Subscribe to The Podcast by KevinMD. Catch up on old episodes!

Join J. Wesley Boyd, a psychiatrist, to dive into the critical issue of child and adolescent mental health care accessibility. Drawing insights from a recent study, we’ll explore how the COVID-19 pandemic has exacerbated challenges in obtaining timely treatment for young individuals, particularly those with Medicaid. We shed light on the barriers, disparities, and potential solutions, offering a compelling perspective on the urgent need for collaborative efforts to prioritize mental well-being in the younger generation.

J. Wesley Boyd is a psychiatrist.

He discusses the KevinMD article, “Accessing needed pediatric mental health care was difficult before the pandemic and is now at crisis levels.”

The Podcast by KevinMD is brought to you by the Nuance Dragon Ambient eXperience.

Ambient intelligence augments human capabilities to make our lives easier. The applications are many, especially in health care. Ambient clinical intelligence is offsetting the most pressing challenges in health care today, such as burnout, physician shortages, physician and patient dissatisfaction, and underperforming financial outcomes, by applying the technology to clinical documentation. 

The Nuance Dragon Ambient eXperience, or DAX for short, utilizes artificial intelligence and natural language processing to automatically document care. It securely listens to and captures the natural, clinician-patient encounter conversation unobtrusively, and turns that conversation into a clinical note for the clinician’s review and signature directly in the electronic health record. You just talk naturally, and DAX does the rest. 

DAX is being used by thousands of physicians across 30 different specialties nationwide. It has already won the Silver Stevie award in the health care technology category and was ranked #1 for improving clinician experience in KLAS’s top 20 emerging solutions.

VISIT SPONSOR → https://nuance.com/daxinaction

SUBSCRIBE TO THE PODCAST → https://kevinmd.com/podcast

RECOMMENDED BY KEVINMD → https://kevinmd.com/recommended

GET CME FOR THIS EPISODE → https://earnc.me/niDOCI

Powered by CMEfy.

Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast, and get CME for this episode by clicking on the CME link in the show notes. Today we welcome back J. Wesley Boyd. He’s a psychiatrist, and today’s KevinMD article is titled “Accessing needed pediatric mental health care was difficult before the pandemic and is now at crisis levels.” Wes, welcome back to the show.

J. Wesley Boyd: Delighted to be back. Thank you for having me.

Kevin Pho: So you’re a psychiatrist. Just before we get to your article, tell us a little bit about your practice and your day-to-day life.

J. Wesley Boyd: Well, I’m currently based in Houston, Texas, and I have a faculty appointment in psychiatry and medical ethics at Baylor College of Medicine. I also work day to day at the VA hospital in Houston, where I co-direct the substance disorder program and also co-direct the ethics committee and ethics consult service.

Kevin Pho: All right. So what got you to write this article about pediatric mental health?

J. Wesley Boyd: I’ve been into issues of access to mental health care for over a decade now. In this particular article, we posed as the parent of a 10-year-old patient who had been seen in the ER, diagnosed with depression and told, “You need to follow up with a child psychiatrist.” Posing as patients, we used the Blue Cross Blue Shield database, which has a listing of all of the psychiatrists who are in network, at least in Texas, Illinois and California. We used that database in order to make phone calls asking if we could make appointments with them.

What we found is that even using a major insurance carrier, saying that we had that kind of insurance, we were only able to get appointments 11 percent of the time. In other words, we were not able to get appointments with 89 percent of the people who were listed in the database. As for the reasons we weren’t able to get appointments: A fifth of the time, so almost 20 percent of the time, the phone numbers were simply wrong in the insurance database. A quarter of the time, so 25 percent of the time, the practices said they were full. In a bunch of instances, even though we made two separate phone calls roughly a week apart, we never even got a call back.

What that ends up meaning is, if you are a child or the parent of a child trying to get in to see a child psychiatrist, it’s impossibly difficult. This study that we just did is actually a follow-up of a pre-pandemic study from about five or six years ago. In that study, we were able to get appointments just under 20 percent of the time, as I recall, and again, now we’re only able to get appointments 11 percent of the time. So this is a post-COVID study. Everyone knows that COVID has hit everyone’s mental health dramatically hard, and children have suffered as much as anybody. So rates of depression, anxiety, suicidal thinking, you name it, have increased significantly in children since the pandemic.

Kevin Pho: So in a typical case, when a family and a parent of a child is told to go see a behavioral health specialist from the ER setting, what are they typically given? What kind of resources are they typically given? Are they typically asked to just go through the insurance book and just look for behavioral health help? What’s typically given to them?

