More work needs to be done to address the shortage of psychiatrists, including improvements in training and models of health care delivery, according to a new report from the National Council for Behavioral Health’s Medical Director Institute.

In framing the problem, Joseph Parks, MD, a psychiatrist who serves as medical director of the National Council, said during a March 28 teleconference to introduce the report that “55% of the counties in the United States have no psychiatrist in them” and “77% of the counties report a severe shortage.” He noted that the number of psychiatrists available declined by 10% between 2003 and 2013 and that the average age of practicing psychiatrists is in the mid-50s. In other medical specialties, the average age is in the mid-40s, he said.

“This has resulted in people having long wait times and being unable to get psychiatric services,” Dr. Parks said . Those factors are leading patients to pursue psychiatric care in alternative places, such as in primary care physician practices and emergency departments.

In emergency departments, the average wait for dispositions for some psychiatric patients can reach 23 hours, the report says. And more people are going to EDs for care.

“There has been a 42% increase in patients going to the emergency rooms for psychiatric services in the past 3 years,” Dr. Parks said. “But most of them aren’t staffed with psychiatrists. So people end up stuck in the emergency rooms for hours – two to three times as long as they spend for general medical conditions.”

The report looks at causes, and makes actionable recommendations for payers and providers. It also makes recommendations about the infrastructure needed to train future psychiatrists.

A key part of the problem is the increased demand, which is partly attributable to the expansion of health care coverage through the Affordable Care Act’s Medicaid expansion provisions as well as the normalization of views on behavioral health.

“People want psychiatric services,” said Dr. Parks, who has practiced medicine and worked as a policy maker in Missouri. “They know treatment works. It’s less stigmatized than it used to be, so people are more willing to accept and seek treatment.”

Among the trends cited by the report is a shortage of new psychiatrists coming out of medical schools.

“There are problems with not enough training capacity,” he said. “We’ve had increases in federal support for increased training capacity for ob.gyns. and primary care, but we’ve not had that same increase and support, and there are [fewer] supports for training of psychiatrists and fewer slots.”

Burnout is another problem facing psychiatrists.

“Psychiatrists who are practicing are in many cases forced to do it at lower than usual reimbursements [and] are having short visits,” Dr. Parks said. “They are rushed … they don’t get the same supports that other physicians get. They don’t get the same ancillary staff to assist them in caring for the patients.”

Elaborating on the issues surrounding reimbursement, Dr. Parks noted that 40% of psychiatrists work on a cash-only basis, and 75% of behavioral health organizations lose money on fees collected for psychiatric services.

An ongoing workforce concern, especially in light of changes to the H-1B program, is that 50% of new trainees are foreign medical graduates.

“Luckily, there is a broad range of solutions, and there is something for all the major players to do here,” Dr. Parks said, noting that the report highlights many of these solutions.

“We need to change the care delivery system so it’s not the psychiatrist seeing everybody continuously,” he said. “Psychiatrists need to be used more as expert consultants. People need to be identified using data analytics as opposed to waiting for the patient to complain. And they need to be working more in teams, so they are doing the essential things that only a psychiatrist can do.”

Dr. Parks added that psychiatrists need to delegate “other parts of care and follow-up for people who are stable or for services that can be done by other professionals, such as psychiatric nurses or perhaps physician assistants. “We need an increase not only in more training capacity for psychiatrists but [also in] more alternative providers.”

Patrick Runnels, MD , a psychiatrist who cochairs the Medical Director Institute, highlighted several of the training issues.

“[W]e determined that psychiatrists also bear responsibility for improving this workforce crisis,” Dr. Runnels said during the call. “That starts with making our training consistent with the emerging needs and models of care that are attractive to potential trainees.”

And getting more clinicians into areas of high need, like psychiatry, starts at the medical school level.

“We were able to determine [that] in medical school, medical students were more likely to be recruited into psychiatry based on two characteristics – that the medical school had a strong reputation within their psychiatry department, particularly a strong rotation that was well rated by medical students in psychiatry, and that the length of the rotation was longer,” he said. “When those two things are put together, more students choose to go into psychiatry residency.”

In addition, more exposure is needed to aspects of practice that fit with the way in which medical care is being delivered, including better training in team-based collaborative care and medication-assisted treatment for substance use disorders.

“We also think that residents need to be placed in a range of settings, some settings in which they don’t get very much placement right now, including federally qualified health centers, patient-centered medical homes, [and] experience with telepsychiatry,” said Dr. Runnels, who also serves as medical director of the Centers for Families and Children in Cleveland.

“On top of that, we need our psychiatry residents to graduate with skills in health care data analysis, particularly at the population level,” Dr. Runnels continued. “We need our residents to understand the impact of the treatments that we have on entire populations and how to best allocate resources to deal with the whole population. Those things are hugely important.”

The National Council, based in Washington, is made up of 2,900 member organizations across the country that serve 10 million adults, children, and families who are living with mental health and substance use disorders.


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