The views and opinions expressed in this blog post are those of the author and do not necessarily reflect the official policy or position of the Policy Center for Maternal Mental Health.
Access to mental health care remains the most significant impediment to recovery from maternal mental health disorders (MMHD) – which affect 15-20% of pregnant and postpartum individuals. In historically marginalized populations, for example, Black birthing individuals and birthing individuals experiencing poverty, MMHD rates are exceptionally elevated, often as high as 50%, and access to mental health treatment is even harder to obtain.
To be clear: what is most alarming and frustrating about the high rates of MMHDs is the health care system’s response to them.
We have reliable, effective treatments; what we lack is equitable access to affordable, insurance-based mental health care. As Pro Publica recently chronicled (Aug – Nov 2024), “America is in the midst of a mental health crisis, but finding a therapist who takes insurance can feel impossible.”
Lack of access to mental health care is typically framed as a workforce shortage issue:
More accurately, it is a workforce shortage issue concerning clinicians who accept insurance, particularly in urban areas.
Low clinician reimbursement rates relative to the administrative costs of providing insurance-based mental health care drives clinicians and practices to opt out of taking insurance, contributing to a two-tiered system: lack of access for those who need or want to use insurance for treatment, and easy access for those who can afford to pay out of pocket.
In a 2023 blog for Mental Health America (MHA) titled ‘Fix the Foundation: Unfair Rate Setting Leads to Inaccessible Mental Health Care , Mary Giliberti, MHA Chief Public Policy Officer, identifies the factors that disadvantage and lower insurance reimbursement rates for mental health care. According to Gilbereti, reimbursement rate setting considers value based on the supply costs (e.g., duration of visit, visit costs, and practice expenses), all of which prioritize procedures such as surgery and imaging over cognitive work. Current Procedural Terminology (CPT) codes do not value critical thinking such as analyzing, decision making, and managing patients’ psychological needs. In turn, devaluing clinicians’ cognitive work lowers reimbursement rates for a variety of consultations – from treatment decisions for a cancer diagnosis to mental health care, including psychotherapy and psychopharmacology. Gilbereti cites a recent study showing that Medicare reimburses 3-5x more for procedural work compared to cognitive work.
Moreover, the familiar non-parity issue between reimbursement rates for physical versus mental health care is evident when comparisons are made only within reimbursement rates for cognitive work. Insurance reimbursement data taken from Women’s Mental Health @Ob/Gyn, a clinical service integrated into obstetrical and gynecological practices, illustrate the issue:
Research Findings
Averaged across several commercial insurance payors, a clinical psychologist using CPT code 90834 for a 45-minute psychotherapy visit garners approximately $200; In contrast, a physician, using CPT code 99215 for a 40-minute Evaluation and Management of an established patient (no procedures involved) earns about $350. This illustrates significant imbalances in payment and recognition of expertise among mental health providers, and that we have a long way to go in addressing parity.
To genuinely tackle the barriers to accessing affordable, insurance-based mental health care for MMHDs, a fundamental place to start is clear identification of the problems. Patients struggle to find mental health providers who take insurance, which should be termed an in-network or participating provider workforce shortage; conventions for setting reimbursement rates for treatment contribute to this shortage.
This is one of the reasons why I am grateful to the Policy Center for Maternal Mental Health -for leading conversations about Federal mental health parity
Catherine Monk, PhD, is the Diana Vagelos Professor of Women’s Mental Health and Chief, Division of Women’s Mental Health, in the Department of Obstetrics & Gynecology (Ob/Gyn) and Professor of Medical Psychology in the Department of Psychiatry at Columbia University Vagelos College of Physicians and Surgeons. Dr. Monk directs Women’s Mental Health @Ob/Gyn, an integrated clinical service within Ob/Gyn. She and collaborators recently launched the research-to-practice Center for the Transition to Parenthood with the goal to enhance the perinatal ecosystem for 2Gen impact.
