Seek­ing so­lu­tions for be­hav­ioral health­care short­age

Modern Healthcare - - NEWS - By Steven Ross John­son

Pa­tients in Chicago who need men­tal health coun­sel­ing can wait a year or more be­fore they see a spe­cial­ist, ac­cord­ing to Joanne May, di­rec­tor of be­hav­ioral health ser­vices at Ad­vo­cate Illi­nois Ma­sonic Med­i­cal Cen­ter.

That’s why Ad­vo­cate Health Care, the state’s largest health­care sys­tem, re­cently be­gan em­bed­ding be­hav­ioral health spe­cial­ists in its pri­mary-care prac­tices. The sys­tem’s flag­ship hos­pi­tal also of­fers a walk-in men­tal health clinic six days a week for pa­tients in cri­sis. Care is pro­vided on a first-come, first-served ba­sis. Pa­tients are get­ting same-day as­sess­ment and treat­ment.

“When peo­ple are in cri­sis, they might not be able to wait for an ap­point­ment that is two months down the road or even 14 months down the road,” May said.

But Ad­vo­cate, which like most sys­tems across the coun­try is grap­pling with huge un­met men­tal health needs among its clien­tele, has run into a ma­jor stum­bling block. There aren’t enough psy­chi­a­trists and coun­selors to meet the bur­geon­ing de­mand for ser­vices.

The short­age is pro­jected to grow acute over the next decade, ac­cord­ing to a re­cent anal­y­sis by HHS’ Health Re­sources & Ser­vices Ad­min­is­tra­tion. The na­tion needs to add 10,000 providers to each of seven sep­a­rate men­tal health­care pro­fes­sions by 2025 to meet the ex­pected growth in de­mand.

The widen­ing gap be­tween de­mand and the sup­ply of avail­able be­hav­ioral health­care providers is be­ing driven by a greater em­pha­sis on ad­dress­ing men­tal health is­sues within pri­mary-care set­tings. While the fate of plans sold un­der the Af­ford­able Care Act—which must in­clude men­tal health and sub­stance abuse treat­ment as one of the 10 es­sen­tial ben­e­fits—is up in the air, the fi­nal rules for the 2008 Men­tal Health Par­ity and Ad­dic­tion Eq­uity Act, which cov­ers all plans, es­tab­lished the same de­ductibles, co­pay­ments and lim­its on vis­its for men­tal health as of­fered for med­i­cal and sur­gi­cal ser­vices.

The prom­ise of com­pre­hen­sive care for be­hav­ioral health prob­lems has high­lighted how un­pre­pared the health­care sys­tem is for meet­ing the in­creased de­mand. The prob­lem has been years in the mak­ing, pub­lic health ex­perts say.

The num­ber of newly trained physi­cians will­ing to en­ter psy­chi­a­try hasn’t kept pace with the grow­ing de­mand for care. In fact, there aren’t even enough new pro­fes­sion­als to re­place ag­ing baby

Poor re­im­burse­ment has af­fected ef­forts to re­cruit med­i­cal stu­dents into the spe­cialty.

boomer psy­chi­a­trists, who are start­ing to re­tire in droves. “It is both a com­ing prob­lem and a prob­lem we are deal­ing with right now,” said John Snook, ex­ec­u­tive di­rec­tor for the Treat­ment Ad­vo­cacy Cen­ter, a men­tal health ad­vo­cacy group.

An anal­y­sis re­leased in Novem­ber by HRSA pro­jected the na­tion will need an ad­di­tional 5,000 psy­chi­a­trists by 2025 on top of the more than 45,000 providers al­ready em­ployed. The re­port es­ti­mates 20,470 psy­chi­a­trists will likely en­ter the work­force over the next decade.

But the num­ber of providers that are ex­pected to leave the work­force dur­ing the same pe­riod will re­sult in a 1% net de­crease in 2025 com­pared to the num­ber psy­chi­a­trists in the work­force in 2013. In fact, the re­port projects short­ages over the next decade in pro­fes­sions that span the scope of the be­hav­ioral health­care work­force, which in­cludes nurse prac­ti­tion­ers, physi­cian as­sis­tants, psy­chol­o­gists, coun­selors, ther­a­pists and so­cial work­ers.

“The re­cruit­ment rate into psy­chi­a­try has been flat for a cou­ple of decades while the de­mand has gone up,” said Dr. Joe Parks, se­nior med­i­cal di­rec­tor for the Na­tional Coun­cil for Be­hav­ioral Health.

