The Hippo


May 26, 2020








Underpaid psychiatrists
Mental health disparities in N.H. linked to low pay

By Ryan Lessard

 Two recent reports point to continuing disparities in access to mental health care compared to medical care nationwide due to lower reimbursement rates for behavioral health specialists — and in New Hampshire, the issue is more pronounced than anywhere else.

The disparities
Ken Norton, executive director of the National Alliance on Mental Illness New Hampshire, said psychiatrists in the state experienced the greatest disparities in pay compared to other medical providers than any other state in the country. 
According to a report by Milliman, an international actuarial firm, New Hampshire topped the list of disparities between primary care and behavioral care reimbursements by Medicare in 2015, with a difference of about 69 percent. The national average was 21 percent. The report also found that psychiatrists were generally paid less than medical providers across the country for the same types of services, even using the same billing codes.
Norton said lower reimbursement for psychiatric services is feeding into the growing scarcity of mental health workers and psychiatrists specifically in the Granite State.
A national survey by NAMI found that people generally lack the same access to behavioral health providers as they have with medical providers. More than a third of respondents said they had trouble finding a therapist, compared to 13 percent who had trouble finding a medical specialist. 
And more people are going out-of-network to find mental health care. While 28 percent said they found a therapist out of their insurance carrier’s network, only 7 percent had to do the same for medical specialists.
Part of the problem is how few psychiatrists there are. A 2015 report by consulting firm Merritt Hawkins estimated the state has a little more than 140 psychiatrists. That’s a rate of 10.8 per 100,000, compared to a national rate of 12.4. Lisa Mistler of the New Hampshire Psychiatric Society said she thinks that number hasn’t changed much in the state over the past few years.
According to the NAMI report, nearly 91 million Americans live in regions with severe shortages of mental health professionals. It’s estimated that at least 1,846 psychiatrists and 5,931 other practitioners would be needed to meet the demand.
Norton said the difficulty finding therapists and psychiatrists in-network is tied to the low pay and reimbursements. Essentially, it’s driving behavioral health specialists to only accept direct payments as a way to get more money on par with workers in other medical fields.
“That could be because there’s such a shortage and such demand that people are just willing to pay, no matter what,” Norton said. “It was also cited [in the study] that many of them are in solo practices and they don’t want to get into the whole insurance billing piece. But the underlying theory was that they’re aware that they’re being reimbursed at rates much lower than their medical counterparts, and so they’re just not accepting insurance because they don’t want to get paid less.”
Matthew Davis, a psychiatrist and director of behavioral services at Portsmouth Regional Hospital, said chronically low pay for psychiatrists is frustrating for those doctors.
“If you work in medicine, psychiatry is one of the lowest-paid specialities across the board. It’s probably one of the two or three lowest-paid specialities out of 20 or 25 different medical specialities or subspecialities,” Davis said. 
But psychiatrists still have the same heavy student debt load as any other MD. As such, one of the things that exacerbates disparities in New Hampshire, Davis said, is the absence of a public medical school. He estimates public university med schools cost a fifth to a tenth in in-state tuition what it costs to attend a private school.
The other problem Davis sees is the extra time providers in behavioral services have to spend dealing with insurance providers to get authorization for things like medication to help suicidal patients or hospitalization. That time, he said, would be better spent treating patients.
“I think we, in spite of parity laws, still are confronted with those challenges pretty often,” Davis said.
In New Hampshire, mental health centers and hospitals are already losing a national talent war for psychiatrists, as the Hippo previously reported. Some of the general frustrations expressed by employers have included the high cost of recruiting and retaining behavioral physicians. 
Norton said it can cost between $250,000 and $500,000 just to recruit a psychiatrist from out of state. Meanwhile, the psychiatrists on staff are bombarded on a weekly or even daily basis with unsolicited recruitment offers from elsewhere. 
Plus, the shortage is getting worse as fewer med school students enter the psychiatric field — in part because of the well-known disparity in pay, Norton said.
Norton said fixing reimbursement disparities would be an important first step, but it wouldn’t fix the problem overnight.
“Even if there was parity at the moment, would that immediately solve the access issue? No,” Norton said.
Davis said the state also has a role to play in attracting health care talent in the state, and some initiatives like tuition forgiveness might be a way to do that. Another option would be some sort of reciprocity agreement with a public medical school in a neighboring state to give local med students a cheaper alternative and incentive to stay local.
“Things like that would be relatively cost-effective for the state and would really help to recruit and retain high quality people in an area that’s really underserved,” Davis said. 

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