By Liz Kowalczyk
Boston Globe, May 9, 2017
Harvard researchers posing as the parent of a depressed 12-year-old called hundreds of child psychiatrists and pediatricians looking for appointments, and discovered what many actual parents know through bitter experience: Most of the time the calls were fruitless.
The group phoned 913 doctors listed as network providers by Blue Cross Blue Shield organizations in Boston, Chapel Hill, N.C., Houston, Minneapolis, and Seattle. After two attempts, they were able to get an appointment with a pediatrician 40 percent of the time and with a psychiatrist a meager 17 percent, according to the study published Tuesday in the International Journal of Health Services.
The obstacles began with the insurers’ online provider directories, which they tout as a tool to help consumers find doctors. But when researchers called the offices listed, they were often told that the doctor had retired or moved, or that the phone number was simply wrong. Even when the listing was accurate, a longstanding shortage of child psychiatrists meant that many practices were not taking new patients or had long wait lists.
Cheryl Meas, the mother of a teenager in Lowell, can vouch for the study’s discouraging results. A year and a half ago, the clinic that had been treating her 15-year-old son for anxiety and a mood disorder for five years suddenly closed due to bankruptcy. There, he had seen a therapist and a nurse practitioner who, working with a psychiatrist, prescribed his medications.
After the clinic closed, her son’s pediatrician agreed to prescribe his medicines temporarily, but that grew into months. Meas repeatedly called Magellan Health, which handles mental health benefits for her employer. She told the company that she would take any doctor within an hour and 15 minute drive of her home. Each time Magellan gave her names of psychiatrists in the network who treat children. Each time, she struck out.
“They sent me a bunch of doctors who don’t even practice anymore,’’ Meas said. “We went through this for six months. We just went in circles.’’
She ultimately called more than 40 psychiatrists, including a few from the Yellow Pages, she said. Meanwhile, her son was taking a turn for the worse and his pediatrician was not sure how to adjust his medicine, Meas said. The Department of Mental Health eventually referred her to an agency in Lowell and, with help from an advocate, was able to persuade Magellan to pay for an out-of-network provider. The company said in a statement that it “strives to provide the most accurate and up-to-date information.’’
Meas was able to keep her son stable during this unsettled period, but that is not always the case, said Dr. J. Wesley Boyd, a study coauthor and a psychiatrist at Cambridge Health Alliance.
“In some cases, kids will hold on and be OK until they get to that first appointment,’’ he said. “In other cases, a crisis will arise in the meantime and they will end up in the emergency room.’’
School work and relationships with family and friends also can suffer during the delay, said Lisa Lambert, executive director of the Parent/Professional Advocacy League in Boston and Worcester. “Parents are often exhausted because they are trying to manage what is happening but they are not sure if they are doing the right thing,’’ she said.
In the study, Boyd, who is affiliated with Harvard Medical School, and his coauthors chose five cities in different regions that spanned the country. They made the calls in 2015, and included pediatricians because they provide a growing amount of mental health care amid the psychiatrist shortage. The callers asked for the first available appointment — but did not go through with making it.
They tracked the wait for an appointment in cases where a slot was available. It ranged from an average of 12 days in Chapel Hill to 30 days in Seattle — though the average wait time for a psychiatrist was far longer at 43 days. The overall average wait in the Boston area was 15 days.
Researchers also found that the chance of getting an appointment plummeted when they said the child was insured by Medicaid, the government program for the poor and disabled. When they told doctors’ offices they had private insurance or would pay out-of-pocket, they got an appointment 37 percent of the time. When they mentioned Medicaid, that dropped to 22 percent. Boyd said fewer doctors accept Medicaid, which tends to pay doctors lower rates.
Twenty-two percent of the pediatricians called and 26 percent of psychiatrists were not accepting new patients.
The shortage of child psychiatrists has been well documented. The American Academy of Child & Adolescent Psychiatry said there are about 8,000 child and adolescent psychiatrists in the United States but that about 30,000 are needed to treat children afflicted with mental illness; estimates are that about one in five children requires such treatment.
The group ranks Massachusetts as a state with a “high’’ but not “severe’’ shortage overall, with about 442 child psychiatrists. The gap, however, is considered severe on the North Shore, the South Shore, and in Hampden County.
The organization blames the shortage in part on the extensive training requirements. Residents must finish two additional years of training in treating children, after an initial three years in adult psychiatry, leaving them with huge debts. The academy is lobbying states to approve loan forgiveness programs.
Another obstacle researchers faced was inaccurate provider lists on the Blue Cross websites — a phenomenon Lambert refers to as ghost networks. In 24 percent of the calls made to child psychiatrists, the doctor no longer worked there, the receptionist had never heard of the doctor, or it was otherwise the wrong number.
“We recognize that this is a problem,’’ said Dr. Ken Duckworth, medical director of behavioral health at Blue Cross Blue Shield of Massachusetts. He said the insurer has begun sending quarterly reminders to all its doctors to update their contact information and work status.
Duckworth said Blue Cross provides financial support to the Massachusetts Child Psychiatry Access Project, a longstanding program that assists pediatricians treating patients with mental health diagnoses.
“We want people to get the help they need, and we want them to be seen,’’ he said.
But not all pediatricians are comfortable caring for these patients, even with extra help, especially given the increasing use of psychiatric drugs, leading to some children being on three or four medications at once.
Asked if he has any advice for parents trying to find a child psychiatrist, Boyd said “you just have to be dramatically persistent.’’
Meas is bracing for another frustrating search. Her son’s new psychiatrist told her last week that she is leaving the Lowell practice. If the organization can’t replace her, it will be up to Meas to find someone.