The lack of new physi­cians en­ter­ing psy­chi­a­try has re­sulted in an ag­ing work­force. Close to 60% of ac­tive psy­chi­a­trists in 2013 were ages 55 or older, ac­cord­ing to the As­so­ci­a­tion of Amer­i­can Med­i­cal Col­leges’ 2014 Physi­cian Spe­cialty Data Book, well above the av­er­age of 42% for all med­i­cal spe­cial­ties.

A ma­jor rea­son young physi­cians ig­nore psy­chi­a­try is in­ad­e­quate re­im­burse­ment by com­mer­cial and govern­ment pay­ers. Psy­chi­a­try was ranked fourth low­est among 23 med­i­cal spe­cial­ties in Mod­ern Health­care’s 2016 Physi­cian Com­pen­sa­tion Sur­vey.

Low re­im­burse­ment rates have led many in the field to only ac­cept out-of-pocket pay­ment from pa­tients. As many as 45% of psy­chi­a­trists take cash-only re­im­burse­ment for ser­vices com­pared to just 11% of physi­cians in all other spe­cial­ties.

Poor re­im­burse­ment has af­fected ef­forts to re­cruit med­i­cal stu­dents into the spe­cialty. “De­spite the fact that these folks have a sig­nif­i­cant amount of pro­fes­sional train­ing, the salaries don’t of­ten track with other health­care spe­cial­ists,” said Paul Gion­friddo, CEO of Men­tal Health Amer­ica. “It’s dis­cour­aged peo­ple from en­ter­ing those par­tic­u­lar spe­cial­ties.”

Amid the short­age, de­mand for the ser­vice is sky­rock­et­ing. One ap­proach be­ing pur­sued by sys­tems such as Ad­vo­cate is to em­pha­size be­hav­ioral health within pri­mary-care set­tings. Men­tal health screen­ings dur­ing a pri­mary-care visit can iden­tify pa­tients suf­fer­ing from stress, anx­i­ety and de­pres­sion. Quick re­fer­rals and ap­point­ments with spe­cial­ists can pre­vent more se­vere health is­sues down the road.

“There is an in­creas­ing un­der­stand­ing that all health­care has a be­hav­ioral health com­po­nent,” said Mara La­der­man, a se­nior re­search as­so­ciate at the In­sti­tute for Health­care Im­prove­ment. “Pa­tients are in­creas­ingly ex­pect­ing that they will be able to get all of their needs met in one place, and that place is gen­er­ally within pri­mary care.”

But the push by health­care sys­tems and large physi­cian prac­tices to pro­vide men­tal health ser­vices within pri­mary-care set­tings can­not by it­self end a short­age of be­hav­ioral health­care pro­fes­sion­als that will likely grow worse in the years ahead.

That may put more de­mands on pri­mary-care physi- cians to man­age men­tal health con­di­tions. They are al­ready the main pre­scribers of psy­chotropic med­i­ca­tions. “If I can get my meds and main­tain my meds through my pri­mary-care clin­i­cian I’m a lot less likely to go and seek out a be­hav­ioral health provider,” Gion­friddo said.

Yet for most pri­mary-care physi­cians, it’s been years since they went through their rudi­men­tary train­ing in of­fer­ing an­cil­lary be­hav­ioral health ser­vices such as coun­sel­ing. Congress rec­og­nized the need by in­clud­ing a num­ber of pro­vi­sions aimed at ex­pand­ing the be­hav­ioral health work­force in the re­cently en­acted 21st Cen­tury Cures Act.

The bill in­cluded $12.7 mil­lion to fund a mi­nor­ity fel­low­ship pro­gram to train cul­tur­ally com­pe­tent men­tal health pro­fes­sion­als; $15 mil­lion for the Grad­u­ate Psy­chol­ogy Ed­u­ca­tion Pro­gram; and $10 mil­lion in grants for aca­demic pro­grams to im­prove the screen­ing and treat­ment of be­hav­ioral health and sub­stance use disor­ders and ex­pand ac­cess to care in un­der­served com­mu­ni­ties.

Other pro­vi­sions in­cluded tougher en­force­ment of the 2008 men­tal health par­ity law, which re­quires in­sur­ers to cover coun­sel­ing and treat­ment like any other med­i­cal con­di­tion. The leg­is­la­tion also in­creased fund­ing to train law en­force­ment of­fi­cers to seek al­ter­na­tives to in­car­cer­a­tion when en­coun­ter­ing peo­ple with men­tal health is­sues.

“Now that we know we have this pop­u­la­tion that needs treat­ment, how do we do this smartly and how do we make changes that re­ally en­sure peo­ple get the care that they need,” Snook said. “The next step … is fig­ur­ing out how we pro­vide care right away.”

Por­tions of this ar­ti­cle first ap­peared on Mod­ern Health­care’s Trans­for­ma­tion Hub, mod­ern­health­care.com /trans­for­ma­tion

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