working so hard to instill?”
I became increasingly skeptical of that message as residency progressed. Despite various duty-hour regulations and ostensible protections, the problematic working conditions combined with limited institutional support pushed me away from hospital-based clinical work. I enjoyed seeing patients, though, and didn’t want to flee to the relative safety of research or working in hospital administration. I decided to start a private practice and avoid the soul-selling trap by both taking insurance and providing very generous fee-scaling arrangements to patients for whom paying privately would be a financial burden. I kept overhead low by doing everything myself: the care (both therapy and medication management), the documentation, the billing, the calls, and the scheduling. My practice filled quickly, driven primarily by the tremendous mismatch between psychiatrist supply and demand. I soon had to start telling prospective patients that my practice was full.
At the same time, I found myself spending increasing amounts of time on the phone with insurance claims service representatives. At first, the issues involved paper claims that simply disappeared into the ether or were rejected because I had included too much or too little information. Filling out the forms became like defusing a bomb — be exceedingly careful about which wires to cut and which wires to leave alone, and maybe, just maybe, I’d receive payment a couple of months later. Slight deviations from the insurer’s opaque and ever-changing protocol would necessitate resubmitting the claim, even after waiting several weeks to hear back. Once the insurers permitted me to start filing online, the claims stopped disappearing, but the denials persisted, often for no apparent reason.
I increasingly allocated blocks of time every day to address claims problems, such that my administrative time started exceeding my clinical time. I logged each call in a spreadsheet so that when the reimbursement failed to materialize several weeks later, I could cite the relevant claims reference numbers to help the service reps locate my calls in their database, saving us precious minutes of time. I grew to know which service reps were helpful and unhelpful, and I’d hope before each call that I’d get lucky and reach one of the good ones. I considered hiring a billing service, but adding expenses and another layer of bureaucracy to address the first layer seemed counterproductive.
My breaking point came in 2022 with claims involving an older patient whom I’d treated for more than a decade. Despite a half-dozen calls over several months, at roughly 30 minutes per call (including the time spent navigating the lengthy automated menus and on hold), the insurer continued to deny the claims, stating that I should’ve submitted them to a different insurer. Each conversation ended with the service rep’s acknowledging the insurance company’s error, stating that the claims would be reprocessed, and asserting that I would know the outcome in a few weeks. Notably, the insurer’s portion of each of the five visits was a mere $30. I routinely debated just writing off the charges, or at least the insurer’s portion thereof. But if I were going to write it off, why take insurance altogether?
Meanwhile, throughout these months, I informed numerous prospective patients that I had no time available to see them. I did not tell them that I’d have more availability if I weren’t spending hours arguing with their insurance reps, trying to get paid $30 for work that everyone agreed I had performed.
Finally, I realized that from the insurer’s perspective, the numbers mattered more than the care: The insurer was getting paid from the premiums of my patient, and from the premiums of prospective patients, all while denying me payment for my work and preventing me from doing additional work. This is the business model — customers pay for the right to be deprived of the product they’re purchasing. I decided I would stop spending portions of my days fighting that model, and instead I’d follow most other solo practitioner psychiatrists who do not take insurance.
In late 2022, I notified the insurer of my intent to terminate our contract, and I prepared my patients for the transition. My first year post-insurance has gone reasonably well, albeit with some obvious challenges. I’ve kept nearly all of my patients, with some sacrifices on all of our parts. I have had to increase my already liberal fee-scaling, which reduces my income but allows me to continue to treat my longtime patients. Some of my patients — those who can afford it — have seen their out-of-pocket costs increase; many patients with out-of-network benefits are now submitting their own claims to get reimbursed for our appointments. So far, while the insurers have been somewhat slow to reimburse my patients, outright denials of claims have diminished. Most importantly, I’ve had more time to see patients. I’ve seen more new patients in the past six months than I did in the previous three years. While my practice revenues fell 10% (not counting inflation) in 2023, I am serving more patients in total. But asking clinicians to see more patients for less money is not a sustainable path to improving access to mental health care.
My experience runs counter to the prevailing psychiatric narrative that insurance = access. Commercial insurers primarily serve the interests of investors and/or highly paid executives, whether corporate or “nonprofit.” Their salaries indicate society values them more highly than clinicians in addressing the current mental health crisis, but these individuals’ interests are often misaligned with the public good. The insurance business model saps clinic revenues, so clinic administrators consequently push mental health clinicians to see more patients in less time. Dissatisfied clinicians then depart for out-of-network private practice, or shift into academia or administration, where they see far fewer patients, if any at all. If we care about solving the mental health access equation, we need to understand where the dollars flow.
How can we bring psychiatrists like me back into the networks used for other aspects of our health care? For starters, insurers could signal meaningfully that they actually want psychiatrists in-network. Insurers’ management of reimbursements clearly conveys the opposite, and understandably so — an outpatient clinician’s main utility to an insurer is to reduce costly hospital admissions and procedures. Psychiatry has few procedures, and the dearth of psychiatric hospital beds often makes inpatient admissions infeasible even in emergencies. Thus, while my actions help patients get back to work, care for their children, communicate respectfully with others in their communities, and feel better about their lives and their potential, none of these activities generates revenue for insurers.
From the insurers’ perspective, psychiatrists add value in two ways. First, we divert medically anxious patients from seeking costly tests via other doctors. Second, and more important, we serve as window dressing for potential customers of insurers, which market policies with ostensible mental health benefits.
I entered psychiatry not to join the advertising division of an oligopoly, but rather to help people in need. Until insurers — or legislators — value psychiatrists’ less-tangible contributions to society, in-network psychiatry will be increasingly confined to hospital-based clinics that have their own complicated motives. And we will be left hoping that some psychiatrist somewhere is available to help those in crisis.
Andrew Popper is a psychiatrist in solo private practice. He is a volunteer faculty member at Harvard Medical School and at Brigham and Women’s Hospital.