For organizations delivering health and human services, there is the often-discussed behavioral health workforce shortage. Health plan managers are continuously looking for expanded capacity for psychiatric services. Provider organization executives often have recruiting and retention at the top of their list of strategic issues.
The subject of clinical capacity and consumer access to care are the subject of a wide range of recent studies and reporting. A new study found that by 2028, California will have 41% fewer psychiatrists than are needed to meet demand (see California Faces Major Shortage Of Behavioral Health Professionals). A state-level analysis showed that Nebraska is currently far below the national average when it comes to psychiatrist-to-population ratios (Nebraska’s Psychiatrist-To-Population Ratio At 8.8 Per 100,000 Is 41% Below National Average Of 12.4 Per 100,000). And, the National Council Medical Director Institute reported last year that psychiatric services have been deemed “in crisis” and that “the pool of psychiatrists working with public sector and insured populations declined by 10% from 2003-2013” (see The Psychiatric Shortage Causes and Solutions).
The behavioral health workforce is so “top of mind” in health care that it was the focus of a recent special issue of the American Journal of Preventive Medicine–The Behavioral Health Workforce: Planning, Practice, and Preparation. The edition opens with an overview, The Future of the Behavioral Health Workforce: Optimism and Opportunity, which explains the landscape facing the field–44 million American adults and counting have a diagnosable mental health condition, but the number of professionals who will choose behavioral health as a profession is predicted to be 250,000 “workers” short by 2025.
The issue also summarized the geographic variations in service capacity by types of clinical professionals—see Geographic Variation in the Supply of Selected Behavioral Health Providers. The analysis found that the percentage of counties that lack a psychiatrist ranged from a low of 6% in the New England Census Division to a high of 69% in the North Central Census Division. New England metropolitan areas have the highest proportion of mental health professionals per 100,000 population with 36.0 psychiatrists, 55.6 psychologists, and 5.8 psychiatric nurse practitioners (NP) per 100,000 population. The lowest proportion is in the West South Central metropolitan areas with 11.1 psychologists, 16.4 psychologists, and 1.4 psychiatric NPs per 100,000. (For more of our coverage of this study, check out New England Metropolitan Areas Have Highest Proportion Of Mental Health Professionals.)
Another key issue identified in the behavioral health workforce special issue was the opioid crisis. Of the at least 2.3 million people in the U.S. that have an opioid use disorder, less than 40% receive evidence-based treatment (see Policy Pathways to Address Provider Workforce Barriers to Buprenorphine Treatment). The “prominent barrier” to this is that, despite buprenorphine’s documented effectiveness, there is a lack of knowledge, training, education, and experience in buprenorphine prescribing. Other major barriers identified include a lack of institutional and clinician peer support, poor care coordination, provider organization stigma, and inadequate or burdensome reimbursement and regulations.
These impediments are reflected in the effective capacity of the existing prescribing professionals. In the article, Prescribing Practices of Rural Physicians Waivered to Prescribe Buprenorphine, the authors report that rural physicians with a 30-person waiver to prescribe buprenorphine for opioid use disorder (OUD) treat an average of 8.8 consumers, with 53% not treating any consumers at all. Rural physicians with a 100-person waiver treat an average of 56.9 consumers. Of the 89.4% of rural physicians that report prescribing buprenorphine, only 56.2% were currently accepting new consumers for treatment. (For more of our coverage of this story, check out Rural Physicians With 30-Person Buprenorphine Waiver Average 8.8 Consumers.)
Another big topic of the workforce issue is the possible future roles of peers in the system. As of 2014, there were 36 states where mental health peer support services are a Medicaid billable service, and at least 11 states peer support for substance use disorders or co-occurring conditions is a billable service (see Peer Workers in the Behavioral and Integrated Health Workforce: Opportunities and Future Directions). In addition, the role of peers is expanding to become an integral part of care teams and consumer recovery efforts. While there are issues that need to be addressed in regards to wages, stigma, training and funding, peer support specialists represent an important workforce that can help connect consumers to resources and alleviate some of the current workforce shortages (see Emerging Roles for Peer Providers in Mental Health and Substance Use Disorders).
But, how to address these behavioral health workforce issues? There appear to be no easy solutions. I wrote earlier this week about the opportunities that technology presents for task shifting —see Will Clinical Professional Compensation Drive Task Shifting? One of the key problems identified is that there is no national data about the actual size of the behavioral health workforce, as discussed in the article, Improving Data for Behavioral Health Workforce Planning: Development of a Minimum Data Set, which makes planning difficult. The authors note that despite 27 national data sources that collect workforce data, “no combination of data sources provides adequate data across the field of behavioral health to construct a national behavioral health workforce monitoring.” The solution presented by the authors is to create a minimum data set (MDS) that encompasses five elements: demographics; licensure and certification; education and training; occupation and area of practice; and practice characteristics and settings. This would be a great area of focus for SAMHSA, but is unlikely to happen.
For more, I reached out to OPEN MINDS Senior Associate Sharon Hicks, who noted the need to rethink the roles of service professionals in the service delivery system:
For years, the non-medical, sometime called ancillary, professions in health care have been underpaid and undervalued as professional parts of the team. At the same time, people with Master’s degrees in clinical fields began to be replaced by bachelor-level staff. Salaries were driven down, while the responsibility for the safety of the people on one’s caseload went up.
I think that we have to re-professionalize the roles of people who do direct service, especially those who are doing so in community and other non-supervised settings – and allow all service professionals to work at the top of their license. A great start would be to develop standard definitions for activities and the skills required for each.
In many other Organization for Economic Co-operation and Development (OECD) countries, human service workers are coupled with health care service staff so that things like homelessness and poverty don’t have to be a barrier to effective care for chronic illness. But until we respect those who provide human services, compensate them at a reasonable level, require them to have advanced education and treat them as an important, and integral, part of the treatment team, the system in the United States won’t get there.
For more on staffing options, join me on August 16 at The 2018 OPEN MINDS Management Best Practices Institute for the session, “The Future Of Peer Support Services: A Review Of Successful Models In A Value-Based Market,” led by Ken Carr, Senior Associate, OPEN MINDS, and featuring Briana Gilmore, Director of Planning & Recovery Practice, Community Access; and Sue Ann Atkerson, LPC, MBA, Chief Operating Officer, RI International.