Report Details National Shortage of Psychiatrists and Possible Solutions
Abstract
APA joins medical directors in looking at causes of and remedies for the shortage of psychiatrists in the United States.
An increasing shortage of psychiatrists, especially those working in public sector and Medicaid-funded programs, is occurring even as demand for services increases, according to a report from the National Council for Behavioral Health.
The report cited a study commissioned by the U.S. Department of Health and Human Services indicating that the current workforce of approximately 45,580 psychiatrists would need to increase by 2,800 to meet current demands for psychiatric care. In other words, there is currently a 6.4 percent shortage in the psychiatry workforce. Based on estimates of retirement and new entries into the workforce, the projected unmet need in 2025 will be 6,090 psychiatrists, or a deficit of 12 percent of the workforce.
Psychiatrists are essential to the larger mental health care system because of their medical training and their ability to prescribe and manage medications for patients, but they face a number of constraints.
“Aging of the current workforce, low rates of reimbursement, burnout, burdensome documentation requirements, and restrictive regulations around sharing clinical information necessary to coordinate care are some of the reasons for the shrinkage,” said the report, which was produced by representatives from professional societies (including APA), insurers, patient groups, government agencies, and service providers.
Like other medical professionals, psychiatrists are concentrated in metropolitan areas, leaving 77 percent of U.S. counties ranked as “underserved.”
Recommendations to Increase Access to Psychiatric Care
The National Council for Behavioral Health’s report recommends that APA and the council work together with their members to increase the engagement of psychiatrists with outpatient and inpatient programs that accept commercial, Medicare, and Medicaid coverage. Here are some steps that can be taken to accomplish that goal:
Expand opportunities for psychiatric providers to practice in alternative clinical settings, such as peer-run services and family support services.
Negotiate with payers to establish models of reimbursement that recognize the true cost of psychiatric providers.
Provide more support in clinical settings that allow providers to work up to their level of licensure.
Build competence in the workforce to address the impact of psychiatric providers on reducing the total cost of care for high-need, high-risk, high-cost populations that have mental health and substance user disorders co-occurring with chronic medical conditions.
Address billing and reimbursement inequities and limits to help to level the playing field as innovative models of care become established.
Establish payment rate and methodology parity with medical-surgical reimbursement in Federally Qualified Health Centers and other primary care settings that will provide incentives for psychiatric providers to participate in these programs and remove the business incentive to minimize psychiatric services in order to avoid financial losses.
Moreover, steps can be taken to improve efficiency of the delivery of psychiatric services. Among them:
Reduce no-shows in outpatient psychiatric programs by setting up open-access models of scheduling.
Expand telepsychiatry by reducing regulatory barriers and reimbursing adequately.
Add adequate support for prescribers.
Reduce the administrative burdens around information sharing and documentation requirements.
In addition, psychiatry largely uses an “old-fashioned” delivery system, said Joseph Parks, M.D., chair of the National Council for Behavioral Health, whose National Council Medical Director Institute issued the report.
“We need to make greater use of data analytics, work more in teams with other providers like psychiatric nurses and physician assistants, and expand systems to pay for telepsychiatry and collaborative care,” said Parks in a teleconference at the report’s release.
Telepsychiatry is helpful not only for patients in remote locations but also for those who have trouble getting to a clinic because of physical disabilities. Patients have largely accepted the modality, and electronic communications systems have become standard elements in the lives of younger people.
National politics could play a role, as well. About 50 percent of new psychiatry trainees are international medical graduates, and possible changes in the H1B visa program could interfere with that flow, said Parks, who is also director of the Missouri Department of Mental Health.
APA is advocating for additional funding and slots for graduate psychiatric training and for loan-forgiveness programs that encourage psychiatrists and other clinicians to practice in underserved areas, said APA CEO and Medical Director Saul Levin, M.D., M.P.A. New billing codes are needed to pay for collaborative care as well. Last year the Centers for Medicare and Medicaid Services created a CPT code and a fee for Psychiatric Collaborative Care Management Services that are now part of the 2017 Medicare fee schedule.
However, better reimbursement and a commitment to mental health parity are meaningless unless all insurance networks have adequate numbers of psychiatrists on their panels, he said.
As a practical matter, training must align with needs, said Patrick Runnels, M.D., an associate professor of psychiatry at Case Western Reserve School of Medicine in Cleveland and co-chair of the National Medical Director Institute.
“That process should start in medical schools, beginning with stronger and longer rotations in psychiatry to expose medical students to the range of practice in psychiatry today,” he said.
In residency, trainees need more exposure and experience with telepsychiatry, medication-assisted treatment for substance use, and collaboraton with other professionals. Experience with updated integrated care models and time in Federally Qualified Health Centers should be required for all residents, said Runnels, who is also program director for community psychiatry at University Hospitals Cleveland Medical Center.
“The biggest opportunity to expand the workforce is to reduce the portion of psychiatric providers who practice exclusively in cash-only practice,” said the report. “APA and the National Council need to work with their members to implement a wide range of incentives that promote the engagement of psychiatric providers with outpatient and inpatient psychiatric programs that accept commercial, Medicare, and Medicaid coverage that pays for the majority of Americans with psychiatric health care needs.”
The report’s conclusions will be pushed out through professional associations and advocacy as a step toward placing its recommendations into action, said Parks. ■
“The Psychiatric Shortage: Causes and Solutions” can be accessed here.
