Reaching out for help when no one's there
The problem of ghost networks in the mental health provider world and what to do about it
Imagine for a minute a scenario where you are paying for a service that promises to provide you with essential items, only to find out that those items are not actually available. For instance, let's say you subscribe to a monthly service that guarantees you unlimited access to food at any time. The company presents you with a comprehensive list of all the food items they offer, but when you attempt to order something, you discover that it's not in stock. After contacting the company, they inform you that the list you were using was outdated, and provide you with a new one. But even with the updated list, you still can't get the food you want. When you inquire again, the company tells you that others have already claimed the items you wanted, and if you really want them, you'll need to pay a higher price to acquire them from a different source. At this point, you might begin to question why you're paying for a service that can't provide what you need. If the items you want aren't available, you're left to fend for yourself to find a viable solution.
This scenario happens to countless people daily when they are seeking mental health care. It’s a frustrating gauntlet we have to run just to be able to get access to some of the most basic services.
The decision to seek help for mental health issues can be incredibly difficult for a variety of reasons. One major barrier that is often talked about is the persistent stigma and misconceptions that surround mental health. People fear being judged or discriminated against if they are open about their struggles with mental health, which can make it hard to seek the support they need. Additionally, mental health challenges can be deeply personal and sensitive topics, and it can take a lot of courage to talk about them with others, even professionals. Finally, there may be practical barriers to accessing mental health care, such as a lack of resources or insurance coverage, which can make it difficult to get the help needed to address mental health challenges.
Ok, so take into account all these factors and imagine finally getting to a place where you want help and there’s no one there. This, my friends, is an experience that people have all too often in our country. The term ghost network is used by many in the health care world to describe provider networks that aren’t really there. Each health insurance company has a list of providers that are in their networks available to see you at a negotiated rate. The problem for too many people is that they call these providers that are in these networks and hear things like this:
“I am sorry, we are not accepting new patients at this time.”
“Dr. Smith has retired.”
“Oh, Dr. Jones left the state last year.”
On paper, it looks like you have a ton of options for providers, but in reality, there are few, if any, who can see you.
Take for example a couple of studies that used a “secret shopper” method. Basically, researchers, posing as patients, called a variety of providers on a list to see if they could get in and be seen. One study had their researchers call 360 psychiatrists listed in a health insurer database and found that 16% of the numbers were wrong (one even went to a local McDonalds!). There was significant geographical variation with psychiatrists in Houston most likely to answer calls and calls least likely to be answered in Boston. However, psychiatrists in Boston were were more likely to return calls than those in Houston. In total, the researchers were able to obtain appointments with 93 psychiatrists, representing 26% of their sample. The mean number of days until the first available appointment was 25 days and did not differ significantly across city or payment type.
Another study, using the same method found that appointments were obtained with 40% of pediatricians and 17% of child psychiatrists, with the mean wait time for psychiatry appointments being 30 days longer than for pediatric appointments. Providers were also less likely to have available appointments for children on Medicaid, and incorrect phone numbers were the most common reason for being unable to make an appointment. Pediatricians were twice as likely to see new patients and to see them sooner than child psychiatrists.
It would seem that in 2023 we should be able to keep up accurate databases for those who are the frontline for helping.
Inaccurate provider lists, also referred to as "directory errors" or "directory inaccuracies" by the industry, can be a major challenge for patients seeking appropriate health care. These inaccuracies can be caused by a variety of factors, such as outdated information or intentional misrepresentation by certain providers or insurance companies. It’s pretty obvious, but the consequences of inaccurate provider lists can be significant, leading to delays in care, frustration for patients, and missed opportunities to help for health care providers. Simply put, more needs to be done to ensure that patients can find the care they need when they need it.
This is not a new issue, not at all, and it does appear that there is more movement to address this problem. Here are a few things, both policy and personal, that we can do to address this egregious issue.
If this has happened to you, tell your story. Let’s start with the simple fact that your experience matters. If you have had a difficult time finding a provider who is supposedly in network, are told they can’t see you, or even worse, told it will be weeks if not months to be seen, someone needs to know about this. Write an op-ed, testify, show up in meetings, and tell your story! One of the most significant problems we face in redesigning how we approach mental health is access. If we can’t get into care, we are limited in moving forward with the help we need. This of course begs us to embrace the challenge of expanding our workforce and becoming more creative about who does what, where, and for whom. Don’t let your story go untold!
Have better enforcement over provider networks. As I have described above, numerous studies have shown the limited network available for mental health services. I have written about the Mental Health Parity and Addiction Equity Act before and see the parity law as having some solutions to this issue. First, regulations under parity include a number of restrictions that plans must evaluate in terms of network adequacy as nonquantitative treatment limitations (NQTLs). There’s a lot of detail here that’s useful, including limitations that involve rules concerning the admission of providers to a network (who gets in so they can see you), reimbursement rates (how much providers get paid), ad restrictions on the types of facilities covered by the network (where you can be seen). The main consideration for evaluating these limitations, as with other NQTLs, is whether the process for establishing standards is comparable and not more rigorous for mental health providers than for medical providers. Although having an unequal number of mental health providers versus medical/surgical providers in a plan’s network could indicate a parity violation, it is not necessarily a violation in and of itself. All this being said, without a robust enforcement on this issue, ghost networks may still be allowed to exist leaving the patient and family out in the cold.
Create more accurate, up to date provider directories. A big problem with these ghost networks is that the information we are working from is just wrong. Outdated information hurts people when they are desperate to get help for themselves or a loved one. Federal and state regulators can hold those responsible for provider lists accountable through simple mechanisms like having a data stamp on the directory indicating the last time it was updated. Or even better, having a real time dashboard that shows the availability of providers and the average wait time to get in. We do this for emergency departments on bill boards and even the number of parking spaces at an airport, why can’t we do it for our provider networks?
It can be daunting to discuss your problems and seek assistance for mental health. The process involves being candid with a stranger, which can be difficult, especially when you're not in a good place. However, if we can push through these obstacles and obtain prompt and effective support, it can make a significant difference in our lives. The catch is that such help must be accessible. To this end, let's strive to establish more accurate networks for mental health providers, so that when we reach out for assistance, we can be confident that someone will answer the call and help.
This is a fabulous article about a serious issue in getting mental health treatment and substance use treatment. The hurdles to quality health care are many. I love how you made sharing your story such an important point, but I'd love more guidance on how to share and where to share. Last year, I called every single one of the 8 providers in my town and was told that none were taking new patients~ except for the last one who only had an intern. Even spending all of that time on the phone calling doctor after doctor after doctor is a hurdle~ and all of the doctors were listed in the insurance company's portal as accepting new patients. Of course, what happens when people can't get the care they need? The situation gets more serious until those people are hospitalized and/or incarcerated~ because, as a country or system, we would rather put the mentally ill in jail instead of working to create a system that catches them before they get that far.