(Withdrawn) Assessing Real-World Access to Outpatient Mental Health Services for Youth: A Mystery Shopper Study

Background and Purpose. One in five adolescents in the United States have a mental health (MH) disorder, yet less than half receive MH care. Community mental health centers (CMHCs) and Federally Qualified Health Centers (FQHCs) are key access points for adolescents, especially those enrolled in Medicaid. However, barriers exist which may reduce their accessibility, including a shortage of specialty providers, lack of insurance acceptance, and long wait times. Further, previous research indicates discrimination may occur at the point of scheduling, creating additional barriers for families of color. Given that Medicaid insures 38% of youth in the U.S., it is imperative to analyze the accessibility of the safety-net agencies that serve this population. Using an innovative mystery shopper method, this study aims to understand how access to trauma-informed MH services delivered in community-based outpatient health agencies varies by insurance type, the race of the caller, and organizational type.

Methods. Three pseudo mothers (voice actresses) called eligible CMHCs and FQHCs (N=229) in Cook County, Illinois, requesting to schedule an actual MH appointment for their adolescent child who recently witnessed a traumatic event. Women of different races (White, Latina, and Black) were hired as voice actresses to understand the impact of race on access to MH care. Each agency was called twice (once using Medicaid script and once using private insurance script in random order) in the Spring and Summer of 2021, during the COVID-19 pandemic. All appointments were canceled at the end of the call. We used descriptive statistics to evaluate barriers to accessing care, length of wait time, and the availability of trauma-informed treatment. We ran a generalized linear model to assess the impact of contributing factors (e.g., race) on scheduling an appointment.

Results. Only 17% (n=78) of pseudo mothers could schedule an appointment across both waves of data collection. The primary barriers families experienced when scheduling an appointment were capacity/waitlist reasons (n=87) and an administrative requirement to switch their primary care provider (PCP) into the organization's network (n=71). The average wait time for scheduled appointments was 12 days, and 38% of agencies reported offering trauma-informed treatment. Insurance and organizational type did not predict the ability to schedule a MH appointment, but the caller's race did. The Black and Latina callers were 18% more likely to be denied an appointment than the White caller (p = .019).

Conclusion. Alarmingly, less than one in five pseudo mothers could schedule a MH appointment for their adolescent child. Appointments were primarily denied to families for administrative and capacity reasons. On a positive note, insurance type did not predict the ability to schedule an appointment, indicating agencies were just as likely to accept clients enrolled in Medicaid as private insurance. However, the caller's race did predict access, indicating discrimination may be occurring at the point of scheduling. The results of this study will inform the development of organizational-level strategies to reduce administrative requirements and enforce anti-discrimination policies.