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Biomedical Research

The National Psychiatrist Shortage: A Public Health Threat

Introduction

A report published by the Health Resources and Services Administration (HRSA) identified a scarcity of behavioral health professionals as the primary barrier to meeting the national demand for mental health services. In the United States (U.S.), one in five people have some form of psychological disorder (Weiner, 2018). Moreover, as the demand for psychiatrists rises, the size of the workforce curtails. As of September 2020, there were 30,451 practicing psychiatrists in the field. This means there are 9 physicians per 100,000 people and the workforce deficit falls at 6.4%. By 2025, this deficit is projected to escalate to 25%. The demand for psychiatry will outstrip supply by 15,600 psychiatrists (Harrar, 2020). As the gap between those in dire need of treatment and available providers steadily widens, it is crucial to analyze the causes of this imminent threat to public health.

A Further Analysis

Although a 6.4% national deficit in mental health providers doesn’t appear too substandard, the deficit hits worse for many. In a 2017 New American Economy report, it is stated that over 60% of all U.S. counties have no practicing psychiatrists. While there are an estimated 612 psychiatrists per 100,000 people in parts of New York, there is less than 1 in Idaho. In 185 out of 254 counties in Texas, there are 0. Finding a provider is only half the problem.

Those in need of a psychiatrist must also consider their provider’s wait times and if their insurance will cover the cost of consultations. In an interview with Psycom, Dr. Benzion Blech, a neurologist at the Mayo Clinic, reported that just 15% of psychiatrists are accepting new patients. On top of that, the median fee for consultation is $450. Cost is a large factor of concern, especially when it is not covered by insurance. A study in JAMA Psychiatry indicates that 45% of providers don’t accept private health insurances or Medicare (Sherill, 2017). Those lucky enough to have access to a nearby provider ultimately rule out the hope of seeking help due to the exorbitant cost.

How Did the Deficit Come to This State?

Psychiatry is a medical specialty with the highest number of practicing physicians older than 55 (third to hematology and oncology.) The AAMC has reported that there are over 28,000 psychiatrists above the age of 55 currently in practice (Weiner, 2018). As these existing physicians begin to retire, the gap between demand and the psychiatrist workforce will only widen. New physicians must take their place. As such, it is imperative to understand why students in medical schools are not inclined to match with psychiatry residency programs.

Physician Burnout

The administrative burdens that psychiatrists are faced with in the public health community fall into an extensive list. Depending on the state, U.S. hospitals have restrictive regulations on sharing information that can potentially improve patient care. Psychiatrists are provided with minimal support and resources to  schedule and arrange for filing of legal documentations, conduct routine medical examinations, and organize medical records. Subsequently, this limits a physician’s time with patients, weakening the efficacy of care. A study conducted by the U.S. Veterans Affairs concluded that between 2014 to 2017, the percentage of reported psychiatrist burnout increased from 40% to 48%. Further, 90% of the study participants reported the profession was prone to high cynicism and exhaustion.

Low Reimbursement Rates for Practicing Physicians

Federally, reimbursement rates are low for both inpatient and outpatient behavioral health services from Medicaid programs. Federal cuts to such grants have also affected public sector medical centers that treat patients with severe mental disorders. These budget cuts serve to offset the financial losses created by the preexisting low reimbursement rates from Medicaid programs. Because of this, psychiatrists are not reimbursed well by their respective medical institutions and are forced into a position where they cannot accept most health insurances from prospective patients. Patients must be able to pay out of pocket. This creates a cycle where desperate patients pay for consults out of pocket and ultimately refuse treatment when they realize they are unable to pay. A 2017 report by the National Council entails a survey regarding psychiatrist reimbursement. The results show that 75% of the members in the National Council for Psychiatry have been subjected to a median three-year loss totaling to $481,000 in 2013. In 2015, these losses had a median of over $550,000 (National Council, 2017). As a result of these patterns, psychiatrist salaries are among the lowest of all medical specialties.

Workforce of Outsider Providers

Unfortunately, psychiatrists have never been and will never be first responders to any patient who walks into a hospital. Historically, most behavioral disorder diagnoses and initial treatment plans have been given by the patient’s primary care provider. As mentioned earlier in this article, the demand for psychiatrists is projected to exceed the supply by 15,600 psychiatrists by 2025. When this deficit takes place, other healthcare professionals such as internists and neurologists will be expected to take over the duties of psychiatrists. Thus, psychiatry is predicted to soon be an obsolete field.

What Are Some Solutions to Address this Issue?

Currently, the objective is to ensure that the role of psychiatrists in healthcare remain stable and that the efficacy of care delivery to patients is improved. This should be done by remodeling the existing psychiatry recruitment model to better initiate an expansion of the psychiatric workforce. The secondary concern is that the national psychiatrist distribution should be even. Care should be accessible to more people.