J. Wesley Boyd: That is one thing that happens. I know some emergency rooms will hand out lists of clinics and providers, but my assumption is that even when emergency rooms are handing out lists like that, they’re inevitably going to have many, many names where the practices are full. The phone numbers are probably going to be wrong even in some of those instances as well, or they’re not going to take certain forms of insurance.

What we did find in our study was that we could get appointments a few percentage points more if we were willing to pay out of pocket, but if we were trying to use Medicaid for insurance, it was nearly impossible to secure an appointment. What that means is, since so many people who have Medicaid are in the lower socioeconomic spectrum, those very individuals are the same ones who’ve been hit the hardest by COVID. And so, you know, if you have Medicaid and you’re trying to get pediatric mental health care, it’s a double whammy, because it’s almost impossibly difficult.

Kevin Pho: You mentioned different parts of the country where you did the study. You mentioned Texas; you mentioned Illinois. What other parts of the country did you try to find behavioral health help for your pediatric population?

J. Wesley Boyd: The cities that we picked are somewhat arbitrary, but what we wanted to do was to pick cities that were geographically diverse. So the three cities we chose were Houston, Chicago and Los Angeles, and the reason we picked those cities is because in those states, California, Illinois and Texas, the Blue Cross Blue Shield database is actually entirely online, readily accessible and easy to use. I previously did studies looking at the ability to obtain appointments in other parts of the country as well, including Seattle, North Carolina, Boston, etc., and our findings in the most recent study are basically consistent with what we found elsewhere. So we were just looking for geographic diversity, but we also wanted states where Blue Cross Blue Shield was the major insurance provider.

Kevin Pho: And among those three cities, you found similar results in terms of the difficulty of obtaining a child psychiatry appointment?

J. Wesley Boyd: Yeah, I mean, there are some very, very minor differences, but again, we were only able to get appointments 11 percent of the time. So the numbers where we actually got appointments were really vanishingly small. There are some minor differences, but when your number is so low to begin with, I’m not going to say too much more about this.

Kevin Pho: You said that one of the major reasons why you couldn’t get an appointment was the fact that the phone numbers in the directories were simply wrong. It sounds like that could be correctable. Why does that happen?

J. Wesley Boyd: It happens, in my opinion, because insurance companies actually have little incentive to make sure that the phone numbers in their databases are accurate. But why is that? Because insurance companies make money by collecting premiums. When people actually are able to access care, insurance companies obviously have to pay money for that care, and so if people who have certain forms of insurance aren’t able to access care, that just leaves more money in the pockets of the insurance companies. I mean, it’s very cynical, and on the one hand, I’m very sorry to even say that out loud, but that’s the reality.

There have been some efforts by some states and some state attorneys general to ensure that insurance companies’ databases of supposedly in-network providers are accurate, but those efforts have fallen short. I’ll give you an example. After the first of the studies like this that I published, probably roughly a decade ago at this point, I actually, as a psychiatrist who took certain forms of insurance in my private practice, got a letter mailed to me from the insurance company. It said, “Can you please go on to our database and ensure that your information is correct?” That was basically the sum total of what the letter said.

There are several problems with that, though. If they’ve got a lot of wrong phone numbers, they might have a lot of wrong addresses too, so the letter may never have even reached me. Secondly, there were no penalties whatsoever for me not going into the database to ensure that my information in their insurance database was accurate. In other words, they didn’t say, “If you don’t go in and verify and then let us know that your information is correct, we’re going to take you off our rolls.” They just said, “Please go do this,” but there was no penalty if I didn’t do it. And I’ve always been, probably just like you and so many of your viewers, super, super busy, and it was just an extra thing I needed to do where there was no incentive for me.

Kevin Pho: It almost seems like it would be more accurate simply to just Google behavioral health specialists in the area, and hopefully a Google or a Yelp listing would have more accurate information.

J. Wesley Boyd: Those can be more accurate. We actually are doing another study, based out of Boston in this case, and in that other study that I’m part of, which we haven’t yet published, we cross-referenced insurance databases with Psychology Today listings and with national provider database listings. In each instance, you know, the more you cross-reference, the more accurate you get, but you never get anywhere close to 100 percent accuracy.

Kevin Pho: OK, so that’s one reason why the rates were so low in terms of finding behavioral health specialists. What are some other reasons behind that low rate? You mentioned, you know, Medicaid reimbursement. What are some other major reasons?

