From the Journals

More U.S. psychiatrists restricting practices to self-pay patients


A growing number of psychiatrists in the United States no longer accept insurance and will only see patients who can pay upfront, out-of-pocket for office visits, a new trends analysis shows.

Ivy Benjenk, BSN, MPH, and Jie Chen, PhD, from the University of Maryland, College Park, wrote that psychiatrists may be more likely than other specialties to adopt a self-pay-only model because of low insurance reimbursement rates, particularly for psychotherapy, as well as a demand for psychiatric services that outstrips supply.

There is a “limited supply” of psychiatrists in the United States and a “great deal of administrative hoops that go into accepting insurance for pretty minimal payment. So it makes some sense for psychiatrists to move entirely into the self-pay market,” Ms. Benjenk said in an interview.

The study was published online July 15 in JAMA Psychiatry.

Barrier to care

To explore patterns in self-payment for office-based psychiatric services and changes over time, the researchers analyzed data from 2007 to 2016 from the National Ambulatory Medical Care Survey, a nationally representative survey of physicians who were not federally employed, were office based, and were primarily engaged in direct patient care.

Of 15,790 psychiatrist visits, 3445 (21.8%) were self-paid by patients, compared with 4336 of 119,749 primary care clinician visits (3.6%).

Of the 750 psychiatrists in the sample, 146 (19.5%) were reimbursed predominantly by self-payment, compared with 69 of 4,294 primary care clinicians (1.6%).

The percentage of self-paid psychiatrist office visits has trended upward (from 18.5% in 2007-2009 to 26.7% in 2014-2016), whereas the percentage of self-paid primary care visits has trended downward (from 4.1% in 2007-2009 to 2.8% in 2014-2016).

The percentage of psychiatrists who work in predominantly self-pay practices has also trended upward (from 16.4% in 2007-2009 to 26.4% in 2014-2016), whereas the percentage of primary care clinicians who work in predominantly self-pay practices has not changed significantly (from 1.5% to 1.7%).

Psychiatrists who are reimbursed predominantly by self-payment were more likely to work in solo practices than group practices. Most self-pay psychiatry patients were White men.

Self-pay visits lasted longer than visits paid for by a third party (average duration, 38.3 min vs. 28.8 min; P < .001). Self-pay patients also made more visits to their psychiatrist than patients with third-party payers (mean, 18.3 visits vs. 9.4 visits in preceding 12 months; P < .001).

Ms. Benjenk and Dr. Chen wrote that self-pay psychiatry is a “hurdle many patients cannot surmount,” even if a portion of that payment is eventually paid by insurance.

“Either they have to pay out-of-pocket entirely or try to bill their insurance after the fact. It’s a lot of work to try to get an insurance company to pay for something after the fact. I couldn’t imagine someone who’s depressed or having some other psychiatric comorbidities actually go through the rigmarole of getting that done,” Ms. Benjenk said.

Ms. Benjenk believes that, with COVID-19 and a large shift to telepsychiatry, more psychiatrists might be interested in accepting insurance because they may be able to see more patients in a day.

“With telehealth, psychiatrists also can practice anywhere in their state, so that opens up a whole new pool of patients. And it’s cost saving; they don’t have to travel to an office, worry about office space or about no-shows, and there can be less lag time between appointments,” Ms. Benjenk said.

The study had no specific funding. Ms. Benjenk and Dr. Chen disclosed no relevant financial relationships.

A version of this article originally appeared on

Next Article: