Experts Move to Halt Crisis in US Psychiatry

Pauline Anderson

March 30, 2017

An expert panel has released a new report containing recommendations to rectify the severe shortage of psychiatrists and the dearth of mental health services in the United States.

Released by the National Council Medical Director Institute, which advises the National Council for Behavioral Health on issues strongly related to clinical practice, the report, The Psychiatric Crisis: Causes and Solutions, contains a wide-ranging set of recommendations that touch on every area of the specialty, including training, funding, and models of care delivery.

Lead authors Joe Parks, MD, medical director, National Council for Behavioral Health, and Patrick Runnels, MD, co-chair, Medical Director Institute, discussed the report's recommendations at a press briefing on March 28, where they were joined by Saul M. Levin, MD, CEO and medical director of the American Psychiatric Association (APA).

The number of psychiatrists is plummeting – down by 10% from 2003 to 2013. The average age of practicing psychiatrists is the mid-50s, compared to the mid-40s for other specialties, said Dr Parks.

Furthermore, approximately 55% of counties across the United States currently have no psychiatrist, and 77% report a severe shortage – a situation that is partially due to an increase in demand.

"People want psychiatric services. They know treatment works, and it's less stigmatizing than it used to be, so people are more willing to accept and seek treatment," said Dr Parks.

But their search is often in vain. Two thirds of primary care physicians report having trouble getting psychiatric services for patients, so patients often end up in the emergency department.

"There has been a 42% increase in patients going to ERs for psychiatric services in the past 3 years, but most of them aren't staffed with psychiatrists," Dr Parks noted.

"So people end up stuck in the ERs for hours and at times days – two to three times as long as for general medical conditions."

To make matters worse, some hospitals are closing inpatient psychiatric units because they cannot find psychiatrists to staff and run them.

The lack of services and long wait times for these scarce services are taking a toll on patients.

"These are people burdened and suffering from anxiety, from depression. Some of them feel suicidal, and some of them have hallucinations," said Dr Parks.

Psychiatrist Burnout

Psychiatry has not received the increase in support that some other specialties, such as obstetrics and gynecology, have. Psychiatrists also do not get the same ancillary staff to assist them in tasks such as arranging patient follow-up, he added.

In many cases, psychiatrists are forced to receive reimbursement that is lower than usual. "About 40% of psychiatrists are in cash-only services. Psychiatrists are rushed, and they burn out and leave the profession earlier," said Dr Parks.

He described the current mental health care delivery system as "old fashioned," noting that it "has not kept up with modern, data-driven, evidence-based technologies and has certainly not taken advantage of some of the new, innovative social media ways we can reach out and touch patients."

Another "looming potential problem" is immigration. Some 50% of new psychiatry trainees are foreign medical graduates, and changes in visa requirements by the Trump administration could add to the workforce problems, he said.

If nothing is done about the psychiatrist shortage, the demand for psychiatry is expected to outstrip supply by 25% by 2025.

Becoming a psychiatrist requires 12,000 hours of training, said Dr Levin, who heads the APA, the largest psychiatric association in the world.

According to Dr Runnels, medical students are more likely to opt for a psychiatry residency if the medical school's psychiatric department offers a highly-rated and relatively long rotation.

"That's hugely important, and medical schools need to start working on that," he said. He added that currently, many training "milestones" are "fuzzily or not well-defined."

Training does not adequately address team-based collaborative care or supervision of clinicians from other disciplines, for example, physician assistants, said Dr Runnels.

"Medication-assisted treatment for addictions is definitely something that most residents get very little exposure to," he added.

New Models of Care

The expert panel that developed the report included representatives from all areas of healthcare. In addition to psychiatrists, it included CEOs of healthcare organizations, primary and managed care representatives, academic experts, and those representing related professions, such as nursing.

The panel was tasked to develop recommendations that were "specific and actionable – not broad, vague, pie in the sky but things that a payer could do, things that government could do, things that individual psychiatrists could do, and things that the professional organizations could do to relieve this emergency," said Dr Parks.

The expert panel recommended that the care delivery system be updated so that psychiatrists would operate more as expert consultants and work in teams, said Dr Parks.

"So they would do the essential things only psychiatrists can do and delegate other parts of care and follow-up for patients who are stable, or services that can be provided by other professionals, such as psychiatric nurses or perhaps physician assistants."

The panel also recommended new and advanced forms of treatment, such as collaborative care and telepsychiatry.

"We should all be advocating for new, innovative models of care, such as telepsychiatry, which can increase access to specialty psychiatric services across the country," said Dr Levin.

"We would love to see more telepsychiatry, and we would love to see the payment system actually pay for it," he added. However, he said, it is important to ensure that patients who receive treatment remotely are "always safe" and that if they begin to show signs and symptoms of distress on the psychiatry call, "we are able to get them help very quickly."

The APA has a toolkit to help educate psychiatrists and other healthcare providers on how to practice telepsychiatry, said Dr Levin. "I think we all see this as one of the ways we are going to be practicing well into the future."

The panel also wants to see burdensome governmental rules removed. For example, said Dr Parks, a psychiatrist who provides telepsychiatry services in eight states now has to be licensed in all eight states.

As for medical education, the task force recommended that all residents receive integrated care experience and be placed in a range of different settings to broaden their experience with medication-assisted treatment programs and collaboration with other professions.

Cost-Saving Investment

All of this requires additional funding, which the panel also addressed.

"We are aware that overall, the healthcare system is looking to cut costs, so we want to point out that our call for increased funding for psychiatry was not something we took lightly," said Dr Runnels.

"However, we want people to understand that our call for increased funding is about helping to save money overall."

He pointed out that the use of psychiatry services leads to overall reductions in spending on healthcare.

"We believe insurance companies are leaving money on the table by not adequately funding those services."

Some of the report's specific recommendations include the following:

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  • Removing barriers to integrated care: Fund technical assistance programs that help develop alternatives to fee-for-service reimbursement models, because chronic physical conditions are known to improve when mental health conditions are managed, particularly among high-risk populations.

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  • Cutting red tape: Streamline administrative paperwork so that physicians can spend more time with patients and that information exchanges between physicians are more attuned to the patients' needs.

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  • Changing how psychiatrists are paid: Create awareness about behavioral health's role in the 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.

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  • Improving confidentiality regulations: Although the recently revised 42 CFR Part 2 confidentiality regulations are advances, they burden psychiatrists by restricting information regarding treatment of substance use disorder, sometimes keeping patients and their families in the dark to protect psychiatrists.

The authors of the report made other recommendations specific to government and payers, healthcare treatment, and advocacy organizations, as well as nurse practitioners, physician assistants, and other stakeholders. The full report is available for download.

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