The Behavioral Health Care Workforce Shortage — Sources and Solutions
By Kate Jackson
Today’s Geriatric Medicine
Vol. 13 No. 1 P. 22
With demand for behavioral health care higher than ever, access is diminishing. Experts agree, a crisis is looming. How did we get here, and what are the solutions that could work?
The authors of an article in a special issue of the American Journal of Preventive Medicine focusing on behavioral health human resources note that at least 44 million adults in the United States experience a diagnosable mental illness, and among the nation’s youth, rates of severe depression are on the rise. They observe that “State and federal policies supporting mental health parity, reimbursement, and insurance expansion have collectively improved access to care, yet as the rates of uninsured adults decrease, more than half of the population with mental health conditions still does not receive treatment.”
It’s a situation projected to worsen in the coming years. Not only will vulnerable individuals lack adequate care but also, says Daniel Do, MSW, LICSW, MPH, an adjunct lecturer in the Boston University School of Social Work, “The shortage will continue to burn out and stress the existing workers within the system.”
A 2016 report by the Health Resources and Services Administration’s (HRSA) National Center for Health Workforce Analysis forecasts a shortage of psychiatrists; clinical, counseling, and school psychologists; mental health and substance use disorder (SUD) social workers; school counselors; and marriage and family therapists through 2025. Furthermore, it projects shortfalls of more than 10,000 full-time employees for mental health and SUD social workers and school counselors. Also contributing to lack of access to care by those in need is geographic disparity. “Maldistribution intensifies the magnitude of provider shortages, as certain areas of the country have few or no behavioral health providers available,” says Michelle Washko, PhD, acting director of the HRSA National Center for Health Workforce Analysis.
“Our human resources are at the level of a crisis now,” says Ron Manderscheid, PhD, executive director of the National Association of County Behavioral Health and Developmental Disability Directors and the National Association for Rural Mental Health in Washington, D.C., an adjunct professor at the Suzanne Dworak-Peck School of Social Work at the University of Southern California and the Bloomberg School of Public Health at Johns Hopkins University, and one of the contributors to the special issue of the American Journal of Preventive Medicine. He points to HRSA projections suggesting a shortage of 25,000 providers in nine behavioral health occupations by 2025. “About 85% of counties have inadequate or no behavioral health services, and 63% of counties have no psychiatrist,” Manderscheid says.
Need Is Growing Faster Than Capacity
The Affordable Care Act (ACA), Manderscheid says, has greatly increased the number of people with insurance. “In the Medicaid expansion up to 40%, and in the state health insurance marketplace probably 25% to 30%, of those are people with behavioral health conditions.” While there are many more people eligible to receive services, he says, there’s been no change in the capacity of the system to serve them. “There haven’t been changes to any of the protocols in training at universities; they’re turning out the same number of people they always turned out, so need is growing relative to our capacity to serve.”
Manderscheid describes the capacity of the behavioral health care work force as soft, referring to the fact that much of the current work force will no longer be there in five years. From state agencies to community mental health centers, the field, he says, has been run by baby boomers, who are now retiring in droves. The next generation, he says, tended not to enter these fields during the years of the Reagan presidency. Gen X individuals are coming on line as the next generation of managers, he says, but as their boomer bosses retire, they haven’t had a lot of management experience and may not know a great deal about Medicaid. “Work all the way down to the millennials, and they’ve never taken hold in the field,” Manderscheid says, adding that it’s not uncommon for them to work at a job for two to three years and move on to the next place, “so we have a huge amount of churn.” If this remains true and nothing changes, he says, capacity is at risk of diminishing over time.
Behavioral health care historically has been an urban discipline, Manderscheid says. “If you live in New York, Washington, D.C., San Francisco, or Chicago, you can get the best behavioral health services available and it will be state of the art. But if you live in Allamakee County, Iowa, population 15,000, you’ll be hard pressed to get any services.” To bring providers to Allamakee county, he says, they’d have to be recruited from that county so they want to return there. If they’re recruited from New York, even if they incur a four-year obligation through government-funded training through the National Health Service Corps, “The minute the obligation is over, they’re out of there, back to New York.” There’s a poor distribution of existing resources, “and they tilt very heavily toward urban areas.”
