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.

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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.

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  • Thank you for your insightful message about the reality of the psychiatric situation regarding the necessity for one’s own mental health practitioner’s own experiences as a patient too. Also the accuracy of this seemingly ongoing situation with health insurance companies who intentionally try to block patients in need, from trying to access their own providers’ disingenuous attitudes of the way they actually prevent those most needed to find the professional health care from credible and ethical psychiatrists, psychologists, and the several other practitioners who are highly qualified for their health care knowledge and ethics to treat their patients with a great benefit to help patients who are amongst those who require treatment for their mental and emotional health care.

    When I received my several degrees years ago I already had been in therapy with my psychiatrist for years. Our approach to the treatment protocols advanced as I became more than not, a psychotherapist in private practice. I was still doing my own inner work with my own issues with my three different psychiatrist, psychologist, and the continued supervision of more than what was required to remain in my professional life as a therapist who had also ancillary degrees and personal training in my field of my expertise, always keeping the protocol for attending conferences and workshops each year, which was a great experience for me as it was for my colleagues too.

    I especially felt strongly that the practitioner had to have access to one’s own mental health care treatment for themselves too. I would speak to this each moment I could, because we know that it is something that is indeed helpful for all, that our own professional practitioners were doing their own inner work too!

    When I first started my own private practice, after being employed by some of the most well known practitioners in our field, I finally had the opportunity for my own practice that I was very satisfied and passionate about for the years of my private practice experience in one phenomenal state where I lived longer than the other seven states for my entire professional life; that was especially difficult for me to find in a few of the states where I resided throughout the USA.

    However as I did in the Philadelphia area, I always vetted a psychiatrist or two with my patients seeing them for medications and for explicit cases that I personally and professionally recognized those patients who actually required the specific treatment that I did not have, because the differences that exist in the professional health care issues that are most beneficial with a psychiatrist, rather than only seeing a therapist who did not have the same type of training that we did not have in our demanding professional training which Psychiatrist’s receive that we did not.

    Also I never accepted insurance companies and instead back in the day, would provide my patients with everything they needed for reimbursement from their insurance companies. I also had a sliding fee scale for the people who could not afford to purchase insurance for their treatment. Additionally, I would see one individual, one couple and one family pro bono as my own personal life experiences to be available to those of patients in need but could not afford the sessions that they were in need of being helped by practitioners who do not have a sliding fee scale, nor a pro bono system.

    I wanted to do something for some individuals who really needed this care to navigate their journeys to self realization about the plethora to recognize the aspects of themselves who they seldom knew existed in all living patients and the connections that they would benefit from their recognition of their own sense of Self, seen in more than not individuals who are committed to the process of their own, to grow into the self they didn’t know existed.

    Finally, I am somewhat disturbed by the app’s as therapist in this manner. I am not familiar enough to adequately evaluate the new therapy treatment with apps for the absent therapists. It’s something that I want to know much more about, before I am ready to write about this relatively new methodology into the human condition via an app. But I admit that I am not as happy with this app for patients who have been working with there therapists, for a while. The whole concept is something that I must learn more about, before I endorse, or disagree with this new app.

    It is after all, part of the necessity for my own development of gaining experience about something that I admit to not typically thinking that this has the merits of which it states it has.

    Thank you for your interesting article about this topic that I would like to keep informed by the outcome data that will require some time yet to make that it well informed individual who has data for the purposes of gaining the results from a significant number of subjects in a trial that is a scientific research outcome of the complexities of the human condition.

    Respectfully,
    Catherine M. Dunn

  • Not true, Mary. I am a therapist, and I have asked other therapists, and none of us have solid connections with psychiatrists who have openings, are good, and return calls! It’s heartbreaking that access cannot be had even with therapists advocating.

  • Most psychiatrists do not do therapy so I am wondering did you go to an old time psychoanalyst or did the psychiatrist refer you to a Clinical Psychologist or LISW?
    What your mentor should have suggested you do is volunteer at a homeless shelter or food pantry with observing various 12 steps groups and oh my – maybe a Hearing Voices group. Another aspect of education and self support would be to do some Music Therapy or Art Therapy.
    Maybe some EDMR therapy if you have had trauma in your life and if you are in the field , I can guarantee you have some type of bones in the closet.
    Again, this is old old news. This was talked about in my Department of Psychiatry staff meetings in the 1980’s it has only exponentially gotten worse between bad technology and greed and malfesence in the medical/ insurance complex.
    Actually, the only reason to seek psychiatric support these days is for biopsychistry unless you want or need an old school psychoanalyst.
    Otherwise just look up Clinical Psychologists and LISWs.
    They have course have their own problems these days. Your mentor gave you old timer and current bad advice.
    All therapists these days have a direct line to a psychiatrist and that for the past thirty years is always the fastest way to be seen.
    But kudus for the wonderful examples of current day total incompetence for all those involved in the so called helping and support professions.

    • Mary, your comments do not answer my experiences over the years. I do agree that the problem is not new, and is getting MUCH worse. I’m adventurous in terms of therapeutic approaches, but I still want an experienced psychiatrist as well. I have been to “hearing voices” groups and appreciate the recovery model, but I dont hear voices. Many of the other therapies you mention are either equally hard to find in many areas or not effective (EMDR), in my experience.
      I do agree that good licensed therapists are worth more than gold, but they’ve never gotten me anywhere with a psychiatrist, other than names and numbers to try.

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