This story is the third installment in a five-part series on mental health care. Click here for the entire series.

Credit Mary Rose Madden

Millions of Americans are expected to have expanded mental health and substance abuse benefits underObamacareand the 2008 Mental Health Parity Law.

But finding a therapist, psychiatrist, or hospital bed will remain a challenge.

Michael Hoge, a professor of psychiatry at the Yale School of Medicine, says the shortage of mental health and substance abuse professionals is already at a crisis point, “the most sophisticated data we have is that 77 percent of the counties in the United States have a severe shortage of psychiatrists.”  Even for patients looking for therapy without medications, he says the federal government has found 20 percent of counties have a significant need for providers like social workers, psychologists, and outreach workers – and this is before the Affordable Care Act takes effect.

Another example of the workforce shortage: non-profit behavioral health organizations report high vacancy rates and high turnover rates that range from 20-40 percent.  They have a lot of trouble filling their job posts and if they do, it’s hard to keep them filled.  On top of that, Hoge adds, there are many reportsof people who can’t find psychiatrists and other therapists who take insurance.   

The main reasonnon-profits are struggling to keep the “front line” folks who answer calls and coordinate care--and the reason psychiatrists don’t take insurance - is money, he points out:  “one of the major problems is that reimbursements for mental health providers are very, very low”.

Susan Pisano from AHIP, America’s Health Insurance Plans, denies low reimbursement rates are a problem for mental health professionals.   She said, “it’s certainly quite common for various professionals to make the argument to health plans that they should be reimbursed at a higher level.   What health plans are trying to do is make a really good insurance product available to the public that provides good value and is affordable”.

The result is that an existing shortage of mental health professionals grows worse because many of them refuse to take insurance. Experts say another result is that more and more primary care physicians are being called upon to provide mental healthcare.  Steven Sharfstein, president and CEO of Sheppard Pratt in Towson, says for relative minor ailments that makes sense. But, he says, “we know most people do best when they have a combination of talk and medication.  They have to write prescriptions WELL.  They need guidance from an experienced psychiatrist”.

State leaders say the guidance could come through telemedicine: doctors skyping and video chatting.  But there’s also a shortage of primary care physicians, which intensifies the problem.  Sharfsteinsays the heart of the issue is the severe shortage of psychiatrists and behavioral health professionals.  He says, “most insurance companies discourage psychiatrists from being a part of their network.  They like to have smaller networks.” StevenSharfsteinadds the shortage of professionals suits the insurance companies just fine. 

Not so, says Pamela Greenberg whose organization, the Association of Behavioral Health and Wellness, represents behavioral health insurance companies, “we need providers in our network or we won’t be able to operate and providers often times need to take insurance because that’s where people want to go”.  There’s a shortage overall, yes, she says, but the psychiatrists who are out there and not taking insurance will ultimately join the insurance networks because consumers will want to use the insurance they bought. And they won’t have the money to pay out of pocket.

But many say it’s unlikely to change, despite new laws. People will buy health insurance, but still have to pay full price for mental healthcare.

And mental health care will remain a luxury to many.

“It was always the medication, the mental healthcare that went first,” says Jared Wilmer, 29, who was diagnosed when he was 19 with Bipolar Disorder.  He says the out of pocket costs for therapy and medication were hundreds and hundreds a month, “I would convince myself I didn’t need it or cut my dose in half to make it last longer”. 

Wilmer says jumping between therapists, psychiatrists, and medication made him feel like he was starting all over – with whatever progress he had made – gone.

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