J. Wesley Boyd: A major reason is simply that there are not enough child psychiatrists to handle the demand, and the lack of child psychiatry resources is worse in rural settings, which we didn’t explore in our study, than it is in urban settings. Everyone who knows anything about the availability of child psychiatry is aware of that. Also, in general, insurance reimbursements are less to much less than what child psychiatrists can charge if they don’t accept insurance. In fact, when I was at Cambridge Health Alliance, where I was for many years, I had a number of trainees under me, and a lot of them ended up going into child psychiatry. I don’t know one of them who has a child psychiatry private practice who accepts insurance, not only because you can get paid a lot more if you don’t accept insurance, but you also have a ton less paperwork. So the insurance companies don’t make it worth the while of a child psychiatrist to accept payments from them.

Kevin Pho: Now, did you look specifically at patients looking for child psychiatrists? What about advanced practice practitioners? What about counselors, therapists and other forms of behavioral health support?

J. Wesley Boyd: That’s a great question. I’ve received that question many times, and it’s a really good question, because for a lot of people, the first contact in mental health is not going to be a psychiatrist. It’s going to be a social work therapist, a psychologist or an advanced practice nurse, as you said. But for research purposes, we just had to draw the line somewhere. My suspicion is, I could imagine it might be easier to access care through someone other than a child psychiatrist, but I think a lot of the difficulties are still going to remain. They might not be quite as extreme, but they’re still going to be there.

Kevin Pho: Now, I’m not sure if you studied this. This is from a population that received care from the emergency department and was essentially almost cold-calling and looking for a child psychiatrist. What about patients referred through their primary care clinician, or maybe a referral through a larger health system? Any differences in terms of accessing child psychiatry through settings outside of the emergency department?

J. Wesley Boyd: I think that the best likelihood of obtaining an appointment with a child psychiatrist is if that psychiatrist is paired with a primary care practice. That, in fact, is the model for the best way to deliver mental health care, namely, you have mental health care embedded in primary care. So when that happens, that’s a great way of actually ensuring that someone has access to care. It just so happens that that doesn’t happen.

Kevin Pho: So let’s talk about this from the patient’s and family’s point of view. You’ve done a lot of research on this, and for those patients and families listening to this, it paints a pretty bleak picture in terms of receiving child psychiatry support. Do you have any tips that you’ve learned that you could offer to patients who are looking for pediatric behavioral care support?

J. Wesley Boyd: If you have anybody who knows anybody. I mean, I hate to say it, but that, in fact, is one of the best ways to access care. Generally speaking, it’s easier to get in through a clinic than it is through an individual practitioner. What we found when we called looking for appointments in Houston, Chicago and LA was that there were entire clinics and entire university hospital systems that were shut down entirely to receiving any new pediatric mental health patients. In one case, one of the major universities in the United States said, “We’re not accepting new patients into our child psychiatry practice for at least 18 months.” And that’s dire. I mean, this is in the midst of COVID and in the midst of a pediatric mental health care crisis. The fact that you have entire university and hospital systems closed to receiving any new patients whatsoever is highly concerning.

Kevin Pho: We’re talking to J. Wesley Boyd. He’s a psychiatrist, and we’re discussing the KevinMD article “Accessing needed pediatric mental health care was difficult before the pandemic and is now at crisis levels.” So Wes, tell us the path forward. Other than producing more child psychiatrists, or maybe embedding behavioral health into pediatric practices, what do you see as some of the solutions to this?

J. Wesley Boyd: I think those are the solutions. Increasing the number of child psychiatry training positions would go a long way. As you already said, and as we talked about earlier, embedding mental health care in primary care settings would be a great way. I think training more PAs and clinical nurse specialists, who could potentially provide excellent care to children in mental health crises, would go a long way. And I think also, you know, for many people, the first stop if a child is having any kind of mental health condition is their pediatrician, so I think doing outreach and education with general pediatrics and pediatricians would go a long way as well. And additionally, although we already talked about this, I think increasing the reimbursement rates that insurance companies pay to child psychiatrists would make it more appealing for child psychiatrists to actually take insurance.

Kevin Pho: And my final question, Wes: Tell us some of your take-home messages that you want to leave with the KevinMD audience.

J. Wesley Boyd: Insurance companies really need to make sure that their databases are filled with the names of individuals, and this applies to child psychiatrists, adult psychiatrists and everybody else who’s listed. Insurance companies basically need to do more to ensure that their lists of network providers are accurate. The phone numbers need to be accurate, and the physicians who they list in their networks need to be accepting new patients.

Kevin Pho: Wes, thank you so much for sharing your time and insight, and thanks for coming back on the show.

J. Wesley Boyd: Thank you. It’s great to be back.