Medical Directors’ Report Recommends Training More Psychiatrists and Expanding Telepsychiatry

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Aaron Cohen
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The New National Council Medical Director Institute Makes Sweeping Recommendations to Combat a Shortage of Psychiatrists as Patient Loads Increase

WASHINGTON, D.C. (March 28, 2017) – Today, the National Council for Mental Wellbeing’s Medical Director Institute released recommendations to ensure there are enough psychiatrists to treat the people who need help.

The need for an adequate psychiatric workforce has never been greater than it is now. In addition to expanded insurance coverage driving demand, our nation faces public health crises in its opioid epidemic and rising suicide rates. Yet, 55 percent of U.S. counties have no psychiatrists at all. If nothing is done, the demand for psychiatry will outstrip supply by 25 percent in 2025.

The report, “The Psychiatric Shortage: Causes and Solutions,” from the National Council Medical Director Institute (the Institute), is a blueprint to grow psychiatry and fundamentally change the way it is practiced in the United States.

National Council President and CEO Linda Rosenberg warned of the dangers from ignoring the report’s conclusions. “In every town in America, we see the unmet need — young pregnant women with untreated addiction living on the streets; older adults who are isolated, anxious, and at risk for suicide; men and women with mental illnesses released from jails without housing or access to care.”

Rosenberg added that, “our nation’s treatment capacity desperately needs to be expanded. We urge all stakeholders to take the recommendations in this report seriously and help modernize psychiatry to avert a crisis that would affect the most vulnerable people in society.”

This report comes at a time when psychiatric patients face overly brief clinical appointments and long wait times for appointments as physicians continue to age out of the profession. At the same time, reimbursement methodology for services are antiquated, physicians are rewarded for volume over value, government regulations thwart progress and the system marginalizes allied medical professionals.

The Institute recommends a comprehensive approach that will begin to adjust the imbalances identified in the report. Long-term recommendations include:

• Expanding the workforce that provides psychiatric services.
• Increasing the use of telepsychiatry and other innovative, on-demand technologies for those in rural areas, schools and jails.
• Implementing innovative models of integrated health care delivery.
• Training psychiatric residents and the existing psychiatric workforce treatment and care delivery technologies.
• Adopting effective payment structures.

Led by Joe Parks, M.D., Medical Director at the National Council and Chair of the Institute, and Patrick Runnels, Medical Director at the Centers for Families and Children and Co-Chair of the Institute, with an expert panel led by Howard Liu, University of Nebraska Medical Center and Adam Biuckians, Community Services Group, the report makes a number of specific recommendations.

• First, do no harm: Protect the improvements to patients’ access to treatment and insurance for psychiatric services gained through the Medicaid expansion and do not push people out of treatment.
• Treat the whole person: Often times patients receive mental health care apart from their physical health care. Make behavioral health care delivery more patient-centered and involve the patient more in his/her care, no matter where care takes place.
• Remove barriers to integrated care: Fund technical assistance programs that help develop alternatives to fee-for-service reimbursement models, as chronic physical conditions are known to improve when mental health conditions are managed, particularly among high-risk populations.
• Cut red tape: Streamline administrative paperwork so physicians can spend more time with patients and information exchanges between physicians are more attuned to the patients’ needs.
• Change how psychiatrists are paid: Create awareness about behavioral health’s role in total cost of care; then shift from fee-for-service arrangements to bundled payments to increase the quality of care and reduce the overall cost of care.
• Remove barriers: Reform state and federal laws that prohibit physician assistants and advanced practice registered nurses from practicing to the full extent of their licenses.
• Improve confidentiality regulations: While the recently revised 42 CFR Part 2 regulations are advances, they still burden psychiatrists by restricting substance use disorder treatment information, sometimes keeping patients and their families in the dark to protect psychiatrists.

The report also make a series of recommendations specific to government and payer stakeholders; health care treatment and advocacy organizations; psychiatrists, nurse practitioners, physician assistants, clinical pharmacists and their professional organizations; and psychiatric training programs.

Why now?

The nation is facing a shortage of trained psychiatrists. From 2003–2013 there was a 10 percent decline in the number of practicing psychiatrists.

If the current workforce of 45,580 does not grow, the deficit of psychiatrists will double from around six percent to 12 percent by 2025, according to a 2016 U.S. Department of Health and Human Services-commissioned study.

The psychiatry shortage has manifested itself in myriad ways:

• Extended wait times for patients to see psychiatrists in all settings — an average 25 days according to a 2014 study published in Psychiatric Services — but particularly in Medicaid-covered community behavioral health centers.
• Rationing of services.
• Poor adherence to medications.
• Incomplete symptom management.
• Over-use of nurses and case managers to bridge weeks- or months-long waits between appointments.
• Further reduction of already short appointment times.
• Poor clinical treatment of vulnerable foster children and older adults.

Methodology

The Medical Director Institute brought together a diverse group of practitioners, administrators, policymakers, researchers, innovators, educators, advocates and payers to ensure depth of discussion from a variety of viewpoints. Each provided literature and research from their area of expertise for review, as well as their unique perspectives to the vexing problem of lack of access to psychiatric services.

Stakeholders for whom these recommendations were developed include the Centers for Medicaid and Medicare Services (CMS); the National Association of Medicaid Directors (NAMD); the Substance Abuse and Mental Health Services Administration (SAMHSA); professional membership organizations for psychiatrists, nurse practitioners, physician assistants and pharmacists; health care provider organizations; payers; advocacy organizations and consumer organizations.

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About the Medical Director Institute

The Medical Director Institute advises the National Council for Mental Wellbeing board, staff and membership on issues and topics heavily impacted by clinical practice and provide longer-term guidance through a series of technical papers. It also assesses best practices in medication-assisted treatment (MAT), a method of treating opioid, alcohol and tobacco use disorders. The Medical Director Institute is composed of medical directors from National Council member organizations. The full roster can be found at thenationalcouncil.org/about-us/leadership-experts/medical-director-institute.

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About the National Council for Mental Wellbeing

About the National Council for Mental Wellbeing