Universal coverage without universal access: ICES and CAMH study shows that access to psychiatrists depends on how they practice

Major differences in how Ontario psychiatrists deliver care may explain why some patients have difficulty in accessing treatment , according to a new study released today by the Institute for Clinical Evaluative Sciences (ICES) and the Centre for Addiction and Mental Health (CAMH).  

There is a long-standing assumption, based on widespread difficulties with access, that there is a shortage of psychiatrists, which motivated the researchers to examine the supply and practice patterns of psychiatrists across Ontario.

“One would assume that in regions with more psychiatrists, patients would have better access to care, as well as more timely care after being hospitalized,” said Dr. Paul Kurdyak, lead author and Director, Health Systems Research at CAMH and Lead of the Mental Health and Addictions Research Program at ICES.

“Instead, we found that in such regions, the opposite was true. A substantial number of these psychiatrists saw fewer outpatients, while their colleagues in low-supply, non-urban areas had more patients and more new patients.”

The study which was published today in Open Medicine is the first to investigate the consequences of differing psychiatrist supply and its influence on practice patterns in Canada.

“These results provide an opportunity to improve the mental healthcare system to meet the growing demand for mental healthcare overall, as well as the urgent needs of those with the most severe cases of illness,” says Dr. Kurdyak.

Psychiatrist supply ranges from a high of 63 per 100,000 people in Toronto to seven per 100,000 people in non-urban parts of the province.  But more psychiatrists does not equal more access to psychiatric services.

In fact, the researchers found that the likelihood of a patient being seen following a psychiatric hospitalization (the researchers’ measure of need) is only a little higher in the high supply regions than the lower supply regions.

In Toronto, which has the highest number of psychiatrists per capita, 10 per cent of full-time psychiatrists see fewer than 40 patients a year. These patients were seen more frequently and for longer visits, suggesting that these patients were seen for long-term psychotherapy.

“The fee schedule in Ontario does not have limits on frequency or duration of visits, and does not say anything about the complexity of patients to be seen, so it may play a role in what we observed,” added Dr. Kurdyak.

The study analyzed practice patterns of full-time psychiatrists and post-discharge care to hospitalized psychiatric patients, according to psychiatrist regional supply in 2009 and found:

• In regions with higher supply, psychiatrists saw fewer inpatients and outpatients, they enrolled fewer new outpatients per year, but they saw their patients much more frequently and for longer visits.
• Patients who were seen more frequently were wealthier and less likely to have had a prior psychiatric hospitalization.
• A substantial proportion of full-time Toronto, Champlain, and Southwest LHIN psychiatrists had practices consisting of less than 100 outpatients per year (Toronto: 40 per cent; Champlain: 28 per cent; Southwest: 24 per cent compared to 10 per cent  in non-urban regions of the province).
• The likelihood of being seen following a psychiatric hospitalization is only slightly higher in the high supply regions than the lower supply counterparts.

“This research clearly shows that increasing the number of psychiatrists in Ontario is not the solution,” says Dr. Benoit Mulsant, co-author and Physician-in-Chief at CAMH. “Instead, our study raises questions about psychiatrists’ scope of practice, their practice patterns, and the reimbursement system, as well as how these issues can be addressed to improve the mental healthcare system for all patients.”

One solution adopted in the U.K., Australia and the U.S. has been to shift the psychiatrists’ role to serving as a consultant on a multidisciplinary team, while other mental health professionals such as psychologists provide evidence-based psychotherapy, at a lower cost to the system, the researchers note.

The study “Universal coverage without universal access: a study of psychiatrist supply and practice patterns in Ontario,” was published today in Open Medicine.

Authors: Paul Kurdyak, Thérèse A. Stukel, David Goldbloom, Alexander Kopp, Brandon Zagorski and Benoit H. Mulsant.

ICES is an independent, non-profit organization that uses population-based health information to produce knowledge on a broad range of healthcare issues. Our unbiased evidence provides measures of health system performance, a clearer understanding of the shifting healthcare needs of Ontarians, and a stimulus for discussion of practical solutions to optimize scarce resources. ICES knowledge is highly regarded in Canada and abroad, and is widely used by government, hospitals, planners, and practitioners to make decisions about care delivery and to develop policy.

For the latest ICES news, follow us on Twitter: @ICESOntario

The Centre for Addiction and Mental Health (CAMH) is Canada's largest mental health and addiction teaching hospital, as well as one of the world's leading research centres in its field. CAMH combines clinical care, research, education, policy development and health promotion to help transform the lives of people affected by mental health and addiction issues. CAMH is fully affiliated with the University of Toronto, and is a Pan American Health Organization/World Health Organization Collaborating Centre. For more information, please visit www.camh.ca

FOR FURTHER INFORMATION PLEASE CONTACT:

• Deborah Creatura
• Media Advisor, ICES
• [email protected]
• (o) 416-480-4780 or (c) 647-406-5996

• Kate Richards
• Media Relations, Centre for Addiction and Mental Health (CAMH)
• 416 535-8501 ext. 36015
• [email protected]