When I started my training in psychiatry, a senior doctor told me I should have a therapist of my own. He explained that it’s essential to understand myself so I can better understand my patients.
That made sense, so I started calling a list of psychiatrists who supposedly took my insurance. Some of them were dead. Many weren’t taking new patients. Others didn’t take my insurance. I couldn’t find a single psychiatrist on the list to see me. It took months of networking for me to finally find a therapist.
I later found out that my experience was commonplace, possibly deliberate, and that such inaccurate provider lists have a name: ghost networks or phantom networks.
In a recent study, researchers called 360 psychiatrists on Blue Cross Blue Shield’s in-network provider lists in Houston, Chicago, and Boston. Some of the phone numbers on the list were for McDonald’s locations, others were for jewelry stores. When the researchers actually reached psychiatrists’ offices, many of the doctors didn’t take Blue Cross Blue Shield insurance or weren’t taking new patients. After calling every number twice, the researchers were unable to make appointments with 74% of providers on the list. In a similar study among pediatric psychiatrists, researchers were unable to make appointments with 83% of the providers listed as in-network by Blue Cross Blue Shield.
My patients regularly tell me that this is not unique to Blue Cross Blue Shield and happens with most insurance providers. A 2016 survey by the Centers for Medicare and Medicaid Services showed that it’s also a problem with other medical specialties. The numbers, however, never seem as bad for other specialties as they do for psychiatry.
Maybe insurance companies don’t know their lists are inaccurate. Maybe they do but choose not to do anything about it. A more alarming possibility is that some companies intentionally keep the lists inaccurate to save money by preventing access to mental health care. After all, ghost networks benefit insurance companies: If it’s hard to find a provider who takes your insurance, it’s less likely you will access services that the insurer will have to pay for.
That concern may be founded, given other recently revealed strategies used by insurance companies to avoid paying for mental health. As Massachusetts state Sen. Cindy Friedman, who has been working to get insurance companies to improve their provider lists, told me, “They’ve known about this for a long time and they haven’t done anything about it. It’s difficult not to assume that this kind of barrier is intentional.”
No matter the reason, ghost networks are unacceptable.
Imagine realizing (or acknowledging) that you have depression — a defining feature of which is loss of motivation — and start looking for a psychiatrist. After calling a McDonald’s, a jewelry store, and providers who say they don’t take your insurance but will be happy to see you for $250 per hour that you must pay out of pocket, you’ll likely be inclined to give up.
Ghost networks are particularly disturbing when it comes to Medicaid plans. States provide insurance companies with contracts to create plans for their poorest citizens. Though many of these companies are nonprofits, they often contract with for-profit companies to administer the mental health benefits. By failing to maintain accurate provider lists, these companies profit from taxpayer dollars while the most vulnerable mental health patients can’t find the care they need.
The outcomes have the potential to be devastating: an individual with severe depression who dies from suicide before he finds treatment, or someone with paranoid psychosis hurting herself because she never received access to effective medication.
Friedman told me a story about a Massachusetts parent who struggled to find an in-network psychiatrist for her son who was hearing voices. Despite calling countless psychiatrists who supposedly took her insurance, she was unable to find one. One day before the 19-year-old got help, the police were called to the home because he locked himself in his room and was yelling. He struck a police office and was arrested.
Insurance companies are finally getting called on the carpet about ghost networks. In California, regulators fined two insurance companies for overstating the breadth of their Obamacare networks in all specialties, not just psychiatry. A 2016 California law now requires Medi-Cal plans to update their online provider directories weekly. Aetna recently settled with the state of Massachusetts after its attorney general launched an investigation into the company’s inaccurate network lists. Massachusetts legislators have introduced “An Act to Increase Consumer Transparency about Provider Networks” that would require insurers to keep updated and accurate lists of in-network providers.
State-level progress is good, but this issue deserves national attention since it affects people across the country in all sociodemographic categories. It also should apply to both private and government-sponsored insurance plans.
Without access to appropriate mental health care, vulnerable people across the U.S. will continue to suffer, and some will die. Every insurance company should be required to keep its provider lists updated so they can’t collect premiums for services they don’t actually provide. Insurers should not profit because they have failed to make mental health care accessible.
Jack Turban, M.D., is a resident physician in psychiatry at Massachusetts General Hospital.