Primary Care Physicians Concerned about Patients' Access to Mental Health Services

A substantial number of Americans were unable to obtain mental health care even when their primary care physicians determined it was medically necessary. Survey data collected by the Center for Studying Health System Change found that more than two out of three primary care physicians reported being unable to consistently secure needed, high-quality mental health services for their patients.

Mental Health Care Difficult to Obtain

When physicians were asked to evaluate their ability to arrange a range of medically necessary services, they consistently rated high-quality mental health care as the hardest to secure. This finding carried particular weight because it came from primary care physicians -- family practitioners, internists, and pediatricians -- rather than from mental health specialists who might have had a professional stake in highlighting access problems.

Nationwide, 68 percent of primary care physicians said they could not always or almost always obtain high-quality inpatient mental health care for their patients. By comparison, only 36 percent reported similar difficulty arranging nonemergency medical hospitalizations -- roughly half the rate of difficulty seen with psychiatric inpatient care.

Access to inpatient mental health care proved especially problematic in certain metropolitan areas. In Phoenix, 81 percent of primary care physicians indicated they could not consistently obtain high-quality inpatient mental health services. Syracuse followed closely at 77 percent. Physicians practicing in non-metropolitan areas faced even greater barriers, with 76 percent reporting such difficulty, compared with 67 percent of their counterparts in metropolitan settings.

Outpatient mental health services were similarly hard to arrange. Seventy-two percent of primary care physicians nationwide reported being unable to consistently secure high-quality outpatient mental health care -- four times the proportion who said they had trouble obtaining referrals to high-quality medical specialists. Physicians in Seattle (81 percent), Lansing (80 percent), and Syracuse (80 percent) were the most likely to report difficulty with outpatient mental health referrals.

Even in Miami, the community where primary care physicians were least likely to report trouble, more than half still indicated they could not always or almost always secure high-quality inpatient (58 percent) and outpatient (61 percent) mental health services.

Implications of the Findings

Why were needed mental health services so much harder for primary care physicians to arrange than other medical care? Several factors likely played a role. There may have been an overall shortage of mental health facilities and practitioners, or an uneven geographic distribution of these resources. This could partially account for the higher proportion of access difficulties reported by physicians serving patients in non-metropolitan areas, where behavioral health providers were scarcer.

The rapid expansion of managed behavioral health programs during this period also may have affected the availability of mental health care. These programs introduced additional administrative requirements and utilization controls that could slow or block access to services. Beyond managed care, health insurance policies of the era typically covered mental illness less generously than physical illness, with lower benefit caps, higher copayments, and more restrictive limits on the number of covered visits.

At the time of this research, an active policy debate was underway between advocates of parity -- equivalent insurance coverage for physical and mental health conditions -- and those who argued that existing limitations on mental health benefits were necessary to prevent runaway costs. Congress and several state legislatures had enacted parity laws, though these were limited in scope and fell short of resolving the underlying disparities. The Center planned to continue tracking changes in physicians' ability to obtain mental health care and other services for their patients as the policy landscape evolved.

Mental Health Service Availability by Community

The Community Tracking Study documented access to mental health care across 12 metropolitan areas. The share of primary care physicians who could not always or almost always obtain inpatient and outpatient mental health care, respectively, by community: Boston (63 percent, 70 percent); Cleveland (67 percent, 70 percent); Greenville, S.C. (59 percent, 65 percent); Indianapolis (67 percent, 79 percent, significantly different); Lansing (74 percent, significantly different, 80 percent, significantly different); Little Rock (68 percent, 75 percent); Miami (58 percent, significantly different, 61 percent, significantly different); Newark (67 percent, 71 percent); Orange County (70 percent, 72 percent); Phoenix (81 percent, significantly different, 76 percent); Seattle (76 percent, significantly different, 81 percent, significantly different); Syracuse (77 percent, significantly different, 80 percent, significantly different). For metropolitan areas over 200,000 population, the averages were 67 percent and 71 percent. National averages were 68 percent and 72 percent.

Sources and Further Reading

Data in this bulletin are from the Community Tracking Study Physician Survey, conducted by the Center for Studying Health System Change. The survey covered primary care physicians across 12 randomly selected metropolitan areas and a nationally representative sample. Statistical significance is noted where site values differ from the mean for metropolitan areas with populations over 200,000.