Expanding the Psychiatric Workforce Efficiently

The most advisable solution to combat the receding workforce lies in the hands of academic medical centers. These institutions should prioritize recruitment of medical students into psychiatry. Additionally, support programs for psychiatric residency programs should be implemented and funding should be increased. The lack of funding for resident positions through Medicare can only be resolved by Graduate Medical Education (GME) institutions. The two primary factors of institutions with the highest recruitment rates for prospective physicians were strong psychiatry department reputations and extended clerkships (time spent in the 3rd year of medical school in a clinical setting). Further, to enhance the effect of national care distribution, these funds from the GME institutions should be directed specifically towards teaching hospitals in rural or underserved suburban to urban communities.

Improving Accessibility of Psychiatric Professionals

One method of care delivery that can greatly improve accessibility is telepsychiatry. For reference, telepsychiatry is a form of practice that involves providing care over the telephone. This method of care distribution has the potential to dramatically widen geographic access to psychiatrists. Telepsychiatry is convenient for both providers and patients. It eliminates the requirement of travelling to a clinic and patients can receive care from anywhere. Primarily, this option is used by medical facilities where there are no available psychiatrists. Another method is to provide psychiatrists with adequate staff support to extend their time spent with patients. These staff members can range from licensed psychiatric nurses and pharmacists to non-licensed personnel with little specialty training. Support staff can help physicians with gathering patient records and lab results, arranging appointments and referrals, and further administrative and clinical work. As of now, psychiatrists working in public sector hospitals are less likely to have this support.

All information from section “How Did the Deficit Come to This State?” up to this point is derived from the Mental Health First Aid National Council for Behavioral Health 2017 report, The Psychiatrist Shortage:  Causes and Solutions. It is listed in the references section below “Conclusion.”

Conclusion

Since 2013, there has been a steadily widening gap between the demand for psychiatrists and patients who require access to mental health services. Today, this deficit of psychiatrists lies at 6.4%. Within five years, it is projected to rise to 25%. This is due to the fact that currently practicing psychiatrists are predominantly above 55 years old. They are expected to retire rapidly with an inadequate number of psychiatrists to occupy their former positions. The lack of interest towards clinical psychiatry is that the physician satisfaction rate is lower than that of other medical specialties. Psychiatrists are known to have the lowest reimbursement rates of all medical professions,  are prone to burnout due to substandard support provided by employing healthcare centers, and often aren’t the ones diagnosing and treating patients for psychiatric disorders. The most sensible solution to prolong the life of this diminishing field is to restore GME institutional funding through Medicaid. These proceeds should then be addressed to teaching hospitals within rural and underserved urban communities. This ensures that care distribution is maximized, and prospective psychiatrists are encouraged to pursue employment in areas lacking access to such care. In theory, this would eliminate the cycle of psychiatrists rejecting patients covered by Medicare insurance. The reimbursement rates owed to psychiatrists would be repaid as well. Thus, the incentive for medical students to reconsider psychiatry as a formidable career path is restored.

Sabriyah Morshed, Youth Medical Journal 2020

References

Addressing the Behavioral Health Workforce Shortage. (2016, September). Retrieved from https://www.bhecon.org/wp-content/uploads/2016/09/BHECON-Behavioral-Health-Workforce-Fact-Sheet-2018.pdf

Article by: Sari Harrar, S. H. (2020, September 08). Inside America’s Psychiatrist Shortage (Special Report). Retrieved December 05, 2020, from https://www.psycom.net/inside-americas-psychiatrist-shortage

Health Resources and Service Administration. (November). Retrieved 2016, from https://bhw.hrsa.gov/sites/default/files/bhw/health-workforce-analysis/research/projections/behavioral-health2013-2025.pdf

Miller, P. (2017). 2017 REVIEW OF PHYSICIAN AND ADVANCED PRACTITIONER RECRUITING INCENTIVES. Retrieved from https://www.merritthawkins.com/uploadedFiles/MerrittHawkins/Pdf/2017_Physician_Incentive_Review_Merritt_Hawkins.pdf

The Psychiatric Shortage: Causes and Solutions. (2017, March). Retrieved from https://www.thenationalcouncil.org/wp-content/uploads/2017/03/Psychiatric-Shortage_National-Council-.pdf?daf=375ateTbd56

Sherrill, E. (2017, October 01). Health Insurance Coverage Changes and Mental Health Care. Retrieved December 05, 2020, from https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2652826

Weiner, S. (2018, February 12). Addressing the escalating psychiatrist shortage. Retrieved December 05, 2020, from https://www.aamc.org/news-insights/addressing-escalating-psychiatrist-shortage

By Sabriyah Morshed

I'm a senior at Delta High School in Pasco, WA. I am interested in genetics and biotechnology. I aspire to be a cardiothoracic surgeon in the distant future.

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