The national mental health provider shortage, especially of psychiatrists, continues unabated. More and more large mental health organizations are now joining the national vocal chorus highlighting this decade and a half (in my own estimate) crisis.
The article I read of August 15, 2019, by Brent Johnson, which stimulated my thoughts on this shortage,”More people know they need mental health services, but facilities cannot find staff to treat them,” was published in a regional business-oriented periodical “ROI” (I guess for Return on Investment). The article featured thoughts from the CEO of a local, regional New Jersey mental health provider agency, Robin’s Nest, Mr. Anthony DiFabio.
Mr. DiFabio is well positioned to speak authoritatively on these issues. He is also board president of the New Jersey Association of Mental Health and Addiction Agencies.
He details that all types of agencies in all service sectors are having enormous troubles recruiting and maintaining practitioners at all levels of expertise, training and professionals. This goes beyond the all too well known national shortage of psychiatrists. Psychologists, social workers, and counselors-therapists at all levels of training from bachelors to master’s level are increasingly hard to recruit and retain. One issue he highlighted I was less aware of, was that agencies now have significant retaining practitioners due to staffers leaving for other positions in other areas of work. Salaries again are touted as causing losses of staff on a continuing basis. I have this as social workers and psychologists, especially the younger ones to their professions, leave public mental health jobs for more lucrative positions, especially in federal systems.
Another issue highlighted in this article is WAGES. In my view this is an issue that has been tiptoed around somewhat in the national conversation about mental health care delivery. Debates and hue and cry about the more mundane economic side of paying for staff at all levels and types of care seems not to be fully recognized at the political level. There is, of course, the bias toward establishing new whiz-bang programs and facilities. Politicians and planners love these crusades and accomplishments. Photo-ops abound with and from such efforts. But feel good articles and publicity do not result from efforts to secure pay raises for overworked service sector staff in almost any sector of our society. Pay raises for public employees are viewed with suspicion. Like so many other sectors of our national employment fabric, mental health professionals, remain yet another poorly paid group. Economic forces have long been in my mind some of the most powerful movers in all our lives. Thousands of teachers leaving their profession in poorly paying states for states like Texas and Georgia illustrated this. So too, the field of mental health service delivery falls prey to the power of economics.
Equity in insurance reimbursement in almost all insurances for mental health care, including federal programs, is still below the cost of providing such services. If robots ever replace therapists of all disciplines, then we will be able to rid ourselves of the largest and most important source of cost in mental health care delivery: the human staff. Mental health care remains firmly a human service intensive (read “labor cost intensive”) enterprise. If it ever becomes automated, it will suffer and become rote, no matter how much A.I. (artificial intelligence) improves.
The article succinctly offers a long-term consequence of federal reimbursement issues that have kept mental health provider pay low. And that is that payment for mental health services is still lower than staff salary and wages costs. Reimbursement does not cover staff costs. So staff salaries are lower than they should be. The article makes the connection that younger female mental health staff, therapists, etc., will work until they have children. Then they leave work because they cannot afford to pay child care costs on their salaries. This is a subset of this kind of economic discrimination problem for women and single parent or single earner families nationally in many kinds of work/professions.
The third issue that made this article very worthwhile reading was that of the increase in the need for mental health services. I have long held the view that this is a no-brainer. Our population has increased by almost 100%, or doubled, in my lifetime. So it stands to reason that the need for services for such health care would increase like every other kind of healthcare.
I have long mumbled to myself other reasons for the increased need for mental health services, in moments of idle explanatory, homemade policy wonk speculations. These have centered on two ideas. One is that our level of expertise and specificity of therapies, whether pharmacological or psychotherapeutic have all improved by leaps and bounds not imaginable when I entered psychiatric training. As our services have multiplied, clients/customers/patients have responded by requesting and seeking such services, tests, and therapies. A mental health sort of ‘build it and they will come’ analogy.
My second general notion which is likely shared by many millions of persons is that our modern lives are exponentially more stressful and complicated. We also have less and fewer support systems available to use than ever before. We work too much. Our work and email and electronic intrusions now endemic in our lives, follow us everywhere. I personally am convinced that the road rage, unprovoked assaults, and near violence we can encounter anywhere in the public byways (read WalMart, any shop, a sidewalk, airport, parking garage, JUST ANYWHERE) is evidence of how stressful our daily lives are compared to perhaps just 30 years ago.
