When I wrote about this in 2018, the trend was a decreasing rate of mental health clinicians opting out of Medicare, despite flattening reimbursement rates and other concerns. At that time, a total of 8,661 psychiatrists, psychologists, and clinical social workers had formally opted out, estimated to represent fewer than 2% of available mental health clinicians. The number opting out peaked in 2016, with decreases in new opt-outs the following two years, and a similar trend among the three mental health specialties which together provided almost 98% of all psychotherapy for Medicare beneficiaries.

What’s happened since then?

This and the following information is based analyses of the “Opt Out Affidavits” dataset (replications welcome).

All Specialties Opting Out

As of 1/1/23, a total of 29,309 clinicians have formally opted out of Medicare.

 

Mental Health Specialties Opting Out

As of 1/1/23, a total of 12,566 mental health clinicians have opted out, a 45% increase since 2018, and 43% of all specialists opting out of Medicare. Psychologists have the most opt-outs (5,022), followed by psychiatrists (4,322) and social workers (3,212).

For the first time, as of January 2023, psychologists topped 5,000 who have opted out. By policy, opt-out status continues for two years from the initial opt-out date, and renews automatically unless reversed by the opting out clinican.

Psychologists are the greatest proportion of all specialties who have opted out of Medicare, at 17%. Psychiatrists have the second highest proportion of opted out clinicians (15%), with social workers the 5th most frequently opted-out of the specialties (11%).

Trends Over Time

2016 was the peak year for new opt-outs among psychiatrists (979 that year) and psychologists (713). Single year new opt-outs peaked in 2017 for social workers, at 546.

From 2016-2020, the overall trend was decreasing new opt-outs across the three specialties, with a decrease of 45% among new psychiatry opt-outs and 79% decrease among psychologists, through 2020, and a decrease of 57% in new opt-outs among social workers from 2017-2020.

Since 2020, the rate of new optouts has increased among all three specialities, by 64% among social workers, 43% among psychologists, and 30% among psychiatrists.

Taking a closer look at the year preceding the pandemic and the following years, fewer mental health clinicians opted out in the first pandemic year than the prior year, with increasing numbers in 2021-2022.

Potential implications of mental health clinician opt-outs for delivery of mental health services may be seen when total therapy sessions provided by social workers, psychologists and psychiatrists are shown in contrast to opt-outs. Data are not yet available for number of sessions provided in 2022.

The trend shows that the total number of sessions provided by mental health specialists declined from 2019 to 2020, even though the number of newly opted out clinicians also declined. And, despite a 2020-2021 increase in the number of newly opted out mental health clinicians, the total number of therapy sessions provided increased as well.

Considerations

• Given the year-to-year variation in new opt-outs, considerable speculation is possible about factors influencing decisions to opt out. Factors could include fluctuations and uncertainty in reimbursement, non-compensable administrative and time burdens, and others. Current data alone are not able to provide reliable clarification.
• Mental health specialties rank 1st, 2nd, and 5th among all specialties opting out. It seems likely there are one or more common contributing factors for these specialties to opt out.