Only 15 percent of phone calls requesting psychiatric appointments for Medicaid patients resulted in an appointment in Los Angeles, the lowest percentage of four cities in a “mystery shopper” audit, the researchers found.
Los Angeles also had the longest wait times, with a median wait of 64 days, more than twice as long as in New York or Chicago and nearly six times longer than the median wait in Phoenix, mystery shoppers found.
The findings, published Wednesday in a JAMA research letter, underscore long-standing concerns about Medicaid recipients’ inability to access mental health care when they need it.
Previous research has shown that psychiatrists are less likely than other doctors to accept Medicaid, a public insurance program for low-income people. Potential patients’ headaches are exacerbated by what critics call “shadow networks,” in which health insurers list medical providers in their directories who don’t accept new patients, don’t take their insurance or are otherwise inaccessible to patients.
As a medical student at Weill Cornell Medical College trying to track patients leaving the hospital, “one area where I constantly hit a wall was scheduling outpatient mental health appointments,” said Dr. Diksha Brahmbhatt, who helped lead the audit and is now a resident physician at Brigham and Women’s Hospital in Boston.
For one young man on Medicaid, “it took about an hour and a half to try to get an appointment for him” — and he was scheduled about 40 days after he was discharged, Brahmbhatt said.
Such experiences led her to ask: “How big is this problem, especially in urban areas where you might expect access to actually be better for patients?”
To see what Medicaid patients might encounter when seeking psychiatric care, researchers at Weill Cornell Medical College randomly selected dozens of “psychiatric prescribing clinicians”—psychiatrists, nurse practitioners and physician assistants—who were listed as accepting new patients by the largest managed care plans for Medicaid patients in each city, then called to request the nearest available appointment.
They found that fewer than 18 percent of the listed doctors they tried to contact were reachable, accepted Medicaid, and could schedule an appointment for a new patient enrolled in the insurance program. Even among psychiatric providers who were able to schedule an appointment, wait times could be as long as six months.
Overall, only 27.2% of the practices contacted had an appointment available for a Medicaid patient, either with the scheduled provider or with another provider in the same practice. In Los Angeles, that rate was just 15%, compared to 27.5% in Chicago, 30% in Phoenix, and 36.3% in New York. Wait times were also much longer in Los Angeles.
The JAMA letter did not speculate on why such appointments might be rarer or wait longer in Los Angeles. Brahmbhatt said the study was not designed to examine such differences, and the number of offices they called — 320 in total — limited their ability to draw conclusions.
Health economist William L. Schpero, one of the researchers who conducted the audit, said that “the access problems we identified are likely the product of multiple factors,” including “inaccuracies in plan directories, clinician reluctance to participate in Medicaid, and a shortage of psychiatric clinicians in some areas.”
“Which of these factors, among others, is primarily driving the relatively low appointment availability we saw in Los Angeles requires further research,” Schpero said.
Schpero and Brahmbhatt found that among psychiatric providers with whom they could not make an appointment, 15.2% had listed phone numbers that were incorrect or out of service, and 35% did not answer the phone after two attempts.
This is a patient population that “already faces many barriers to getting the care they need” and may already be struggling with mental health symptoms when they seek an appointment, Brahmbhatt said.
If they encounter barriers, they are “even more likely to disengage from the health system.”
In California, lawmakers are considering a bill that would require health insurers to maintain accurate listings or face fines. The bill, AB 236, would gradually impose requirements to increase the accuracy of provider directories, starting with at least 60% next summer and increasing to at least 95% by July 2028. Fines for inaccurate listings could be as high as $10,000 for every 1,000 people insured by a health plan, and those penalties could be adjusted upward over time.
“When Californians can’t find a provider, care is delayed or more expensive,” said Katie Van Deynze, a policy and legislative advocate at the consumer advocacy group Health Access California, which sponsored the legislation. “AB 236 puts health insurance plans on a path to improvement, so patients no longer have to call lists of outdated providers who have moved, retired or aren’t accepting new patients.”
The California Department of Managed Health Care estimated in January that implementing the bill could cost up to $12 million a year in additional staffing, but a department spokesperson said it was updating its estimate based on the latest version of the bill ahead of a hearing Monday.
The January estimate was based on “additional workload to promulgate regulations and guidance, develop methodology and review plan documents for compliance” and other tasks needed to meet the bill’s requirements, department spokesman Kevin Durawa said in an email.
In June, AB 236 was supported by the National Union of Healthcare Workers and the National Multiple Sclerosis Society, among others, but rejected by industry groups including the California Assn. of Health Plans and the California Medical Assn.
Mary Ellen Grant, vice president of communications for the California Assn. of Health Plans, said her members understand the frustration over inaccurate listings, but that “AB 236 does nothing to address the root cause of the problem” and “simply places the entire responsibility for the accuracy of provider directories on health plans.”
Their accuracy “depends largely on the ability of providers and medical groups to maintain their own accurate records and provide that information to health plans in a timely manner,” the group said. “The bill fails to recognize this shared responsibility” and is “unfairly punitive against health plans.”
