A study that colleagues and I authored, published in the American Journal of Emergency Medicine, found lengthy waits for severely ill child and adolescent psychiatric patients in need of immediate hospitalization due, in part, to time-consuming prior authorizations required by insurance companies (1).  Mental health workers spent, on average, 60 minutes on the telephone obtaining authorization.  In one case obtaining authorization took 4.5 hours.  Over half of these youth who required hospitalization were suicidal, and a substantial minority were aggressive, assaultive, and or homicidal.

Four million children and adolescents in the U.S. suffer from a serious mental disorder that causes significant functional impairments at home, at school and with peers.  In youth, many of these disorders can have lifelong deleterious effects.  Timely access to care might reduce the harms mental illness imposes on youth, along with their families and communities.

For the present study, over a five-month period, psychiatric clinicians in the Hasbro Children’s Hospital emergency room (ER) in Rhode Island tabulated data each time they contacted an insurance company on behalf of a child deemed in need of psychiatric admission. Patients ranged in age from 4 to 19 years old and the most common reasons for admission included suicidal ideation or a suicide attempt (56%), aggression (22%), and homicidal ideation (10%).  The average time required to obtain authorization from the insurance company from the time of first contact to authorization was 59.8 minutes.  The time spent on these calls simply added to the total time these children spent in the ER prior to being admitted to an inpatient unit, which increases the danger for both the children and their clinicians (2). 

The shocking fact is that not one request for authorization was denied; every single request for admission was granted.

Given the total number of psychiatric admissions nationwide each year, 60 minutes of phone time to obtain authorization translates into over a million hours of wasted clinician time annually. The cost of this wasted time is staggering.  One nationwide study of the time that physicians and other practice administrators spend interacting with insurance companies calculated that the annual cost to our health care system for all physicians nationwide to engage in these non-reimbursable interactions was approximately $31 billion.

Lead author Amy Funkenstein, MD, currently on staff at Tufts University, led the study while she was a child psychiatry fellow at Brown University. She noted:  “Psychiatry is singled out for this kind of scrutiny.  Pediatricians do not have to contact insurers prior to admitting a child with pneumonia.  Obstetricians do not have to do so if a woman is in labor.  Surgeons do not have to haggle with insurers if a patient has acute appendicitis.  These onerous prior authorization requirements that single out the most severely ill psychiatric patients should be halted.  Given that the need to obtain prior authorizations can extend what is already a lengthy emergency room stay, I wonder if the need to obtain prior authorizations represents a violation of either mental health parity or the Emergency Medical Treatment and Active Labor Act.”

Healthcare workers are already overburdened and to add this requirement for prior authorization is unconscionable.  It violates any notion of parity for those with mental illness.  Insurers hope that clinicians will be so hassled by authorization procedures that they won’t seek admission for their patients, and less utilization of services means greater profits for the insurers.  Insurers are thus placing profits ahead of patient safety and well-being.  If we didn’t have a profit driven healthcare system this simply wouldn’t be happening. 

By contrast to profit driven insurance companies, Medicare (whose overhead is a fraction of that of private insurers) does not require this onerous prior authorization process.  If we had an improved Medicare-for-all system, psychiatric patients and their clinicians would not be subjected to this process and could obtain more timely care.

The paper concludes by saying, “Insurance reviews and pre-authorization requests are just a part of what makes accessing needed psychiatric care difficult for children and adolescents, given that finding comprehensive services for children is only possible in certain parts of the country. Adding prior authorization to an already difficult process, especially for psychiatric patients who are deemed to be of “imminent risk” to themselves or others, seems both dangerous and predatory.  Onerous prior authorization requirements that single out the most severely ill psychiatric patients should be halted. It burdens our psychiatric clinicians and functions to limit care by placing time consuming bureaucratic burdens on clinicians rather than meaningfully evaluating patient’s needs.”


1. Funkenstein A, Hartselle S, Boyd JW.  Prior Authorization for Child and Adolescent Psychiatric Patients Deemed to be in Need of Inpatient Admission. The American Journal of Emergency Medicine.  doi:10.1016/j.ajem.2016.02.027.

2.Stephens RJ, White SE, Cudnik M, et al. Factors Associated with Longer Length of Stay for Mental Health Emergency Department Patients. The Journal of Emergency Medicine 47 (4):  412-419,  2014.

About the Author

J. Wesley Boyd, M.D., Ph.D.

Wes Boyd, Ph.D., is on faculty at Harvard Medical School and is an attending psychiatrist at Cambridge Health Alliance and Children’s Hospital Boston.

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