In this editorial, the author argues that psychiatrists going cash-pay are responding rationally to low insurance reimbursement and heavy paperwork, not acting out of greed. The access problem is real, but the fix is fixing the payment system, not shaming the doctors who leave it.
Key takeaways
- This is a clearly labeled opinion piece; the views are the author's own.
- Psychiatrists accept insurance at markedly lower rates than other specialties, and the trend has worsened over time.
- The author argues going out of network is a rational response to low reimbursement and heavy administration, not greed.
- The other side: whatever the intent, the effect is a two-tiered system that hits the poorest and sickest patients hardest.
The charge against cash-pay psychiatrists
Let me be clear up front that this is an opinion, and it's mine. The common story goes like this: psychiatrists have abandoned insurance in droves, they charge cash, and in doing so they've made mental health care a luxury good available only to people who can afford to pay out of pocket. In this telling, the cash-pay psychiatrist is a kind of villain, a doctor who chose money over the patients who need help most. It's an easy story to tell because part of it is true. Access to insurance-based psychiatry is genuinely poor, and cash-pay practice is a big reason why.
Research has documented the gap. In a widely cited study, Bishop and colleagues found that psychiatrists accepted insurance at markedly lower rates than physicians in other specialties, and the trend has moved in the wrong direction over time. So the phenomenon is real. My disagreement isn't with the fact. It's with the moral. Treating the individual psychiatrist as the villain gets the causation backwards.
Why psychiatrists actually leave the networks
Consider what an insurance-based psychiatry practice actually looks like from the inside. Reimbursement rates for psychiatric visits are often low relative to the time the work requires, and psychiatry is time-intensive in a way that a high-volume procedural specialty isn't. On top of that sits the paperwork: prior authorizations for medications, claims that get denied and reworked, documentation demands, and the overhead of billing staff to chase all of it. For a solo psychiatrist, that administrative load can eat hours that aren't reimbursed at all.
Put those together and going out of network isn't greed. It's arithmetic. A psychiatrist who can see patients for longer, spend less time fighting insurers, and actually get paid for the work is making a rational choice that also, not incidentally, tends to be a better clinical setup. When a system pays poorly for careful work and buries clinicians in unpaid administration, it shouldn't surprise anyone that clinicians leave. They're responding to incentives the system built.
Blaming clinicians aims at the wrong target
Here's the core of my argument. When we frame cash-pay as a moral failing of individual doctors, we let the actual culprits off the hook. The low reimbursement rates were set by payers. The administrative burden was designed by the same system. The shortage of psychiatrists that gives each one leverage to go cash-pay is a workforce and policy failure decades in the making. None of that is the fault of the individual clinician deciding how to run a sustainable practice.
Shaming doctors also doesn't work. It hasn't reversed the trend, and it won't, because you can't guilt people into accepting a payment arrangement that doesn't let them practice sustainably. If the goal is access, the lever is the payment system: reimbursement that reflects the time psychiatry takes, less administrative friction, and payment models like collaborative care that make network participation viable. Cash-pay is a symptom of a payment system that stopped working for this specialty. You treat a symptom by treating the cause.
The other side
The strongest counterargument deserves a fair hearing, because it's a good one. Whatever the incentives, the result of widespread cash-pay practice is a two-tiered system, and the people who lose are the ones with the least. A patient on Medicaid, or anyone who can't front a hundred-plus dollars a session, is effectively locked out of a large share of the psychiatric workforce. Explaining that outcome as rational doesn't make it just. Intent and effect are different things, and the effect here falls hardest on the sickest and poorest patients, who tend to have the greatest need.
On this view, clinicians aren't merely passive responders to incentives. They're professionals who took on obligations to the public, and there's a serious argument that the profession as a whole bears responsibility for the access crisis it has, collectively, participated in creating. Rational individual choices can add up to a collective harm, and pointing at the system doesn't dissolve that. A person who believes access is a matter of equity and even of justice can accept every fact in my argument and still conclude that the profession should hold itself to a higher standard than the incentives demand. I don't fully agree, but I don't think that position is unreasonable, and any honest version of this debate has to sit with it.
Common questions
Is this article an opinion or a news report?
It's an opinion piece, an editorial. The argument and conclusions are the author's own and don't represent a statement of fact or shrinkiatry's editorial position. The other side of the argument is presented fairly at the end.
Do psychiatrists really accept insurance less than other doctors?
Yes. Peer-reviewed research, including a widely cited study by Bishop and colleagues, found psychiatrists accepted insurance at substantially lower rates than physicians in other specialties, and the gap has persisted. The reasons most often cited are low reimbursement and heavy administrative burden.
Sources
- Bishop TF, et al. Acceptance of insurance by psychiatrists and the implications for access to mental health care. JAMA Psychiatry. 2014. https://pubmed.ncbi.nlm.nih.gov/24337499/
- American Psychiatric Association. Practice resources on payment, coverage, and administrative burden. https://www.psychiatry.org/psychiatrists/practice
- American Psychiatric Association. Learn about the collaborative care model. https://www.psychiatry.org/psychiatrists/practice/professional-interests/integrated-care/learn