Good afternoon. My name is Dr. Michael Silver. I am the Chief Medical officer at The Providence Center
where I have practiced for 39 years. I am speaking this afternoon on behalf of the Rhode Island
Psychiatric Society.
I would like to talk for a little bit about what it feels like to be a community-based psychiatrist in Rhode
Island.
First, we are a group that is shrinking, when we need to grow to meet unmet community needs.
A recent survey by the Association of American Medical Colleges found that 59 percent of psychiatrists
are 55 or older, the fourth oldest of 41 medical specialties, signaling that many may soon be retiring or
reducing their workload.
According to the American Medical Association, the total number of physicians in the U.S. increased by
45 percent from 1995 to 2013, while the number of adult and child psychiatrists rose by only 12 percent,
from 43,640 to 49,079. During that span, the U.S. population increased by about 37 percent; meanwhile,
millions more Americans have become eligible for mental health coverage under the Affordable Care
Act.
Nationally, the number of psychiatrists graduating from residency programs from 2007-2013 was
essentially flat, showing a slight uptick in 2015.
Over the last several years, the General Assembly and other state leaders have focused attention on the
shortage of primary care practitioners and the state seems to be making progress. The shortage is
psychiatrists is just as pressing.
In Rhode Island, there is some evidence that the dynamics of the psychiatric workforce are getting
worse. At the Butler Hospital Medical Staff, the leading factor for staff resignations is psychiatrists
moving out of state – 39% of total resignations. Reimbursement rates in Rhode Island are lower than in
surrounding states.
While Rhode Island is not a federally-designated Mental Health Professional Shortage Area, we see
shortages of psychiatrists available to see people in community settings.
This is especially true for child psychiatrists. Last week, SAMHSA’s deputy director commented on the
national scene saying, “Child psychiatrists are like unicorns: I've heard of them but I've never really seen
them." I’m pleased to report that I work with several talented child psychiatrists, so the breed isn’t
completely extinct here, but it’s not growing either.
One critical problem affecting the supply of psychiatrists available to see patients in the community is
the trend away from psychiatrists accepting any kind of insurance.
A study published in the journal JAMA Psychiatry, found that 55 percent of psychiatrists accepted
private insurance, compared with 89 percent of other doctors. Likewise, the study said, 55 percent of
psychiatrists accept patients covered by Medicare, against 86 percent of other doctors. And 43 percent
of psychiatrists accept Medicaid, which provides coverage for low-income people, while 73 percent of
other doctors do.
There are several reasons for this. Payments by insurers for many services provided by psychiatrists are
relatively low. Treatment is often subject to review by managed care companies. With more demand
than supply, many psychiatrists just don’t have to accept insurance. Psychiatrists are more likely than
other doctors to practice on their own, and solo practitioners, regardless of specialty, are less likely to
accept insurance, in part because they do not have the back-office staff to deal with insurance
companies. Given the high demand and low supply of prescribers, they can afford to not accept
insurance rates.
Our reimbursement system remains a mish-mash of rates that vary considerably from insurer to insurer.
There are some areas of stable, sustainable rates such as the Medicaid Integrated Health Home
program, but, the reimbursement for general outpatient care involving the majority of patients is
problematic. Rates vary widely, and one major insurance company hasn’t raised reimbursement in over
10 years. This results in difficulty in getting access to care and to the right medication.
Another significant factor affecting psychiatrists and job satisfaction is engaging in the tug of war of preauthorization, authorization, and re-authorization with insurers. By and large, these processes result in
care decisions that are made for all sorts of reasons unrelated to the best medical evidence. What ends
up determining what care gets provided is whether psychiatrists can spend hours on hold, waiting to
speak to insurers’ utilization review staff. For example, although it certainly makes sense for managed
care companies to require the use of cheaper generic medications whenever possible, this is not always
the right choice for an individual patient. For the sole purpose of saving money, the managed care
companies have created barriers making the appeals process time consuming and difficult. The most
recent creative idea by a major managed care company was to require that the physician obtain written
permission from the patient to “allow” the physician (the very one who ordered the medication and had
already obtained informed consent) to pursue the appeal. The logistics of this of course leads to delays,
and within the past month contributed to a hospitalization of one of my patients who was unable to
obtain a medication I prescribed.
I estimate that I spend 5% of my time each week trying to get authorization for care, medication, or
needed services.
Our patients are often resourceful. Most know how to get needed care most immediately – and that’s
to go to the emergency department and from there to get admitted.
This is a leading factor in how inadequate rates, the friction of working with insurance companies, and a
workforce that’s inadequate add up to higher levels of behavioral health utilization in our state.
I’d like to recommend that the General Assembly examine three possible areas for action:
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Review the adequacy and variability of fee-for-service rates for behavioral health services.
Incentivize moving away from fee-for-service to bundled rates, case rates, and other structures
that reduce administrative complexity.
Explore strategies that would make loan forgiveness and other incentives available to
community-based psychiatrists in the same way that Rhode Island has provided such supports
to primary care physicians.
Thank you for your time and consideration.