Another regional administrator type, the Carrier Clinic CEO Don Parker, furnished good insights as well. He focused on one of the past and continuing efforts to address the psychiatrist shortage. He made the telling point that his organization, Carrier Clinic, a dominant and respected hospital and health care clinic system in New Jersey, had recognized the coming shortage of psychiatrists twenty years ago. And at that time they started employing “telepsychiatry” as a solution. His observations are well worth reading.
I would offer some other thoughts on telepsychiatry. There are many systems utilizing it well. North Carolina has utilized it in their state prison system and in my first hand experience with it briefly several years ago, it was well done. East Carolina University’s School of Medicine has long had a telemedicine program of some national renown of nearly 30 years, with psychiatric service delivery a well-done component for a number of years. A very early effort nationally in child psychiatry was in Montana where child services were mobilized via early technological versions of “telepsychiatry” from the state hospital to the eastern part of the state perhaps some 20 years ago with success. Of course, there are dozens if not more such programs all over the country as we all try to scramble to multiply outreach to address our national shortfall in capacity.
But without more professionals, there is still an absolute asymptotic limit to what we can do until our training program capacity catches up. And we all know that this is still decades away.
It isn’t. And that’s a tough pill to swallow for the industry.
Anthony DiFabio, whose organization offers a broad swath of services, including mental health and substance abuse recovery programs, will be first to admit the field’s pay leaves a lot to be desired.
“You have these incredibly talented young professionals working hard in our field, with stakes of not getting it right that are in some respects literally between life and death … realizing that someone working at Costco could be paid the same,” he said. “And they’ll only work 9 to 5 and they won’t be working off-hours or be in high-risk situations.”
DiFabio, CEO and president of Robins’ Nest, said this exact disillusionment — something he’s seen happen firsthand — is one of the reasons that mental health service providers are hurting for qualified employees right now.
“This workforce question is the most significant challenge in our field today,” he said. “The lifeblood of our system is the incredibly dedicated and well-trained staff. And, in almost every single area, we’re really struggling to hire. And where we do hire, we struggle to retain them.”
Mental health providers are experiencing record levels of turnover among all of their entry-level and non-degree positions, DiFabio said. And that staff is being lost to entirely different industries, ones not limited by public contracts or fee-for-service rates, he added. Simultaneously, providers are encountering difficulties hiring master’s degree-level staff; they’re short of psychiatrists, as well as licensed practical nurses, licensed clinical alcohol and drug counselors and licensed clinical social workers.
DiFabio is board president of the New Jersey Association of Mental Health and Addiction Agencies. That organization’s head, CEO and President Debra Wentz, identified this as a statewide trend.
And it couldn’t be a more inconvenient time for it.
The Angela R. Estes Center for Children & Families, part of the Robins’ Nest organization.
The behavioral health industry is busy reorganizing itself to better integrate with the medical side of the health care sector.
The shift is partly the result of a recognition that medical conditions can often have a behavioral component. And it’s also partly the upshot of a 2008 federal parity law that said coverage of mental health and addiction services had be equal to other medical services.
“On the ground, through various innovative programs, providers have really moved forward with this,” Wentz said. “We think the role of integration is excellent.”
At the same time, mental health providers’ aspiration of complete integration within the health care system carries with it the expectation that there will be a certain amount of credentialed staff on the mental health side who are prepared for working across partnered institutions.
Industry leaders say this further complicates an already difficult situation, because those employees are harder to find — and keep — than ever.
To add to that, Carrier Clinic CEO Don Parker said the labor shortage is becoming apparent in tandem with an uptick in the need for these services.
“The sheer demand for psychiatry has definitely increased,” he said. “And that demand is disproportionate to availability of providers in this field — on the part of individual professionals and organizations both. We don’t have enough people to meet the needs at this point.”
Carrier Clinic is a behavioral health care system in Belle Mead that recently agreed to form a partnership with Hackensack Meridian Health as part of the industry’s integration movement. The clinic has brought in 5 percent additional volume each year for the past five years.
And in the mental health world, you don’t grow by 25 percent in such a short period of time without there being some larger forces at play.
“I suspect demand is going up due to the increasing complexities of peoples’ lifestyle,” Parker said. “I think there has a significant impact on individual stability from over-reliance on technology to communicate with one another. The dominant ways of interacting today have diminished the quality of interactions.”