Lack of Investment in Community Services
Community services have gone through major ups and downs in the last 25 years, Manderscheid says. “In the 1990s, our community services were being squeezed pretty badly by managed care, meaning that we never made the investment into our community services that we need to make, and as a consequence we never had the capacity we needed to serve people there.” Among the consequences, he says, are that some people rely on emergency departments (EDs) for treatment and others fall through the cracks, “becoming mentally ill, homeless, picked up and put in jail, resulting in a lot of people in city and county jails due to the lack of capacity in building our community system.”
The Opioid Epidemic
The opioid crisis, says Joe Parks, MD, medical director of the National Council for Behavioral Health, has boosted demand, yet most behavioral health providers are untrained in SUDs generally or opioid use specifically. Before the ACA, Manderscheid says, only 10% of people with SUDs received specialty care. “Under the ACA, we’ve been able to get that number up to 16% and 17%, which means between 82% and 83% are still getting no care from the specialty sector. That’s a crisis level.” The system, he says, doesn’t have the capacity to treat the numbers of people with the problem. “Demand occurs in EDs, substance abuse treatment, and county jails, after police pick up someone who’s overdosed in the street or at home and is almost dead. Police give the person naloxone and they come back to life, but if they don’t get interpersonal care or better continuing care including medication-assisted treatment after that, the probability is very high the person will overdose again and probably die,” Manderscheid says.
Approximately 44 million people in the United States are 65 or older. According to Manderscheid, by 2060 there will be 100 million older adults, the population going from 14% to more than 20%, or from 1 person in 10 being older than 65 or older to 1 in 5. Factoring in only the 56 million additional older adults by 2060, he estimates that there will be far more than 10 million people who will need behavioral health care. The systems, he says, are already laboring, and there’s a tendency in our society to “push the [problem] down the road,” and say we don’t have to worry about it until 2025. “It’s fallacious logic,” he says.
High Turnover Rates and Low Compensation
Turnover rates, Do says, have been related to pay, burnout, and institutional culture. “Looking at the statistics of growing rates of accredited MSW, PsyD, LMHC, and LMFT programs across the country, we should be able to stem some of the shortage of mental health providers in community settings. The issue is when providers do join these settings they often feel overworked and underpaid. Institutions have to grapple with lower insurance reimbursements (compared to medical doctors and nurse practitioners), and when working with populations who are facing numerous barriers to health and wellness, the ‘show rate’ is often lower, resulting in decreased income for agencies. All of this puts a stressor on the system, and many agencies are trying to figure out how to address these issues,” he says. “A potential consequence of this high turnover rate is that people could start with a therapist for a few months but then that therapist transitions, and the patient keeps getting reassigned to a new therapist. I’ve seen many people who on the first session ask ‘When will you leave?’ after having had numerous therapists over the course of a few years or a few months. This issue exacerbates existing mental health conditions,” Do says.
Inadequate compensation also contributes to attrition in the workforce. “We have seen agencies try to increase their access to mental health providers over the years, and yet the pay is sharply lower when compared with other health professions such as nursing and primary care providers. The benefit is noticed and recognized; the ability to pay based on current reimbursement rates and structures makes it much more difficult,” Do says. “Many social workers say that they didn’t go into the field for money, but we still need to be able to make a wage that can allow a person to thrive,” Do says. “Many therapists enjoy the work in the community and recognize that the pay can be lower, but that should not be the norm.” It shouldn’t be necessary, he says, for so many people in the field to work a full-time community-based mental health job and do private practice hours on the side in order to make ends meet or be able to save money.
Compensation rates for behavioral health providers are lower compared with those of other clinical specialties, Parks says, “which results in a higher portion of behavioral health clinicians in cash-only practices and higher rates of out-of-network care, which means higher deductibles and copays for patients.”
Although low compensation is often cited as contributing to the shortage, Holly Andrilla, MS, research scientist at WWAMI (Washington, Wyoming, Alaska, Montana, Idaho) Rural Health Research Center in the department of family medicine at the University of Washington School of Medicine in Seattle, cites other, more common sources of provider dissatisfaction, particularly among those working with people with opioid use disorder, including issues related to medication diversion, lack of confidence, and lack of time. In addition, she says, many providers don’t want to work with certain populations of patients such as those with SUDs.
