Seeking solutions for behavioral healthcare shortage

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 and 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 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 physicians 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.