Parker refers to the effect of the endless back-and-forth of social media, emails and text. People are attending to all of it simultaneously, and the pace of it can take a toll.
Susan Buchwald, chief operating officer for Legacy Treatment Services, which provides housing and treatment for mentally ill adults, also has seen an increased demand for mental health services. She attributes it to a different societal trend.
“Some of it is driven by the fact that the stigma for mental health issues is being addressed,” she said. “People once didn’t talk about mental health issues, and that prevented people from seeking treatment. But with enough celebrities and other public figures talking about mental health and addiction problems, that’s going away.”
As the demand increases for mental health services, more facilities are turning to telepsychiatry, which, like telemedicine, puts patients in touch with a doctor at a distance through videoconferencing.
The market for qualified psychiatrists has gotten so tight that DiFabio said mental health service providers often pay as much today for these off-site psychiatrists as they were paying on-site personnel several years ago.
Although that may suggest the shortages of these professionals are a recent phenomenon, Joseph Masciandaro, CEO and president of Care Plus NJ, said everyone saw it coming a long way off.
Robins’ Nest provides services to children and families.
“This is actually something of a longstanding problem,” he said. “Twenty years ago, we were complaining at the time that there average age of our professionals was 56. So, we identified it as an issue, but there has been very little done in that time to increase pool of qualified people in this field.”
The problem is so acute that in Bergen County, where Care Plus NJ provides outpatient programs, there might be a six-week waiting period before a patient can be seen by a psychiatrist.
Some managed care companies pay inadequate rates for these specialized services, Masciandaro said, so there’s no incentive on the part of a provider to sign on with an insurance network plan. That makes it so many psychiatric practices in the region charge for services on an out-of-pocket basis.
“That works fine for people with the means to have that care,” he said. “But I think even for a well-off family with someone who has a chronic disease, they’re not going to be able to afford those out-of-pocket expenses.”
Organizations that participate in Medicaid and other medical insurance plans are dealing with the inability of adjusting prices for services in relation to today’s labor costs. The result is a level of pay that doesn’t help retain staff at these organizations.
DiFabio said part of the calculus for a significant portion of the industry’s millennial workforce is that they’re starting to have families — and they are finding the field’s pay to be inadequate to support that. About 85 percent of his organization’s staff are women.
“And, often, they can’t afford child care while working in this field,” he said. “Sometimes they’re leaving the labor force altogether. The economics don’t work for them. … And for us, there are things we can do in terms of staff engagement, but fundamentally it comes down to a dollars-and-cents question.”
Wage increases are not covered by current reimbursements, DiFabio said. And the talk of additional funding from both state and federal governments hasn’t always been a shot in the arm.
“Whenever spending a new dollar is looked at, the natural inclination is to use it to buy more capacity — more services or programs — instead of a fundamental like helping compensation for this needed workforce,” DiFabio said. “But it’s sort of like putting satellite radio in a car and heating or ventilated seats when you need to put money into the engines, brakes and tires.”
Hopeless as it may sound, local mental health industry leaders such as DiFabio remain optimistic.
“Even as we look to address on our path to integration a workforce challenge that is deeply rooted, I still feel incredibly optimistic that we’re having the right discussions with the leadership in the state Legislature and the Governor’s Office,” DiFabio said. “I’m confident we’ll get to better place with their help. It will take significant commitments and difficult discussions to get there. But we don’t have benefit of ignorance.”
Telepsychiatry: Yes, it’s here. And it needs an upgrade
The system of telepsychiatry is getting a face-lift.
Don Parker of Carrier Clinic, the state’s largest mental health facility, said his organization is working with on binding facial recognition software from the Department of Defense with telepsychiatry systems.
The technology is being tested at the facility now for its potential to more accurately diagnose patients, and even assess something like their risk of relapse.
Telepsychiatry needs an upgrade, Parker said. It’s not the cutting-edge technology it once was.
“We were doing telepsychiatry when I was at AtlantiCare 20 years ago, so it has been around,” he said. “But the process has not had many enhancements during that time. So, we’re excited about this new product.”
Conversation Starter
Reach Anthony DiFabio of Robins’ Nest at: adifabio@robinsnestinc.org or 856-881-8689.
The Mental Health Reform Blog 