Jon Lehrmann, MD; David Peterson, MBA, FACMPE; Joseph E. Kerschner, MD; John R. Raymond Sr., MD
WMJ. 2018;117(3):133-134.
There is considerable evidence that Wisconsin is experiencing the effects of a nationwide shortage of psychiatrists and mental health practitioners that directly affects the health of Wisconsin citizens. This “continued crisis” in the delivery of and access to adult, child and adolescent mental health care is caused by resonating factors that include an inadequate supply of providers, inadequate insurance reimbursements, Medicaid reimbursement rates for outpatient behavioral health care that trail other states, professional stigma, and greater recognition and awareness that mental health is an integral component of population health, to name a few. For example:
- A Wisconsin Department of Health Services’ Division of Public Health study revealed that 68 of 72 Wisconsin counties have inadequate numbers of psychiatrists to meet population needs.1
- According to a study published in Psychiatric Services in Advance, the psychiatry workforce in the United States will continue to contract and, by 2024, a minimal shortage of over 14,000 psychiatrists nationwide is projected.2
- An industry analysis of 42 million insurance claims between 2013 and 2015 revealed that psychiatrists were paid an average of 20% less than their primary care and medical/ surgical peers when the same service was delivered using the same billing codes.3
- A Milwaukee Journal Sentinel analysis of 2016 workforce data “found that Wisconsin is worse than most states in its per-capita workforce of all types of mental health professionals: nurses, social workers, psychologists and psychiatrists.”4
- A leading physician search and consulting firm’s white paper on the psychiatric shortage revealed that the average age of practicing psychiatrists is third oldest, with 59% of the nation’s 30,451 active psychiatrists aged 55 years or older.” According to a Kaiser study cited in the white paper, Wisconsin is only meeting 20.8% of the state’s mental health needs, ranking it 49th of 50 states.5
To address the shortage of primary care providers and psychiatrists across Wisconsin directly, The Medical College of Wisconsin (MCW) has developed two innovative, 3-year community medical schools in central and northeastern Wisconsin, a major goal of which is to increase the number of primary care clinicians and ultimately, psychiatrists. To further address our goal of increasing psychiatrists, MCW created two newly accredited psychiatry residencies near the campuses. This was first described in the WMJ Dean’s Column:“Working to Increase Access to Mental Health Care in Wisconsin” in December 2016.6 The new residency programs have the capacity to increase the number psychiatry residents trained in Wisconsin by 41%. This was accomplished with local community, Veteran Administration (VA), State of Wisconsin, and health system support. MCW also created an accredited addiction psychiatry fellowship to help address the shortage of addiction psychiatrists.
Another MCW strategy to improve access to mental health care providers has been to develop other allied health care providers by encouraging nonphysician providers to work at the top of their license, and by integrating them into interprofessional mental health care teams. Such an approach to mental health care maximizes a health system’s ability to care for populations. MCW also developed a new pharmacy school that emphasizes the development of clinical pharmacists. Mental health clinical pharmacists can nicely complement and extend the psychiatrist’s ability to prescribe for patients. The Department of Veterans Affairs has been a leader in developing this clinical pharmacist model. In partnership with Froedtert Health, MCW opened a health psychology training program this past year to help further establish inter-professional mental health care. In addition, partnering with local universities that are training advance practice providers (APP), MCW and its affiliate health system partners are providing clinical mental health care training for APPs that enhances this interprofessional model further.
Integrating behavioral health care into primary care is a very important strategy, which can mitigate stigma by facilitating the provision of mental health care from the primary care provider team. There is developing evidence that demonstrates the downstream cost-effectiveness of these collaborative care models. MCW is working with its major health care partners to implement models that expand the mental health care provider team.
Finally, drawing from experience in the Department of Veterans Affairs, MCW has developed a “specialty care access network extension for community healthcare outcomes (SCAN ECHO)” in partnership with the State of Wisconsin, health system partners, generous influential families, and the United Health Foundation. SCAN ECHO incorporates population health-focused consultation programs including the Child Psychiatry Consultation Program (CPCP), and a perinatal psychiatry consultation program (Periscope Project). Please note that the VA’s SCAN ECHO program was developed from Dr Sanjeev Arora’s innovative thinking at the University of New Mexico, where he developed the ECHO Model in 2003. In addition, MCW worked with state legislators to target funding for the development of an Addiction Medicine Consultation Program. All of those consultation programs have the potential to expand to cover the state and to enhance the ability of primary care providers to provide front line mental/behavioral health care; and hence, refer only more severely ill patients to psychiatrists. This model of care also provides mental health care education to primary care clinicians to maximize the mental health care delivered in primary care clinics. This model also helps to connect patients to other mental health care resources.
MCW is making many efforts to address critical mental health access problems through a multifaceted approach that includes increasing the number of psychiatrists trained in Wisconsin, training psychiatrists in regions that have more extreme shortages, and developing a psychiatry fellowship in addiction psychiatry; developing and implementing population-based consultation programs that enhance primary care clinicians’ ability to deliver front-line mental health care; developing clinical mental health-trained pharmacists; training APPs in mental health care and utilizing their expertise to allow them to work at the top of their license as part of an interprofessional team; developing health psychologists; and integrating mental health care into primary care clinics.
The serious shortage of access to mental health care is a complex problem that cannot be resolved easily or without deploying substantial resources. MCW’s work to mitigate the shortage has been possible primarily because of a willingness to innovate and because of the support of forward-thinking community partners, philanthropists, foundations, health systems, state legislators, and agencies. Any progress made to address this continuing crisis will save lives, minimize suffering, and lead to downstream financial savings. However, despite the multifaceted approach being undertaken in Wisconsin, full resolution of this mental/behavioral health access crisis will not be attainable until there is true national and local parity of funding for mental health care, elimination or diminution of stigma associated with receiving mental health care, and expansion of funding for graduate education of mental health professionals.
References
- Wisconsin Department of Health Services. Number of psychiatrist FTEs needed to reduce significant shortages for the resident population. P-00376. Published November 2012. Accessed August 29, 2018.
- Santiani A, Niedermier J, Sanitiani B, Svendsen DP. Projected workforce of psychiatrists in the United States: a population analysis. Psychiatr Serv. 2018;69(6):710-713. doi:10.1176/appi.ps.201700344.
- Moran M. Survey finds dramatic disparities in reimbursement, out-of-network use. Psychiatric News. Published online December 26, 2017. Accessed August 29, 2018.
- Linnane R. Shortage of mental health care providers hits crisis point just as more teens seek help. Milwaukee Journal Sentinel. Updated January 4, 2018. Accessed August 29, 2018.
- Merrit Hawkins. The silent shortage – a white paper examining supply, demand and recruitment trends in psychiatry. Accessed 11 Apr 2018. Published February 22, 2018. Accessed April 11, 2018.
- Lerhmann JA, Kerschner JE. Working to increase access to mental health care in Wisconsin. WMJ. 2016;115(6):329-330.