Looking for Solutions
Manderscheid acknowledges that while some offer “pie in the sky” solutions, much of what’s being done and will be done is “bailing water and filling potholes.” He doesn’t envision anyone coming up with the grand solution. “I don’t see how they can, because the grand ideas must be paid for, and we as a society don’t have the wherewithal to pay for the grand ideas.” Still, he acknowledges, steps are being taken to find ways to mitigate the problem.
According to Parks, the most significant actions being taken to address the shortage are undertaken by the Certified Community Behavioral Health Center project, “an initiative to expand clinics’ capacity to serve more people via an expanded workforce by paying rates that actually cover the cost of providing care” (www.thenationalcouncil.org/topics/certified-community-behavioral-health-clinics) and better enforcement of the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008, especially with respect to rates and network adequacy. Others pin their hopes on shifting responsibilities, new technologies, embracing peers and community health workers (CHWs), and a variety of strategic programs.
Peers and CHWs
“Peers and community health workers are awesome professionals to add to the team. They are not here to replace mental health counselors but rather to work alongside them,” Do says. “Having the additional peer or community health worker voice in the team has been a fantastic change. Peers and CHWs can relate and help advocate for patients in a way that those in professional social work cannot. These models provide support to patients when the system is stressed and help get the concerns of the patients to the organizations in a different way,” Do adds.
Andrilla, who, like Manderscheid, contributed to the special issue of the American Journal of Preventive Medicine devoted to the behavioral health care workforce shortage, studies the supply of behavioral health providers in rural areas. She observes that one-half of US counties don’t have a psychiatrist. For people in need, if they can even find a provider, they’ll be faced with a long wait to get an appointment. To address that, she says, “telemedicine is starting to take off in a real way, and that may be a really good answer to at least reduce the disparities between rural and urban areas.”
One way to reduce the burden and increase access, Andrilla says, involves shifting responsibilities. “A psychiatrist doesn’t need to provide all the services, so one solution might be to broaden the scope of practice or shift tasks so people are operating at the top of their scope in terms of what they can do,” saving for psychiatrists the responsibilities that only they can fulfill. In several states, she observes, psychologists are allowed to prescribe. And in terms of the opioid epidemic, she points to a five-year demo project that was ended early and made permanent to allow nurse practitioners and physician assistants to provide buprenorphine (an office-based medication-assisted treatment). It’s shown to be a highly effective treatment that a lot of people couldn’t get because it required having a physician with a waiver, and a very small percentage of US physicians had them.” The cap on how many patients can be treated has been expanded, and there are efforts made by the federal government to get physicians waivered, train them, and provide mentors. To solve the problem, it’s not enough to bolster our mental health force, Andrilla says. “We also need to expand what each group can do.”
“Paired with an assessment of the nation’s behavioral health workforce magnitude, distribution, capacity, and unmet needs, HRSA administers a number of programs intended to strengthen the health workforce and connect skilled professionals to communities in need,” Washko says. In addition to providing $293 million in awards to primary health care clinicians and students through the National Health Service Corps and Nurse Corps programs that provide scholarships and loan repayment to health care providers in exchange for work in underserved areas in the United States, it administers the following programs:
• the Behavioral Health Workforce Education and Training program, which increases the numbers of behavioral health providers entering and continuing practice; and
• the Opioid Workforce Expansion Program, which enhances the community-based experiential training focused on opioid use disorders and SUDs for students preparing to become behavior health professionals and paraprofessionals. In fiscal year 2019, HRSA plans to award approximately $69 million in the Opioid Workforce Expansion Program.
According to Washko, it will be necessary to make access to health care quick and effective by improving integration of behavioral health into primary care. Additional factors, he says, may improve access to services, including “the use of health information technology, elevation of prevention and recovery-oriented systems, strengthening the quality of care and services delivered, easing administrative burdens for physicians, facilitating shifts in health care delivery models toward team-based care, fully embracing telemedicine modalities, and focusing attention on the value of using peers and paraprofessionals in behavioral health care delivery.”
— Kate Jackson is editor of Today’s Geriatric Medicine.