Universal coverage without universal access: a study of psychiatrist supply and practice patterns in Ontario

BACKGROUND We studied the relationships among psychiatrist supply, practice patterns, and access to psychiatrists in Ontario Local Health Integration Networks (LHINs) with differing levels of psychiatrist supply. METHODS We analyzed practice patterns of full-time psychiatrists (n = 1379) and postdischarge care to patients who had been admitted to hospital for psychiatric care, according to LHIN psychiatrist supply in 2009. We measured the characteristics of psychiatrists' patient panels, including sociodemographic characteristics, outpatient panel size, number of new patients, inpatient and outpatient visits per psychiatrist, and percentages of psychiatrists seeing fewer than 40 and fewer than 100 unique patients. Among patients admitted to hospital with schizophrenia, bipolar disorder, or major depression (n = 21,123), we measured rates of psychiatrist visits, readmissions, and visits to the emergency department within 30 and 180 days after discharge. RESULTS Psychiatrist supply varied from 7.2 per 100 000 residents in LHINs with below-average supply to 62.7 per 100 000 in the Toronto Central LHIN. Population-based outpatient and inpatient visit rates and psychiatric admission rates increased with LHIN psychiatrist supply. However, as the supply of psychiatrists increased, outpatient panel size for full-time psychiatrists decreased, with Toronto psychiatrists having 58% smaller outpatient panels and seeing 57% fewer new outpatients relative to LHINs with the lowest psychiatrist supply. Similar patterns were found for inpatient practice. Moreover, as supply increased, annual outpatient visit frequency increased: the average visit frequency was 7 visits per outpatient for Toronto psychiatrists and 3.9 visits per outpatient in low-supply LHINs. One-quarter of Toronto psychiatrists and 2% of psychiatrists in the lowest-supply LHINs saw their outpatients more than 16 times per year. Of full-time psychiatrists in Toronto, 10% saw fewer than 40 unique patients and 40% saw fewer than 100 unique patients annually; the corresponding proportions were 4% and 10%, respectively, in the lowest-supply LHINs. Overall, follow-up visits after psychiatric discharge were low, with slightly higher rates in LHINs with a high psychiatrist supply. INTERPRETATION Full-time psychiatrists who practised in Ontario LHINs with high psychiatrist supply saw fewer patients, but they saw those patients more frequently than was the case for psychiatrists in low-supply LHINs. Increasing the supply of psychiatrists while funding unlimited frequency and duration of psychotherapy care may not improve access for patients who need psychiatric services.